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EDITORS 

Or.  CHARLES  L.^DANA  Dr.  HUGH  T.  PATRICK 

Dr.  F.  X.  DERCUM  Dr.  J  AS.  J.  PUTNAM 

Dr.  CHA5.  K.  MILLS  Dr.  B.  SACHS 

Dr.  M.  ALLEN  STARR 

ASSOCIATE   EDITOR 

Dr.   WILLIAM  G.  SPILLER 

MANAQINQ  EDITOR 

Dr.  CHARLES  HENRY  BROWN 

>5  W.  45th  Street.  New  York 


VOLUME      XXV.,       I8Q8 


NEW    YORK 
No.    25  West   45TH    Street 

1898 


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ORIGINAL  CONTRIBUTIONS. 


PAGE. 

A  Contribution  to  the  Study  of  Secondary  Degeneration  Follow- 
ing Cejrebral  Lesions,  by  W.  G.  Spiller i 

Some  Notes  on  Echolalia,  with  the  Report  of  an   Extraordinary 

Case,  by  M.  W.  Barr 20 

On  Arrested  Development  and  Little's  Disease,  by  VV.  G.  Spiller..  81 
On  the  Advisability  of  Operation  in  Microcephaly,  by  W.  W.  Keen.  105 
Glioma  of  the  Right  Frontal  Lobe  of  the  Brain,  by  W.  C.  Krauss. .  109 

The  Psychical  Mechanism  of  Delusions,  by  W.  Hirsch 159 

Equilibration  and  Its  Relations  to  Vertigo,  by  F.  K.  Hallock 175 

A  Report  of  a  Case  of  Unusual  Edema  in  Hemiplegia,  by  H.  A. 

Hare    189 

Friedreich's  Ataxia,  by  M.  A.  Starr 194 

Sexual  Perversion  or  Vice?  A  Pathological  and  Therapeutic  In- 
quiry, by  Morton  Prince 2y] 

Dissociation  of  Sensation  of  the  Syringomyelic  Type:  Occurring  in 

Pott's  Disease,  by  D.  L.  Edsall 257 

A  Case  of  Landry's  Paralysis,  by  W.  L.  Worcester 299 

Glia  and  Gliomatosis,  by  S.  Flexner 306 

Double  Ophthalmoplegia  Chronica  Externa,  by  F.  Peterson 310 

On    Multiple   Sclerosis,   with    Especial   Reference  to   Its   Clinical 

Symptoms,  Its  Etiology  and  Pathology,  by  B.  Sachs.  314,  464 
On  Landry's  Paralysis,  with  the  Report  of  a  Case,  by  C.  K.  Mills 

and  W.  G.  Spiller 365 

Cases  of  Trigeminal  Spasm:  Resection — Probable  Presence  of  Sen- 
sory Fibres  in  the  Seventh  Nerve,  by  J.  K.  Mitchell 392 

Hypertrophic  Nodular  Gliosis,  by  J.  Sailer 402 

President's  Address.  New  Paths  in  Psychiatry,  by  F.  Peterson. ..  .444 
A  Case  of  Serous  (Alcoholic)  Meningitis  Simulating  Brain  Tumor, 

by  Theodore  Diller.  ^ 441 

A  Case  of  Universal  Muscular  Atrophy,  by  H.  A.  Hare 450 

Cases  of  Ophthalmoplegia,  by  B.  Sachs 452 

A  Case  of  Myxoedema  Treated  with  Thyroid   Extract  and  with 

Thyrocolloid,  by  R.   H.   Cunningham 458 

President's  Address,  American  Neurological  Association,  by  G.  M. 

Hammond  505 

On  Myotonia,  by  G.  W.  Jacoby 508 

A  Case  of  Amaurotic  Family  Idiocy,  with  Autopsy,  by  F.  Peter- 
son   529 

The  Pathological  Anatomy  of  a  "Fatal  Disease  of  Infancy,  with 
Symmetrical  Changes  in  the  Region  of  the  Yellow  Spot" 
(Warren  Tay);  "Amaurotic  Family  Idiocy"  (Sachs);  "Infan- 
tile Cerebral  Degeneration"  (Kingdon  and  Russell),  by  W. 

Hirsch    538 

Pathological   Report  on  the   Eyes  of  Dr.   Hirsch's  Patient,  with 

Amaurotic  Family  Idiocy,  by  W.  A.  Holden 550 

Congenital  Facial  Paralysis,  by  H.  M.  Thomas 573 

A  Case  of  Multiple  Syphilitic  Neuritis,  F.  R.  Fry 594 

Long  Remissions  in  Epilepsy  and  Their  Bearing  on  Prognosis,  by 

Wharton  Sinkler  601 

Report  of  a  Case  of  Purulent  Internal  Pachymeningitis,  Complicat- 
ing Middle  Ear  Disease,  by  W.  M.  Lcszynsky 609 

Family  Periodic  Paralysis,  by  E.  W.  Taylor 637,  719 


INDEX.  iii 

FAGS. 

\  experimental  Researches  on  the  Localization  of  the  Sympathetic 

>  Nerve  in  the  Spinal  Cord  and  Braiii^  and  Contributions  to 

Its  Physiology,  B.  Onuf  and  J.  Collins. 66i 

A  Summary  of  the  Symptoms  in  Sixty-one  Cases  of  Locomotor 

Ataxia,  with  Additional  Remarks,  by  W.  H.  Rjley 679 

On  Regeneration  of  Nerve  Fibres  in  the  Central  Nerv^ous  System, 

by  W.  L.  Worcester 698 

On  Scleroderma  and  Chronic  Rheumatoid  Arthritis,  by  F.  X.  Der- 

cum   703 

A  Case  of  Katatonic  Melancholia,  by  J.  E.  Courtney 747 

On  the  Etiology  and  Pathogenesis  of  the  Post-Tfaumatic  Psychoses 

and  Neuroses,  by  J.  J.  Putnam 769 

On  Resection  of  the  Gasserian  Ganglion,  by  W.  W.  Keen;  with  a 

Pathological   Report  on  Seven  Ganglia  Removed  by  Prof. 

Keen,  by  W.  G.  Spiller 800 

A  Case  of  Cerebral  Ataxia,  AflFecting  Chiefly  the  Right  Upper  Ex- 
tremity,   with    Marked    Involvement   of    the    Stereognostic 

Sense,  by  L  Olmstead 807 

A   Case    of  Syringomyelia  and  Two  Cases  of  Tabes  with  Irunk 

Anaesthesia,  by  H.  T.  Patrick , 837 

A  Case  of  Huntington's  Chorea  with  Remarks  Upon  the  Propriety 

of  Naming  the  Disease  **Dementia  Choreica,"  by  F.K.Hallock.851 

The  Bruce  Microtome,  by  C.  E.  Riggs 865 

A  Qinical  Consideration  of  Herpes  Zoster,  by  L.  Weber 868 

Chlorosis  and  Retinopapillitis,  by  H.  M.  Bannister 874 

Brain  Tumor  Simulated  by  Anaemia,  by  H.  T.  Patrick 882 


INDEX  OF  AUTHORS'  NAMES. 


Figures  in  parentheses  (  )  indicate  discussions.  Figures  with  asterisk  * 
indicate  original  articles  and  are  accompanied  with  title.  Figures  unac- 
centuated,  accompanied  with  title,  indicate  abstracts  ;  without  title,  book 
reviews. 


PAGE. 

Achard — Paraplegia    71 

Achard,    M.,    and    Levi    L. — 
Transitory      Paralyses,      356, 

Tabes  and  Reflexes 498 

Adams,     S.     S. — Choreic     Em- 
bolism   354 

Alexander,   H. — Mental   Phases 

of  Tuberculosis 632 

Allerhand,  J. — Tcchnic 139 

Allyn,    H.    B.— Multiple    Neu- 
ritis   287 

Alzheimer,  A. — Colloid  Degen- 
eration Brain 565 

Angdl,  E.  B (32),  (613) 

Apathy,  S (45) 

Apart,      M. — Bacteriology      of 

Chorea  564 

Ayres,   S (34) 

Babinski,  J. — Reflexes 220 

Bailey,  P.-(8o),  (136),  635,   (821) 

Baker.  Smith (38) 

Ball,  M.  v.— Paralytic  Chorea.. 356 
Bannister.     H.     M.  —  Chlorosis 

and  Retinopapillitis *874 

Barker,  L.  F. — 5-2.343.  Epidemic 
Cerebro  -  Spinal      Meningitis, 

S65.  826 

Barr,  M.  W.— Echolalia *20 

Barrows,  F.  W. — Inanition  and 

Nerve  Cells 283 

Barteit. — Thyroidine   701 

Bastian,  H.  C. — Aphasia 897 

Bastianelli,  G. — Combined  Scle- 
roses    142 

Batten,  E. — Muscle  Spindle. . .  .282 
Bechterew,  A. — Letter  from 
232,  Eye  Muscle  Nuclei  346, 
Early  Symptoms  of  Tabes, 
499,  Ankylosis  Spinal  Cord.  .762 
Bell,  J. — Bullet  shown  by  Skia- 
graph    566 

Bennett. — Ulnar  Nerve  Injuries .  293 
Berger,      H. — Anterior      Horn 

Cells  in  General  Paresis 493 

Berkeley  H.  J. — ^Technic 623 

Biernacki. — Endarteritic  Myelo- 
pathy   892 


PAGE 

Biro,  M. — Sciatic  Neuritis.    ...291 
Bitot,    E.,    and    Sabrazes,    J. — 
Tabes  and   Sensibility   of  the 

Testicle    499 

Bohn. — Insomnia   75 

Bolton,  F.  E. — Illusions 357 

Bolton,  J.   S. — Tcchnic 214,347 

Bolton,  J (821) 

Bond,  C.  H. — Diabetes  and  In- 
sanity     146 

P.oniiier,  P. — Sense  of  Position. 493 
Bonnus,    <j. — Friedreich's    Dis- 
ease    70 

Booth.     J.     A.-(i28),      (336), 
(483),       Thyroidectomy       in 

Graves'  Disease 766,  872 

Borda,  J.  F. — Prognosis  in  In- 
sanity    633 

Bordicr     and     Frenkel — Facial 

Paralysis    289 

Botezat.  E. — Nerve  Endings  of 

Tactile  Hairs  281 

Bourdon,    P. — Muscular   Sensi- 
bility of  the  Eyes. 493 

Bramwell,     B. — Pseudo-Hyper- 
trophy, 220;  Aphasia 763 

Blower,    D. — Friedreich's    Dis- 
ease     72 

Bruce,  A. — Endogenous  Fibres, 

215 

Bull,   S.  —  Lumbar  Puncture.  .151 

Bunzl-Federn,     E.  —  Accessory 

Nerve   Nucleus 346 

Burr,    C.    W.-(37),    (125),    (278). 

(279) 
Cabitto,     C. — Epilepsy     Treat- 
ment by  Hot  Air,  489;  Tox- 
icity of  Sweat 493 

Cagigal   &   Lepierrc. — Sleeping 

Sickness 593 

Capitan. — Thyroid  Chlorosis  . .  .899 
Cassirer,  R. — Muscle  Pathology, 

890 

Cattell,  H.  W (42) 

Chantemesse,  M.  and  Marinesco. 
— Tetanus    626* 


INDEX. 


PAGE. 

Charon,    R.,   and    Briche,    E. — 

Blood  in  Epilepsy 701 

Cheron,  P. — Chorea 74 

Chipault.  —  Lumbar     Puncture, 

150;  Perforating  Ulcer 293 

Clarke. — Anaemia     and     Spinal 

Cord  Lesions  » 14^ 

Clemesha,     J.      C. — Thorn  sen's 

Disease    608 

Collins,  J.— (57),  (267),  {^27)  \ 
Glioma  of  Medulla,  569.  (607); 
Sympathetic,  *66i,   (677),   (699). 

(815),  (816),  (863) 

Coston. — Delirium  7- 

Courtney,      J.       E. — Katatonic 

Melancholia   *747 

Courtney,  J.W. — Pseudo  Tabes  500 
Crawford,    J.    F. — Temperature 

Sense    492 

Cunningham,     R.     H. — Myxoe- 

dema  *458 

Curtis,  B.  F.— (479),    (480),    (483) 

Daland,  J (752) 

Dana,  C.  L.— (203),  (336).  (483). 
(598),  (599),  (744),  (805),  (870) 
Darkschewitsch,  L.  O. — Paraly- 
sis and  Pasteur  Treatment.  ...604 
Dearborn,  G.V. — Imaj?inations.357 
Dearborn,  G.  V..  and  Spindler, 

F.  N. — Motor  Reactions 765 

Dejerine,    J. — Hysterical    Con- 
tracture    355 

Dejerine  and  Serieux. — Aphasia.824 
Dejerine    and    Thomas. — Alco- 
holic Paralysis  285 

Delabarre.  —  Reaction      Move- 
ments    145 

Dercum,  F.  X.— -(124),  (125), 
(127),  225,  (273),  (276).  Move- 
ment of  Neron,  348.  (485), 
(488),  (558),  (614).  (615),  (617). 
Scleroderma,  *703,  (750). 
Desplats,  M. — Saturnine  En- 
cephalopathy      77 

Dignat,      P.  —  Electricity      in 

Hemiplegia 634 

Diller,     T. — Alcoholic      Menin- 
gitis  ♦441,   (527).   (614) 

Diller,  T.,  &  Meyer,  A.— Lan- 
dry's Paralysis 285 

Donath.      J. — Facial      Hemiat- 
rophy     224 

Dniry.    M..    and    Folsom    C. — 

Study  Effects    614 

Dukes. — Backward  Children  and 

Thyroid    881 

Edsall,    D.    L. — Syringomyelic 
Dissociation   *257 


PAGE. 

Egger,  F.— Muscular  Atrophy.. 223 
Ehlers.— Paresis  and  Syphilis;  .147 
Elder,  G. — Intracranial  Circula- 
tion  . : 623 

Erb,    W.— Intermittent     Lame- 
ness    891 

Eshner,     A.     A.— (44),     (208); 

Tremor    562 

Eurich,  F.  W.— Neuroglia 490 

Facklam,    F.    C— Huntington's 

Chorea  352 

Faure,  M. — Re-education  Meth- 
od in  Tabes 50i 

Fere — Hemiplegia,  Infantile — 628 
Fere,  Ch.— Reflexes  in  Epilep- 
tics   220 

Finlay,  F.  G— Tic  Convulsif.  ..356 
Fisher,  E.   D.— (78),   (606),   (815). 

Flatau,  E 67 

Fleischmann. — Lumbar      Punc- 
ture    148 

Flemming,  W. — Spinal  Ganglia.401 
Flexner,     S. — Gliomatosis .  *3o6, 

(340) 
Fournier,  L.— Death  in  Hyster- 
ia    19 

Fraenkel,   J.— (129),    (266).    (269), 

(336),  (823) 

Fressonn,  H.— Paraplegia 71 

Friedlander,  A.— Facial  Paraly- 
sis in  Typhoid 889 

Frey.— M.  V.  Technic. 281 

Fry,   F.    R. — Multiple   Neuritis. 

♦594,  (600) 
Gilles    de    la    Tourette.— Treat- 
ment of  Tabes  by  Stretching.. 500 
Goldflam,  S.— Family  Paralysis.825 
Goldschcider,    S.,    and    Brasch, 

F.— Nerve  Cells  in  Fever 351 

Goldscheider,  S.,  and  Flatau,  E. 

—Nerve  Cells  in  Fever 351 

Goldscheider,  S.,  and  Moxter.— 

Nerve  Cells  in  Fever 35i 

Goldthwait.-Paralytic  Deformi- 
ties     633 

Griinbaum,  A.  S. — Muscle  Spin- 
dle    219 

Gudden,    H.— Technic i39 

Habel,  A.— Tabes  and  Floating 

Kidney  498 

Hall,  G.  S.,  &  Allen  A.— Tick- 
ling and  Laughing 292 

Hallock,     F.     K.— Vertigo,   *  I7S; 

Huntington's  Chorea *85i 

Hammond,   G.   H. — President's 

Address ♦soS,    (527),    (608) 

Hand,  A (279) 


VI 


INDEX. 


PAGE. 

Hare,  H.  A. — Edema  in  Hemi- 
plegia, ♦iSg;  Muscular  Atro- 
phy   *45o 

Hcinersdorff,  H. — Amaurosis 
and  Occipital  Lobe  Abscess. 567 

Held,  H.— Nerve  Cell  Structure, 
214;  Acoustic  Paths 281 

Hcnschen,  S.  E.~Roentgen 
Rays   627 

Herter     C.     A.--(54).     (57),     153, 

(201),  (815),  (820),  (821) 
Hibbard,     C.     M.— Melancholia 

and  Urea 631 

Higier,  H.— Optic  Diseases. . .  .289 
Hill,  A.— Granules,  491 ;  Thorns.561 
Hirsch,    W.~(i3o),    (134),    Delu- 
sions,   *i59.    228,    (264),    (269); 
Amaurotic  Idiocy +538,  (559) 

Hirschberg.— Fraenkel's  Meth- 
od in  Tabes 501 

Hirtz  and  Lesne.  —  Landry's 
Paralysis    286 

Hoche,  A.—Pyramidal  Tracts.  .215 

Hodge.— Friedreich's  Disease..  70 

Hoffmann,  J.— Hereditary  Mus- 
cular Atrophy,  222;  Muscular 
Dystrophy   §93 

Holden,    W.    A.— Fluttering,    351; 
Amaurotic      Family      Idiocy. 
Eye  Changes +550 

Howard,  W.  L.— Impulse  to 
Drink    ^^^ 

Jaboulay.— Cerebral    Cysts 549 

Jaccoud.— Acute  Myelitis 702 

Jackson,  H 137 

Jacobi,       Mary       Putnam.— "(200), 
T       .  ^  (202).   (820) 

Jacobson.— Capsular    Tumor. .  .568 
Jacoby.   G.   W.— (53).    (265);    My- 

^^^om2.  *5o8,  (527) 

Jacquet,  M.  L.— Facial  Paraly- 
sis     ^27 

Jelliffe,   S.    E.— 227,  230.  359.  360, 
504.  835,  901,  902,  904 
Jemma.  —  Cure     of     Cerebro- 
spinal  Meningitis 150 

Jemma  and  Bruno. — Lumbar 
Puncture    151 

Joukowski.— Frontal   Lobes 347 

Juliusberger,  O.,  and  Meyer.  E. 

—Ganglion  Cell  Pathology.  .626 
Jumon,     L.  —  Glycosuria     and 

Nervous  Disease 887 

Karplus,J.  P.— Immobile  Pupils 

in  Hysteria  and  Epilepsy 895 

Keen,  W.  W. — Microcephaly,  *io5, 

Gasserian   Ganglion.  .*8oo,   (806) 


PAGR. 

Keen,  W.  W.,  and  Spiller,  W.  G. 

— Gasserian  Ganglion *8oo 

Kempf. — Uraemia   570 

Kiernan,  J.  G. — Encephalitis. .  .401 
Klippel,    M.— Taste   and   Smell 

in  Tabes 499 

Knapp,  P.  C (849) 

Koller.  C (205),  (557) 

Krainsky,  N.— Epilepsy  Path- 
ology   758 

Krauss,  W.  C. — Glioma  Frontal 

Lobe   *  109 

Krewer,  L. — Landry's  Paralysis.286 

jLancereux. — Alcohol    65 

Landenheimer,       R.  —  Diabetic 

Pseudo-Paresis    631 

Langdon    {677) 

Langley,    J.    N. — Regeneration 

Nerve  Fibres  63- 

Lannois. — Chorea    352 

Lax     and     Miiller. — Traumatic 

Disease  of  Spinal  Cord 697 

Lemoine,    G.— Methylene    Blue 

in  Ataxia  Pains 74 

Lc  Noble,  E. — Spinal  Cord  and 

Pernicious  Anaemia    142 

Lupine,  R. — Pyramidon 537 

Lermoyez. — Recurrent  Paraly- 
ses      64 

Leszynsky,  VV.  M.— (30).  (203). 
(264).  (336),  (483);  Pachymen- 
ingitis  *6o9.   (614) 

Leuba,  J. — Religious  Phe- 
nomena, 146;  Moral  Impera- 
tive   6y^ 

Levet,  M. — Crossed  Paralysis.  .63* 

Lewis,  W.  B. — Cerebral  Cortex. 
62\  Technic 347 

Lloyd,   J.    H.-(45),    (123),    (127). 
360,    (622),    (74q).    (752),   Sy- 
ringomyelia and  Trauma,  871,  902 

Longues. — Congenital  Amputa- 
tion  67 

Luce,  H. — Hemiplegia  and 
Whooping  Cough 626 

Lugaro  &  Chiozzi. — Inanition . .  284 

Luisada,  E.,  and  Pacchioni,  D. 
— Diphtheria  Toxin 625 

Lyonnet  and  Bonne. — Hy.steri- 
cal   Hemiplegia 355 

Macalester,  R.  K 227 

MacLeod. — Morphine  Habit 
Cured  by  Bromide 633 

Mairet. — Epilepsy    61 

Marie,  P.  —  Is  there  Aran- 
Duchenne's  Disease? 22c 


WBEX. 


vli 


PAGE. 

Marincsco. — Congenital  Ampu- 
tation. 67;  Bulbar  Paralysis. 
68:  Minute  Anatomy  Nerve 
Cell,  138;  Localization  Motor 

Nerves  in   Cord 757 

Martin. — Ocular  Manifestations 

in  Tumor 566 

Marty,  A. — Treatment  Sciatica .  .293 

Mason.  R.  O. — Hypnotism 175 

McCasky,  G.  W. — Neurasthenia. 

890 

McConncll,  J.  W (277),  (618) 

McGrew. — Epilepsy  i77 

McKcrron. — Hemiplegia       and 

Whooping  Cough 61 

Meirowitz.  P 157.  229 

Mendel,  E.— Tabes  and  Multiple 

Sclerosis  and  Trauma 391 

Meyer,  A. — Facial  Paralysis, 
284;  Hereditary  Ataxia,  Path- 
ology of 494 

Mills,  C.  K.— (50),  (124).  (125), 
(210);  Landry's  Paralysis,  *365. 
(485).  (558),  (620),  (804),  (863) 
Miljs,  C  K..  and  Spiller,  W.  G. 

— Landry's  Paralysis  *3^5 

"Mills,  W. — Cortical  Localiza- 
tion        700 

Minor,  L. — Syringomyelia 758 

Mitchell,    J.    K. — Hysteria    and 

Seborrhoea      nigricans.      354. 

(485);       Trigeminal      Spasm. 

♦392,  (615).  (620),  (622).  (756) 

Mitchell.  S.  W.,  and  Rhein.  J. 

W.— Chorea  354 

Molliere  and  Perret. — Perimen- 
ingitis     4^3 

Mongorer  et  Cariere. — Myelitis. 759 

Mongour. — Egotism    629 

Monoco,    L. — Optic  Thalamus. 350 

Montgomery,   T.    H (45) 

Morasca. — Atrophy  muscular.  ..221 
Morton.  S.  W.— Multiple  Paral- 
ysis and  Measles 288 

Mouclaire,  P. — Surgical  Treat- 
ment Facial   Neuralgia 358 

Moyet. — Friedreich's  Disease...   70 
Miiller.  L.  R. — Tuberculosis  of 

Spinal   Cord 759 

Mya,  G. — Lumbar  Puncture  — 151 

Negro. — Chorea    75 

Nonne.  M. — Leukemia 140 

Nouvatzke,  H. — Cerebro- Spinal 

Fluid    138 

Noyes,  W.  B (129) 

Ohlmacher.  A.  P. — Technic, 
139;  Pathology  Epilep.sy 564 


PAGE. 

Olmstead,  L — Cerebral  Ataxia.*8o7 
Onuf,  B.   (60);  Inhibition,  217, 

(678),  (823) 
Onuf,  B.,  and  Collins,  J. — Sym- 
pathetic Nervous  System. .  ..*66i 

Oppenheim. — Dorsal  Roots 65 

Ortner,     N. — Collateral     Hemi- 
plegia     763 

Osier.   W.— Vertigo 68,   (123) 

Ostankow,  P. — Gastric  Crisis... 499 
Overend,     W. — Chorea     Treat- 
ment     358 

Packard,   F.   A.— (42),   (43),  (124), 

(279).  (342) 
Patrick,  H. — (606);  Spinal  Irri- 
tation, 746;  Syringomyelia,  *837; 
Brain  Tumor  and  Anaemia.  .*882 
Patrizi.    M.    L. — Vascular    Re- 
flexes    624 

Patry,  G. — Chorea 353 

Pearce,  F.  S (754).   if 5^) 

Peli,   G. — Prognathism 867 

Pergens,  E. — Colored  Lights  on 

Retina   5^>i 

Pershing.  H.  T. — (32),  Pressure 

Neuritis    2S8 

Peterson,  F.— (54).  (57).  (i3'>. 
(132),  (133).  (265),  297,  Oph- 
thalmoplegia chronica  ex- 
terna, *3I0,  New  Paths  in 
Psychiatry,  *444,  (483).  Am- 
aurotic Idiocy *529.  (^815) 

Peterson,  F.,  and  Langdon,  W. 

— Katalonia   632 

Petren,  K. — Neuromata 65 

Pfister. — Technic    757 

Pillsbury,      VV.      B. — Appercep- 
tion     764 

Pitres,    A.,   and   Carriere,    G.— 

Tabes  and  Arthropathies 494 

Potain. — Enteralgia  826 

Prince,  Morton. — Sexual  Per- 
version     *237 

Probst.  M.— Multiple  Sclerosis. 888 
Pugnat,     A.     M.  —  Histology 

Nerve  Cells  in  Fatigue 563 

Punton,  J (804) 

Putnam,  J.  J.— (32),    (487),   (627), 
(600) ;  Post-Traumatic  Psych- 
oses, *769.  (862).  (869) 
Quartz,    J.    O. — Psychology    of 

Reading   630 

Queyrat  and  Chretien. — Sy- 
ringomyelia   660 

Raymond. — Amyotrophic  Lat- 
eral Sclerosis 678 

Rcmlinger.  —  Landry's  Par- 
alysis     286 


▼Ill 


INDEX. 


PAGE. 

Rhein,  J.  H.  W (278) 

Rjggs,  C.  E. — Bruce  Microtome, 

♦865 
Riggs,      E. — Friedreich's      Dis- 
ease      69 

Riley.  W.  H. — Tabes,  Symp- 
toms in  *679 

Riviere,    E. — Epicondylalgia 290 

Rochet. — Paralytic   Deformitics.634 

Rockwell.  A.   D (137) 

Rosenbaum. — Friedreich's  Dis- 
ease      71 

Rosenthal,  J.,  and  Mendelssohn, 

M.— Reflexes    ji8 

Ruffini,  A. — Sensory  nerve  end- 
ings    j8j 

Sachs,  B.-— iss.  158,  (201).  (270). 
(271).  (272).  294,  Multiple 
Sclerosis,  ^314,  336;  Ophthal- 
moplegia, *452;  Multiple 
Sclerosis,  *464,  (480).  (483). 
(502),  (555);  Amaurotic 
Idiocy.      567.      (592).      (5(^). 

(815).  (819).  (823).  (849) 
Sailer,  J.--(28o).  339,  Hypertro- 
phic  Gli(»si< *40-? 

Savill. — Dormato-neuroscs   895 

Schaffer,  K. —  A.nterior  Horn 
Cells  in  Tabes.  495:  Tabes  and 

Spinal  Ganglia 496 

Schiff,  A. — Lumbar  Puncture.  .629 
Schlesinger,  H. — Abscess  Spinal 

Cord    895 

Schreiner,   E (209) 

Schlapp,  M. — Monkey  Cortex.. 491 

Schule,  V. — Katatonia 632 

Schwartz,    E. — Post-Anaesthetic 

Paralysis    760 

Seguin,  Edward  Constant 233 

Siemerling,  E.— Pupillary  Re- 
actions, 147;  Muscular  Atro- 
phy     223 

Sinkler,  W.— (206).  345,  Epi- 
lepsy, ♦601,  (608),  (617),  (620), 

{676),  (744).  (754),  (756). 
(863).  (870) 
Spiller,  W.  G. — Secondary  Degen- 
erations, *i,  (50);  Arrested  De- 
velopment,    *8i,     (122).     (127), 
(212),   231.    (277).   339.   340,   345. 
359:     Landry's     Paralysis,     *365. 
(486),  (527),  (559),   (592),  (618), 
(620),       (636),       (756),       (767): 
Gasserian  Ganglion  ..*8oo.  (870) 
Soukhanoflf,  S. — Polyneuritis..  .284 
Spindler,   F.   N. — Touch ".  .291 


PAGE. 

Starr,   M.  A.— (33),   158,   Fried--' 

rcich's  Ataxia .^194,  (599) 

Starr,  M.  A.  and  Weir,  R.  S.— 
Tumor      of      left      Temporal 

Lobe   568 

Sterling,   J.    W. — Tumoi'    Men- 
inges    566 

Stewart,  P. — Adductor  Jerk 219 

Stieglitz,    L. — (201),     (202),    (814) 
Strauss,  F. — Lumbar  Puncture.  152 
Striimpell,  A. — Chronic  Inflam- 
mation Vertebral  Column 762 

Taylor,     E.    W. — (35),     Family 
Periodic    Paralysis.      *637,    *7I9, 

(745) 
Taylor,  W. — Neuroglia 491 

Teichmuller. — Pernicious    Anae- 
mia     140 

Thayer    (341) 

Thomas.    H.    M.— (343),    (345), 

Facial  Paralysis *573,  (592) 

Trepinski. — Tabes    and     Poste- 
rior Columns-. 496 

Tschistowitsch,   T. — Healing   of 

Cerebral  Wounds  900 

Tucker,      M.      A. — Involuntary 

Movements   145 

Upson,    IT.    S. — Tumor   of   Ob- 
longata     568 

Ursin,  J. — Spinal  Cord  Changes 

in   Brain  Tumor 563 

Valentine. — Neurasthenia. .  .75,   121 
Van    Gehuchten,    A. — Reflexes, 
143,    Reflex    Movements,   218, 
Chromatolysis,  283,   Muscular 

Rigidity  760 

Van  Gieson,  I (806) 

Villers. — Aran-Duchenne   Atro- 
phy   221 

Vitzou..— Regeneration  of  Nerve 

Cells  63 

Vogel,  K.  M 503,  504 

Voisin,    A.  —  Persecutory    De- 
lirium  560 

von     Solder,     F. — Constipation 

Psychoses    799 

Voss,    G.    V.  —  Anjemia    and 

Spinal   Cord 141 

Walton,  G.  L ...(613) 

Weber,  L. — (600);  Herpes  Zos- 
ter   *868 

Welander,  E. — Polyneuritis 288 

Werbitzky,   M. — Tabes 570 

Werth. — Organotherapy 887 

Wostphal,     A. — Myelin     Sheath 

Development   348 

Whitewell,    J.    R. — Neuroglia.  .490 
Widal  and   Marinesco. — Bulbar 
Paralysis    68 


INDEX. 


IX 


PAGE. 

Wiener,  A.— (332),  (337).  Oph- 
thalmoplegia   ♦455 

Wilms. — Lumbar  Puncture. 152 

Witmer,  A.  F.— (40),   (44),   (617), 

(618) 

Wolfe,     H.     K.— Judgment    of 
Size   562 

Wolfe,    J.,    and   R.— Effects    of 
Size  on  Judgments 357 

Wood. — Sixth   Nerveparalysis.  .899 


PAGB. 

Worcester,  W.  L.— -(33),  Lan- 
dry's Paralysis,  *299,  (656), 
(663);  Nerve  Fibre  Regen- 
eration  *698,  (699) 

Worotynski,  B. — Secondary  De- 
generation  216 

Wullensoeber. — Central  Soften- 
ing of  Cord 894 

Zaroubine,  V.— Reflexes. ..:...  .220 


\ 


INDEX  OF  SUBJECTS. 


Figures  in  parentheses  (  )  indicate  discussions.  Figures  with  asterisk 
indicate  original  articles  and  are  accompanied  with  title.    Figures  unac- 
cetttuated,  accompanied  with  title,  indicate  abstracts ;  without  title,  book 
reviews. 


PAGE. 

Abscess  of  Brain (132),  (276) 

Abscess  in  both  Occipital  Lobes 

with  Central  Amaurosis 567 

Abscess  of  Spinal  Cord 895 

Accessory  Nerve  Nucleus 346 

Acoustic   Paths 281 

Acromegaly   and    Hypertrophic 

Pulmonary  Ostco-arthropathy, 

(341) 

Adductor  Jerk — Crossed 219 

Aesthesiometer — A    New 52 

Akromegaly — A  Case  of (40) 

Akromegaly — The     Brain     and 

Spinal  Cord  from  a  Case  of.  .(42) 
Alcoholic  Drinks — Comparative 

EflFect   of 65 

Alcoholic     Paralysis     with     no 

Changes    285 

Amaurosis  and  Occipital   Lobe 

Abscess   567 

Amaurotic      Family      Idiocy.  *529. 

*538,  *550,  567 
American     Neurological     Asso- 
ciation   3^»  505 

Amyotrophic  Lateral  Scle- 
rosis  (134),   (617).  678 

Anaemia  and  Brain  Tumor. .,.  .*882 
Anaemia — The    Spinal    Cord    in 

Pernicious 140,  141.  ^4^ 

Anaesthesia  in  Tabes *837 

Anatomy  —  Cerebral  Cortex, 
Structure  of,  First  or  Outer- 
most Layer  of 62 

Anatomy — Nerve     Cells,     New 

Formation  of 63 

Anatomy  —  Regeneration  of 
Pre-ganglionic  and  of  Post- 
Ganglionic     Visceral      Nerve 

Fibres  63 

Ankylosis  of  Spinal  Column. . .  .762 

Aphasia  763.  897 

Aphasia  Sensory 824 

Aphasia — Subcortical  Visual . .  (337) 

Apperception   7^>4 

Aran-Duchenne — M  u  s  c  u  1  a  r 

Atrophy 221 

Arsenic  and  Belladonna  in 
Chorea    35^ 


PAGE. 

Arsenical  Poisoning (209) 

Arthropathies  in  Tabes. ..  .494,  499 
Arthropathy — Osteo- Hypertro- 
phic   (341) 

Astasia   Abasia (206),    (279) 

Asymmetry   in   Face  in   Hemi- 
plegia     ^>-8 

Ataxia  and  Methylene  Blue. ...  74 

Ataxia — Cerebral   *8o7 

Ataxia,  Friedreich's,  69,  70,  71.  7-2. 

*I94 
Ataxia — Hereditary  Pathology . 404 
Ataxia — Locomotor.    (See  Tabes.) 

Ataxic    Paraplegia (754) 

Athetosis  and  Infantile  Cerebral 

Palsy  (814) 

Atrophy — Muscular   *4S^ 

Atrophy — Muscular    and    Thy- 
roid     2.>4 

Atrophy  Muscular — Progressive 

Spinal 221,  22J,  22}, 

Atrophy  of  Brain — Unilateral. ('i36> 
Blood— Alkalinity    of.    in    Epi- 
lepsy     701 

Brain    Tumor — Report    of    two 

Cases  of ...(3;^2l 

Brain  Tumor  and  Anaemia. ..  .*88o 
Bulbar  Paralysis — Descending.  68 
Bullet     in      Brain      shown     by 

Skiagraph    5^6 

Capsule — Internal,  Softening  of, 

(-'75) 

Capsular  Tumor 5^ 

Cataleptoid         Symptoms         in 

UrcTmia ^7^ 

Cell    Body — Functional    Impor- 
tance of 562 

Cells — Nerve,  in  Fatigue 563 

Cells — Nerve.  Structural  Altera- 
tions   757 

Cerebellar  Tumor (275) 

Cerebral    Ataxia *8o7 

Cerebro-Spinal   Fluid 138 

Cerebro-Spinal   Fluid 138 

by  Lumbar  Puncture 150 

Chloiosis  and  Retinopapillitis.*874 
Chorea — Bacteriology  of 564 


k 


moEx. 


xt 


PAGE. 

Chore»--Oii]icai     Re-examina- 
tion of  Motor  Symptoms. . .  .354 
Chorea — Huntington's ....  352,  "^51 
Chorea — Huntington's,    Pathol- 
ogy   and    Morbid    Anatomy 

of  (57) 

Chorea — Lesions  in 352 

Chorea — Paralytic  356 

Chorea — Pathology   and  Treat- 
ment of 74,    75 

Chorea — ^Treatment  of 358 

Chorea  —  Variable      or      Poly- 
morphous     353 

Choreic  Embolism 354 

Chromatolysis    283 

Circulation — Intracranial   623 

Colloid  Degeneration  of  Brain. 565 
Conduction  Paths  for  Reflexes. 218  , 

Constipation  Psychoses 799 

Cord  Changes  in  Cerebro-Spinal 

Meningitis    565 

Cord — Endogenous     Fibres     in 

the   215 

Cord    Localization 757 

Cord — Secondary  Degeneration 
in    216 

Cord — Spinal  and  Brain  Tumor.563 
Cord — Spinal  and  Tuberculosis. 759 

Cortex  of  Monkey 491 

Cortical    Localization    in    Ani- 
mals    700 

Crossed    Paralysis  —  Meningeal 

Hemorrhage 630 

Cysts — Cerebral 549 

Defective  Brains-— Five (35) 

Deformities — Paralytic,    Muscle 

Transplanting   634 

Degeneration  —   Colloid,       of 

Brain   565 

Degeneration   of   Nervous   Sys- 
tem in  Diphtheria 496 

Degeneration  Secondary 216 

Delirium   Acute 72 

Delusions  and  Gait (278) 

Delusions  —  Psychical     Mech- 
anism  of ♦159 

Dementia    Paralytica — Anterior 

Horn  Cells  in 493 

Dcrmato  Neuroses 895 

Development         of         Myelin 

Sheaths   348 

Diabetes  and  Insanity 146 

Diabetic  Pseudo — Paresis 631 

Diphtheria  —  Acute    Degenera- 
tion in 496 

Diphtheria  Toxin  on    Nervous 
System   625 


PAGE. 

Disseminated  Insular  Sclerosis, 

(816) 
Dissociation  in  Pott's  Disease, 

*2sr 

Drink  Impulse ' 873 

Dystrophy  Muscular 893. 

Echolalia  ^20 

Electrical   Stimulation  of  First 

Dorsal  Root 65 

Electrical      Therapeutics — New 

Device  (^37) 

Embolism — Choreic    354 

Encephalitis  and  Epilepsy 405 

Encephalopathy  Saturnine 77 

Endarteritic  Myelopathy 892 

Endogenous      Fibres      in      the 

Cord    215 

Enteralgia  826 

Epicondylalgia 290- 

Epilepsy  and  Encephalitis 401 

Epilepsy — A  New  Sign  of 61 

Epilepsy — Blood    in 701 

Epilepsy  following  Infantile 
Cerebral  Palsy.  Improve- 
ment after  Craniotomy  and 
Evacuation    of   a    Subcortical 

Cyst (30) 

Epilepsy — Hot  Air  as  Treat- 
ment     489 

Epilepsy  and  Immobile  Pupils.  .895. 
Epilepsy — Pathology  of... 564,  758 

Epilepsy — Remissions  in *6oi 

Epilepsy,  Surgical  treatment. . . .  77 
Epilepsy — Trephining  for. . . .  (480) 

Epileptics — Reflexes  in 220 

Epileptics — Toxicity'   of   Sweat. 493 
Ergotism  and  Local  Asphyxia. 629 

Eye — Motor  Nerve  Nuclei 346 

Eyes — Muscular  Sensibility  of. 493 

Facial    Hemiatrophy 224 

Facial       Paralysis — Anatomical 

Findings  in 284 

Facial  Paralysis — Congenital.  .*573 
Facial    Paralysis — New    Symp- 
tom of 280- 

Facial     Paralysis     in     Typhoid 

Fever 889 

Family  Optic  Diseases 289 

Family  Paroxysmal  Paralysis.  .825 
Fatigue — Histology  Nerve  Cells 

after 563 

Fever  and  Nerve  Cells 351 

Fluttering   351 

F*ormalinc  as  a  Fixative 139 

Functional  Importance  of  Cell 

Body  562 

F'renkel's  Method  of  Treating 
Tabes  501 


XI] 


INDEX. 


PAGE. 

Friedreich's  Ataxia  69,  70,  71,  72 

*I94 
h  rontal      Lobes  —  Connections 

oi   347 

Frontal   Lobe — Glioma   of *I09 

Ganglion  Gasserian '"Soo 

Ganglion  Cell  Pathology 626 

Gasserian  Ganglion,  Pathology 

of   ♦Soo 

Gasserian  Ganglion  Removal. *8oo 

Gastric  Crises 499 

Glioma — Brain,  Attempted  Re- 
moval    568 

Glioma  of  the  Frontal  Lobe 109 

Glioma  of  Medulla 569 

Giiomatosis ♦306 

Gliosis — Hypertrophic       Nodu- 
lar     *402 

Glycosuria   and    Nervous    Dis- 
ease    887 

Gonorrhoea  and  Polyneuritis. .  .288 

Granules — Notes  on 491 

Graves*       Disease  —  Thyroid- 
ectomy in 766 

Graves*  Disease (872) 

•Gray  Matter — Constitution  of.. 561 
Haematomyelia,  Traumatic. . .  (821) 
Healing  of  Cerebral  Wounds. .  .900 

Hemialgia  (^73) 

Hemiatrophy  Facial 224 

Hemiatrophy  of  Brain (133) 

Hematemesis  in  Neurasthenia.  .749 

Hemiplegia  and  Edema *i89 

Hemiplegia      and      Whooping 

Cough  626 

Hemiplegia        in        Whooping 

Cough  61 

Hemiplegia — Collateral  763 

Hemiplegia — Electricity  in 634 

Hemiplegia — Hysterical  355 

Hemiplegia — Infantile  and   Fa- 
cial Asymmetry 628 

Hemorrhage  —  Cerebral      and 

Kidneys  (820) 

Hereditary  Muscular  Atrophy.  .222 

Herpes  and  Facial  Paralysis 627 

Herpes  Zoster  *8^ 

Hydrocephalus  (131) 

Hypnotism — Educational    Uses 

of  174 

Hysteria  and  Toxic  Tremor.  .(128) 

Hysteria — Death  in 19 

Hysteria  —  Seborrhoea     Nigri- 
cans  354 

Hysteria  and  Immobile  Pupils.  .895 

Hysterical  Contracture 355 

Hysterical  Hemiplegia. 355 

Idiocy — Amaurotic     Family, 

♦529.  ♦537,  *549.  567 


PACK. 

Inanition  and  Nerve  Cells.  283,  284 
Infantile    Cerebral     Palsy    and ' 

Athetosis  (814) 

Inflammation  —  Chronic — Ver- 
tebral Column  762 

Influenza  and  Neuritis 287 

Inhibition  and  Function  of  Py- 
ramidal Tracts 217 

Insanity  and  Diabetes 146 

Insanity — Sedatives  in  75 

Insanity — Steps  Toward. ......  (38) 

Insomnia     of     Insanity — Treat- 
ment of 75 

Irido-plegia — Reflex  Unilateral 

(203) 

I  rritation — Spinal   74^ 

Judgments  of  Size 562 

Katatonia 632 

Katatonic   Melancholia ^747 

Kidneys    in    Cerebral    Hemor- 
rhage and  Cerebral  Softening 

(820) 

Knee  Jerk  Returned 615 

Landry's  Paralysis.    285,  286,  *299, 

365 

Lameness,   Intermittent 891 

Leukemia — Spinal  Cord  in 140 

Lights    on    Retina — Action    of 

Colored   561 

Little's   Disease *8i 

Localization    Motor    Nerves   in 

Cord 757 

Locomotor  Ataxia  (see  Tabes). 
Lumbar    Puncture,    148,    150,    151. 

152,  629 
Measles  and  Multiple  Paralysis. 288 
Median  Nerve — Suture  of. . .   (479) 

Medulla — Glioma  of 569 

Medulla  Oblongata — Tumor  of. 568 

Melancholia  and  Urea 631 

Melancholia — Katatonic    *747 

Meningeal     Hemorrhage     and 

Crossed   Paralysis 630 

Meningeal  Vascular  Reflexes..  .624 
Meningitis  —  Alcoholic        and 

Brain  Tumor 441 

Meningitis — Cerebro-Spinal  Le- 
sions in  Cord 565 

Meningitis — Contribution    to    a 

Case  of (208) 

Meningo-Myelitis (752) 

Mental  Phases  of  Tuberculosis. 632 

Meralgia  Paraesthetica (756) 

Methylene  Blue  in  Ataxia 74 

Microcephaly — Operation  in..*ioS 

Monkey  Cortex  491 

Morphine  Habit  Cured  by  Bro- 
mide   633 

Motor  Reaction  to  Stimuli 765 


INDEX. 


XttK 


PAGE. 

Moyexnent  of  the  Neuron 348 

Multiple  Neuritis 594 

Multiple  Neuritis — Recurrent.  (343) 
Multiple  Sclerosis... ♦314,  *464,  888 
Multiple    Sclerosis    and    Func- 
tional Tremor (620) 

Multiple  Sclerosis  and  Trauma. 391 

Muscle  Spindle 282 

Muscle     Spindle     in     Pseudo- 
Hypertrophy  219 

Muscle  Pathology 890 

Muscular  Atrophy  *450 

Muscular  Atrophy — Hereditary.222 
Muscular  Atrophy — Progressive 

Spinal 221,  222,  223 

Muscular  Dystrophy 893 

Muscular  Rigidity 760 

Myelin  Development 348 

Myelitis — Acute   702 

Myelitis  —  Acute     Dorso-  Lum- 
bar   759 

Myotonia   ♦SoS 

Myxcedema *4S8 

Nephralgia   199 

Nerve  Cell  Changes  in  Fevers.  .351 
Nerve    Cell — Minute    Anatomy 

of  138 

Nerve  Cell  Structure 214 

Nerve      Endings      of      Tactile 

Hairs 281 

Nerve  Fibre  Regeneration ^698 

Nerve,  Sixth,  Paralysis 899 

Nervous       System  —  Apathy's 

Views  on  the  Structure  of. .  .(45) 
Nervous    System    and    Yellow 

Fever  Bacillus 758 

Neuralgia  —  Facial    Treatment, 

Surgical  358 

Neurasthenia    and    Hemateme- 
sis  749 

Neurasthenia       and       Psycho- 
therapy   75,  (121) 

Neurasthenia  and  Gastro-Intes- 

tlnal  Disease 890 

Neuritis  and  Vaccination (129) 

Neuritis  —  Arsenical,  Following 

Use  of  Fowler's  solution . .  (209) 
Neuritis  —  Multiple,   Following 

Influenza 287 

Neuritis  of   Fifth    Nerve   with 

Herpes  and  Eczema (^7) 

Neuritis — Pressure 288 

Neuritis — Sciatic  291 

Neuritis — Syphilitic  Multiple.. *594 
Neuritis — ^IJlnar,  Traumatic  (480) 
Neuroglia — Structure  of.  ..490,  491 

Neurological  Fragments 137 

Netiromata — General  Multiple..  65 


PAGE. 

New  York  Neurological  So- 
ciety. . .  .53,  128,  200,  264,  332,  479. 

Nuclei  of  Motor  Nerves  of  Eye. 346 

Ocular  Manifestations  in  Intra- 
cranial Tumor 566 

Ophthalmoplegia *452,  ♦455. 

Ophthalmoplegia — A  Case  of 
Total  and  Complete  Unilateral, 

(45) 
Ophthalmoplegia  Chronica  Ex- 
terna   ♦310 

Optic  Disease — Family 289 

Optic     Thalamus  —  Physiology 

of   350 

Organotherapy  in  Chlorosis 887 

Pachymeningitis  Hemorrhagica 

Interna  in  Children  (54) 

Pachymeningitis — Internal    ...♦609 

Paraesthetic  Meralgia (756) 

Paraesthetic  Neurosis — Nasal.. (34) 

Paralyses — Post  Anaesthetic 760 

Paralyses      followinor      Pasteur 

Treatment   864 

Paralysis — Periodic    *7i9 

Paralysis — Brown-Sequard   759 

Paralysis — Bulbar,  Descending.  68 
Paralysis — Crossed    and    Meni- 

geal  Hemorrhage 630 

Paralysis — Facial  289 

Paralysis— Facial,    Congenital .  ♦573 
Paralysis — Facial  and  Herpes.  .627 
Paralysis — Family   Periodic.  ..*637 
Paralysis— Multiple    and    Mea- 
sles   288 

Paralysis— Paroxysmal,  Family.825 

Paralysis,  Sixth  Nerve 899 

Paralysis — Transitory,    of    Car- 
diac Origin 356 

Paralytic  Deformities 633,  634 

Paraplegia  Ataxic (754) 

Paraplegia  —  Hereditary    Spas- 
modic    71 

Paresis — General  and  Syphilis.  147 
Paresis  —   General,      Anterior 

Horn  Cells  in 493 

Paresis— Pseudo  and  Diabetes.  .631 
Pasteur   Treatment   and   Paral- 
ysis   864 

Pathology    of    Spinal    Cord    in 

Traumatism  697 

Pathology — Ganglion  Cell 625 

Pellotin  600 

Perimeningitis  —  Primary    Spi- 
nal    463 

Persecutory  Delirium  Cured  by 

Laparotomy   560 

Philadelphia    Neurological   So- 
ciety. . .  .40,  122,  206,  273,  339,  485 
Polyneuritis  and  Gonorrhoea. .  .288 


XIV 


INDEX. 


PAGE. 

Polyneuritis — Pathology 284 

Porencephalic  Brain  (125) 

Posterior  Column  Development 

and  Tabes 496 

Post-Traumatic  Psychoses *76g 

Prognathism 867 

Prognosis  in  Insanity 633 

Psychology — 

Effects  of  Size  on  Judgment      » 

of  Weight 397 

Illusions — Study  of 357 

Imaginations — Study  of 357 

Psychology  of  Moral  Impera- 
tive   630 

Movements  —  Involuntary  of 

Adults  and  Children 145 

Psychology  of  Reading 630 

Reaction    Movements — Force 

and  Rapidity  of 145 

Religious     Phenomena — Psy- 
chology of 146 

Psychoses — Due    to    Constipa- 
tion   799 

Psychoses — Post-Traumatic. .   *7^ 
Pseudo-Hypertrophy  —  Muscle 

Spindle  in 219 

Pseudo- Hypertrophic  Paralysis.220 

Pseudo-Tabes  in  Diphtheria 500 

Psychiatry— New  Paths  in ^444 

Psychic  Anaesthesia — A  Case  of, 

(37) 
Pupils,    Immobile,    in    Hysteria 

and  Epilepsy 895 

Pupillary   Reactions  in   Mental 

Disease   147 

Pyramidal  Tracts— Variations  in, 

215 

Pyramidon 537 

Recurrent    Paralyses  —  Causes 

of  64 

Reflex  Movements 218 

Reflexes — Conduction  Paths  for 

218 
Reflexes — Exaggeration    of,    in 

Spastic  and  Hemiplegic 143 

Reflexes  in  Epileptics 220 

Reflexes  in  Syphilis 220 

Reflexes  in  Sciatica 220 

Reflexes — Patellar  in  Tabes 498 

IRegeneration  of  Nerve  Fibres. *698 

Retina  and  Colored  Lights 561 

Retinooaoillitis  and  Chlorosis .  *874 
Rheumatoid       Arthritis       and 

Scleroderma  *703 

Roentgen  Rays — Bullet  in  Brain, 

566 

Roentgen  Rays  in  Surgery 627 

!Sciatica — ^Treatment 293 


PAGE. 

Scleroderma  and  Chronic  Rheu- 
matoid Arthritis  *703 

Scleroses — Combined,    in    Per- 

-   nicious  Anaemia 142 

Sclerosis — Disseminated  (816) 

Secondary    Degenerations    fol- 
lowing Cerebral   Lesions *i 

Sense  of  Position 493 

Sensibility  of  Eyes — Muscular.  .493 
Sensory      Nerve      Endings     in 

Muscles    282 

Sexual  Perversion ^237 

Skiagraph.    See  Roentgen  Rays. 
Sleeping  Sickness  and  its   Ba- 
cillus   593 

Softening,    Central,    in    Spinal 

Cord   894 

Spinal  Column  Anchylosis 762 

Spinal   Cord  after   Removal   of 

Large  Portions  of  the  Limbs.  67 
Spinal  Cord  and  Traumatism. .  .697 
Spinal  Cord  in  Congenital  Am- 
putation of  the  Fingers 67 

Spinal  Cord  in  Leukemia 140 

Spinal      Cord      in      Pernicious 

Anaemia  140,  141,  142 

Spinal  Cord  Abscess 895 

Spinal  Cord,  Central,  Softening 

in    894 

Spinal  Ganglia  in  Tabes 496 

Spinal  Ganglia  of  Mammals 491 

Spinal  Irritation  746 

Structural  Alterations  in  Nerve 

Cells 757 

Study    and    its    Effects   on    the 

Nervous  System  614 

Sympathetic     Nerve     Localiza- 
tion    *66i 

Syphilis  and  Paretic  Dementia. .  147 

Syringomyelia 758 

Syringomyelia   " *837 

Syringomyelia — Localized  . .  .(202) 
Syringomyelia   and    Ilemi-atro- 

phy  660 

Syringomyelia  of  Lumbar  Cord 

(488) 

Syringomyelia  and  Trauma 871 

Syringomyelic    Dissociation    in 

Pott's  Disease ♦257 

Tabes  and  Arthropathies... 494,  499 
Tabes    and    Embryonal    Poste- 
rior Column  Development...  .496 

Tabes  and  Floating  Kidney 498 

Tabes    and    Multiple    Sclerosis 

and  Trauma  391 

Tabes  and  Spinal  Ganglia  Cells. 496 

Tabes  and  Taste  and  Smell 499 

Tabes     and     Testicular     Sensi- 
bility    499 


INDEX. 


XV 


PAGE. 

Tabes     and     the     Re-education 

Method   501 

Tabes  and  Trunk  Anaesthesia.  .*^y7 

Tabes  and  Tuberculosis (i^^J 

Tabes — Anterior  Horn  Cells  in. 495 
Tabes    Arrested   bv   Blindness, 

(122) 
Tabes — Early  Symptoms  of . . .  .499 
Tabes  —   Pseudo,       Following 

Diphtheria  500 

Tabes — Symptoms  in 679 

Tabes — Treatment    by    Stretch- 
ing   500 

Tabes  —  Treated     with     Sper- 

minium-Poehl  570 

Tabes  with  Intercurrent  Hemi- 
plegia, Returned  Knee  Jerk.  .615 
Tabes  with  Patellar  Reflexes. .  .498 

Tabes — Vomiting  in  499 

Taste  and  Smell  in  Tabes 499 

Technic — 

Cerebral  Development (343) 

Chrome      Silver      Impregna- 

tions    214 

Fixing  Fluid  139 

Formaline  as  a  Fixative 139 

•Gold   Staining  of  Nerve   Fi- 
bres    281 

Hardening     Nervous    System 

in  Situ  757 

Modification     of      Sublimate 

Method   347 

New  Method  of  Staining  Ner- 
vous Tissue  139 

On  the  Nature  of  the  Wiegert 

Pal  Method  347 

Present  Methods  of  Prepara- 
tion Nervous  System 623 

Temperature  Sense 492 

Tetanus  Lesions 626 

Thomsen's  Disease (53),  608 

Thorns  and  Constitution  of  Gray 

Matter  561 

ThyrocoUoid  ^458 

Thyroidectomy  in  Graves'  Dis- 
ease    y6S 

Thyroid  Chlorosis 899 

Thyroid  for  Backward  Children. 881 
Thyroid  in  Muscular  Atrophy.. 224 

Thyroidine  701 

Tic  Convulsif (130),  356 


PAGE. 

Tickling    and    Laughing — Psy- 
chology of 292 

Tinnitus  with  Hysteria (618) 

Touch — After  Sensations  of. . .  .291 

Trauma  and  Syringomyelia 871 

Traumatism  and  Spinal  Cord. .  .697 
Treatment     of     Paralytic     De- 
formities   633,  634 

Tremor — Graphic  Study  of 562 

Tremor      Simulating      Multiple 

Sclerosis  (620) 

Tremor,  Toxic,  and  Hysteria  in 

a  Male (i^) 

Trigeminal  Spasm  *392 

Tuberculosis  and  Tabes (129) 

Tuberculosis-r-Spinal  Cord 759 

Tumor   Brain   and   Changes   in 

Spinal  Cord 563 

Tumor — Intracranial  and   Ocu- 
lar Manifestations 566 

Tumor — Left  Temporal  Lobe..  .568 

Tumor  of  Inner  Capsule 568 

Tumor  of  Meninges 566 

Tumor  of  Oblongata 568 

Tumor  Cerebellar (7So),  (752) 

Tumors  of  Brain — Multiple.  .(279) 
Typhoid     Fever    and     Isolated 

Paralysis  889 

Typhoid  Fever  and  Suppuration 

in  Sella  Turcica (280) 

Ulcer,  Perforating — Cure  of 293 

Ulnar  Nerve  Injury 293 

Unilateral  Sweating  and  Flush- 
ing   (278) 

Uraemia    Cerebral    with    Cata- 

leptoid  Symptoms 570 

Vascular    Diseases   and    Lame- 
ness    891 

Vascular  Reflexes  in  Meninges. 624 
Vertebral  Column — Chronic  In- 
flammation of 762 

Vertigo  and  Equilibration ♦175 

Vertigo  and  Ocular  Defects. ...  68 
Whooping    Cough    and    Hemi- 
plegia   626 

Word  Deafness — Autopsy 824 

Wounds  of  Cerebrum,  Healing 
of   900 

Yellow  Fever  Bacillus  and  Ner- 
,     vous  System 758 


INDEX  TO  BOOK  REVIEWS* 


PAGE. 

A  Manual  of  Legal  Medicine, 
Justin  Harold 635 

Atlas  of  Legal  Medicine,  E. 
von  Hoflfmann  635 

A  Text  Book  of  the  Practice  of 
Medicine,  Jas.  M.  Anders. . .  .5^3 

An  Epitome  of  the  History  of 
Medicine,  L.  Park 230 

A  Text  Book  on  Mental  Dis- 
eases, T.  H.  Kellogg 225 

Beitrag  zur  Klinik  der  Riicken- 
marks-  und  Wirbeltumoren  by 
Herman  Schlesinger ^(yj 

Bulletin  of  the  Ohio  Hospital 
for  Epileptics 297 

Clinical  Lectures  in  Mental  Dis- 
eases, J.  T.  S.  Clouston 158 

Crime  and  Criminals,  J.  S. 
Christison    157 

Die  Bedeutung  der  Augen- 
storungen  fiir  die  Diagnose 
der  Hirn  und  Riickenmarks- 
Krankhcitcn,  O.  Schwartz.  . .  .350 

Dvsknesias  Arsenicales,  J.  Mo- 
reira 227 

Die  Darstellung  Krankhafter 
Geisteszustaenue  in  Shakes- 
peare's  Dramcn,   H.   Laehr.  .228 

Die  Geschwiilste  des  Nerven 
Systems,  von  Ludwig  Bruns..90i 

Die  Akromegalic,  M.  Stern- 
berg    229 

Eye  Strain  in  Health  and  Dis- 
ease, A.  L.  Ranney 157 

Festschrift  anlasslich  des  funf- 
zigjaehrigen  Bestehcns  der 
Provinzial  Irren  Anstalt  zu 
Nietleben  bei  Halle 903 

Gehimpathologie,  I,  Allge- 
meine  Einleitung;  H,  Lo- 
calisation; HI,  Gehimblutun- 
gen;  IV,  Verstopfung  der 
Hirnarterien,  von  Dr.  C.  v. 
Monakow    826 

Hysteria  and  Certain  Allied 
Conditions.  Their  •  Nature 
and  Treatment  with  Special 
Reference  to  the  Application 
of  the  Rest  Cure.  Massage, 
Electrical  Therapy,  Hypno- 
tism, G.  J.  Preston 155 


PAGE 

Hypnotism  and  its  Application 
to  Practical  Medicine,  JH.  G. 
Petersen 153 

Les  localizations  des  fonctions 
motrice  de  la  moelle  epiniere, 
F.  Sano 359 

Leitfaden  der  Physiologischen 
Psychologic,  von  Pr.  Dr.  Th. 
Ziehen   835 

Les  affections  nerveuses  sys- 
tematiques  et  la  theorie  des 
neurones,  J.  M.  Gerest 359 

Le3  hydrocephalies  par  Dr. 
Leon  d' Astros 902 

Les  myelites  syphilitiques, 
formes  cliniques,  et  traitement, 
par  le  Dr.  Gillcs  de  la  Tou- 
rette 901 

T/hystcrie  aux  XVII  et  XVIII 
.siecles,  Mme.  G.  AbricossofT.360 

Normale  und  pathologische 
Anatomic  der  Nervenzellen 
auf  Grund  der  neueren  Fors- 
chungen,  A.  Goldschcidcr  and 
E.  Flatau 636 

Normal  and  Pathological  Cir- 
culation of  the  Central  Ner- 
vous System,  W.  Browning. .  78 

Psychologic  de  I'instinct  sexuel 
par  Dr.  Joanny  Roux 901 

Psychology  of  the  Emotions, 
Th.   Ribot 360 

Sulla  opportunita  ed  elficacia 
della  cura  chirurgico-gineco- 
logico  nella  n^urosi  isterica, 
Angellucci   et  Pierraccini. ..  .227 

System  nerveux  central,  J. 
Dagonet   231 

The  Genesis  and  Dissolution  of 
the  Faculty  of  Speech,  J.  Col- 
lins    502 

The  Psychology  of  Suggestion, 
Boris  Sidis 504 

The  Proceedings  of  the  Ameri- 
can Medico-Psychological  As- 
sociation   504 

The  Nervous  System  and  its 
Diseases,  Chas.  K.  Mills 294 

Traumatic  Injuries  of  the  Brain 
and  its  Membranes,  C.  Phelps  78 

Twentieth  Century  Practice 80 


0^  ^f^ajScM^^kMiv,  yU'^fAAd 


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VOL.  XXV.  January,  1898.  No.  i. 


Nervous  and  Menta 


A  CONTRIBUTION  TO  THE  STUDY  OF  SECON- 
DARY DEGENERATION  FOLLOWING  CERE- 
BRAL LESIONS.^ 

By  WILLIAM    G.   SPILLER,   M.D., 

Professor  of  Diseases  of  the  Nervous  System  in  the  Phfladelphia  Polyclinic;  Pathologist 
to  the  Pennsylvania  Trainingr  School  for  Peeble-Minded  Children. 

Prom  the  Wistar  Institute  of  Anatomy  and  Biology. 

This  case  and  the  following,  K.  K.,  have  been  obtained 
from  the  Pennsylvania  Training  School  for  Feeble-Minded 
Children. 

The  history  of  the  boy,  W.  M.,  as  far  as  known,  is  as 
follows: 

He  was  born  January  28th,  1882,  and  began  to  walk 
when  abo\it  a  year  and  a-half  old.     When  he  was  little 
more  than  two  years  old,  he  "  was  frightened  by  a  cat  and 
was  paralyzed/'  so  that  he  had  no  use  of  the  right  upper 
limb.     About  this  time  he  was  noticed  to  be  weak-minded. 
It   seems  probable  that  the  vascular  lesion,  which  caused 
the  right  hemiplegia,  developed  at  this  age.The  boy  learned 
to  walk  after  braces  had  been  applied  to  the  right  lower 
limb,    but  later  these  became  unnecessary  and  were  re- 
moved.     He  never  used  a  crutch.     Epileptic  attacks  first 
appeared  when  the  child  was  ten  years  old,  and  at  the  age 

*One    of  two  papers  presented  for  membership  in  the  American 
^r^xirologrical   Association. 


2  WILLIAM  G.  S/'ILLER. 

of  thirteen  these  became  more  severe,  and  walking  became 
impossible.  In  the  convulsions  the  muscles  of  the  entire 
body,  as  well  as  those  of  the  head,  were  contracted.  The 
mother  states  that  the  attacks  were  announced  byscreams, 
and  that  these  were  followed  by  partial  unconsciousness. 
The  boy  never  attended  school,  and  was  mentally  not 
more  developed  than  a  child  at  the  age  of  three.  He  spoke 
very  indistinctly,  but  could  be  understood  by  his  relatives, 
and  seemed  to  understand  what  was  said  to  him.  He  was 
left-handed,  and  the  right  upper  limb  was  contractured 
and  imperfectly  developed.  The  labor  is  said  to  have  been 
verv  difficult. 


Fig.  I. 

The  photograph  represents  very  well  the  condition  of 
the  brain.  The  area  nourished  by  the  Sylvian  artery  was 
sclerotic.  Only  the  cortex  of  the  superior  part  of  the 
central  gyri  was  preserved,  and  yet  the  connection  of  this 
part  with  the  internal  capsule  was  destroyed.  The  foot 
of  the  third  frontal  gyrus  was  sclerotic,  though  to  a  less 
degree  than  the  other  parts  of  the  Sylvian  area.    The  first 


SECONDARY  DEGENERATION.  3. 

temporal  and  supramarginal  gyri  and  the  insula  were  en- 
tirely destroyed,  and  the  angular  convolution  was  also 
affected.  The  entire  left  hemisphere  was  notably  smaller 
than  the  right.  The  area  of  Broca  and  the  centres  for 
word-hearing  and  word-seeing  were  in  the  sclerotic  region. 
The  prefrontal  lobe,  the  upper  part  of  the  central  and 
parietal  and  the  occipital  and  temporal  lobes,  in  large 
part,  were  intact.  These  unaffected  portions  do  not  re- 
ceive their  blood-supply  from  the  Sylvian  artery.  The 
brain,  with  the  pons  and  oblongata,  was  hardened  and  cut 
in  about  nine  hundred  serial  sections.  The  terminology 
employed  in  this  description  is  chiefly  that  used  by  Dejer- 
ine  in  his  Anatomie  des  Centres  Nerveux. 

The  large  pyramidal  cells  {Riesenzelkn)  are  absent  in  the 
upper  part  of  the  central  gyri  in  sections  taken  from  a  portion 
which  externally  appeared  normal,  and  indeed  the  smaller  cells 
are  not  as  numerous  as  in  a  normal  brain,  and  are  irregular  and 
very  imperfect. 

Sections  Nos.  875  to  860  through  the  upper  part  of  the 
tail  of  the  caudate  nucleus  show  that  the  sclerosis  involves  the 
posterior  limb  of  the  internal  capsule  so  completely  that  only 
a  very  few  horizontal  medullated  fibres  may  be  found  within 
it.  The  inferior  longitudinal  fasciculus,  the  optic  radiation, 
and  the  tapetum  are  interrupted  by  the  primary  lesion.  A 
narrow  band  of  fibres  near  the  tajl  of  the  caudate  nucleus,  and 
a  larger  band  more  posteriorly  on  the  lateral  side  of  the  ven- 
tricle are  left.  The  tail  of  the  caudate  nucleus  has  not  been' 
destroyed,  and  contains  many  fine  black  points  by  Weigert's- 
stain,  representing  bundles  of  fibres  cut  transversely.  Within 
the  posterior  part  of  the  head  of  the  caudate  nucleus  (the  an- 
terior part  is  not  in  the  sections)  there  are  also  many  of  these 
points.  The  anterior  limb  of  the  internal  capsule  at  this  high 
level  shows  a  slight  degeneration,  though  it  is  intact  at  lower 
levels.  The  sections  contain  the  uppermost  part  of  the  thala- 
mus, which  is  very  small.  It  has  been  impossible  to  keep  the 
sections  from  the  t^^'o  hemispheres  in  the  same  plane,  as  the 
left  half  of  the  brain  was  so  contracted.  The  cortex  consists; 
of  sclerotic  tissue. 

Sections  Nos.  846  to  833: — The  few  fibres  present  in  the 
posterior  limb  of  the  internal  capsule  have  almost  entirely  a 
horizontal  course,  and  pass  into  the  external  nucleus  of  the 
thalamus.  The  anterior  limb  of  the  internal  capsule  is  nearly 
normal,  though  smaller  than  that  of  the  right  side.    The  fibres 


Ull.UAM  G.  SI'IU.ER. 


Section  860.  (a)  Oplic  radiation  and  inferior  longitudinal  fas- 
viunlus:  (b)  degenerated  cortex;  (c)  tail  of  the  caudate  nucleus;  (d) 
posterior  limb  of  the  internal  capsnie:  (e)  anterior  limb  of  the  internal 
capsule;   (f)   thalamus. 

present  in  tlie  knee  of  the  internal  capsule  have  a  horizontal 
course  and  seem  to  connect  the  anterior  part  of  the  putamen 
with  the  thalanm.';.  though  some,  evidently,  belong  more  di- 
rectly to  the  anterior  linih  of  the  capsule.  The  extreme  anterior 
end  of  the  putamen  is  preserved,  and  contains  a  number  of 
horizontal  niediillated  fibres.  All  the  middle  and  posterior 
])art  of  the  putamen  is  involved  in  tlic  primary  lesion.  Tlie 
l>osterior  part  of  the  head  of  the  caudate  nucleus  (the  only  part 
in  the  sections!  appears  normal.  The  anterior  nucleus  of  the 
thalamus  is  smaller  than  that  of  the  right  side,  and  contains 
fewer  medullated  fibres.  The  stratum  zonale  is  preserved,  as 
are  also  the  laminae  medullares  of  the  thalamus.  The  external 
nucleus  of  the  thalamus  is  very  small,  but  contains  tuany  me- 
dullated fibres.  M  this  level  the  posterior  part  of  the  thalamus 
receives  a  certain  number  of  fibres  from  the  optic  radiation. 
The  tail  of  the  caudate  nucleus  is  intact,  duly  the  anterior 
part  of  the  external  capsule  is  preserved.  There  are  a  few 
masses  of  gray  matter  belonging  to  the  po.sterinr  part  o(  the 
putamen.  These  give  origin  to  numerous  horizontal  fibres 
which  pass  into  the  external  nucleus  of  the  thalamus;  some, 
however,  pass  only  part  way  through  the  sclerotic  tissue  of 
the  posterior  limh  of  the  internal  capsule. 


SF.COSDAKy  DEGENERATIOS.  5 

Sections  Nos.  827  to  816: — As  the  perpendicular  fibres 
of  the  posterior  limb  of  the  internal  capsule  are  destroyed, 
except  a  very  few,  it  is  important  to  notice  the  horizontal 
fibres  which  connect  the  lenticula  with  the  external  nucleus 
of  the  thalamus.  The  second  segment  of  the  lenticula  is  now 
visible  and  contains  many  medullated  fibres.  The  horizontal 
fibres  of  the  posterior  limb  of  the  internal  capsule  are  somewhat 
more  numerous  in  the  posterior  part  of  the  limb.  The  inferior 
longitudinal  fasciculus  and  the  optic  radiation  contain  more 
fibres  than  in  sections  from  higher  levels.  The  anterior  nucleus 
of  the  thalamus  has  become  much  smaller.  The  internal 
nucleus  is  distinct,  but  is  smaller  than  that  of  the  right  side. 
The  txnia  thalami  is  well  preserved.  The  anterior  limb  of 
the  interna!  capsule  is  intact,  and  some  fibres  in  the  knee  of 
ihe  capsule  are  preserved.  The  inferior  longitudinal  bundle, 
optic  radiation  and  tapetum  at  sonic  little  distance  from  the 
tail  of  the  caudate  nucleus  are  much  degenerated,  but  as  there 
are  many  fibres  in  the  retrolenticular  segment  of  the  internal 
capsule,  they  must  represent  fibres  which  ascend  in  theircour>e 
for^vard.  A  large  part  of  the  putamen  and  external  capsule 
are  destroyed.    The  habenula  is  well  formed. 


Fic.  III. 
Section   8j2.      (a)    Optic   radiation   anil   iin\riur   iungiiudhial    fas- 
ciculus; (b)  poMerior  liVnb  of  the  internal  capsule  (degenerated);  <c) 
posterior  part  of  the  putamen  destroyed  by  tlie   primary  lesion:   Id) 
anterior  part  of  the  putamen  (normal). 


6  WILLIAM  G.  SPILLER. 

Sections  Nos.  812  to  800: — Only  the  posterior  part  of  the 
putamen  is  destroyed.  The  second  segment  of  the  lenticula 
is  well  formed,  and  contains  many  meduUated  fibres.  The 
first  segment  also  appears  normal.  The  posterior  limb  of  the 
internal  capsule  is  much  contracted.  The  internal  nucleus  of 
the  thalamus  is  distinctly  separated  from  the  external  by  the 
lamina  medullaris  interna.  The  pulvinar  begins  to  be  promi- 
nent. The  lamina  medullaris  externa  and  the  zona  reticulata 
are  distinct.  The  laminae  of  the  lenticula  are  also  well  formed. 
The  bundle  of  Vicq  d'Azyr  on  the  left  side  is  a  trifle  smaller 
and  less  deeply  stained.  The  anterior  pillars  of  the  fornix  are 
the  same  on  two  sides.  The  taenia  semicircularis  is  of  good  size 
and  well  stained.  The  fibres  of  the  inferior  longitudinal  bundle, 
optic  radiation  and  tapetum  are  only  interrupted  at  one  por- 
tion of  their  course.  The  zone  of  Wernicke  is  deeply  stained 
and  appears  normal,  as  only  the  uppermost  part  of  the  optic 
radiation  was  cut.  The  fasciculus  of  Tiirck  begins  to  appear. 
The  external  capsule  now  forms  an  unbroken  band,  but  the 
fibres  are  not  numerous.  There  are  medullated  perpendicular 
fibres  present  in  the  extreme  anterior  part  of  the  posterior  limb 
of  the  internal  capsule. 

Sections  Nos.  799  to  792: — The  posterior  commissure  is 
normal.  The  putamen  is  no  longer  destroyed  in  its  posterior 
part.  The  pulvinar  is  not  quite  as  large  as  that  of  the  right  side 
at  higher  levels,  and  probably  this  is  the  result  of  destruction  of 
the  superior  fibres  belonging  to  the  optic  radiation.  Fibres 
may  be  noticed  passing  toward  the  anterior  and  outer  part  of 
the  posterior  limb  of  the  internal  capsule.  These  are  coarser 
than  the  fibres  which  enter  the  thalamus  directly.  Some  of 
these  coarser  fibres  appear  to  pass  through  the  anterior  part  of 
the  posterior  limb  of  the  internal  capsule  into  the  thalamus,  for 
though  it  is  impossible  to  trace  them  in  their  passage  through 
the  capsule,  there  are  fibres  on  the  outer  side  of  the  bundle  of 
Vicq  d'Azyr  which  appear  to  be  the  continuation  of  these. 
Some  of  these  fibres,  however,  seem  to  remain  in  the  anterior 
part  of  the  posterior  limb  of  the  internal  capsule,  and  from  this 
level  medullated  fibres  may  be  traced  in  this  part  into  the  me- 
dian bundle  of  the  peduncle. 

Sections  784  to  773 : — The  fasciculus  retroflexus  of  Meynert, 
arising  in  the  habenula,  is  well  colored.  The  horizontal  fibres 
connecting  the  thalamus  with  the  lenticula  are  more  numerous 
than  in  sections  from  higher  levels.  The  fasciculus  of  Vicq 
d'Azyr  is  well  stained,  and  is  about  the  size  of  that  on  the 
right  side.  The  thalamic  fasciculus  of  Forel  (Markfeld  Hi)  is 
distinct,  as  is  also  the  lenticular  fasciculus  of  Forel  {Mark- 
feld H2),  These  do  not  appear  to  be  atrophied,  or  if  so,  they 
are  to  a  very  slight  degree.    The  median  nucleus  of  Luys  has 


i 


SECONDARY  DEGENERATION.  7 

nearly  the  normal  size,  but  the  semilunar  nucleus  of  Flechsig, 
so  called  by  Dejerine,  (Schalenf  ormtgerkrper)  is  very  small. 
Fibres  from  the  lamina  medullaris  interna  of  the  lenticula  be- 
gin now  to  pass  through  the  internal  capsule.  The  pulvinar  is 
of  good  size,  and  the  zone  of  Wernicke  is  intensely  stained. 
The  fasciculus  of  Tiirck  is  very  distinct.  The  left  anterior  pillar 
of  the  fornix  is  fully  as  large  as  the  right.  The  left  ansa  lenticu- 
laris  at  this  level  is  smaller  than  the  right,  but  this  is  chiefly  the 
result  of  a  difference  in  the  level  of  the  two  sides.  The  zona 
incerta  is  small. 

Sections  Nos.  755  to  743: — The  ansa  lenticularis  is  a  little 
smaller  on  the  left  side.  The  internal  geniculate  body  appears 
in  its  most  superficial  part,  and  is  much  atrophied.  The  upper 
portion  of  the  external  geniculate  body  is  also  visible,  and  the 
peculiar  divisions  of  this  body  are  very  distinct.  The  peduncle 
of  the  anterior  quadrigeminal  body  is  intact.  The  peduncle 
of  the  posterior  does  not  contain  the  normal  number  of  fibres. 
The  median  side  of  the  capsule  of  the  nucleus  ruber,  i.  e.,  the 
Haubenstrahiung  in  the  sense  of  v.  Monakow, — contains  fibres 
from  the  ansa  lenticularis  (Dejerine),  and  no  difference  in  the 
sizeof  thismedian  portion  in  the  two  hemispheres  is  observable. 
The  left  nucleus  ruber  is  much  smaller  thart  the  right,  but  the 
level  on  the  two  sides  is  not  the  same.     The  anterior  com- 


Section  736.     (a)  Internal  geniculate  body  (partly  atrophied) :  (b) 
external  geniculate  body;    (c)   ansa  lenticularis:     (d)   corpus   subtha- 


8  WILLIAM  G.  SPILLER. 

missure  is  small.  The  posterior  longitudinal  bundles  are  the 
same  on  the  two  sides.  The  left  corpus  subthalamicum  may 
be  a  little  smaller  than  the  rig^ht  in  its  greatest  development, 
bnt  there  Is  no  great  difference  between  the  two.  In  Mahaim's' 
case  this  body  was  much  degenerated,  but  the  destruction  of 
the  putamen  seems  to  have  been  greater. 

Sections  Nos.  736  to  724: — The  peduncle  of  the  posterior 
corpus  quadrigeminuni  contains  quite  a  number  of  fibres  at 
this  level,  though  not  as  many  as  the  corresponding  bundle  on 
the  right  side  at  higher  levels.  The  ansa  lenticularis  is  well 
formed  at  this  level  and  cannot  be  regarded  as  degenerated  to 
any  noteworthy  degree.  The  anterior  part  of  the  posterior 
limb  of  the  internal  capsule  in  all  these  sections  contains  med- 
ullated  fibres.  The  commissure  of  Meynert  is  normal,  and 
fibres  of  this  band  may  be  seen  entering  the  posterior  part  of 
the  internal  capsule.    These  fibres  are  of  fine  calibre. 


Fig.  V. 
1   676.      (a>    Lateral   bundle   of   the   peduncle;    (b)    intvrnal 
he  peduncle. 

Sections  714  to  661 : — The  left  nucleus  ruber  is  about  equal 
in  size  to  the  right,  though  the  latter  in  its  greatest  develop- 
jnent  is  larger.  The  peduncle  of  the  lateral  mammillary  bo<ly 
is  normal,  as  is  also  the  tubercle  itself.  Many  horizontal  fibres 
may  be  seen  passing  from  the  substantia  nigra  into  the  crusta. 
which  is  not  as  yet  detached  from  the  rest  of  the  brain.  The 
area  which  in  higher  levels  is  much  degenerated,  and  which 
corresponds  to  the  portion  occupied  by  the  motor  fibres,  con- 
tains many  horizontal  fibres.  The  commissure  of  Forel  and  the 
optic  nerve  are  normal.  The  two  mammillary  bodies  are  about 
the  same  in  size.  The  substantia  nigra  of  the  left  side  appar- 
ently contains  as  many  cells  and  fine  fibres  a.s  that  in  the  right 
peduncle,  but  as  the  left  cms  is  nuich  smaller  than  the  right 
the  total  nnmber  of  cells  in  the  substantia  nigra  is  probably 
also  less.  The  median  ])ortion  of  the  crusta  is  well  colored, 
as  is  also  the  lateral,  which  is  about  one-fifth  of  the  width  of 

=Mahaim:   Arrhiv   fiir   P.;yi-hiatri<',   vol,    nxv. 


SECONDARY  DEGENERATJOX.  9 

the  normal  crusta.  This  lateral  bundle  contains  no  visible  de- 
j;enerated  fibres.  The  fibres  passing  from  the  nucleus  ruber  to 
jonn  the  anterior  cerebellar  peduncle  of  the  right  side  are  appar- 
ently as  numerous  as  on  the  left  side.  The  lateral  lemniscus-is 
normal,  and  may  be  seen  passing  toward  the  nucleus  of  the 
posterior  corpus  quadrigeminum.  This  nucleus  is  of  good 
size. 

Below  section  661  it  is  not  worth  while  to  give  the  numbers, 
as  the  changes  are  not  sufficiently  numerous  to  justify  such  a 
procedure.  There  is  no  apparent  difference  in  the  number  of 
the  fibres  constituting  the  middle  cerebellar  peduncles,  but  the 
left  half  of  the  pons  is  much  narrower  than  the  right.  The  right 
anterior  cerebellar  peduncle  is  a  little  smaller  than  the  left. 
There  are  only  a  few  perpendicular  medullated  fibres  enclosed 
by  the  left  middle  cerebellar  peduncle.  The  nuclei  of  the  pon- 
tine gray  matter  seem  to  be  equally  numerous  on  the  two  sides, 
but  there  are  probably  not  as  many  of  these  on  the  left  side 
in  toto.  The  left  median  lemniscus  is  smaller  than  the  right. 
There  are  many  cells  in  both  sensory  and  motor  nuclei  of  the 
fifth  nerve  on  each  side,  and  the  spinal  roots  of  the  two  fifth 
nerves  seem  to  be  of  equal  size.  The  nuclei  of  the  sixth  nerves 
are  normal.  The  cells  of  the  formatio  reticularis  appear  equally 
numerous  on  the  two  sides.  The  ventral  acoustic  nuclei  and 
the  acoustic  tubercles  are  well  formed  on  both  sides.  The  left 
interolivary  layer  is  one-third  smaller  than  the  right,  and  the 
fibres  appear  to  be  of  smaller  calibre,  and  yet  th7s  is  a  point 
nost  difficult  to  decide,  although  the  method  of  coloration  by 
the  carmine  en  masse  has  been  employed,  and  the  result  is  ex- 
cellent. The  left  pyramid  is  entirely  degenerated.  The  right 
pyramid  does  not  appear  extraordinarily  large,  although  it  is 
of  full  size.  The  nuclei  of  Burdach  and  Goll  are  smaller  on  the 
right  side,  and  contain  fewer  cells.  At  the  motor  decussation 
there  are  fibres  which  appear  to  penetrate  the  gray  matter  to 
enter  the  lateral  column  on  the  side  of  the  normal  pyramid. 
The  cranial  nerv^es  and  nuclei  all  appear  to  be  normal. 

A  history  of  a  fright,  which  was  supposed  to  have  been 
the  cause  of  the  paralysis,  is  given  in  this  case.  It  is  dififi- 
cult  to  picture  any  morbid  process  which  could  he  pro- 
duced in  this  way.  A  much  more  probable  explanation  is 
that  the  fright  occurred  simultaneously  with  the  occlusion 
of  the  Sylvian  artery.  In  attempting  to  remove  this  artery 
from  the  hardened  brain  it  broke  near  the  sclerotic  area. 
Nothing  pathological  could  be  observed  in  the  piece  thus 
obtained.     The  cortical  branches  of  the  arterv  could  not 


lO  WILLIAM  G.  SPILLER. 

be  distinguished  from  the  sclerotic  tissue.  It  is  impossible 
to  state  whether  the  occlusion  was  the  result  of  a  throm- 
bus or  embolus.  Most  physicians  would  probably  think 
of  the  latter  cause,  though  Gowers^  believes  that  throm- 
bosis in  situ  is  more  common  in  such  cases  as  this.  Taylor,* 
however,  reports  a  case  in  which  embolism  of  the  left 
middle  cerebral  artery  was  found  in  a  child  of  five.  The 
feeble  intellect  of  W.  M.  was  probably  the  result  of  this 
sclerosis,  although  the  prefrontal  lobe  was  well  developed. 
The  intellect  may  thus  be  of  low  grade  when  the  greater 
part  of  the  prefrontal  lobe  is  intact,  but  considerable  de- 
struction of  cortical  tissue  in  some  cases  has  not  made 
the  patient  feeble-minded  (v.  Monakow's^  case,  No.  3). 
There  may  be  a  difference  in  this  respect  in  proportion 
to  the  devlopment  of  the  brain  at  the  time  the  lesion 
occurs.  Probably  a  congenital  lesion  in  some  cases  may 
not  produce  the  same  symptoms  as  one  which  occurs  when 
the  child  is  two  or  three  years  old;  and,  therefore,  at  an 
age  when  the  brain  has  attained  a  higher  degree  of  de- 
velopment, and  the  nerve  cells  are  less  likely  to  assume 
abnormal  functions. 

The  motor  fibres  of  the  left  cerebral  hemisphere  were 
totally  destroyed,  and  yet  this  boy  was  able  to  walk  with- 
out a  crutch,  although  in  an  imperfect  manner.  He  had 
no  use  of  the  right  upper  limb.  The  conviction  is  forced 
upon  us  that  the  motor  impulses  to  the  right  lower  limb 
were  transmitted  through  the  pyramidal  fibres  from  the 
right  cerebral  hemisphere.  This  preservation  of  bilateral 
motion  with  the  absence  of  one  pyramid  is  well  shown  in 
another  case  from  the  Elwyn  institution.  The  pyramid 
on  the  same  side  as  the  normal  hemisphere  in  this  case  i& 
unusually  large,  and  there  is  entire  absence  of  the  left 
pyramid.    The  case  is  one  of  porencephaly  of  the  left  lower 


*Gowers:  Diseases  of  the  Nervous  System,  vol.  ii.,  English  edition, 
p.  461. 

*Taylor:    British  Medical  Journal,  1880,  vol.  ii. 
*V.  Monakow:   Archiv  fiir  Psychiatrie,  vol.  xxvii. 


r 


SECONDARY  DEGENERA  TION.  1 1 

Rolandic  region,  and  a  picture  of  this  brain  was  given  in 
the  January,  1 897,number of  theJouRNAL  of  Nervous  and 
Mental  Disease.  This  boy  also  was  able  to  walk  every- 
where, although  he  limped,  and  the  only  motor  fibres 
present  were  from  the  right  pyramid.  In  the  case  of  W. 
M.,  the  right  pyramid  is  not  as  large  as  in  the  case  of 
porencephaly.  It  is  probable  that  in  the  first  case  the 
lesion  was  post-natal,  and  in  the  second  ante-natal,  which 
accounts  for  the  better  compensatory  development  of 
fi!)res  in  the  second  case.  A  case  in  which  the  innervation 
of  both  sides  of  the  body  was  probably  from  one  cerebral 
hemisphere,  has  been  reported  by  v.  Monakow,®  and  the 
same  explanation  as  above  has  been  given.  In  Mahaim's'' 
case,  the  lesion  was  in  the  Sylvian  region,  and  involved 
the  supramarginal,  the  first  temporal  gyrus,  the  insula, 
the  claustrum,  almost  all  the  putamen,  the  head  of  the 
caudate  nucleus,  and  the  fibres  from  the  central  gyri. 
The  hemiplegia  developed  at  the  age  of  nine  months.  Al- 
though the  fibres  from  the  right  motor  cortex  were  de- 
stroyed, the  gait  of  the  patient  was  not  strikingly  ab- 
normal, and  spastic  phenomena  were  not  present  in  the 
left  lower  limb.  The  left  upper  limb  was  contractured, 
but  still  of  service.  Mahaim  says  this  case  is  an  evidence 
of  the  connection  of  each  pyramid  with  both  sides  of  the 
cord,  and  this  bilateral  innervation  is  more  perfect  for  the 
lower  limbs  than  for  the  upper.  Dejerine  and  Thomas® 
have  reported  a  case  similar  to  these.  In  one  of  v.  Mona- 
kow's  cases  of  infantile  cerebral  paralysis  contracture  of 
the  upper  limb,  with  shortening  and  diminution  in  the 
circumference  of  the  forearm,  was  noticed,  and  yet  the 
'pyramid  containing  the  fibres  for  this  side  of  the  body  was 
only  moderately  degenerated.  The  hemiplegia  developed 
at  the  early  age  of  six  months,  and,  therefore,  at  a  period 
when  compensation  as  a  rule  is  more  perfect.    V.  Mona- 

^ -|-  IIIBIIIBII  ■  M^IIMI 

•V.  Monakow:    Archiv  fiir  Psychiatric,  vol.  xxvii,  p.  408. 

'Mahaitn:  Archiv  fiir  Psychiatric,  vol.  xxv. 

•Dejerine  and  Thomas:    Archives  de  Physiologic,  1896. 


12  WILLIAM  G.  S FILLER. 

kow  says  this  case  shows  that  a  partial  interruption  of  the 
motor  fibres  may  cause  a  considerable  hemiatrophy  with 
contracture.  On  the  other  hand/occasionally  in  cases  of 
total  pyramidal  degeneration ''the  hemiatrophy  and  con- 
tracture may  be  less,as  in  Mahaim's  case,and  consequently 
the  hemiatrophy  is  not  directly  proportional  to  the  pyram- 
idal degeneration,  but  is  dependent  on  other  unknown 
factors.  Zacher®  also  has  reported  a  case  of  partial  degen- 
eration of  the  pyramidal  tract  without  evidences  of  paral- 
ysis during  life.  It  is  a  curious  coincidence  that  the  epi- 
leptic attacks  developed  in  the  boy,  W.  M.,  at  the  same 
age  as  in  the  patient  reported  by  v.  Monakow  as  Case  3. 
In  both  cases  the  convulsions  began  at  the  age  of  ten  and 
were  general.  This  is  additional  proof  that  both  sides  of 
the  body  were  innervated  from  one  hemisphere.  It  is  well 
known  that  extirpation  of  motor  centres  usually  causes  a 
cessation  of  epileptic  movements  in  the  corresponding 
limb.  It  seems  probable  that  these  bilateral  convulsions 
were  made  possible  by  the  formation  of  a  lesion  at  an  early 
age.  The  nervous  system  can  adapt  itself  much  better 
to  altered  circumstances  if  destruction  of  tissue  occurs 
before  the  nerve  cells  and  fibres  are  fully  formed,  and  it 
would  seem  that  even  additional  fibres  may  develop  (cases 
of  Mahaim,  v.  Monakow,  Dejerine  and  Thomas,  Adolf 
Meyer^^  and  S])iller. 

W.  M.  spoke  very  indistinctly,  but  he  was  able  to  make 
himself  understood,  and  appeared  to  understand  any 
simple  remark  made  to  him.  This  is  very  interesting  as  the 
fibres  from  Broca's  region  w-ere  certainly  very  much  dam- 
aged, and  Freud's  speech  zone  was  sclerosed.  Such  a 
lesion  in  the  adult  causes  both  motor  and  sensory  aphasia. 
V.  Monakow  reports  a  similar  condition  in  his  Case  2,  and 
other  cases  are  known  in  the  literature. 

"Zacher:    .Archiv  fur  Psychiatric,  vol.  xxvii.;  see  also  vol.  xix. 
"Meyer:  Pathological  Report  of  the  Illinois  Eastern  Hospital  for 
the  Insane. 


V-" 


SECONDARY  DEGEXERAT/OX.  1 3 

Many  years  ago  v.  Monakow  showed  that  the  internal 
geniculate  body  degenerates  after  lesions  of  the  temporal 
lobe.  According  to  Zacher,*^  Wernicke  claimed  that  there 
is  direct  connection  between  this  nucleus  and  the  first 
temporal  gyrus  and  the  insula,  and  Zacher,  from  a  study 
of  his  cases,  is  inclined  to  accept  this  statement,  although 
he  thinks  the  second  temporal  gyrus  is  probably  also  con- 
nected with  this  nucleus.  This  connection  with  the  tem- 
poral lobe  has  been  also  observed  by  others.  In  v.  Mona- 
kow's  paper,  to  which  reference  must  repeatedly  be  made, 
the  internal  geniculate  body  in  Case  2  was  degenerated 
from  a  lesion  in  the  first  temporal  gyrus,  the  operculum, 
tiie  insula,  the  third  frontal  convolution,  and  the  putamen. 
This  body  was  also  smaller  on  the  side  of  the  lesion  in 
Case  3.  In  my  case  this  body  is  much  atrophied,  though 
not  entirelv  absent,  and  destruction  of  the  cortex  of  the 

m 

hemisphere  is  extensive.  The  first  temporal  gyrus  is  en- 
tirely destroyed,  and  it  is  with  this  that  the  internal  genic- 
ulate body  is  chiefly  connected  (v.  Monakow).  There  is 
also  decrease  in  the  size  of  the  peduncle  of  the  posterior 
corpus  quadrigeminum,  as  was  seen  also  in  v.  Monakow's 
Cases  2  and  3.  The  nucleus  of  this  quadrate  body  in  the 
case  W.  M.  is  of  good  size.  After  extensive  lesions  of  the 
operculum  and  temporal  lobe  the  atrophy  of  the  peduncle 
of  the  posterior  corpus  quadrigeminum  is  only  of  moder- 
ate intensity  (v.  Monakow).  This  is  because  the  cortical 
neuron  begins  in  the  internal  geniculate  body.  The  case 
of  \V.  M.  confirms  this  statement. 

Mahaim  and  v.  Monakow  in  his  Case  2  report  degen- 
eration of  the  ansa  lenticularis,  but  the  destruction  of  the 
putamen  in  both  these  cases  was  evidently  greater  than 
in  mv  case.  The  ansa  lenticularis  on  the  left  side  of  the 
brain  of  W.  M.  is  very  nearly  as  well  developed  as  on  the 
right,  and  this  is  probably  to  be  attributed  to  the  fact  that 


II 


Zacher:  Arcliiv  fiir  Psychiatrie.  vol,  xxii. 


14  WILLIAM  G,  S FILLER. 

the  destruction  of  the  lenticula  was  Hmited  to  the  posteri- 
or and  superior  part  of  the  putamen,  and  did  not  extend 
very  far  downward.  In  Mahaim's  case  the  ansa  lenticular- 
is  was  not  as  much  degenerated  as  in  v.  Monakow's,  as  the 
latter  states.  The  lenticular  fasciculus  of  Forel,  and  the 
lenticular  laminae  in  v.  Monakow's  Case  2  contained  fewer 
fibres.  These  parts  are  quite  well  formed  in  the  case  W. 
M.,  and  the  median  portion  of  the  tegmental  radiation 
(Haubenstrahliing)  on  the  left  side  contains  as  many  fibres 
as  on  the  right.  '•According  to  Dejerine  the  ansa  lenticu- 
laris  contributes  fibres  to  the  tegmental  radiation.  In 
the  sense  of  v.  Monakow  (I.e.,  p.  113),  the  tegmental 
radiation  includes  all  the  fibres  immediately  surrounding 
the  nucleus  ruber.  It  seems  probable  that  the  ansa 
lenticularis  arises  chiefly  from  the  lower  part  of  the 
lenticula. 

Zacher,  Mahaim,  and  v.  Monakow  report  degeneration 
of  the  nucleus  ruber  on  the  side  of  the  primary  lesion.  In 
the  case  W.  M.  the  left  nucleus  ruber  is  a  little  smaller 
than  the  right,  but  contains  proportionally  as  many  me- 
dullated  fibres.  The  substantia  nigra  has  been  reported 
as  atrophied  in  several  cases  of  cerebral  lesions.  In  the  case 
W.  M.  this  is  not  very  evident.  The  substantia  nigra  is 
smaller,  as  the  whole  cerebral  peduncle  is  smaller,  but 
proportionally  speaking  it  seems  to  contain  a  normal  num- 
ber of  cells  and  fibres.  According  to  v.  Monakow  this 
part  is  probably  connected  with  the  third  frontal  gyrus 
and  anterior  part  of  the  insula  and  operculum.  Edinger^^ 
states  that  fibres  of  the  stratum  intermedium  come  from 
the  lenticula.  V.  Bechterew^*  says  that  the  cells  of  the 
substantia  nigra  do  not  degenerate  after  lesions  of  the 
cortex  and  internal  capsule.  This  substance  was  degen- 
erated in  Witkowski's^*  case  and  the  lesion  involved  the 
lenticula  with  other  parts  of  the  brain. 

"Edinger:  Vorlesungen  iiber  den  Bau  der  nervosen  Centralorgane. 
Fifth  edition,  pp.  288,  257. 

"V.  Bechterew:   Archiv  fiir  Psychiatrie,  vol.  xix. 

**Witkowski:    Archiv  fiir  Psychiatrie,  vol.  xiv. 


r 


SECONDARY  DEGENERATION.  1 5 

In  Case  2  of  v.  Monakow's  paper  the  cerebral  peduncle 
was  intensely  degenerated  on  the  median  and  lateral 
borders.  These  are  intact  in  the  case  of  W.  M.  Dejerine^^ 
believes  that  the  median  bundle  of  the  peduncle  comes 
from  the  Rolandic  operculum  and  adjacent  part  of  the 
frontal  operculum.  Zacher  (1.  c.)  believes  this  portion  of 
the  crusta  is  chiefly  connected  with  the  insula.  Flechsig 
and  Wernicke  think  this  bundle  comes  from  the  frontal 
lobe  (quoted  by  v.  Monakow).  V.  Monakow  is  in  favor 
of  the  latter  vifew  after  a  study  of  his  Case  2.  In  the  case 
W.  M.  the  most  internal  portion  of  the  inner  bundle  of  tlie 
crusta  is  well  stained  and  may  be  traced  from  quite  high 
levels  of  the  internal  capsule  in  the  anterior  part  of  the 
posterior  limb.  The  operculum  is  degenerated.  This 
seems  to  indicate  that  the  origin  of  a  portion  of  this 
bundle  is  anterior  to  the  Rolandic  operculum.  In  Ma- 
haim's  case  (1.  c.)  this  median  bundle  was  degenerated, 
but  the  head  of  the  caudate  nucleus  was  destroyed  by  the 
primary  lesion,  and  it  is  probable  that  the  anterior  limb 
of  the  internal  capsule  was  also  affected. 

The  degeneration  of  the  lateral  bundle  of  the  crusta  in 
V.  Monakow's  Case  2  is  noteworthy,  as  the  second  and 
third  temporal  gyri  were  not  degenerated.  It  may  be  that 
the  fasciculus  of  Tiirck  was  cut  internally  to  the  cortex  of 
the  temporal  lobe  in  its  passage  to  the  posterior  part  of 
the  posterior  limb  of  the  internal  capsule.  In  Mahdim's 
case  (1.  c.)  the  external  fourth  of  the  cerebral  peduncle 
contained  normal  fibres,  and  the  first  temporal  gyrus  was 
involved  in  the  primary  lesion.  V.  Bechterew^®  in  1888 
reached  the  conclusion  that  the  lateral  bundle  of  the  cer- 
ebral peduncle  arises  in  the  temporal  and  basal  part  of  the 
occipital  lobe.  Zacher  (1.  c.)  also  places  the  origin  of  these 
fibres  in  the  occipital  and  temporal  lobes.  Dejerine  (1.  c.) 
has  shown  that  the  origin  of  this  bundle  is  in  the  temporal 


u 


Dejerine:   Anatomie  des  Centres  Nerveux,  vol.  i,  p.  602. 
"V.  Bechtcrew:  Archiv  fur  Psychiatrie,  vol.  xix. 


1 6  WILLIAM  G.  SFILLHR. 

lobe  alone,  and  chiefly  from  the  second  and  third  con- 
volutions. Kam^"  also  believes  that  these  fibres  come 
only  from  the  temporal  lobe.  Mills  and  Spilier*®  have 
shown  that  probably  none  of  these  fibres  arise  in  the  first 
temporal  gyrus.  This  case,  W.  M.,  strengthens  this  latter 
view.  The  first  temporal  gyrus  was  entirely  destroyed  at 
an  early  age,  and  secondary  degeneration  elsewhere  is 
distinct,  and  yet  no  indication  of  degeneration  is  found  in 
the  lateral  bundle  of  the  peduncle. 

The  anterior  and  internal  nuclei  of  the  thalamus  in 
Case  3  of  v.  Monakow's  paper  were  almost  of  normal  size. 
The  central  gyri  with  the  operculum,  the  anterior  part  of 
the  supramarginal  gyrus,  and  the  first  temporal  were  de- 
stroyed by  porencephaly.  Only  the  frontal  lobe  and  por- 
tions of  the  temporal  lobe  remained  in  connection  with 
the  internal  capsule.  This  case  in  many  respects  is  similar 
to  mine.  The  left  anterior  nucleus  in  my  case  is  only  a 
little  smaller  than  the  right,  and  the  internal  nucleus  is 
not  nearly  as  much  altered  as  the  external  (lateral).  The 
lateral  nucleus  is  greatly  degenerated,  as  it  was  also  in  v. 
Monakow's  Cases  2  and  3.  in  which  also  the  ventral  nuclei, 
as  he  calls  them,  and  the  posterior  nucleus  were  degen- 
erated. In  Mahaim's  case  the  anterior  tubercle  was  the 
only  thalamic  nucleus  intact,  though  the  pulvinar  was 
onlv  a  little  smaller.  From  eleven  himian  brains  and  from 
a  niimber  of  brains  of  lower  animals,  in  which  experi- 
mental lesions  were  produced,  v.  Monakow  concludes  that 
every  portion  of  the  thalamus  is  in  connection  with  some 
])art  of  the  cerebral  cortex.  Other  cases  in  the  literature 
support  his  views.  This  is  contrary  to  the  opinion  held 
by  Flechsi^-  as  regards  his  association  centres.  According 
to  V.  Monakow,  a  thalamic  nucleus  may  not  degenerate 
if  some  of  the  fibres  passing  to  it  are  intact.  Fibres  from 
the  first  and  second  parietal  gyri  are  in  connection  with 


"Kam:    Arcliiv  tiir  Psychiatric,  vol.  xxvii. 

"Mills  and  Spillor:   Journal  of  Nervous  and  Mental  Disease,  1896. 


SECONDARY  DEC  EN  ERA  TION.  l  7 

the  frontal  and  median  portions  of  the  pulvinar  (v.  Mona- 
kow).  This  probably  explains  the  slight  diminution  in 
the  size  of  the  left  pulvinar,  as  compared  with  the  right, 
in  the  case  of  W.  M.  The  ventral  nuclei  of  the  thalamus 
are  supposed  to  be  chiefly  connected  with  the  operciilum, 
the  central  and  the  supramarginal  gyri.  The  semilunar 
nucleus  of  Flechsig  (Dejerine)  is  identical  with  v.  Mona- 
kow's  vent.  b.  nucleus.  The  ventral  nuclei  are  the  groups 
of  cells  situated  in  the  ventral  portion  of  the  thalamus.  In 
the  case  W.  M.  these  cortical  areas  are  degenerated,  and 
the  area  occupied  by  the  ventral  nuclei  is  small.  The  in- 
ternal nucleus  probably  receives  its  fibres  from  the  second 
and  third  frontal  gyri  and  the  anterior  part  of  the  insula. 
This  explains  the  moderate  degeneration  in  the  case  of 
W.  M.  By  lateral  nucleus  v-  Monakow  means  only  the 
dorsal  part  of  the  external  nucleus.  It  is  probable  that 
this  nucleus  derives  its  fibres  from  the  central  gyri  (oper- 
culum), the  superior  parietal,  the  anterior  part  of  the 
supramarginal,  the  angular,  the  posterior  part  of  the 
frontal  gyri,  and  the  temporal  lobe.  We  have  thus  a  satis- 
factory explanation  for  the  great  degeneration  of  the 
lateral  nucleus  in  the  case  of  W.  M.  It  is  certain,  says 
V.  Monakow,  that  fibres  to  the  lateral  nucleus  come  chiefly 
from  the  central  gyri.  The  anterior  tubercle  of  the  thala- 
mus probably  receives  fibres  from  the  median  portion  of 
the  first  frontal,  the  paracentral  lobe  and  gyrus  fornicatus. 
All  these  parts  were  outside  the  sclerotic  area,  and  yet  as 
some  of  the  projection  fibres  were  doubtless  cut,  we  have 
an  explanation  for  the  slight  degeneration  of  the  anterior 
tubercle  in  the  case  of  W.  M. 

The  preservation  of  the  external  geniculate  body,  of 
the  peduncle  of  the  anterior  quadrigeminal  body,  and  of 
this  body  itself,  are  explained  by  the  normal  condition  of 
the  optic  cortex  and  the  preservation  of  the  optic  radia- 
tion, except  in  its  most  superior  part. 

The  corpus  mammillare  receiv.es  fibres  from  the  uncus. 


iS  WILLIAM  G.  S FILLER. 

cornu  ammonis  and  surrounding  tissue,  through  the  for- 
nix. None  of  these  parts  were  degenerated  in  the  case  of 
\V.  M.  In  another  case,  which  has  only  been  examined 
macroscopically,  and  which  I  hope  to  be  able  to  report 
later,  more  in  detail,  the  occipital  lobe  is  destroyed  and 
the  cornu  ammonis  is,  to  all  appearances,  much  aflfected  by 
the  primary  lesion.  The  corpus  mammillare  on  the  same 
side  is  only  half  as  large  as  the  corresponding  body  on  the 
normal  side  of  the  brain. 

The  corpus  subthalamicum  is  not  closely  connected 
with  the  cerbral  cortex,  but  it  is  with  the  caudate  nucleus 
and  anterior  part  of  the  putamen  (v.  Monakow).  Only 
the  posterior  and  superior  part  of  the  putamen  wjls  de- 
stroyed in  the  case  of  W.  M.  The  normal  appearance,  or 
at  least  very  slight  diminution  in  the  size  of  the  subthal- 
amic body,  may  be  easily  explained. 

The  fibres  of  the  nucleus  ruber  have  been  found  atro- 
phied after  lesions  of  the  cortex  of  the  operculum,  the 
second  parietal  gyrus  and  possibly  the  temporal  lobe  (v. 
Monakow).  This  nucleus  is  not  much  smaller  on  the  left 
side  than  on  the  right  in  the  case  W.  M. 

The  sensory  nucleus  of  the  fifth  nerve  on  the  side  op- 
posite to  the  cerebral  lesion  is  not  degenerated;  the  case 
therefore  supports  the  statements  of  Mahaim  (1.  c),  but 
is  contrarv  to  those  of  Hosel.^^  The  latter  asserts  that 
the  sensory  nucleus  of  the  fifth  nerve  is  in  direct  connec- 
tion with  the  central  gyri  of  the  opposite  side.  It  is  well 
known  that  Hosel  found  the  contralateral  sensory  nu- 
cleus of  the  fifth  nerve  atrophied,  after  a  lesion  of  the 
central  gyri.  The  right  anterior  cerebellar  peduncle  is 
a  little  smaller  than  the  left.  Unfortunately,  a  portion  of 
the  tissue  was  lost  just  at  this  part  by  the  sections  which 
were  made  for  the  purpose  of  hardening.  Hosel  (1.  c.) 
found  the  anterior  cerebellar  peduncle  on  the  side  opposite 
the  lesion  one-third  less  in  size,  and  he  believed  his  case 

"Hosel:    Archiv  fur  Psychiatric,  vol.  xxiv.,  xxv. 


K' 


SECONDARY  DEGENERATION.  19 

showed  that  there  is  a  connection  of  this  with  the  cen- 
tral lobe.  Edinger  believes  the  connection  is  indirectly 
with  the  parietal  lobe.  According  to  Hosel,  Meynert  also 
thought  that  there  is  a  connection  of  the  nucleus  ruber 
with  the  parietal  lobe.  V.  Monakow  also  reports  atrophy 
of  the  contralateral  anterior  cerebellar  peduncle. 

In  sections  taken  from  the  extreme  upper  part  of  the 
ascending  frontal  convolution  which  externally  appeared 
to  be  normal,  as  may  be  seen  in  the  picture,  search  was 
made  for  the  giant  pyramidal  cells  (Betz).  These  cannot 
be  found.  Mahaim  states  that  Moeli  and  Henschen  as 
well  as  he  himself  have  noted  the  absence  of  these  cells 
in  cerebral  lesions  tn  man. 


La  Mort  dans  i/Hysterie    (Death  in  Hysteria).       (Journ.  de  Med. 

et  Chir.  prat.,  Aug.  25th,  '96.) 

Although  the  manifestations  of  hysteria  are  usually  considered 
to  be  of  a  benignant  character,  cases  have  been  observed  in  which 
death,  due  to  various  conditions,  has  occurred  suddenly.  Dr.  Le 
Foumier,  in  a  thesis,  has  collected  a  number  of  illustrative  cases,  and 
points  to  the  dangers  connected  with  spasm  of  the  glottis,  and  anorexia. 
Thus  several  cases  are  reported  in  which  tracheotomy  was  resorted  to, 
in  order  to  prevent  asphyxia.  A  child,  six  years  old,  in  imminent 
danger  of  being  asphyxiated,  the  attack  lasting  one  hour,  was  saved 
by  applying  the  faradic  current.  Another  case  was  that  of  a  girl,  20 
years  old,  subject  to  laryngeal  spasms,  who  was  revived  by  artificial 
respiration,  but  who  died  shortly  afterwards  in  a  similar  attack.  Hys- 
terical anorexia  ends  fatally  quite  often.  After  a  certain  duration  the 
patients  fall  into  a  semi-comatose  condition,  become  sleepless,  greatly 
emaciated,  and  bedridden.  If  fed  artificially  in  this  state  the  patients 
continue  to  lose  flesh,  the  stomach  being  unable  to  perform  its  func- 
tions. Death  may  also  occur  from  incessant  vomiting,  as  for  instance: 
A  patient,  who  was  subject  to  attacks  of  hysterical  vomiting,  after 
taking  her  evening  meal  as  usual,  went  to  bed  and  died  during  the 
night.  The  autopsy,  made  thirty-six  hours  after  death,  revealed  noth- 
ing abnormal  of  note,  and  the  stomach  contained  four  ounces  of  food. 
Occurrence  of  sudden  death  in  hysterical  subjects  has  further  been  ob- 
served to  be  due  to  attacks  of  angina  pectoris,  and  supervening  upon 
abdominal  operations,  especial  vaginal  hysterectomy.     Macalester. 


SOME  NOTES  OX  ECHOLALIA,'  WITH  THE  RE- 
PORT  OF  AN    EXTRAORDINARY   CASE.^ 

By  martin  W.  BARR,  M.D.. 

Chirf  FbyiticuD  Featuylvaau  TrainiuE  Schoal  for  FFcble-Hinded  Chidrcn. 
Elwyn,  P«. 

WITHIN  the  last  decade  contributions  to  literature 
relating  to  the  various  forms  of  cerebral  speech 
disturbance  have  been  more  or  less  voluminous, 
but  they  have  been  devoted  almost  exclusively  to  those 
most  frequently  met  with,  and  the  rarer  one  of  echolalia 
has  been,  by  the  alienist  touched  but  lightly — the  analy- 
sis of  tlie  term,  the  definition,  a  passing  word  of  comment 
— and  then  dropped.  It  remains,  therefore  that  the  litera- 
ture of  this  subject  is  most  meagre,  the  search  for  informa- 
tion most  discouraging. 

Echolalia  or  echophrasia,  a  broa<ler  and  more  compre- 
hensive term,  although  not  yet  sanctioned  by  common 
usage,  is  a  speech  affection  characterized  by  a  tendency 
t  words  or  phrases  spoken  by  others,  hitherto 
■nerally    observed  and  described  in  combination 
rolalia*  or  with  palmus^. 

term  echolalia  was  first  employed  by  Romberg, 
sidered  it  an  evidence  of  cerebral  softening,  but 
ia'"  notes  it  as  a  sign  of  will  perversion  or  of  im- 
■  defective  inhibition, 

de  la  Tourette.  in  1885.  next  takes  it  up  and  de- 
in  connection  with  coprolalia  and  palmus. 

Echo;  lalia.  Speech. 

before  the  Philadelphia  Neurological  Society,  May  31,  1897. 

ij.  Fillh.  the  tendency  to  repeat  foul  language. 

IS,  A  twitch,  also  known  as  Latah.  Myriacliit,  Tic  eonvulsif 

■r's  disease;  a  nervous  affection   characterized  by  localized 

mary  of  Psyohologicnl   Medicine.  Vol.  I,,  p,  424. 


ECHOLALIA.  2 1 

Noir,  in  1893,  n^ade  a  careful  study  of  the  mental  de- 
generates (idiots  and  imbeciles)  of  France,  and  asserts 
that  the  affection  may  occur  singly  as  well  as  in  combina- 
tion. Landon  Carter  Gray**  coincides  in  this  opinion, 
and  my  own  experience  would  seem  to  verify  the  same. 

Tuke''  givf s  echolalia  as  a  symptom  of  the  general  pa- 
ralysis of  the  insane,  and  adds  that  it  may  be  associated 
with  many  other  nervous  disorders,  most  frequently  with 
epilepsy — the  patient  in  some  cases  imitating  in  his  speech 
not  only  the  words  of  the  person  addressing  him,  but  the 
tones  also. 

Diligent  inquiry  among  alienists,  both  here  and  abroad, 
and  a  careful  study  of  imbeciles  and  speech  defectives, 
covering  together  over  eight  thousand  cases,  gives  the  fol- 
lowing data,  which,  while  throwing  but  little  added  light 
upon  the  subject  to-day,  yet  may  by  its  grouping,  aid  in 
future  scientific  investigations. 

Fletcher  Beach,  late  of  Darenth  Asylum,  says  that 
echolalia  was  there  very  uncommon,  although  it  did  exist 
in  a  few  cases. 

Shuttleworth  also  found  it  in  a  few  cases  at  the  Royal 
Albert  Asylum,  but  neither  of  the  gentlemen  gives  sta- 
tistics. 

Reginald  Langdon  Down  finds  it  in  four  per  cent,  of 
the  cases  of  imbeciles  under  his  care. 

Cesare  Lombroso,  in  a  personal  letter,  says  that  he  has 
observed  echolalia  in  hysterical  imbeciles,  but  never  in 
microcephalic  idiots  or  cretins,  while  W.  W.  Ireland's 
opinion  in  this  direction  narrows  the  field  even  more,  as 
he  states  in  a  recent  letter  that  in  his  experience  echola- 
lia is  not  found  among  the  feeble-minded. 

A  case  reported  by  Lichtheim,  and  by  him  defined  as 
transcortical  motor  aphasia,  may  best  be  explained  by  the 
following  diagram.®    Of  the  triangle  A  B  M  let  B  repre- 


•  The  American  Journal  of  the  Medical  Sciences,  May,  1895. 
'  A  Dictionary  of  Psychological  Medicine,  p.  526. 

•  With  thanks  to  Dr.  Spiller. 


22  MARTI \  If.  BARR. 


^ 


B 


/ 


\: 


m 


!>eni  the  so-called  concept  centre  {Be griff scentr urn  of  the 
Germans),  M  the  centre  of  motor  images,  and  A  the  centre 
of  auditor}-  images.  "  The  reflex  arc  consists  in  an  afferent 
branch  Aa,  which  transmits  the  acoustic  impressions  to 
A:  and  an  efferent  branch  Mm,  which  conducts  the  im- 
pulses from  M  to  the  organs  of  speech,  and  is  completed 
by  the  commissure  binding  together  A  and  M."  (Licht- 
heim.  Brain,  Vol.  VII.) 

"A  variety  of  motor  aphasia  is  created  by  interruption 
of  the  path  B  M,  of  which  we  have  many  examples.  From 
the  diagram  we  should  expect  the  loss  of 

(a)  volitional  speech, 

(b)  volitional  writing, 
whilst  there  are  presen-ed — 

(c)  understanding  of  spoken  language, 

(d)  understanding  of  written  language, 

(e)  the  faculty  of  copying. 

So  far  the  symptoms  coincide  with  those  of  Broca's 
aphasia.    They  differ  inasmuch  as  there  is  preservation  of 

(f)  faculty  of  repeating  words, 

(g)  writing  to  dictation, 

(h)  reading  aloud."    (Lichtheim  C.  c.) 

Charlton  Bastian.  referring  to  this  says:*'  Lichtheim's 
interpretation  of  this  case  is  wholly  different  from  mine. 
He  accounts  for  it  by  supposing  a  damage  of  commissural 
fibres  to  exist,  which  pass  between  his  postulated  centre 


ECHOLALIA.  23 

for  concepts  and  Broca's  convolution,  which  for  him  also 
is  a  motor  region  rather  than  one  of  sensory  type." 

He  goes  on  to  explain :  "  The  meaning  of  this  ability 
to  read  aloud  in  such  a  case  is  that  though  the  auditory 
word-centre  is  so  much  damaged  as  to  be  unable  to  act 
spontaneously  (that  is,  under  volitional  stimuli),  it  is  still 
capable  of  responding  to  the  associational  stimuli  coming 
to  it  as  a  result  of  strong  exitation  of  the  visual  centre. 
Persons  so  affected  are  also  quite  capable  of  responding  to 
sensory  stimuli  passing  direct  to  the  auditory  centre  itself 
— that  is,  they  can  at  once  repeat  words  uttered  before 
them."   (The  Lancet,  April  loth,  1897,  p.  1016.) 

(1.  c.)  "  In  this  relation  it  may  be  mentioned  that  it 
sometimes  happens  that  the  speech  of  patients  is  entirely 
limited  to  a  mere  imitative  repetition  of  words  spoken  in 
their  hearing,  while  they  are  without  the  power  of-volun- 
teering  any  statement;  that  is,  their  auditory  word- 
centres  respond  only  to  direct  sensory  incitations,  and  not 
at  all  to  those  of  an  associational  or  volitional  order.  In 
these  cases  (usually  included  under  the  term  "  echolalia  '*) 
a  marked  general  impairment  almost  invariably  co-exists. 
'"'A  defect  of  this  kind  (occurring  in  a  woman  who  was 
hemiplegic  from  cerebral  hemorrhage)  has  been  recorded 
by  Professor  Behier.  She  was  born  in  Italy,  and  had  re- 
sided both  in  Spain  and  France.  Of  the  three  languages 
she  had  thus  acquired  she  had  completely  forgotten  the 
Italian  and  Spanish,  and  had  only  retained  a  most  limited 
use  of  the  French.  In  this  latter  language  she  only  repeated 
like  an  echo  the  words  pronounced  in  her  presence,  without, 
however,  attaching  any  meaning  to  them.  But  in  the  case 
of  a  woman  seen  at  the  Salpetriere,  by  Bateman,  the  mi- 
metic tendency  was  much  stronger.  She  even  reproduced 
foreign  words  with  which  she  had  never  been  familiar.  It 
is  clear  that  in  such  a  case  as  this  there  must  have  been  a 
mental  degradation  of  a  much  wider  kind  than  that  which 
occurs  when  the  auditory  word-centre  alone  is  reduced  to 
its  lowest  grade  of  functional  activity." 


24  MARTIN  IV.  BARR. 

Transcortical  motor  aphasia,  according  to  Dejerine, 
is  entirely  hypothetical,  being  in  his  opinion  only  a  stage 
of  amelioration  in  the  cortical  motor  aphasia  of  Broca. 

Mills,®in  1891,  cites  two  cases  occurring  in  his  own 
practice — one  a  woman  of  cultivation  and  refinement  who 
would  burst  out  with  a  thrice-repeated  oath  accompanied 
with  an  abrupt  action;  the  other,  a  boy  who  would  give 
unprovoked  utterance  to  filthy  language,  accompanied 
with  violent  movements  of  the  head,  shoulders  and  arms. 

Here  is  undoubted  association  with  both  coprolalia  and 
palmus,  as  is  an  analogous  case  coming  under  my  own  ob- 
servation of  a  beautiful  and  refined  young  girl  attending 
a  mixed  boarding  school,  who  would  at  intervals  give  sud- 
den expression  to  three  words  successively:  The  first  vul- 
gar, the  second  foolish,  the  third  profane;  these  also  asso- 
ciated with  like  convulsive  movements. 

Again,^®  Mills  thinks  echolalia  might  as  properly  be 
classed  under  morbid  impulses  as  under  aphasia,  and  de- 
scribes it  as  "an  aflfection  in  which  convulsive  movements 
are  associated  with  sudden  explosion  of  speech.  The  pa- 
tient with  a  grimace,  contortion  or  violent  movement  of 
some  kind,  suddenly  bursts  into  an  obscene,  profane  or 
absurd  expression.  This  expression  may  be  the  echo  of 
something  overheard — hence  the  name,  echolalia — or  it 
may  be  a  spontaneous  outcry.  It  is  not  simply  an  hyster- 
ical affection,  controllable  and  curable,  but  it  is  a  true 
monomania,  the  affection  of  speech  being  beyond  the  pa- 
tient's volition."  In  a  still  later  article  he  classes  true  echo- 
lalia as  a  characteristic  symptom  of  transcortical  or  supra- 
pictorial  sensory  aphasia.^^ 

In  my  own  personal  examination  of  fifteen  hundred 
and  twenty-five  mentally  defective  children,  I  can  find  but 


•  Aphasia.       Reprint  from  the  Review  of  Insanity  and  Nervous 
Disease  for  September  and  December,  1891,  p.  75. 

"American  Text  Book  of  Diseases  of  Children;  Speech  Defects 
and  Anomalies,  p.  663. 

A  Text  Book  on  Nervous  Diseases.  Dercum,  p.  440. 


11 


ECHOLAUA.  25 

two  cases  of  what  might  be  called  true  echolalia.  One  is 
not  available,  but  the  other,  which  is  unique,  I  here  pre- 
sent. 

Kirtie  M.  Mansfield,  idio-imbecile,  white,  male,  epilep- 
tic, aged  twenty-two  years,  with  the  intelligence  of  a  child 
of  five.  He  is  the  eldest  of  three  children,  the  brother  and 
sister  being  strong  and  healthy,  both  mentally  and  physi- 
cally. Family  history  good,  with  no  trace  of  nervous  or 
mental  disease.  The  parents,  people  of  exceptional  refine- 
ment and  intelligence,  are  distantly  related — the  maternal 
mother  and  paternal  grandmother  bein'g  cousins  german. 
Paternal  grandfather  died  of  some  kidney  trouble  (form 
unknown)  aged  forty;  maternal  grandmother  of  some 
heart  disease  (form  also  unknown)  aged  sixty-seven.  Fa- 
ther thirty-two  and  mother  twenty  at  time  of  thi«  child's 
birth.  Born  at  full  term,  ordinary  labor,  nursed  by  mother, 
with  no  peculiarities  beyond  an  unusually  large  head;  a  per- 
fectly healthy  infant  up  to  sixteen  months,  showing,  the 
father  says,  no  indication  of  mental  disease.  During  teeth- 
ing he  had  petit  mal,  gradually  followed  by  prolonged 
spasms,  and  at  the  age  of  four  developed  true  epilepsy, 
any  excitement  precipitating  an  attack.  He  began  to  talk 
with  the  ease  of  a  normal  child,  but  early  developed  a  habit 
of  peculiar  repetition,  learned  the  alphabet  and  to  repeat 
with  facility  Mother  Goose  rhymes  (which  he  craved  to 
have  sung  to  him  daily).  His  precocious  memory  just  at 
this  period,  coupled  with  these  abnormal  repetitions,  first 
attracted  the  attention  of  those  about  him  as  evidencing 
something  wrong. 

In  disposition  he.  was  gentle,  easily  governed,  social, 
liking  the  presence  of  other  children,  although  not  joining 
in  their  plays,  spending  hours  apart,  amusing  himself  with 
blocks  or  weaving  strings. 

He  had  the  usual  diseases  of  childhood.  In  1884  a 
severe  attack  of  diphtheria  was  followed  by  vaso-motor 
paralysis  of  the  left  side  of  the  face,  which  gradually  yield- 
ed to  treatment.     In  1882,  when  he  first  came  under  the 


26  MARTIN  W.  BARR. 

care  of  the  Pennsylvania  Training  School,  he  cried  a  great 
deal  and  talked  constantly  about  "  a  nice  packer  o'  pins 
and  a  buggy  and  wagon."  Sight  and  hearing  good,  speech 
limited  and  enunciation  slightly  defective.  Nervous,  rest- 
less and  self-willed,  working  himself  into  a  fury  when 
thwarted,  muttering  incoherently  to  himself,  he  spent  a 
great  deal  of  time  twirling  and  untwirling  a  string  until 
at  last  his  nervous  fingers  found  employment  in  knitting; 
in  this  he  accomplished  quite  difficult  patterns  without  as- 
sistance, himself  setting  up  the  required  number  of  stitch- 
es, and  adding  as  directed. 

He  can  now  count  to  fifty;  is  fond  of  music;  is  unable 
to  read  and  write,  but  household  service  has  provedameans 
of  development  for  him,  as  he  has  learned  to  wash  dishes, 
sweep  and  dust,  and  is  orderly  and  methodical  to  a  degree 
quite  remarkable  for  one  of  his  intellectual  grade;  thus  he 
will  voluntarily  gather  up  all  the  litter  from  the  floor, 
winding  the  strings  into  a  ball,  and  never  omits  on  leaving 
the  school-room,  to  say:  "  Kirtie  come  to  school  this  af- 
ternoon?" "  Kirtie  come  to  school  to-morrow?"  "  Kirtie 
come  to  school  Monday  morning?"  as  the  period  may  be, 
without  once  misplacing  time  or  event.  This  he  does  day 
after  day,  invariably  speaking  of  himself  in  the  third  per- 
son. 

From  this  it  will  be  seen  that  he  has  a  certain  amount 
ntelHgence,  although  he  still  passes  much  time  in  a 
le^  smiling  and  muttering  vacant  repetitions.  Re- 
ting  whatever  he  hears,  his  thoughts  are  those  of  others 
his  speech  automatic.  When  addressed  he  rarely  fails 
epetition  before  reply.  Thus  one  may  ask:  "  How  old 
you.  Kirtie?"  and  he  will  immediately  repeat,  taking 
ds  and  tones,  "  How  old  are  you,  Kirtie?"  But  here 
■  be  noted  a  departure  from  the  habitof  precision  before 
itioned.  He  is  now  twenty-two  years  of  age,  and  yet 
he  question,  "  How  old  are  you,  Kirtie?"  following  the 
iriable  repetition,  "  How  old  are  you,  Kirtie?  "  comes 
answer,  '"  Twelve."   Though  accepting  the  suggestion 


ECHOLALIA,  27 

that  he  is  now  twenty-iwo,  he  will,  after  a  few  moments, 
give  the  same  reply,  "  Twelve."  This  is  the  only  indication 
he  gives  of  any  loss  of  memory,  but,  indeed,  I  think  it  may 
rather  show  the  presence  of  some  strong  overlaying  asso- 
ciation with  that  number.  His  keen  sense  of  association 
is  further  shown  in  the  following  instance: 

A  companion  of  whom  he  was  very  fond,  died,  and, 
after  attending  a  service  of  song  some  four  years  after, 
on  being  questioned  as  to  where  he  had  been,  replied, 
•'Heaven,  heaven — home,  Joe  Zun — die  song — heaven," 
the  hymn,  "  Heaven  is  my  Home,"  evidently  recalling  his 
loss. 

His  memory  is,  indeed,  phenominal.  He  recalls  not 
only  the  visits  of  his  parents  and  other  incidents  occurring 
-curing  the  year,  but  also  the  names  of  boys  and  attendants 
he  has  neither  seen  nor  heard  of  for  years,  and  he  will  sit 
talking  to  himself  of  them.  He  catches  readily  both 
words  and  music  of  all  the  popular  songs  at  first  hearing, 
repeating  the  words  almost  verbatim,  or  if  substituting, 
giving  equivalents. 

One  of  the  most  interesting  experiment s  wit  h  him  appears 
all  the  more  wonderful  when  we  consider  his  low  mentality. 
As  before  stated,  he  not  only  repeats  words,  but  also  imi- 
tates voice  and  tone  of  the  speaker  and  frequently  follows 
accurately  in  pantomine  every  movement.  One  afternoon 
I  gave  him,  in  rapid  succession,  words  and  sentences  in 
nine  different  languages:  English,  French,  German,  Span- 
ish, Italian,  Japanese,  Latin,  Greek  and  Norwegian,  and 
each  time  I  found  that,  although  the  words  were  unfamil- 
iar and  would  have  been  difficult  for  an  ordinary  person, 
certainly. for  a  normal  child,  Kirtie  took  the  pronouncia- 
tion  with  facility,  his  voice  keeping  pace  with  mine  as  I 
repeated: 

"  I  am  here  with  thee  and  thy  goats,  as  the  most  ca- 
pricious poet,  honest  Ovid,  was  among  the  Goths." 

"Liberty!    Freedom!    Tyranny  is  dead!    Run  hence. 


r 


2.^  MARTIN  IV.  BARE. 

proclaim  it — cry  about  the  streets,  liberty,  freedom  and 
enfranchisement !" 

"  Pas  a  pas  on  va  bien  loin." 

**  Wir  seufzen  im  nachtlichen  Winde.  Vom  Zweige  ein 
Wink  so  fern." 

"  Superabmidantissimente." 

"  Vedi!  le  fosche  notturne  spoglie,  de'cieli  sveste  I'im- 
mensa  volta." 

'*  Namu  mio  ho  ren  ge  Rio." 

"  Potentissimus  est  qui  se  habet  in  potestate." 

"  Zoe  mou  sas  agapo." 

"  Min  norske  vinter  er  sa  vakker,  med  hoida  snebe- 
dakte  bakker  og  gronne  gran  med  pudret  haar." 

On  another  occasion  he  followed  me  in  the  same  words 
through  three  different  tones  and  inflections  of  voice — 
the  first  a  mere  whisper,  the  last  amounting  to  a  shout, 
his  voice  always  keeping  tally  with  mine.  **  How  do  you 
do,  Kirtie?"  "  How  do  you  do,  Kirtie?  Pretty  well."  I 
repeated  the  question  in  the  same  voice,  then  suddenly 
changing  I  asked  the  question  in  a  loud  voice:  "Are  you 
well,  Kirtie?"  He,  expecting  the  other  question,  shouted 
back,  **  How  do  you  do,  Kirtie?  Pretty  well."  Realizing 
that  his  answer  was  automatic,  and  that  there  was  no 
reasoning  in  it,  I  repeated  it  three  times  before  he  grasped 
the  change,  when  he  replied,  **Are  you  well,  Kirtie?  Yes." 
Placing  my  hat  on  the  floor,  I  said,  **  Go  get  my  hat, 
Kirtie."  This  he  repeated  three  times  without  attempting 
to  move  from  his  seat,  seeming  not  to  understand.  Final- 
ly, picking  it  up  and  tossing  it  from  me,  I  repeated  the 
request,  and,  as  if  aroused  by  the  action,  he  brought  it, 
still  repeating,  "  Go  get  my  hat,  Kirtie."  "  Thsink  you," 
Isaid."Thankyou,  thank  you,  thank  you;  you  are  welcome." 
he  replied.  "What  did  you  take  out  of  Miss  Annie's  room?" 
"  What  did  you  take  out  of  Miss  Annie's  room?  Pins. 
Must  not  steal  pins  to  put  in  coat."  "  What  did  B.  B.  do 
on  the  base-ball  field?"    "  What  did  B.  B.  do  on  the  base- 


ECHOLAUA. 


29 


ball  field?     Ran  away  home.     Bad  boy,"  and  so  on,  with 
indefinite  repetition. 

He  is  extravagantly  fond  of  blocks,  with  which  he  will 
amuse  himself  for  hours. 

Some  years  ago  he  contracted  the  habit,  when  irri- 
tated, of  deliberately  tearing  his  clothing,  especially  his 
stockings,  to  pieces.  The  deprivation  of  his  favorite  play- 
thing was  found  to  be  the  best  discipline  for  this  oflfence. 
Now,  when  his  nurse  attempts  to  put  away  his  blocks,  he 
will  say,  '*  Do  not  take  away  blocks;  will  not  tear  any 
more."  If  asked  if  he  will  loan  or  give  a  block,  he  will  reply, 
always  repeating  the  question,  **  No,  no,  I  will  not  tear  my 
clothes,"  and  when  asked  what  clothes,  replies,  "  My 
stockings."  Occasionally,  if  his  play  is  interrupted  by  a 
spasm,  the  blocks  will  be  scattered,  but  on  regaining  con- 
sciousness he  immediately  gathers  them  up,  knowing 
exactly  both  the  position  and  number. 

I  call  attention  here  to  the  fact  that  this  case  is  associ- 
ated with  epilepsy,  but  neither  with  coprolalia  nor  with 
palmus. 

Dr.  William  G.  Spiller  who  has  been  an  interested  ob- 
server of  the  case,  and  to  whom  I  am  greatly  indebted  for 
aid  in  the  work  of  research  and  comparison,  says,  **  In  per- 
forming a  necropsy  in  a  case  such  as  you  present,  I  should 
notice  especially  the  condition  of  the  posterior  part  of 
the  left  first  temporal  convolution.  The  fact  that  the  boy 
is  an  epileptic  is  a  point  in  favor  of  a  cortical  lesion, 
though,  .of  course,  it  is  no  proof.  As  he  understands  all 
simple  commands,  and  obeys  them,  the  auditory  centre 
cannot,  therefore,  be  destroyed,  but  it  may  be  so  damaged 
that  it  is  incapable  of  responding  to  volitional  stimuli,  yet 
still  be  capable  of  responding  to  impulses  passing  to  it 
over  the  tract  aA.  I  am  not  able  to  accept  the  concept- 
centre,  and  w^ould  prefer  to  explain  your  case  in  the  words 
used  by  Bastian.  To  me  your  patient  presents  a  symptom- 
complex  resembling  that  of  transcortical  motor  aphasia." 
Summing  up  and  comparing,  we  find  echolalia  a  rare 


3()  MARTIN  W.  BARR. 

form  of  aphasia,  betokening  always  a  marked  general  men- 
tal impairment,  and  therefore  most  naturally  associated 
with  other  forms  of  degeneration. 

There  being  no  record  of  an  autopsy  of  such  a  case,  the 
precise  location  of  the  lesion,  if  there  be  one,  is  yet  to  be 
demonstrated. 

In  comparing  the  case  presented  with  Lichtheim's 
proposition,  we  are  confronted  at  once  by  a  difficulty;  the 
boy  is  an  idio-imbecile,  and  his  inability  to  read  or  write 
closes  one  door  of  observation,  but  we  do  find  in  common 
with  his  table,  first  *'  loss  of  volitional  speech,'*  and  second, 
**  preservation  of  understanding  of  spoken  language,  and 
of  faculty  of  repeating  words." 

The  absence  of  volitional  speech,  notwithstanding  an 
abnormal  memory,  would  indicate  a  diseased  condition  of 
the  motor  region,  but  not  destruction,  as  he  does  reply 
and  respond  to  word  of  command. 

Even  the  repetition  of  words  would  almost  appear  to 
be  such  a  response,  or  an  exaggerated  form  of  a  habit  of 
obedience  to  suggestion,  for  it  is  automatic,  not  volitional 
nor  reflective,  such  as  we  often  see  in  normal  persons — an 
effort  to  strengthen  the  sensory  impression  so  as  to  appre- 
hend before  acting. 

Thus  in  the  act  and  in  the  echo  he  is  simply  a  creature 
of  suggestion.  His  capacity  for  receiving  such  suggestions 
so  rapidly  as  to  echo  these  instantaneously  without 
thought  would  tend  to  show  less  impairment  of  the  sen- 
sory than  of  motor  centres,  and  therefore  confirms  my 
impression  that  the  defect,  not  so  much  sensory  as  motor, 
is  rather  to  be  defined  as  transcortical  motor  aphasia. 


j^^' 


jlocietg  l^jeyorts. 


AMERICAN  NEUROLOGICAL  ASSOCIATION. 

Twenty-third  Annual  Meeting,  held  at  St,  John's  Parish  Hall, 
Washington,  D,C,,  May  4ih,  5th  and  6th,  i8gy. 

The  President,  Dr.  M.  A.  Starr,  in  the  chair. 

EPILEPSY  FOLLOWING  INFANTILE  CEREBRAL  PALSY. 
IMPROVEMENT  AFTER  CRANIOTOMY  AND  EVACU- 
ATION OF  A  SUBCORTICAL  CYST. 

Dr.  Wm.  M.  Leszynsky,  of  New  York,  reported  a  case 
of  a  boy  fourteen  years  old. .  At  the  age  of  two  years,  with- 
out known  cause,  general  convulsions  and  unconsciousness 
occurred,  being  rapidly  followed  by  left  hemiplegia  which 
still  exists.  Epilepsy  was  first  manifested  in  his  twelfth 
year.  In  the  beginning  the  attacks  were  limited  to  con- 
jugate deviation  of  the  eyes  and  head  toward  the  paralyzed 
side,  with  momentary  loss  of  consciousness.  These  attacks 
increased  in  frequency.  Later,  the  seizures  were  accom- 
panied by  rigidity  of  the  left  arm,  then  of  the  arm  and  leg, 
and  ultimately  there  were  general  tonic  convulsions  and 
increasing  mental  enfeeblement.  There  was  no  clonic 
i^pasm  at  any  time  while  under  observation.  After  nearly 
a  year  of  ineffectual  hygienic  and  medicinal  treatment 
an  exploratory  operation  was  advised.  An  opening  was 
made  in  the  skull  over  the  right  Rolandic  area,  and  a  large 
subcortical  cyst  was  found  in  this  region.  This  was  com- 
pletely evacuated  after  free  incision  through  the  extremely 
atrophied  cortex.  The  brain  tissue  was  sutured  with 
catgut,  the  wound  closed  in  the  usual  manner,  and  the 
patient  made  a  prompt  and  uneventful  recovery  from  the 
operation. 

This  was  followed  by  absence  of  epileptic  attacks  for 
three  and  a  half  months.    He  then  had  seven  general  con- 


32  AMERICAN  NEUROLOGICAL  ASSOCIATION. 

vulsions,  tonic  in  character,  within  eighteen  hours.  The 
cyst,  which  had  refilled,  was  emptied  by  aspiration,  and 
the  attacks  disappeared  for  more  than  three  months. 
Again  the  cyst  was  evacuated.  Bromide  was  subsequently 
administered,  and  under  its  continued  use  there  have  been 
only  occasional  mild  attacks.  The  boy's  general  and 
mental  condition  have  undergone  considerable  improve- 
ment. The  speaker  referred  t©  the  advisability  of  perma- 
nent drainage  in  such  cases. 

Dr.  J.  W.  Putnam: — In  reference  to  the  question  of  con- 
vulsions being  caused  by  pressure  from  a  cyst,  I  can  say  that 
three  or  four  years  ago  1  had  a  patient,  a  boy  between  two  and 
three  years  old,  in  whom  the  first  convulsion  was  caused  by 
trauma  of  the  head  from  a  fall.  Some  time  afterwards  convul- 
sions developed.  There  was  a  second  trauma  from  a  fall  in  one 
of  these  convulsions.  Operation  was  performed  first  over  the 
point  of  injury,  where  he  had  fallen  forward  and  struck  his 
forehead  ,  and  a  large  amount  of  fluid  was  evacuated  from  the 
cyst.  The  fluid  soaked  through  the  thick  dressing  for  several 
days.  It  was  impossible  to  keep  a  record  of  the  number  of  at- 
tacks of  convulsions  that  the  child  had.  They  numbered  fifteen 
to  twenty  in  an  hour.  It  was  said  that  he  had  sometimes  as 
many  as  sixty  or  eighty  in  the  course  of  the  day.  That  bo> 
had  a  continuous  loss  of  fluid  for  a  week.  Then  the  wound 
healed  and  there  was  no  more  discharge,  and  the  patient  had 
no  convulsions  for  a  period  of  several  weeks,  after  which  time 
they  returned  with  the  same  violence  and  frequency.  Dr.  Par- 
mcnter,  who  made  the  first  operation,  also  made  the  second, 
and  we  again  evacuated  the  fluid  and  put  in  catgut  and  allowed 
drainage  to  go  on  as  long  as  the  fluid  continued  to  flow.  The 
convulsions  commenced  after  a  time  as  the  flowing  of  the  fluid 
ceased,  and  a  third  time  the  opening  of  the  old  wound  was 
necessary.  The  child  was  last  heard  from  six  months  ago  and 
had  had  no  convulsions  whatever  for  two  years. 

Dr.  Angell: — Three  years  ago  I  reported  a  case  of  imbecil- 
ity and  epilepsy  in  a  child  on  whom  craniotomy  had  been  per- 
formed. I  have  recentlv  heard  from  that  child  and  desire  to 
record  the  result,  which  has  been  successful  after  an  interval  oi 
three  years.  Since  the  operation  he  has  not  had  an  attack  ot 
epilepsy,  and  there  has  been  a  steady,  though  rather  slow,  im- 
provement in  his  mental  condition.  His  habits  are  no  longer 
vicious  and  he  is  gradually  acquiring  some  knowledge  and  is 
able  to  take  proper  care  of  himself,  and  in  all  ways  he  is  in  a 
condition  of  satisfactory  development.  The  pathologic  condi- 
tion was  a  hemorrhagic  meningeal  cyst,  which  offers  one  of  the 
most  promising  opportunities  for  surgical  interference. 


iT 


fpVENTY-THIRD  ANNUAL  MEETING.  33 

In  the  case  of  subcortical  cyst  reported  by  Dr.  Leszynsky, 
I  should  think  that  he  would  have  to  remove  a  portion  of  the 
cvst  wall  if  he  wished  to  obtain  relief  from  the  attacks. 

Dr.  Pershing: — Six  years  ago  I  reported  the  case  of  a  man 
who  had  had  a  blow  on  the  head,  and  some  time  afterwards  be- 
gan to  have  attacks  of  Jacksonian  epilepsy.  A  cyst  about  an 
inch  and  a  quarter  deep  was  found  under  the  upper  face  cen- 
tre, and  was  drained.  At  the  time  the  case  was  reported  here 
only  about  three  months  had  elapsed  since  the  operation.  I 
heard  from  the  patient  for  a  year  after  the  operation,  and  he 
had  no  return  of  the  attacks.    After  that  I  lost  sieht  of  him.  . 

Dr.  Worcester: — I  have  had  one  case  of  epilepsy,  which  I 
considered  to  be  due  to  a  brain  cyst,  in  a  negro^  who  had  no 
paralysisatall.  I  foundat  the  necropsy  a  cyst  containing,!  should 
think,  three  drachms  of  fluid  and  situated  on  the  surface  of  the 
left  frontal  lobe.  This  seems  to  me  to  have  probably  been  the 
cause  of  his  convulsions,  although  there  was  nothing  localizing 
in  his  movements. 

I  have  had  the  opportunity  of  making  seven  autopsies  in 
cases  of  infantile  cerebral  palsies,  and  as  autopsies  in  these 
cases  are  not  very  frequently  reported,  perhaps  it  would  be 
proper  for  me  to  speak  of  what  I  found,  because  the  findings 
were  very  uniform.  In  all  but  one  there  was  very  great  asym- 
metry of  the  hemispheres,  and  I  am  inclined  to  think  that  I 
may  have  overlooked  some  asymmetry  in  the  first  one,  as  I 
was  not  expecting  to  find  it.  There  was  great  asymmetry  of 
the  optic  thalami  in  that  case,  and  the  comu  ammonis  of  the 
left  side  was  sclerotic.  In  four  of  the  others  the  asymmetry 
was  mainly  observed  in  the  external  surface;  that  is,  the  af- 
fected hemisphere  was  very  much  smaller  than  the  other,  and 
the  optic  thalamus,  and  to  a  less  extent  the  corpus  striatum, 
were  atrophied.  In  the  other  two  cases  the  ventricles  were 
ver>'  greatly  dilated.  In  one,  the' brain,  when  exposed,  showed 
but  little  difference  in  the  two  sides,  but  the  greater  part  of  one 
hemisphere  was  not  more  than  one-fourth  to  one-half  an  inch 
thick,  and  the  corpus  callosum  was  reduced  to  a  transparent 
membrane.  In  the  other  case  the  dilatation  was  not  so  great  in 
the  ant<*rior  comu  of  the  ventricle,  but  the  posterior  portion  of 
the  ventricle  was  greatly  dilated,  and  the  wall  of  the  hemis- 
phere greatly  thinned  in  one  place,  where  the  external  wall  of 
the  ventricle  was  reduced  to  a  translucent  membrane. 

I  judge  that  this  must  be  a  very  common  condition  in  such 
cases,  and  of  course  in  cases  of  that  sort  I  do  not  suppose  that 
any  benefit  could  be  anticipated  from  operation,  fspeak  of 
these  cases  especially  with  reference  to  the  matter  of  prognosis 
in  regfard  to  operations. 

The  President: — I  have  not  drained  a  cyst  permanently;  I 
have  seen  cysts  drained  as  long  as  three  months,  and  that  is  the 


34  AMERICAN  NEUROLOGIC  4L  ASSOCIATION. 

longest.  My  experience  with  cysts  is  an  unfortunate  one.  I 
have  seen  the  symptoms  return  so  many  times  after  the  re- 
moval of  the  fluid  from  the  cyst  that  I  think  it  is  useless  to  open 
them.  The  only  thing  that  is  of  service,  is  to  keep  the  cyst 
open  so  that  it  fills  up  from  the  bottom.  In  the  long  run  oper- 
ations on  cysts  of  the  brain,  whether  of  traumatic  or  unknown 
origin,  are  almost  futile.  I  base  this  statement  on  my  experi- 
ence in  eight  cases;  two  of  them,  which  have  been  operated  on 
within  three  months  in  spite  of  my  semi-approval  of  the  oper- 
ation, have  shown  that  it  is  practically  useless,  and  in  none  has 
there  been  permanent  recovery  from  the  epilepsy. 

Dr.  Wm.  M.  Leszynsky,  of  New  York: — We  all  know  that, 
as  a  rule,  these  are  the  most  unfortunate  cases  for  surgical 
treatment.  However,  in  a  case  of  this  character,  I  think  we  are 
justified  in  recommending  an  exploratory  operation. 

In  the  case  reported,  considerable  relief  followed  each  evac- 
uation of  the  cyst,  and  the  improvement  has  been  permanent. 


Dr.  Graeme  M.  Hammond  read  by  title  a 

REPORT   OF   A   CASE   OF  JACKSONIAN    EPILEPSY,    RE 

LIEVED  BY  AN  OPERATION. 


Dr.  Chas.  L.  Dana,  of  New  York,  read  by  title  the  fol 
lowing  paper: 

TWO    CASES    OF    BASEDOW'S    DISEASE,    WITH 

AUTOPSIES. 


Dr.  Samuel  Ayres,  of  Pittsburg,  read  a  paper  entitled: 

AN  UNCOMMON  NASAL  PARESTHETIC  NEUROSIS. 

Dr.  Baker: — A  patient  of  mine,  a  woman  approaching  the 
menopause,  has  a  similar  sensation  in  the  tongue,  recurring  at- 
tacks of  fullness  and  pain,  and  disagreeable  sensations  in  the 
tongue,  that  come  and  go.  Sometimes  they  will  be  absent  for 
a  number  of  weeks,  then,  again,  they  will  recur  frequently  for 
a  few  days,  and  then  will  be  followed  by  a  longer  period  of  de- 
cline and  a  final  subsidence,  and  so  on. 

I  have  always  found  in  the  management  of  her  affection 
that  sharp  faradization  of  the  tongue  stops  the  attack.  She  is 
of  a  neurasthenic  constitution  and  degenerate  tyne.    I  have  no 


TWENTY-THIRD  ANNUAL  MEETING,  35 

theory  to  advance.  The  thought  occurred  to  me  that  possibly 
the  condition  of  the  nose  in  the  patient  of  Dr.  Ayres  may  be 
allied  to  that  condition  of  flushing  of  the  eyes  and  smarting  of 
the  lids  which  is  found  connected  with  the  rheumatic  or  gouty 
diathesis.  If  I  had  such  a  case  I  should  attempt  to  treat  it  with 
this  idea  in  mind. 


Dr.  E.  W.  Taylor,  of  Boston,  read  by  title  a  paper  on 

FIVE  DEFECTIVE  BRAINS. 

These  brains  were  all  taken  from  persons  who  showed 
more  or  less  unmistakable  signs  of  insufficient  mental  de- 
velopment. The  exact  determination  of  mental  deficiency 
was,  in  certain  of  the  cases,  difficult,  owing  to  the  extreme 
youth  of  the  patients.  The  brains  show  marked  alteration 
in  gross  structure,  to  which  fact  we  desire  now  to  call  spe- 
cial attention,  rather  than  to  the  more  fundamental  micro- 
scopical alterations,  which  it  is  hoped  may  form  part  of  a 
more  complete  piece  of  work  to  follow  this  preliminary  re- 
port. 

Case  I. — The  brain  is  from  a  young  child  from  the  In- 
fants' Hospital,  who  was  supposed  to  have  suffered  a  frac- 
ture of  the  skull  in  the  frontal  region.  Operation  was  per- 
formed and  was  followed  by  death.  The  brain  presents  a 
remarkably  symmetrical,  bilateral  agenesis  of  the  frontal 
lobes,  of  the  type  of  microgyria.  The  remainder  of  the 
brain,  macroscopically,  is  essentially  normal.  The  sharp 
line  of  demarcation  between  the  atrophied  and  the  normal 
convolutions,  suggesting  an  intra-uterine  affection  of  the 
anterior,  and  part  of  the  middle  cerebral  arteries,  as  the 
cause  of  the  maldevelopment,  is  of  particular  interest.  The 
resemblance  of  this  brain  to  that  of  the  higher  apes  is  ex- 
ceedingly striking. 

Case  II. — ^This  brain  is  from  a  microcephalic  idiot  of 
twenty  years,  who  had  neither  spoken  nor  walked  during 
life.  The  specimen  shows  a  defective  development  of  both 
hemispheres,  but  chiefly  of  the  left.  Microgyri  were 
marked  in  the  occipital  region.  The  fissure  of  Rolando 
and  the  general  arrangement  of  the  convolutions  are  en- 
tirely anomalous.  Of  chief  interest  is  the  extreme  thin- 
ning of  the  wall  of  the  hemispheres  in  both  parieto-occi- 
pital  regions,  again  most  markedly  in  the  left,  with  a  con« 


36  AMERICAN   NEUROLOGICAL  ASSOCIATION, 

sequent  dilatation  of  the  posterior  horns  of  the  lateral  ven- 
tricles. The  brain  does  not  cover  the  cerebellum,  which 
is  well  developed. 

Case  III. — The  brain  is  from  an  infant  of  approximate- 
ly eight  months,  from  the  Infants'  Hospital.  Clinically, 
the  child  showed  signs  of  defective  mental  development, 
which  was  associated  with  frequent  convulsive  seizures  of 
a  peculiar  character. 

The  necropsy  showed  a  brain  practically  non-convo- 
luted, a  condition  which  we  believe  to  be  of  most  extreme 
rarity.  There  are  no  marked  gross  defects  in  this  case;  the 
cerebellum  is  well  covered  by  the  hemispheres,  and  the 
island  of  Reil  is  not  exposed.  Apart  from  the  fissure  of 
Sylvius,  which  naturalK  must  be  present,  and  the  first  tem- 
poral sulcus,  there  are  no  fissures  nor  sulci  whatever  on 
the  convexities  of  the  brain,  except  a  few  shallow  and 
anomalous  furrows.  The  fissure  of  Rolando  is  absolutely 
lacking.  The  brain  has  the  general  appearance  of  being 
covered  with  plaster.  The  mesial  aspect  of  the  hemis- 
pheres is  slightly  fissured,  as  is  also  the  base.  The  cerebel- 
lum and  brain  stem  are  normal  in  appearance. 

Case  IV. — The  brain  is  from  a  child  of  two  years,  from 
the  Infants'  Hospital.  There  had  been  marked  mental  de- 
fects. Operation  of  craniotomy  was  performed  and  re- 
peated, but  death  occurred  after  the  second  operation. 

The  specimen  is  also  one  of  great  rarity,  though  not  so 
unusual  as  the  one  preceding.  There  is  complete  absence 
of  both  cerebral  hemispheres,  with  the  exception  of  im- 
perfect occipital  lobes,  and  a  small  portion  of  the  tem- 
poral lobes.  The  central  ganglia  are  present;  the  optic 
thalami  are  poorly  developed;  the  cerebellum  is  well 
formed  and  of  normal  size;  the  pons  is  small,  and  agenesis 
of  the  pyramidal  tracts  is  observed  in  the  medulla  oblon- 
gata. 

Case  V. — The  brain  is  from  a  microcephalic  child  of 
three  months,  from  the  Infants'  Hospital.  In  this  case  a 
small  tumor,  apparently  connected  with  the  dura  mater, 
projected  from  the  vertex  of  the  skull.  Operation  for  its 
removal  resulted  in  death.  The  necropsy  showed  a  small 
brain,  chiefly  anomalous  in  the  extreme  lack  of  develop- 
ment of  the  whole  right  cerebral  and  cerebellar  hemis- 
pheres, with  a  consequent  distortion  of  the  left  hemis- 
phere.    The  longitudinal  fissure  of  the  brain  describes  a 


r 


TWENTY-THIRD  ANNUAL  MEETING.  37 

curved  course,  its  concavity  is  toward  the  atrophied  hem- 
isphere. The  volume  of  the  right  hemisphere  is  approxi- 
mately a  third  of  that  of  the  left.  The  same  is  true  of  the 
cerebellum.  The  convolutions  are  entirely  anomalous  in 
both  hemispheres. 


Dr.  Wm.  C.  Krauss  presented  a  paper  with  the  title 

A  RECEPTACLE  FOR  HARDENING  HUMAN  BRAINS. 
Dr.  Charles  W.  Burr  read  by  title 

A  CASE  OF  PSYCHIC  ANESTHESIA. 

B.  C.  was  twenty-four  years  old  when  he  presented 
himself  to  Dr.  Burr  for  treatment.  When  he  was  about 
ten  years  old  he  was  accidently  struck  on  the  side  of  the 
head  by  an  axe  handle  with  such  force  that  he  was  thrown 
into  a  river,  on  the  bank  of  which  he  had  been  standing. 
Examination  of  the  head  showed  that  he  had  a  simple 
depressed  fracture  of  the  right  parietal  bone  over  the  mo- 
tor area.  He  remained  in  a  state  of  alternate  coma  and 
delirium  for  about  three  weeks.  On  recovering  conscious- 
ness he  found  himself  partially  paralyzed  on  the  left  side 
of  the  body  and  face,  and  completely  anesthetic  upon  the 
same  side.  The  palsy  and  anesthesia  entirely  passed  away 
in  a  few  months,  sensation  returning  before  motion.  He 
was  supposed  to  have  recovered  completely,  until,  on  put- 
ting his  left  hand  into  his  coat  pocket  for  the  first  time 
after  his  illness,  he  discovered  that  he  could  not  tell  what 
he  had  in  his  grasp,  though  he  had  preserved  the  sense  of 
touch.  Little  attention  was  paid  to  this  symptom  at  the 
time,  and  he  was  told  that  it  would  soon  pass  away;  but  it 
has  not  done  so. 

The  present  examination  shows  that  he  is  a  fairly 
healthy-looking  man,  though  neurotic,  supersensitive  and 
morbid.  The  left  leg,  arm  and  face  are  slightly  smaller 
than  the  right.  There  is  no  palsy  of  either  side  of  the 
body,  but  the  left  hand  is  used  a  little  awkwardly.  The 
gait  and  station  are  normal.  The  knee-jerks  are  equal  and 
a  little  exaggerated.  There  is  no  depression  or  pain  on 
pressure  at  the  seat  of  the  alleged  fracture.     Pressure  on 


38  AMERICAN  NEUROLOGICAL  ASSOCIATION. 

the  vertex  over  an  area  about  as  large  as  a  one-cent  piece 
causes  mental  confusion,  a  condition  of  dreaminess,  and, 
if  long  continued,  light  hypnotic  sleep.  With  the  eyes 
shut  he  recognizes  well  variations  in  the  positions  of  the 
hands  or  arms.  Tactile  sense  is  normal  on  both  sides, 
except  that  on  the  entire  left  side,  even  on  the  finger  tips, 
he  fails  to  localize  touch.  He  is  absolutely  unable  to  rec- 
ognize any  object  put  into  his  left  hand,  but  knows  that 
he  is  grasping  something.  His  grasp  is  good,  and  remains 
good  when  the  eyes  are  shut,  there  being  no  muscular 
relaxation  even  after  several  minutes.  There  is  no  sensory- 
trouble  in  the  right  hand.  On  both  sides  the  temperature 
and  pain  senses  are  normal,  and  he  can  distinguish  dull 
objects  from  sharp  ones.  There  is  no  difficulty  with 
speech,  vision,  hearing,  taste  or  smell.  The  urine  is  nor- 
mal. Examination  of  the  thoracic  and  abdominal  viscera 
is  negative.  There  is  a  partial  reversal  of  the  color  fields. 
This  case  differs  frofn  similar  ones  in  the  loss  of  the 
ability  to  localize  sensation,  and  this,  the  writer  believes, 
stands  in  causal  relation  to  the  failure  to  recognize  objects 
by  touch.  He  regards  the  case  as  probably  one  of  hys- 
teria. 


Dr.  Smith  Baker  read  a  paper,  entitled: 

STEPS  TOWARD  INSANITY. 

He  stated  that  recent  studies  of  the  neuron  seem  to  in- 
dicate that  the  biological  doctrine  that  activity  determines 
stucture,  and  thus,  in  turn,  determines  function,  may  be 
applied  to  the  causation  of  insanity.  The  rule  seems  to  be 
that  exhaustion  of  the  brain  cells  comes  first,  then  acute 
intoxication,  and  finally,  structural  changes  as  the  result 
of  these  conditions.  The  major  premise  of  every  study 
of  the  causation  of  insanity  may  be  assumed  to  be  this, 
viz.:  every  pathopsychical  manifestation  in  the  individual 
is  evidence  of  neuronic  structural  defect,  and  until  other- 
wise proved,  every  neuronic  structural  defect  should  be 
regarded  as  evidence  more  or  less  conclusive  of  remote 
untoward  influence  primarily  on  the  part  of  ancestry.  The 
neuronic  defect  itself,  according  to  Van  Gieson,  may  al- 
ways be  regarded  as  a  true  parenchymatous  degeneration, 
involving  not  only  the  cells  proper,  but  primarily  their 


r 


TWENTY-THIRD  ANNUAL  MEETING,  39 

ultimate  protoplasmic  expansions  and  "contact  granules'* 
(Andriezen).  With  reference  to  the  steps  by  which 
vesania  is  initiated,  we  must  look  to  fincestry  for  the  first 
ones.  Marriage  of  unmarriageable  parties  results  in  certain 
tensions  and  stresses  which  lead  to  arrests  and  perversions 
of  development  on  the  part  of  children.  These,  not  gen- 
erally presenting  evidences  of  vesania  themselves,  carry 
over  to  succeeding  generations  their  own  hereditary  de- 
fects of  structure  and  function,  and  in  the  latter  they  be- 
come intensified  and  eventually  break  out  in  pathopsych- 
ical  manifestations.  Probably  one-third  of  all  marriages 
are  of  a  character  which  necessitates  a  bad  prognostica- 
tion as  regards  progeny.  Again,  overstrain,  worry,  nu- 
tritional perversions,  and  toxemia  resulting  from  these 
during  the  child-bearing  period,  are  other  sources  of  ve- 
sanic  predisposition.  The  same  should  be  said  of  the  in- 
adequate training  to  which  so  many  children  are  subjected. 
Accidents,  diseases  and  emergencies  serve  as  exciting 
causes  chiefly  where  birth,  nurture  and  education,  singly 
or  combined,  have  been  deficient.  All  this  suggests  a 
prophylactic  pedagogics  founded  upon  neurological  con- 
clusions. 


PHILADELPHIA  NEUROLOGICAL  SOCIETY. 

October  25th,  1897. 
The  President,  Dr.  Charles  W.  Burr,  in  the  chair. 
Dr.  A.  Ferree  Witmer  exhibited. 

A  CASE  OF  AKROMEGALY. 

The  patient  was  a  female,  aged  fifty-five,  unmarried, 
and  a  native  of  Ireland.  The  early  personal  and  family 
history  were  negative.  The  time  of  onset  of  the  disease 
was  unknown.  A  photograph  of  the  patient,  taken  in  1876, 
showed  disproportionate  development  of  the  lower  part 
of  the  face,  including  the  pinna  of  the  ear.  The  woman  ap- 
plied for  treatment  of  a  dull,  intermittent  pain  in  the  left 
knee  joint.  The  joints  throughout  the  body  were  fully  mov- 
able and  non-crepitant.  She  complained  also  of  somno- 
lence so  intense  that  she  frequently  fell  asleep  while  at 
work.  This  condition  had  been  noted  for  two  years,  and 
was  as  likely  to  occur  in  the  morning  as  in  the  evening 
hours,  and  was  increasing  in  degree.  She  had  complained 
of  vertigo  for  a  period  of  six  months,  about  two  years  ago, 
and  had  a  dull  morning  headache  also  at  that  time.  The 
tongue  was  swollen  at  times.  The  voice  had  become  deeper 
in  pitch,  the  speech  slow  and  muffled,  the  appetite  slightly 
in  excess,  and  the  thirst  constant.  The  urine  was  voided 
frequently  and  in  large  quantities.  She  had  intractable 
diarrhea  at  irregular  intervals,  and  had  had  the  menopause 
twelve  years  ago,  and  no  abnormality  had  been  noted 
throughout  its  course.  She  had  hot  and  cold  flushes;  her 
extremities  were  always  comfortably  warm.  She  was  not 
oversensitive  to  heat  or  cold;  her  memory  had  failed 
slightly;  she  had* worn  a  number  five  boot  comfortably 
five  years  ago,  but  a  number  seven  was  now  required. 
There  were  no  disturbances  of  the  special  senses.  / 

The  weight  of  the  patient  was  two  hundred  pounds; 
her  height  was  five  feet  six  inches. 


PHILADELPHIA  NEUROLOGICAL  SOCIETY.  4 1 

The  enlargement  was  general  and  not  circumscribed 
to  the  extremities.  Skiographs  of  the  hand  and  foot 
showed  marked  increase  of  the  soft  parts,  possibly  with 
changes  in  the  cartilages,  but  with  no  increase  of  the  bony 
structure.  Fluoroscopic  examination  of  the  lower  jaw 
and  of  the  thorax  showed  proportionally  no  increased 
amount  of  bone.  Her  hair  was  abundant  and  natural  in 
color;  her  skin  was  puffy  and  pitted  slightly  on  pressure 
over  the  dorsum  of  the  hands;  the  face  was  elongated  but 
symmetrical;  the  eyelidswere  enlarged;  the  nose  was  thick- 
ened; the  cheek  bones  were  prominent;  the  cheeks  were  flat- 
tened; the  lower  lip  was  protruded;  the  tongue  was  large^ 
flabby  and  slightly  fissured;  the  palate  was  highly  arched; 
the  cartilages  of  the  larynx  and  nose  were  hypertrophied; 
the  lower  jaw  was  very  prominent ;  the  neck  was  short  and 
thick,  and  the  thyroid  body  was  not  prominent.  There 
was  no  retrosternal  dulness;  there  was  slight  cervico- 
dorsal  kyphosis.  The  measurements  of  the  trunk  and  ex- 
tremities gave  normal  averages  in  length,  but  the  width 
was  materially  increased.  The  nails  of  the  fingers  and 
toes  were  normal  in  appearance;  the  heart  and  lungs  were 
normal;  the  respiration  was  shallow;  the  urine  was  of  low 
specific  gravity,  1008  at  one  examination,  but  contained 
no  albumin,  no  sugar,  and  no  peptone;  the  eyeballs  were 
slightly  prominent;  the  visual  fields  for  form  and  color 
were  normal;  the  pupils  responded  freely  to  light  in  ac- 
commodation and  in  convergence,  and  a  far-sighted  astig- 
matism of  mild  degree  was  present.  Tests  to  determine 
rate  of  sense  perception  gave  high  thresholds  in  every 
instance,  showing  an  average  retardation  of  reaction  time 
to  forty  per  cent,  below  the  normal.  Dynamometer  tests 
indicated  average  strength.  The  knee  jerks  were  sluggish; 
there  was  no  clonus;  the  station  was  normal,  and  the  gait 
was  quick.  The  medication  consisted  of  an  extract  of 
thyroid  body  in  doses  of  fifteen  grains  daily  for  a  period 
of  three  months,  but  this  was  without  benefits—and  later  of 
eight  grains  of  an  extract  of  pituitary  body^  daily  for  two 
months,  which  also  was  without  apparent  benefit. 


42  PHILADELFHIA  NEUROLOGICAL  SOCIETY. 

Dr.  Spiller  exhibited,  in  the  names  of  Drs.  F.  A.  Pack- 
ard and  H.  W.  Cattell, 

THE    BRAIN    AND    SPINAL    CORD     FROM    A    CASE    OF 

AKROMEGALY. 

He  stated  that  Striimpell  had  recently  remarked  on 
the  great  number  of  cases  of  akromegaly  in  which  tumor 
of  the  pituitary  body  had  been  found. 

The  specimens  presented  were  from  a  case  which  had 
been  reported  clinically  by  Dr.  Packard.  A  large  tumor 
which  proved  to  be  a  round-cell  sarcoma,  and  was  about 
the  size  of  an  English  walnut  was  found  in  the  pituitary 
body,  and  had  eaten  away  the  base  of  the  skull  by  pressure. 
The  optic  nerves  were  much  pressed  upon,  and  the  nasal 
side  of  the  right  nerve  was  degenerated.  The  left  had 
not,  at  that  time,  been  examined.  Large  calcareous  plates 
were  found  in  the  pia-arachnoid  of  the  cord,  and  were  very 
numerous.  These  were  not  supposed  to  have  been  in  re- 
lation with  the  akromegaly. 

The  speaker  stated  that  it  is  difficult  to  believe  that  a 
small  gland,  such  as  we  know  a  part  of  the  pituitary  body 
to  be,  could  by  its  altered  functions  produce  the  appear- 
ances of  a  systemic  disease  like  akromegaly,  though  he 
could  not  deny  the  possibility  of  this.  He  said  that  occa- 
sionally the  gland  had  been  found  diseased  when  the 
symptoms  of  akromegaly  had  not  been  present,  as  in  a 
case  reported  by  Dr.  Packard  in  connection  with  this  case 
of  akromegaly.  The  frequency  of  disease  of  the  pituitary 
body  in  cases  of  akromegaly,  he  thought,  did  not  prove 
conclusively  that  this  is  the  cause  of  the  latter  affection. 

He  stated  that  he  had  been  much  interested  in  the 
possibility  of  surgical  interference  in  cases  of  akromegaly 
in  which  the  symptoms  rendered  the  diagnosis  of  a  tumor 
of  the  pituitary  body  probable,  as  in  this  case,  in  which 
bilateral  temporal  hemianopsia,  with  optic  atrophy, intense 
headache,  somnolence,  absence  of  the  patellar  reflex,  and 
failure  of  memory,  were  present.  In  other  cases  in  which 
the  diagnosis  of  tumor  could  not  be  made,  the  question 
of  operation,  of  course,  would  hardly  arise.  If  we  believe 
that  altered  function  of  the  pituitary  body  is  the  cause  of 
akromegaly,  he  thought  that  we  might  well  dread  the 
effects  of  removal  of  the  entire  gland.    He  regretted  that 


PHILADELPHIA  NEUROLOGICAL  SOCIETY.  43 

Dr.  Keen  had  been  unable  to  be  present  to  discuss  this 
important  question,  and  read  the  following  communication 
from  him: 

'*  You  are  at  liberty  to  say  that  my  experience  in  the 
case  of  brain  tumor  in  the  frontal  lobe,  operated  on  in 
Baltimore  a  year  ago  last  spring  with  Dr.  H.  M.  Thomas, 
and  shown  at  the  meeting  of  the  American  Neurological 
Association  here  not  long  afterward,  would  make  me  be- 
lieve that  by  lifting  an  osteoplastic  flap  from  the  forehead, 
either  in  one  large  piece  or  possibly  better  by  one  flap, 
on  each  side,  it  would  be  possible  to  reach  the  pituitary 
body.  Whether  the  hemorrhage  and  other  emergencies 
that  might  then  arise  would  be  too  difficult  to  cope  with, 
I  do  not  know,  but  I  should  believe  that  we  could  do  so 
successfully." 

DISCUSSION. 

Dr.  F.  A.  Packard: — I  have  nothing  particular  to  add  to 
what  Dr.  Spiller  has  said.  The  condition  of  the  patient  re- 
mained practically  unaltered  frotn  1892  until  the  last  time  I 
saw  him,  six  months  before  his  death.  Between  1886  and 
1896,  there  was  no  return 'of  the  attacks  of  somnolence.  If  the 
somnolence  had  been  due  to  the  tumor,  is  it  presumable  that  it 
would  have  continued. 

There  was  no  loss  of  smell  when  I  last  tested  it  a  year  ago. 

There  was  one  sympton  which  was  never  sufficiently  studied, 
because  it  was  difficult  to  get  hold  of  the  man,  and  that  was 
the  profuse  secretion  from  the  nose.  The  patient  had  con- 
stant severe  headache  which  brought  tears  to  his  eyes,  and  it 
was  a  question  whether  this  secretion  was  not  composed  in 
great  part  of  tears.  On  one  occasion  I  found  that  this  fluid 
contained  a  large  quantity  of  sodium  chloride,  a  good  deal  of 
nucleo-albumin,  and  under  the  microscope  a  large  number  of 
mucus  corpuscles. 

The  fields  of  vision  were  tested  a  second  time  in  1894  or 
1895  by  Dr.  de  Schweinitz  and  found  to  be  contracted  in  all 
directions,  though  previously  there  had  been  bitemporal  hemi- 
anopsia. There  was  no  material  change  from  the  report  in 
1892.  I  ascribed  the  increase  in  visual  power  to  necrosis  of 
the  sella  turcica  allowing  more  room  for  the  spreading  out  of 
the  nerve  fibres,  although  thi;^  explanation  did  not  seem  to  be 
entirely  satisfactory.  It  is  possible  that  a  hemorrage  occurred 
in  the  tumor  in  1885, giving  rise  to  increase  of  bulk  of  the  mass, 
and  so  producing  somnolence  and  hemianopsia  which  ceased 
as  the  blood  was  absorbed. 

Dr.  Francis  X.  Dercum: — I  am  glad  to  see  these  interest- 


44  PHILADELPHIA  NEUROLOGICAL  SOCIETY. 

ing  specimens  as  I  saw  the  patient  many  times  during  life.  I 
am  also  pleased  to  hear  that  Dr.  Spiller  takes  the  (x^sition  that 
I  did  some  years  ago,  namely,  that  it  is  not  philosophical  to 
ascribe  the  symptoms  of  akromegaly  to  disease  of  the  pituitary 
body.  As  a  matter  of  fact,  there  is  scarcely  a  gland  in  the  body 
that  has  not  been  described  as  enlarged  in  certain  cases  of  this 
affection.  It,  therefore,  seems  premature  to  ascribe  it  to  dis- 
ease of  the  pituitary  body,  even  if  we  exclude  those  cases  in 
which  this  has  been  found  to  be  normal. 

Dr.  A.  A.  Eshner: — I  should  like  to  say  in  connection  with 
this  subject  that  Woods  Hutchison,  in  reporting  a  case  of 
akromegaly,  with  enlargement  of  the  pituitary  body  in  a  giantess 
{American  Journal  of  the  Medical  Sciences,  1895,  p.  190)  sug- 
gests that  at  least  one  form  of  giantism  is  merely  akromegaly 
beginning  in  foetal  or  infantile  life.  He  offers  the  further  sug- 
gestion that  the  nutrition  of  the  body  may  be  presided  over 
by  structures  in  the  pituitary  region.  A  series  of  measure- 
ments showed  that  while  the  pituitary  fossa  in  the  skulls  of 
cretins  and  dwarfs  is  markedly  contracted  in  size,  it  is  i.:> 
usually  enlarged  in  cases  of  giantism  and  akromegaly,  as  well 
as  in  the  skulls  of  the  anthropoid  apes,  which  present  some 
features  of  akromegaly. 

In  reference  to  the  question  of  surgical  interference,  I  would 
call  attention  to  the  fact  that  in  the  British  Medical  Journal  ior 
1893  0^^'  ^722,  p.  142 1 )  Caton  reported  a  case  of  akromegaly 
with  symptoms  of  intracranial  pressure.  An  opening  was 
made  in  the  skull  with  relief  of  suffering  and  prolongation  of 
life.  Operation  had  been  recommended  earlier  but  was  not  at 
first  consented  to.  It  was  hoped  that  by  opening  the  skull  the 
intense  pain  could  at  once  be  relieved,  and  subsequently  the  en- 
larged pituitary  body  be  removed.  Accordingly  the  bones 
forming  the  anterior  portion  of  the  right  temporal  fossa  were 
removed,  but  at  no  time  did  the  condition  of  the  patient  appear 
suitable  for  the  more  radical  operation.  Upon  post-mortem 
examination  the  pituitary  body  was  found  to  be  as  large  as 
a  tangerine  orange  and  presenting  histologically  the  structure 
of  a  round-cell  sarcoma.  In  commenting  on  this  report  at  the 
time,  I  took  occasion  to  say  that  "the  unfortunate  outcome  of 
the  case  .  .  .  lay  in  the  nature  of  the  case  itself,  rather  than 
in  a  failure  of  the  operation  or  of  the  principles  on  which  it 
was  based,  .  .  .  and  in  future  the  propriety  of  operation  in 
selected  cases  of  akromegaly  should  receive  due  consider- 
ation."— (Medical  News,  Jan.  27th,  1894,  p.  108.) 

Dr.  A.  Ferree  Witmer: — In  the  case  that  I  present,  per- 
verted sleep  has  been  a  marked  symptom,  but  there  probably 
is  no  tumor  as  the  eye  grounds  are  normal,  there  is  no  stag- 
gering gait,  and  the  knee  jerks  are  normal. 


PHILADELPHIA  NEUROLOGICAL  SOCIETY.  45 

Dr.  James  Hendrie  Lloyd  reported 

A  CASE  OF  TOTAL  AND  COMPLETE  UNILATERAL 
OPHTHALMOPLEGIA  (BOTH  EXTERNAL  AND  IN- 
TERNAL). 

The  patient,  a  man,  aged  thirty-eight  years,  had  at 
first  what  appeared  to  be  simply  a  paralysis  of  the  third 
nerve  of  the  right  eye.  Later,  however,  the  fourth  and 
sixth  nerves  also  became  involved.  The  eyeball  was  ab- 
solutely immobile  and  was  directed  forward.  There  was 
complete  ptosis,  and  the  pupil  did  not  respond  to  light 
or  on  accommodation.  Severe  headache  was  felt,  and  this 
was  located  above  and  behind  the  orbit.  Slight  exoph- 
thalmos was  noticed  later.  The  sensory  tests  were  of  great 
interest  there  was  complete  anesthesia  of  the  conjunc- 
tiva and  in  the  whole  territory  of  the  supraorbital  nerve 
as  far  back  as  the  vertex.  Both  the  upper  and  lower  lid 
were  anesthetic  on  their  edges,  except  towards  the  inner 
canthus,  and  this  indicated  that  the  nasal  branch  of  the 
ophthalmic  nerve  was  not  completely  involved.  This  was 
shown  also  by  the  fact  that  the  mucous  membrane  on  the 
interior  of  the  nostril  and  the  small  patch  of  skin  on  the 
nose  supplied  by  this  branch  were  not  anesthetic.  There 
was  retardation  of  tactile  sense,  but  not  complete  loss, 
in  the  territory  of  the  superior  maxillary  nerve.  The  in- 
ferior maxillary  division  of  the  fifth  was  entirely  exempt, 
as  was  also  its  motor  branch.  The  seventh  and  eighth 
nerves  were  not  involved.  There  was  a  slight  choking  of 
the  disk  of  the  affected  eye.  The  diagnosis  of  a  syphilitic 
lesion  just  behind  the  orbit  was  made.  The  autopsy  re- 
vealed a  gummatous  inflafnmation  behind  and  extending 
into  the  orbit.  It  had  also  invaded  the  walls  of  the  cav- 
ernous sinus.  The  Gasserian  ganglion  was  not  included 
in  the  growth,  and  the  foramen  rotundum  and  foramen 
ovale,  through  which  pass  respectively  the  superior  and 
inferior  maxillary  nerves,  were  just  on  the  border  of  the 
aflFected  area. 

ABSTRACT   OF  APATHY'S  VIEWS   ON  THE   STRUCTURE 

OF  THE   NERVOUS  SYSTEM. 

This  w^as  the  title  of  a  paper  read,  on  invitation,  by 
Thos.  H.  Montgomery,  Jr.,  Ph.D.  (Berlin)  of  the  Wistar 
Institute  of  Anatomy  and  Biology. 


46  PHILADELPHIA  NEUROLOGICAL  SOCIETY. 

He  said  that  the  structure  of  the  axis-cylinder  process 
has  been  the  object  of  much  discussion,  and  an  equally 
mooted  point  is  the  question  as  to  direct  connections  be- 
tween the  processes  of  nerve  cells.  It  is  here  intended, 
after  a  brief  historical  introduction,  to  present,  without 
criticism,  the  results  contained  in  a  recent  paper  by  Stefan 
Apathy:  ''Das  leitende  Element  des  Nervensy stems  und  seine 
topographischen  Beziehungen  su  den  Zellen,"  which  appeared 
in  the  Mittheil.  d.  sool.  Station  Neapel,  vol.  xii,  1897. 

The  protoplasm  (cytoplasm)  of  the  ganglion  cell  is 
acknowledged  to  consist  of  a  denser  and  a  more  fluid  sub- 
stance; but  the  various  observers  have  proposed  most 
divergent  views  as  to  the  arrangement  of  these  two  con- 
stituents. Thus  Leydig  concludes  that  the  denser  sub- 
stance, his  spongioplasm,  is  arranged  in  the  forni  of  an 
irregular,  spongy  network  in  the  more  fluid  hyaloplasm. 
Hans  and  Max  Schultze,  with  perhaps  the  majority  of 
authors,  consider  the  denser  portion  to  be  arranged  in 
the  form  of  fibrils.  Flemming,  that  the  denser  substance, 
his  mitom,  occurs  in  the  form  of  short  and  isolated  fibrils 
in  the  fluid  paramitom.  Biitschli  considers  the  structure 
of  the  cytoplasm  to  be  alveolar,  and  other  authors,  to  con- 
sist of  granula.  Rohde  stands  alone  in  assuming  the  denser 
substance  of  the  ganglion  cell  to  be  produced  entirely  by 
strands  of  neuroglia  fibres,  which  penetrate  into  the  cell 
body  to  form  a  component  part  of  the  same. 

The  structure  of  the  axis-cylinder  has,  likewise,  been 
most  variously  described;  but  we  will  not  take  the  space 
here  to  present  more  than  a  few  of  the  more  representative 
of  these  views.  The  prevalent  idea,  founded  particularly 
by  Max  Schultze,  is  that  it  consists  of  a  bundle  of 
primitive  nerve  fibrils  imbedded  in  a  homogeneous  matrix ; 
these  fibrils  entering  the  cell  body,  and  according  to  some 
of  the  observers,  encircling  the  nucleus.  Leydig  holds 
that  the  hyaloplasm  is  "  die  eigentliche  Nervenmaterie  ''  (the 
real  nervous  material),  and  alone  forms  the  core  of  the 
axis  cyHnder,  which  is  enveloped  by  a  sheath  of  spongio- 
plasm (not  to  be  confused  with  the  sheath  of  Schwann, 
formed  by  external  neuroglia  fibres).  In  a  recent  study 
on  the  elements  of  the  central  nervous  system  of  the 
Nemertini  (a  group  of  worms),  I  reached  essentially  the 
same  conclusions;  and  indeed  this  view  has  been  adopted 
by   many   investigators   of   the   invertebrates.       Nansen 


r 


PHILADELPHIA  NEUROLOGICAL  SOCIETY.  47 

in  a  brilliant  paper  modifies  the  view  of  Leydig,  describing 
the  axis  cylinder  as  consisting  of  a  bundle  of  nerve  pri- 
mitive tubules,  each  such  tubule  formed  of  a  hyaloplasmic 
core  and  a  spongioplasmic  sheath.  Biitschli  holds  that 
the  primitive  fibrils  are  nothing  but  much  elongated  rows 
of  alveoles. 

As  to  anastomoses  or  direct  connection  between  the 
processes  of  ganglion  cells,  it  may  be  said  to  be  the  most 
generally  accepted  modern  view  that  such  do  not  exist. 

Apathy  has  studied  principally  the  nervous  system 
of  the  leech  (Hirudo)  and  of  the  earth  worm  (Lumbricus) ; 
but  reached  essentially  the  same  conclusions  for  these 
cells  in  other  Hirudinea  and  Mollusca,  and  in  vertebrates, 
in  Lophius,  Triton,  the  rabbit,  and  the  ox.  He  maintains 
that  his  own  methods  of  preparation,  which  are  the  results 
of  years  of  careful  experimentation,  are  the  only  ones 
adequate  for  the  clear  differentiation  of  his  neurofibrils. 
These  are  (i)  a  gold  impregnation  method  (after  fixation); 
(2)  a  methylene  blue  staining  method,  and  (3)  staining 
with  a  certain  hematein  solution.  These  methods  are 
explained  fully  in  his  recent  paper  (with  the  exception  of 
the  previously-described  methylene  blue  method),  and 
though  the  modus  operandi  of  each  is  complex,  and  neces- 
sitates especial  adaptation  for  each  object  to  be  studied, 
it  furnishes,  nevertheless,  very  clear  and  beautiful  prepar- 
ations. 

Apathy  distinguishes  between  nerve  and  ganglion  cell 
as  follows:  The  nerve  cell  is  the  producer  of  the  neuro- 
fibrils, and  hence  the  producer  of  that  which  conducts; 
while  the  ganglion  cell  produces  that  (force)  which  is  to 
be  conducted;  **  a  division  of  labor,  which  has  differenti- 
ated the  neuroganglion  cells,  with  both  kinds  of  functions, 
into  these  two  cell  forms  which  differ  histologically  and 
histogenetically." 

According  to  him  there  are  various  kinds  of  connec- 
tions between  ganglion  cells  serving  to  place  them  in  direct 
and  indirect  conjunction,  and  such  anatomical  connec- 
tions are  histogenetically  referable  to  intercellular  bridges, 
(i)  Two  cells  send  a  process  (either  dendritic  or  axonic) 
into  the  same  nerve;  or  (2)  the  processes  of  several  cells 
join  to  form  one,  or  one  cell  is  apposed  to  another;  or  (3"^ 
a  process  of  one  cell  is  joined  with  the  cell  process  of  an- 
other, or  a  number  of  such  intercellular  bridges  are  pres- 


48  PHILADELPHIA  NEUROLOGICAL  SOCIETY, 

ent,  or  (4)  two  cells  are  united  by  their  collateral  or  ter- 
minal branches;  or  lastly  (5), and  this  is  ''the  principal  mode 
and  means  of  the  conducting  connection,"  the  processes 
(axis  cylinders)  of  two  cells  pass  over,  by  continued  ramifi- 
cation, into  an  anastomosing  lattice-work.  All  these  types 
of  gangion  cell  unions  were  demonstrated  by  his  prepar- 
ations. 

He  finds  that  the  neurofibrils  are  produced  by  the 
nerve  cells,  and  in  the  leech  also  by  the  neuroglia  cells, 
so  that  in  this  animal,  at  least,  neuroglia  cells  must  be 
regarded  as  nervous  and  not  as  simple  connective  tissue 
elements.  Such  neuroglia  cells  may  produce  both  neuro- 
fibrils and  neuroglia  fibrils,  or  only  one  of  these  kinds  of 
fibrils.  These  two  kinds  of  fibrils  are  easily  distinguished 
from  one  another  and  from  connective  tissue  fibrils  by  his 
staining  methods.  Each  neurofibril  consists  proximally 
of  a  bundle  of  elementary  fibrils;  but  in  the  course  of  rami- 
fication of  the  former,  bundles  of  these  elementary  fibrils 
are  given  off,  so  that  at  the  distal  end  of  a  neurofibril  only 
a  single  elementary  fibril  remains.  The  course  of  the 
neurofibrils  is  undulatory.  Varicosities  of  nerve  fibres 
are  artefacts. 

Now  the  most  important  result  of  Apathy's  studies  is 
that  a  neurofibril,  arising  in  some  particular  nerve  cell, 
passes  out  of  one  of  the  processes  of  the  latter,  and  in  its 
further  course  may  transverse  several  ganglion  cells,  and 
pressing  out  of  these  again,  finally  terminate  in  or  around 
a  muscle  or  sense  cell.  In  the  leech  the  ganglion  cells  are 
small  and  close  together,  and  these  results  were  derived 
from  a  study  of  thick  sections,  in  which  only  the  neuro- 
fibrils were  deeply  stained.  From  the  importance  of  this 
conclusion  it  is  necessary  to  consider  more  in  detail  the 
mode  of  distribution  of  neurofibrils  in  ganglion  cells. 

In  the  leech  (Hirudo),  the  object  most  fully  studied, 
he  found  the  body  of  the  ganglion  cell  to  consist  of  the 
following  layers,  enumerating  from  the  outside:  (i)  the 
outer  glia  zone;  (2)  the  inner  glia  zone;  (3)  the  outer  alve- 
olar zone:  (4)  the  outer  so-called  "chromatin"  zone,  the 
granules  of  which  are  chemically  comparable  to  chromo- 
philic  granules:  (5)  the  inner  alveolar  zone;  (6)  the  inner 
^'chromatin"  zone,  connected  with  the  outer  corresponding 
zone  by  radial  bridges:  and  (7)  the  perinuclear  zone,  in 
which  is  a  corpuscle  comparable  to  a  centrosome.     The 


PHILADELPHIA  NEUROLOGICAL  SOCIETY.  49 

''Stamm  fort  sate  "  of  the  cell  does  not  correspond  alone 
to  the  axis-cylinder  process  of  the  vertebrate  ganglion 
cell,  but  to  axis-cylinder,  plus  dendritic  processes  (these 
cells  are  luiipolar);  this  process  consists,  apart  from  the 
contained  neurofibrils,  of  a  dense,  almost  homogeneous 
substance. 

According  to  the  mode  of  distribution  of  neurofibrils 
in  ganglion  cells.  Apathy  distinguishes  two  types  of  cells: 
(G)  that  of  the  larger,  and  (K)  that  of  the  smaller  cells. 
In  the  first  type  the  neurofibrils  form  a  lattice  work  within 
the  outer  ^'chromatin"  zone  of  the  cell,  and  are  irregularly 
grouped  in  the  whole  diameter  of  the  axis  cylinder;  they 
come  out  of  this  process,  coursing  mainly  meridionally, 
and  after  continued  ramifications  and  anastomoses  reach 
the  apex  of  the  cell,  and  then,  on  the  opposite  surface  of 
the  "'chromatin''  zone  of  the  latter,  collecting  together 
again,  pass  out  into  the  cell  process.  **  The  cell  process 
contains  accordingly  cellulipetal  as  well  as  cellulifugal 
neurofibrils,  and  in  the  cell  body  the  cellulipetal  neurofibril 
passes  directly  over  into  the  cellulifugal.''  This  first  type 
of  cells  contains  no  inner  ''chromatin''  zone.  In  the  second 
type  of  cells  the  neurofibrils  are  grouped  into  two  zones, 
concentric  hollow  spheres  of  anastomosing  fibrils,  these 
two  zones  being  connected  by  radial  neurofibrils;  (i)  the 
perinuclear  lattice  work,  which  lies  in  the  cell  body  at  the 
boundary  of  the  perinuclear  and  inner  alveolar  zone;  and 
(2)  the  perisomal  lattice  work,  which  lies  in  the  outer 
"chromatin"  zone  of  the  cell. 

In  this  second  type  of  cells,  then,  the  cellulipetal  fibrils 
pass  from  the  cell  process  into  the  perisomal  lattice  work, 
composing  the  latter,  and  from  there  pass  radially  to  the 
inner,  perinuclear  lattice  work,  and  at  the  distal  pole  of 
the  latter  converge  to  form  a  single,  thick,  cellulifugal 
neurofibril.  *'  The  thick,  axial  primitive  fibril  of  the  cell 
process  accordingly  represents  the  cellulifugal,  and  the 
more  peripheral,  thinner  primitive  fibrils  the  cellulipetal 
portion  of  the  conduit,  and  the  whole  ganglion  cell  of 
type  K  is  most  probably  motor."  That  is,  the  thicker 
neurofibrils  are  motor,  the  thinner,  sensory.  **  No  prim- 
itive fibril  passes  through  the  ganglion  cell  without  having 
ramified  and  taken  part  in  the  production  of  a  lattice  work 
within  the  cell  body.  And,  on  the  other  hand,  no  entering 
primitive  fibril  terminates  in  any  way  within  the  cell  body, 


so  PHILADELPHIA  S EL  RO LOGICAL  SOCIETY. 

nor  does  a  departing  fibril  arise  in  the  ganglion  cell."  Es- 
sentially the  same  conclusions  were  reached  also  for  the 
ganglion  cell  of  Lumhricus,  and  cells  of  the  spinal  chord 
and  medulla  oblongata  of  Lophius,  Triton  and  Bos. 

In  Lumbricus  the  large  cells  of  Leydig  are  not  ganglion 
cells,  though  they  may  be  nerve  cells. 

The  terminal  neurofibrils,  on  reaching  nerve  and  muscle 
cells,  enter  these  cells  but  do  not  terminate  within  them, 
but  leave  them  again  to  anastomose  around  them.  In  cili- 
ated epithelia  the  neurofibrils  appear  not  to  enter  the 
cells,  but  to  form  an  intercellular  lattice  work. 

Such  are.  as  briefly  as  possible,  the  most  striking  re- 
sults of  Apathy's  researches.  His  figures  seem  to  be  quite 
convincing,  and  more  than  one  colleague,  on  seeing  his 
preparations,  has  been  won  over  to  his  views.  The  main 
object  of  this  review  has  been  to  make  American  neurol- 
ogists acquainted  with  this  important  paper,  which  might 
:iot,  otherwise,  have  become  so  fjuickly  known  to  them, 
since  it  was  published  in  a  zoological  journal.  We  should 
not  remain  skeptical  as  to  the  truth  of  his  results,  but 
rather  test  their  validity  by  using  the  microscopic  meth- 
ods recommended  by  him.  For  if  these  results  be  corrob- 
orated, the  structure  of  the  nervous  system  will  be  placed 
in  an  entirely  new  light,  necessitating  a  complete  reversal 
of  most  of  our  present  ideas. 

DISCUSSION. 

T)r. Chas.  K.  Mills: — This  is  one  of  tlie  most  important  ccni- 
numications  ever  made  to  this  Society,  and  while  I  do  not  feel 
competent  to  discuss  the  matter  from  the  standpoint  presented, 
I  cannot  fail  to  express  my  thanks  to  the  speaker  for  its  pre- 
^entation.  As  has  been  said,  these  views  are  not  only  renc- 
tionary,  but  revolutionary,  and  if  confirmed,  will  compel  iis  to 
recede  from  the  views  recently  adopted  as  to  the  nerve  cell 
as  an  anatomical  unit.  Our  theories  of  the  neuron  must  dis- 
ap])ear  or  be  largely  modified.  We  must  wait  for  a  full  con- 
f  rmation  of  views  so  revolutionary. 

Dr.  Spiller: — Possibly  many  here  present  will  share  the 
'iicredulity  I  experienced  when  I  first  heard  these  statements 
When  T  learned,  however,  that  Apathy  had  been  working  on 
these  investigations  many  years:  when  I  read  a  letter  from 
one  of  the  most  famous  histoloc^ists  in  the  world  confirming 
his  statements;  when  I  heard  that  his  specimens  had  been 
(xaniined  by  many  men  and  had  been  acknowledged  by  them 


r 


/ 


PHILADELPHIA  NEUROLOGICAL  SOCIETY.  51 

to  be  demonstrative:  when  I  saw  the  careful  manner  in  which 
the  paper  had  been  prepared;  it  seemed  to  me  that  the  subject 
was  too  important  to  be  dismissed  lightly. 

If  these  views  are  accepted  they  will  upset  our  present  con- 
ceptions.   Anastomoses  of  nerve  cells!    We  are  going  back  to 
something  resembling  the  old  views  of  Gerlach.    It  is  not  easy 
to  believe  that  neuroglia  cells  are  nerve  cells.    We  know  that 
neuroglia  cells  and  nerve  cells  have  embryologically  a  com- 
mon origin,  but  we  have  believed  that  in  their  fviU  development 
they  are  very  diflferent  structures.  Fibrils  within  the  protoplasm 
of  the  ganglion  cells  (in  the  old  sense)  have  been  described 
by  many.    A  friendly  strife  has  arisen  between  LenhosSek  and 
Flemming.    Tlie  former  at  one  time  stated  that  he  w^as  unable 
to  find  the  fibrillary  structure  in  the  axis  cylinder  of  the  spinal 
ganglion  cell,  but  this  year  he  has  published  a  careful  study 
on  the  spinal  ganglion  cells  of  man  in  which  he  acknowledges 
the  existence  of  fibrils  within  the  axis  cylinder.     He  lias  been 
unable  to  observe  them  within  the  cell  body.     Flemming  has 
replied  to  this  paper  and  has  stated  positively  that  they  are 
present  also  within  the  latter. 

Van  Gehuchten,  at  the  recent  congress  in  Moscow,  read 
an  important  paper  on  the  structure  of  the  nerve  cell.  He 
says  that  ganglion  cells  contain  a  network  on  which  there 
is  an  incrustation  of  chromophilic  substance;  that  in  certain 
places  this  incrustation  is  sufficient  to  produce  the  Nissl  cor- 
puscles; and  that  the  vacuoles,  which  have  been  observed  with- 
in these  corpuscles,  are  the  meshes  of  the  network  which  have 
not  been  filled  by  chromophilic  matter.  I  do  not  find,  how- 
ever, any  reference  to  Apathy  neurofibrils  in  this  report. 

Some  years  ago  Marinesco  advanced  the  theory  that  a 
nerve  cell  (in  the  old  sense)  is  only  kept  in  a  normal  condition 
by  the  reception  of  impulses  from  the  periphery  of  the  body 
and  from  the  brain.  If  either  source  is  cut  oflf,  the  cell  suffers. 
A  short  time  ago  I  had  occasion  to  express  the  opinion  that 
the  possibility  of  tertiary  degeneration  in  cerebral  hemiplegia 
had  never  been  irrefutably  demonstrated.  Soon  after  I  had 
made  this  statement,  SchaflFer's  paper,  in  which  changes  are 
described  which  occurred  in  the  motor  cells  of  the  spinal  cord 
in  hemiplegia  forty-eight  days  after  the  beginning  of  the  at- 
tack, came  into  my  hands.  He  believes  that  the  atrophy  of 
hemiplegia  is  the  result  of  destruction  of  motor  fibres  in  the 
pyramidal  tract.  These  views  come  to  us  in  a  new  light  if  we 
may  believe  that  there  is  direct  continuity  of  neurons  by 
means  of  neurofibrils,  and  not  merely  a  loss  of  impulse  to 
motor  spinal  cells. 

-As  another  illustration;  Marinesco  described  chamr^s  in 
the  cells  of  the  posterior  nucleus  of  the  vagus  from  peripheral 


52  PHILADELPHIA  NEUROLOGICAL  SOCIETY. 

lesions  of  this  nerve  and  concluded,  therefore,  that  this  nucleus 
must  be  motor.  Van  Gehuchten  states  that  he  has  found 
changes  in  the  acoustic  nucleus  of  the  oblongata  a  short  time 
after  section  of  the  eighth  nerve.  The  axis  c>'linders  which  pass 
into  this  nucleus,  terminate  about  its  cells.  He  believes  that 
changes  occur  in  the  cell  body  of  the  central  neuron  after 
lesion  of  the  peripheral  neuron.  If  we  dare  believe  that  neuro- 
fibrils pass  from  the  first  neuron  into  the  cell  body  of  the 
second,  we  can  readily  understand  why  there  should  be  an 
alteration  of  structure  in  the  latter. 

Let  us  look  at  the  subject  of  the  reflexes  in  the  light  of 
Apathy's  discoveries.  If  it  is  true  that  neurofibrils  pass  from 
sensory  fibres  into  motor  cells,  we  may  be  able  to  better  under- 
stand the  difficult  subject  of  the  reflexes.  It  is  not  unusual  in 
great  exaggeration  of  the  reflexes  to  obtain  contraction  of 
th^  adductor  muscles  of  one  thigh  by  striking  the  patellar 
tendon  on  the  opposite  limb.  A  reflex  is  not  limited  to  one  or 
even  a  few  muscles.  If  neurofibrils  pass  through  a  number 
of  ganglion  cells,  we  may  readily  understand  how  an  impulse 
acts  on  manv  cells. 

Dare  we  believe  that  the  many  neurofibrils  which  leave  a 
sensory  cell,  in  contrast  to  the  single  one  which  leaves  a  motor 
cell,  are  indicative  of  the  conveyance  of  diflFerent  forms  of 
sensation  ? 

These  are  only  a  few  thoughts  which  occur  to  me.  I  am 
seeking  light,  not  stating  facts,  and  am  well  aware  of  the 
danger  of  theorizing,  but  time  will  demonstrate  the  truth  or 
fallacy  of  these  suggestions. 


New  Aestiiesiometer. 

In  the  June  number  of  the  Bulletin  of  the  Johns  Hopkins  Hospi- 
tal, Dr.  L.  F.  Barker  describes  an  ingenious  little  instrument  recently 
prepared  by  Professor  Von  Frey  for  studying  pain  and  pressure  sense. 
It  is  an  improvement  on  an  apparatus  previously  described  from  Von 
Frey's  clinic  by  Dr.  Barker,  in  which  the  amount  of  pressure  neces- 
sary to  bend  test  hairs  of  various  diameters  was  employed.  The  new 
instrument  has  the  advantage  that  with  a  single  hair  one  can  obtain 
a  number  of  diflFerent  pressure  values. 

It  consists  of  a  long  hair  pushed  through  a  capillary  tube  like  a 
thermometer  tube;  by  sliding  a  sheathing  over  the  tube  it  may  be  made 
to  project  more  or  less.  According  to  the  length  of  the  projection 
of  the  hair  is  the  strength  which  is  necessary  to  make  it  bend,  and  a 
reading  of  the  scales  inscribed  upon  the  tube  gives  thus  some  idea  of 
the  force  used.  Dr.  Barker  quotes  a  case  in  evidence  of  its  usefulness, 
in  which  ordinary  slight  stimuli  appeared  to  cause  pain.  It  was  sup- 
posed that  pressure  sense  was  absent.  It  was  easy  with  this  instru- 
ment to  prove  that  pressure  sense  was  not  abolished,  though  the  level 
for  pain  was  almost  the  same  as  that  for  touch.  The  importance  for 
such  an  observation  is  obvious  for  showing  the  retention  of  tactile 
sense  in  cases  where  it  is  obscured  by  hyperesthesia.  Mitchell 


NEW  YORK   NEUROLOGICAL  SOCIETY. 
Stated  Meeting,  November  2d,  1897. 

Dr.  C.  A.  Herter,  the  Vice-president,  in  the  chair. 

THOMSEN'S  DISEASE. 

Dr.  George  W.  Jacoby  exhibited  a  typical  case  of 
Thomsen's  disease.  The  patient,  a  young  man,  had  been 
referred  to  him  by  Dr.  Schwinn,  of  West  Virginia,  with 
a  correct  diagnosis.  The  patient  was  twenty-eight  years 
of  age  and  had  lived  in  this  country  since  1884.  There 
was  nothing  in  the  family  history  bearing  upon  the  con- 
dition especially,  except  that  a  distant  cousin  was  said  to 
have  walked  stiffly  and  in  a  peculiar  manner  for  fifteen 
years.  The  patient  himself  had  always  been  delicate,  but 
had  been  as  active  as  other  boys.  He  had  had  typhoid 
fever  in  1889,  and  on  recovering  from  this  had  first  noticed 
a  cramp  in  the  legs.  After  a  little  it  was  found  that  he 
could  not  execute  movements  as  quickly  as  before.  In 
1893,  he  first  sought  treatment.  For  the  past  year  or  two 
his  arms  and  hands  had  also  been  affected.  The  condition 
varied  considerably  at  different  times,  but  was  apparently 
not  affected  by  meteorological  changes.  The  examination 
showed  quick  reaction  of  the  eye  muscles,  with  spasm  of 
the  external  rectus;  cramp  of  the  masseter  muscles  on 
bringing  the  jaws  together  forcibly;  no  involvement  of 
the  pterygoids.  All  the  muscles  of  the  upper  extremity 
and  of  the  thorax  were  involved — indeed,  nearly  all  the 
muscles  of  the  body.  The  contraction  of  the  muscles  was 
decidedly  tetanic,  and.  was  very  marked  at  first,  but,  on 
repeated  tests,  it  gradually  subsided.  The  electrical  ex- 
amination showed  marked  myotonic  reaction,  and  also  a 
wave-like  appearance,  but  it  was  not  certain  that  this 
latter  phenomenon  consisted  of  a  series  of  waves,  such 
as  are  observed  in  water.  A  piece  of  muscle  had  been 
excised  from  the  biceps,  and  also  from  the  quadriceps,  but 
thev  have  not  vet  been  minutely  examined.  The  case  was 
quite  characteristic  on  account  of  the  marked  variations 


54  N^^  YORK  NEUROLOGICAL   SOCIETY. 

occurring  from  time  to  time.  The  speaker  said  that  in 
an  article,  published  by  him  ten  or  more  years  ago,  he  had 
taken  the  stand  that  these  cases  were  probably  of  myo- 
pathic origin,  due  to  some  congenital  defect  in  develop- 
ment, but  in  the  light  of  modern  investigation  he  was  now- 
disposed  to  believe  that  some  central  cause  was  at  work — 
that  there  was  a  functional  hereditary  derangement  of 
the  central  nervous  system — a  condition  of  lessened  re- 
sistance in  the  cells.  This  did  not  seem  to  him  a  strange 
assumption,  when  one  considered  the  well-known  idiosyn- 
crasies exhibited  to  various  toxic  influences.  On  the  the- 
ory that  some  kind  of  toxaemia  was  at  the  foundation  of 
this  disease,  he  thought  the  observed  phenomena  could  be 
explained — at  least  in  this  direction  seemed  to  lie  the  pos- 
sibility of  solving  the  pathogeny  of  this  class  of  cases.  This 
patient  had  not  been  affected  by  the  disease  until  eighteen 
years  of  age;  hence,  there  was  no  propriety  in  calling  such 
a  case  ''myotonia  congenita"  He  w^ould  divide  these  cases 
into  three  clsases,  viz.:  (i)  Myotonia  congenita;  (2)  myo- 
tonia acquisita:  and  (3)  myotonia  transitoria. 

DISCUSSION. 

Dr.  Frederick  Peterson  asked  why  a  theory  of  causation 
might  not  be  founded  upon  chemical  changes  in  the  muscles? 
Changes  in  the  structure  of  t^e  muscles,  he  said,  were  known 
to  arise — for  instance,  in  connection  with  typhoid  fever. 

Dr.  Herter  thought  that  we  must  look  to  toxic  agents  as 
furnishing  at  least  a  clew  to  the  causation  of  such  conditions. 
The  peculiar  susceptibility  to  certain  types  of  iX)isons,  seen, 
for,  instance,  in  epilepsy,  must  be  referred  to  peculiarities  of 
the  central  nervous  system.  He  would  agree  with  Dr.  Peter- 
son that  these  cases  did  not  seem  to  be  of  central  origin,  and 
that  it  was  more  probable  that  they  arose  from  chemical  changes 
in  the  muscles.  To  study  this  subject  successfully,  it  would  be 
necessary  to  inquire  into  the  condition  of  the  secretions  and 
excretions  at  the  time  of  the  onset  of  the  disease,  and  not 
after  it  had  become  chronic. 


PACHIMENINGITIS     HEMORRHAGICA     INTERNA     IN 

CHILDREN. 

Dr.  C.  A.  Herter  said  that  internal  hemorrhagic  pachy- 
meningitis was  usually  considered  to  be  a  very  rare  con- 
dition in  children,  yet  one  German  observer  had  found  it 


NEW  YORK  NEUROLOGICAL   SOCIETY.  55 

in  about  ly  per  cent,  of  his  autopsies.    The  following  cases 
were  reported : 

Case  1.  A  female  child,  5I  months  old,  was  admitted 
to  the  Babies'  Hospital  on  Aiay  15th,  1897,  with  an  en- 
tirely negative  family  history.  The  child's  illness  had 
begun  one  month  previously  with  persistent  vomiting. 
The  head  was  of  normal  shape,  and  the  fontanelles  were 
not  bulging.  There  was  a  soft  spot  over  one  parietal  bone. 
The  child  had  no  teeth.  On  the  fifth  day  after  admission 
tremor  and  nystagmus  developed.  Nine  days  after  admis- 
sion there  was  a  general  convulsion,  in  which  the  mouth 
deviated  to  the  left.  Cyanosis  was  a  feature  of  the  con- 
vulsion. A  second  one  occurred  in  ten  hours.  After  these 
seizures  the  fontanelles  were  sunken.  The  child  now  be- 
came semi-comatose,  and  died  after  a  few  days.  The 
autopsy  showed  the  presence  of  hemorrhagic  pachymenin- 
gitis, fibrino-purulent  pleurisy,pulmonary congestion, fatty 
Hver  and  nephritis.  Along  the  superior  longitudinal  fis- 
sure, over  the  entire  base  and  over  the  island  of  Reil  on 
i)Oth  sides  was  a  membrane  covering  the  pia.  The  vent- 
ricles were  normal  in  size, and  contained  about  one  drachm 
of  hemorrhagic  fluid.  There  was  fluid  blood  in  all  the 
sinuses.  The  cervical  cord  showed  the  same  conditions. 
Under  the  microscope  the  right  occipital  region  showed 
the  pia  attached  to  the  cortex  in  many  places,  and  there 
was  a  splitting  up  of  the  membrane  overlying  the  cortex 
into  two  or  more  layers.  The  inner  layer  was  infiltrated 
with  small  round  cells.  The  outer  membranous  layers 
consisted  of  small  round  cells,  fibroblasts  and  connective 
tissue  fibres.  The  island  of  Reil  showed  the  same  con- 
dition, but  much  more  marked,  and  about  the  same  con- 
dition was  present  over  the  cerebellum.  In  the  spinal 
cord  there  were  only  slight  traces  of  hemorrhage. 

Case  II.  Female  infant, 'colored,  22  months  old.  The 
child  had  been  nursed  for  seven  months.  It  had  never 
walked  or  stood  alone,  and  was  markedly  rhachitic.  The 
first  two  months  in  the  hospital  were  marked  by  slight 
loss  in  weight  and  considerable  prostration.  In  October, 
1897.  the  child  was  re-admitted,  with  the  statement  that 
she  had  been  well  up  to  three  days  before,  at  which  time 
she  had  had  four  convulsions,  followed  by  three  more  the 
next  day.  The  general  condition  was  very  bad.  The 
hands  and  feet  were  in  a  position  of  persistent  flexor  con- 


56  NEW  YORK  NEUROLOGICAL  SOCIETY. 

traction,  characteristic  of  tetany.  The  knee-jerks  were 
unobtainable;  the  fontanelles  were  bulging.  There  was 
slight  but  varying  rigidity  of  the  muscles  of  the  back  of 
the  neck.  Bloody  mucous  diarrhoea  was  present,  and  the 
child  died  in  coma.  The  autopsy  showed  pachymenin- 
gitis hemorrhagica  interna,  broncho-pneumonia,  and 
acute  and  chronic  ulcerative  colitis.  Over  the  right  side 
of  the  brain  was  a  recent  blood-clot  covering  the  entire 
hemisphere,  and  over  the  left  occipital  lobe.  The  inner 
surface  of  the  dura  was  covered  with  a  membrane  extend- 
ing from  the  superior  longitudinal  fissure  on  either  side. 
The  pia  was  congested.  The  ventricles  and  brain  sub- 
stance were  apparently  normal.  All  the  sinuses  were  filled 
with  recent  clots.  The  microscopical  examination  showed 
thickening  of  the  pia  over  the  right  tempero-sphenoidaJ 
lobe,  and  the  vessels  of  the  pia-  were  thickened.  There 
was  also  a  thick  membrane  splitting  up  into  layers,  as  in 
the  other  case.  There  were  numerous  small  blood  vessels, 
and  hemorrhage  had  occurred  into  the  meshes  of  the 
membrane.  In  places,  there  were  aggregations  of  small, 
round  cells  undergoing  fragmeiitation.  They  were  found 
chiefly  in  the  superficial  layers  of  the  membrane.  In  the 
dura  the  fibres  were  separated  from  each  other  by  serous 
infiltration,  and  the  dura  was  covered  with  a  membrane 
similar  to  that  already  described.  In  places,  there  was 
very  extensive, pachymeningitis. 

It  was  at  about  five  months  of  age,  the  speaker  said, 
that  this  disease  was  especially  frequent.  The  majority  of 
these  infants  were  badly  nourished,  many  of  them  being 
subjects  of  rhachitis  or  of  chronic  colitis.  The  new  mem- 
brane must  be  regarded  as  originating  from  proliferation 
of  the  dural  endothelia  cells.  In  some  cases  there  was 
little  inclination  to  hemorrhage.  The  membrane  was  very 
variable  in  thickness;  sometimes  it  reached  a  thickness 
of  two  or  three  lines.  It  was  especially  prone  to  occur  in 
the  basal  fossae.  There  seemed  no  good  reason  for  think- 
ing that  the  locality  of  the  pigmentation  indicated  that 
the  layer  of  blood  originated  from  the  inner  surface  of 
the  dura.  On  the  other  hand,  there  was  no  conclusive 
proof  of  the  old  notion  that  the  disease  was  of  inflamma- 
tory origin.  It  was  so  common  to  find  severe  intoxications 
without  such  lesions,  that  the  intoxication  theorv  did  not 
seem  to  him  tenable.     It  was  apparently  impossible  to 


NEIV  YORK  NEUROLOGICAL  SOCIETY.  57 

recognize  the  condition  until  the  hemorrhage  occurred, 
and  even  then  it  was  extremely  difficult  to  make  a  positive 
diagnosis.  Slight  cerebral  symptoms  were  probably 
masked  in  these  very  young  and  usually  marantic 
children.  The  hemorrhage  was  probably  more  often 
unilateral,  and  the  usual  symptoms  present  were 
rigidity,  hemorrhage  and  coma.  Paralysis  was  rarely 
noted.  The  pyrexia  was  usually  less  than  in  meningitis, 
but  these  cases  w^ere  so  commonly  complicated  with  other 
diseases  that  the  range  of  temperature  was  very  variable. 
He  did  not  think  there  was  any  symptom  or  combination 
of  symptoms  in  hemorrhagic  internal  pachymeningitis 
which  might  not  be  encountered  in  any  acute  infection 
without  any  cerebral  affection  being  present;  but  whenever 
unilateral  rigidity  and  convulsions,  w^ith  deepening  stupor, 
were  present  inacachectic  or  rhachitic  child  under  one  year 
of  age,  we  should  think  of  that  diagnosis.  It  was  probable 
that  relatively  slight  traumatisms  to  the  head  might  oc- 
casion rupture  of  vessels  in  the  highly  vascular  membrane. 
This  gave  these  cases  a  certain  medico-legal  importance. 

DISCUSSION. 

Dr.  Peterson  remarked  that  the  condition  was  interesting 
to  him  because  of  the  possibility  of  its  being  found  occasionally 
in  infantile  cerebral  palsy. 

Dr.  Herter  said  that  he  was  inclined  to  think  that  these 
membranes  were  considerably  more  frequent  than  one  would 
suppose  from  the  literature.  It  was  quite  possible  to  overlook 
the  presence  of  the  membrane  if  it  were  not  decidedly  vascular. 


THE  PATHOLOGY  AND  MORBID  ANATOMY  OF  HUNT- 
INGTON'S CHOREA,  WITH  REMARKS  ON  THE  DE- 
VELOPMENT   AND    TREATMENT    OF    THE    DISEASE. 

Dr.  Joseph  Collins  said  that  the  neurologist  frequently 
encountered  knotty  problems,  and  among  these  none  had 
the  secret  of  its  genesis  more  carefully  concealed  than  the 
hereditar)'  degenerative  diseases.  The  pathogenesis  of  the 
acute  inflammatorv  diseases  of  the  nervous  svstem  was  an 
open  book,  but  the  degenerative  diseases  were  discourag- 
ingly  slow  in  yielding  the  mystery  of  their  being.  This 
was  especially  true  of  such  degenerative  diseases  as  the 
hereditary  ataxias,  choreas  and  dystrophies.     The  status 


58  NEIV  YORK  NEUROLOGICAL  SOCIETY. 

of  the  original  lesion  could  not  always  be  inferred  froi 
a  consideration  of  the  lesion  found  at  the  time  of  deatl 
and  this  was  particularly  true  if  the  disease  had  existed 
great  number  of  years.  No  one  could  do  much  laborator 
work  on  the  central  nervous  svstem  of  individuals  wh 
had  succumbed  to  degenerative  nerv^ous  diseases  of  Ion 
duration  without  having  forced  upon  him  the  fact  th; 
there  are  certain  abnormalities  of  the  circulatory  system- 
varying  degrees  of  degeneration  of  vessels,  change  in  tl 
size  of  the  lymph  spaces,  and  relative  disproportion 
glia  tissue  to  the  parenchyma — which  occur  with  all  d 
generative  diseases,  considered  entirely  apart  from  the 
causation.  He  felt  convinced  that  such  changes  were  ve 
often  secondar}^  and  had  no  other  significance  than 
evidences  of  protracted  disturbances  of  nutrition,  and  th 
this  nutritional  depravity  vvas  the  result  of  the  existen 
of  the  original  lesion.  There  w^as  nothing  more  certa 
than  the  occurrence  of  glia  proliferation  in  all  slowly  pr 
gressing  destructive  lesions  of  the  nervous  system,  b 
nothing  could  be  more  misleading  than  to  consider  tl 
glia  overgrowth  to  be  primary,  and  the  changes  in  t 
parenchyma  secondary. 

Huntington^s  chorea.  Dr.  Collins  said,  was  a  compai 
lively  rare  disease,  and  of  rather  recent  recognition;  hen 
the  reports  made  upon  its  pathology  had  not  been  u 
form.  The  discrepancies  were  apparently  the  resulta 
of  the  varying  points  of  view  of  different  observers, 
studying  the  nervous  system  in  cases  of  Huntingto 
chorea,  it  was  scarcely  justifiable  to  maintain  that  all  t 
morbid  conditions  were  inherent  to  the  disease,  for,  as  h 
been  said,  many  of  them  might  be  the  consequence  of  p 
longed  interference  with  nutrition.  A  study  of  two  cases. 
felt  confident,  would  go  far  toward  establishing  the  m 
bid  anatomy  hinting  at  the  pathogenesis.  His  patient  \ 
a  man,  fifty-five  years  of  age,  who  had  married  in  ea 
manhood,  and  who  was  the  father  of  three  children — 
of  them  giving  evidence  of  neuropathic  inheritance.  1 
known  duration  of  the  disease  in  his  case  was  ten  ye; 
At  the  beginnig  the  hands  only  were  affected,  but  in 
last  vears  the  lower  extremities  were  also  involved.  1 
mind  remained  in  fairly  good  condition  up  to  about  th 
years  before  his  death,  when  he  began  to  have  suspici 
.about  his  relatives  and  friends,  and  became  forgetful  : 


K 


NEIV  YORK  NEUROLOGICAL  SOCIETY.  59 

suicidal.  His  speech  was  so  imperfect  that  in  the  last 
years  of  his  life  he  was  understood  with  difficulty.  Dr. 
Collins  had  seen  him  for  the  first  time  a  few  days  before 
his  death.  He  then  had  a  temperature  of  105'  F.,  and 
it  remained  at  about  this  point  until  the  end.  The  move- 
ments were  very  severe  and  incessant,  except  during 
sound  sleep,  although  even  then  they  frequently  awakened 
him.  He  was  quite  conscious,  but  made  no  response  to 
questions.  The  cause  of  death  seemed  to  be  exhaustion 
and  high  temperature.  The  disease  was  traceable  to  the 
maternal  grandfather — an  Irishman — who  had  three  chil- 
dren, two  of  whom  were  affected  with  the  disease.  One  of 
these  was  the  mother  of  this  patient,  and  of  her  seven 
children,  five  were  afflicted  with  the  disease.  The  other 
daughter  had  two  children,  one  of  whom  became  choreic. 
In  three  generations  there  had  been  no  less  than  nine 
affected,  and  when  it  was  considered  that  many  of  these 
children  died  in  infancy,  the  number  of  cases  that  had 
developed  was  surprisingly  great. 

At  the  autopsy,  on  opening  the  skull,  the  dura  was 
considerably  adherent,  the  diploe  dense  and  the  Pacchi- 
onian depressions  marked.  The  brain  had  a  wet  appear- 
ance, as  did  also  the  cord.  The  pia  was  not  adherent  to 
the  brain.  'The  convolution  of  the  anterior  portion  of  the 
brain  were  very  small,  and  the  entire  encephalon  weighed 
43^  ounces.  The  dura  was  intimately  adherent  to  the 
s])inal  column.  The  principal  fissures  were  somewhat 
wider  and  shallower  and  shorter  than  in  the  normal  brain, 
but  there  was  nothing  pointing  to  defective  convolutions. 
The  average  thickness  of  the  gray  matter  was  uniformly 
less  than  in  the  normal  brain  cortex,  but  this  thinnness 
could  not  be  attributed  here  to  age.  An  examination  of 
the  pons  and  medulla  oblongata  did  not  show  any  marked 
variation  from  the  normal,  but  the  changes  were  more 
noticeable  lower  down.  Microscopical  changes  were 
not  confined  exclusively  to  the  Rolandic  region,  but 
the  process  here  was  more  advanced.  The  specimens  were 
stained  by  various  methods,  and  carefully  examined.  The 
macroscopical  changes  were  briefly  as  follows:  (i)  Thin- 
ness and  atrophy  of  the  cortex;  (2)  the  mottled,  streaked 
appearance  and  cribriform  state  on  cross  section  of  the 
brain  in  the  fresh  state,  due  to  diminution  in  number  and 
in  health  of  the  ganglion  cells  and  to  the'  increased  peri- 


6o  NEW  YORK  NEUROLOGICAL  SOCIETY. 

vascular  and  pericellular  spaces  and  increased  patency  ( 
blood  vessels.  The  microscopical  changes  were:  (i)  A  d< 
cay  or  slowly  progressive  degeneration  of  the  ganglio 
cells  of  the  cortex  throughout  the  brain,  especially  of  th 
two  deepest  layers,  the  layers  of  large  pyramids  and  poh 
morphous  cells.  This  cell  death  was  particularly  evider 
in  the  Rolandic  region,  very  much  less  so  in  the  anteric 
pole  of  the  brain,  and  incomparably  less  in  the  posteric 
pole.  (2)  Increase  of  glia  tissue,  but  not  sufficiently  pre 
minent  to  constitute  sclerosis,  the  conspicuous  increai^ 
l)eing  about  blood  vessels  and  ganglion  cells.  (3)  Enlarge 
ment  of  the  pericellular  spaces  and  distention  of  the  per 
cellular  spaces.  (4)  Slightly  diseased  blood  vessels  cor 
sisting  principally  of  a  proliferation  of  the  nuclei  of  th 
adventitia  and  a  thickening  of  the  intima.  This  involve 
ment  of  the  vessels  was  not  regular  or  symmetrical,  bii 
showed  itself  in  certain  sections  of  vessels  only.  (5)  R( 
lative  paucity  of  the  medullated  fibres  of  the  cortex.  1 
short,  it  might  be  said,  that  the  lesion  was  a  chroni 
parenchymatous  degeneration  of  the  cortex,  with  conseci 
tive  and  secondary  changes  in  the  interstices,  the  brun 
of  the  disease  having  been  borne  by  the  motor  region: 
There  was,  in  consequence,  a  degeneration  of  the  pyr^ 
midal  tracts  in  the  spinal  cord.  In  Dr.  Dana's  case  th 
central  convolutions  suffered  most,  and  the  process  oc 
curred  in  patches  throughout  the  affected  cortex.  Ther 
was  nothing  to  justify  the  opinion  that  it  was  an  inflarr 
mation — the  process  was  evidently  one  of  degeneration. 

In  connection  with  the  treatment,  Dr.  Collins  saic 
that  he  desired  to  emphasize  the  necessity  for  delaying  th 
advent  of  the  disease  in  those  who  had  a  hereditary  ten 
dency  to  it,  and  also  to  emphasize  the  folly  of  tenotom 
of  the  eve  muscles — a  method  of  treatment  now  bein; 
carried  out  upon  one  of  these  unfortunate  individuals  i 
this  city,  with  a  promise  of  a  cure.  If  we  wished  to  in 
flence  the  cause  of  hereditarv  chorea  after  it  had  once  be 
come  manifest,  it  would  be  necessarv  to  administer  what 
ever  drug  was  selected  in  the  largest  possible  doses  con 
sistent  with  life,  and  to  maintain  this  medication  for  a  loni 
time. 

DISCUSSION. 

Dr.  Onuf  said  that  he  had  been  present  at  the  autopsy  o 
the  case  reported  in  the  paper,  and  had  been  especially  iir 


NEIV  YORK  NEUROLOGICAL  SOCIETY.  6 1 

pressed  with  the  general  narrowing  of  the  gyri — a  general 
atrophy.     On  section,  the  mottled  appearance  of  the  cortex 
had  been  most  striking,  bu  the  cribriform  appearance  produced 
by  the  enlargement  of  the  perivascular  spaces  was  also  worthy 
of  note.    The  general  appearance  of  the  brain  resembled  very 
closely  that  of  a  brain  from  a  case  of  general  paresis.     The 
microscope  confirmed  the  macroscopical  appearances,  although 
the  changes  were  not  as  marked  as  one  would  have  expected 
from  the  gross  appearance.      The  cell  changes  were  of  the 
atrophic  order.     The  characteristic  feature  was  the  accumu- 
lation of  neuroglia  cells  in  the  pericellular  and  perivascular 
spaces.     His  impressicm  was,  that  this  accumulation  was  due 
to  a  secondary  process  following  atrophy  of  the  cells.     The 
disease  was  evidently  a  degenerative  one,  originating  in  the 
parenchyma  of  the  brain,  and  not  in  the  interstitial  tissue. 


Hemiplegia   in  Whooping   Cough. 

McKerron  (Brit.  Med.  Jour.,  Sept.  12th,  1896)  reports  the  follow- 
ing: A  child  of  five  and  three-(|uarter  years,  who  had  had  whooping 
cough  for  three  weeks,  came  into  the  house  complaining  of  a  headache 
and  of  feeling  sick.  She  vomited  once.  Right  hemiplegia  and  coma 
gradually  came  on,  the  latter  continuing  to  grow  deeper  for  three  days, 
when  it  was  complete.  There  were  repeated  right-sided  convulsions. 
The  condition  remained  stationary  for  three  or  four  days,  and  then 
gradual  improvement  began,  which  progressed  to  almost  complete 
recovery.  At  the  end  of  three  months  the  right  leg  was  as  good  as  the 
left,  but  the  child  preferred  to  use  the  left  hand  rather  than  the  ris2:hi. 

Patrick  (Chicago). 


Ux  NouvEAU  SiGNE  d'Epilepsie  (A  New  Sign  of  Epilepsy).     Dr. 
Mairet.    (La  France  Med.,  Jan.  29th, '97.) 

Numerous  experiments  prove  that  the  urine  of  epileptics  is  hyper- 
toxic  before,  and  hypotoxic  after  an  attack.  The  hypotoxicity  falls 
from  150  to  450  ccm.  (the  quantity  of  urine  required  to  kill  a  rabbit  of 
one  kilogramme),  and  remains  constant  during  the  intervals  between 
seizures.  Hypotoxicity  is  also  present  in  hysterical  subjects,  but  the 
urine  of  epileptics  gives  rise  to  convulsive  phenomena,  whereas  that 
of  the  former  class  is  simply  toxic.  In  all  forms  of  epilepsy,  typical. 
as  well  as  epilepsy  larvata,  hypotoxicity  exists,  which  is  therefore  so 
tharacteristic  as  to  assume  great  clinical  and  medico-legal  importance. 

Macalkster. 


2^cvlscopc. 


With  the  Assistance  of  the  Following  Collaborators: 

Chas.Le\vis  ALLEN,M.D.,Wash.,D.C.R.  K.  Macalester,  M.D.,  N.Y. 
J.  S.  Christison,  M.D.,  Chicago,  111.  J.  K.  Mitchell.  M.D.,  Phila.,  F 
A.  pREEkiAN,  M.D.,  New  York.  H.  Patrick,  M.D.,  Chicago,  111. 

S.  E.  Jelliffe,  M.D.,  New  York.  Henry  L.  Shively,  M.D.,  N. ' 
Wm.C.Krauss,M.D.,  Buffalo,  N.Y.     A.  Sterne,  M.D.,  Indianapolis- 

W.  M.  Leszynsky,  M.D.,  New  York 


ANATOMY. 

1.    The  Structure  of  the  Fir.st  or  Outermost   Layer  of  tu 

Cerebral  Cortex.    W.  Bevan  Lewis.  (Edinburgh  Medical  Jou 

nal,  vol  i:  1897,   p.  573.) 

The  studies  wliosc  results  are  given,  were  made  on  the  braii 
of  the  rat,  mouse,  kitten,  dog.  sheep,  ox,  pig,  the  ape.  and  man.  Tl 
methods  used  were  the  chrome-silver  rapid  method  of  Golgi-Caja 
the  Weigert-Pal,  and  the  author's  "fresh  method"  with  aniline  blu< 
black.  The  "peripheral  zone"  as  the  author  prefers  to  call  th 
first  layer,  decreases  in  thickness,  from  the  sagittal  border  of  tl 
hemisphere  outwards  and  downwards,  and  also  backwards.  It's  coi 
stituents  are: 

"First — Neuroglia  and  IjMiiph  connective  elements. 

"Second — Tangential  or  superficial  mcdullated  belt. 

"Third — Terminal  dendrites  from  the  apices  of  pyramidal  an 
other  cells. 

"Fourth — Termini  of  the  second  layer  of  nerve  cells." 

Of  non-nervous  cells,  there  are  recognizable  by  the  ''fre< 
method,"  two  kinds,  one  small,  the  other  larger,  and  connected  wil 
a  blood  vessel  by  a  peculiar,  sucker-like  process.  By  the  silv< 
method  there  appear  several  different  looking  cell  forms,  all  of  whic 
however,  are  probably  but  different  stages  of  the  spider  cell.  A 
enormous  number  of  medullated  fibres  run  parallel  to  the  surfac 
forming  a  layer  v\hose  depth  varies  in  different  parts  of  the  corte 
These  horizontal  fibres  are  crossed  by  other  fibres,  vertical  an 
oblique,  making  up  a  thick  meshwork.  There  are  also  in  this  bel 
numerous  fine  axis  cylinders  devoid  of  sheath. 

The  nerve  cell  processes  come  (i)  from  the  pyramidal  cells  of  tl 
third  and  fourth  layers  and  (2)  from  the  cells  of  the  second  layer.  Tl 
.ipical  protoplasmic  processes  pass  up  towards  the  periphery,  brand 
ing  continuously  so  as  to  form  a  plumelike  structure. 

These  processes  are  readily  distinguished  from  the  axis  cylinde 
by  their  peculiar  appearance  due  to  the  number  of  short  processes  tht 
give  off.  The  axis  cylinders  and  collaterals  are  numerous,  cros-i  eac 
other  at  various  angles,  and  are  in  close  relationship  to  the  protopla 
mic  processes.  Whether  they  arise  mainly  from  the  nerve  cells  o 
curring  in  this  layer,  is  a  disputed  ciuestion.  The  author  thinks  th 
there  are  too  few  cells  to  account  for  them,  and  thjit  most  of  the 


PERISCOPE.  63 

come  from  the  cells  of  the  deeper  layers.     As  to  communication  be-- 
tween  them  and  the  dendritic  processes,  he  does  not  attempt  to  de- 
cide whether  it  is  by  continuity  or  by  contiguity. 

Going  on,  he  describes  the  cells  of  the  second  layer.     These  pre- 
sent three  peculiarities,  great  variation  in  contour,  a  very  large  nucleus, 
and  a  peculiar  branching,  giving  the  cell  a  somewhat  horned  appear- 
ance.   There  is  sudden  change  in  type  of  cells,  in  passing  from  one 
region  to  another,  and  a  general  suggestion  of  grouping  of  special 
cell  forms,   in   particular  regions   of  the   cortex,    in    very   specialized 
regions,  one  form  occuring  to  complete  exclusion  of  the  others.  These 
cells  the  author  regards   as   probably   .sensory   elements,    and   thinks 
that  their  varied  form   may   have   some  connection   with   the  varied 
qualities  of  sensation.     In  conclusion  he  suggests  that  the  peripheral 
zone  is  an  enormous  field  of  the  cortex,  in    which    the    transferance 
of  sensory  currents  into  motor  impulses  is  accomplished.       This  ab- 
stract gives  but  the  briefest  outline  of  this  carefully  prepared,  and  well 
illustrated  article. 

C.  L.  Allen. 

1.  L\  Neoformation  des  Cellules  Nerveu.ses  dans  le  Cervealt 
DU  Singe  (New  Formation  of  Nerve  Cells  in  the  Brains  of  Mon- 
keys, Vitzou.)    Archives  de  Physiologie.  9,  1897,  p.  29. 

An  interesting  series  of  experiments  upon  monkeys,  carried  on 
by  Vitzou.  seems  to  show  that  it  is  possible  to  reproduce  new  nervou-^ 
tissue  in  the  higher  animals,  although  the  contrary  opinion  has  been 
held  by  many.  His  subjects  were  young  monkeys.  He  removed  por- 
tions of  the  cortex  of  the  occipital  lobes  of  both  sides,  thereby  render- 
ing the  animals  quite  blind.  But  in  the  course  of  several  months  they 
bcffan  to  regain  their  sight,  and  at  the  end  of  two  years,  could  see 
tp.irly  well.  It  was  found  upon  repeating  the  operation,  that  a  quantity 
of  new  nerve-like  material  had  grown  in  the  former  site.  It  showed 
upon  microscopical  examination  that  nerve  cells  and  nerve  fibres  were 
present.  But  after  the  second  operation  no  new  fibres  grew,  and  the 
monkeys  remained  blind.  Jelliffe. 

.1  Ox  THE  Regeneration  of  Pre-ganglionk  and  of  Post-c.an- 
r.LioNic  Visceral  Nerve  Fibres.  J.  N.  Langley.  Journal  of 
Physiology.  22,  1897,  o.  215. 

The  author  has  conducted  a  series  of  experiments,  chiefly  upo!i 
cats,  in  which  the  cervical  sympathetics  were  severed,  the  vagus  bein;^ 
left  intact.  His  general  conclusions  arc  as  follows:  The  regcieration 
"^  pre-ganglionic  fibres  takes  place  by  the  formation  of  fresh  termina 
tions  in  connection  with  nerve  cells.  In  nearly  all  cases,  so  far  a^ 
regards  the  cervical  sympathetic,  the  different  classes  of  pre-ganglionic 
fibres  form  their  new  endings  in  connection  with  nerve  cells  of  their 
own  cla.ss  and  possibly  in  connection  with  the  same  nerve  cells  with 
which  they  were  originally  connected. 

Nevertheless  it  appears  that  in  certain  conditions,  pre-ganglionic 
nene  fibres  are  able  to  form  endings  in  connection  with  nerve  cells 
not  belonging  to  their  own  class,  so  that,  for  example,  pupillo-dilator 
ne^^•e  fibres,  may  become  united  during  regeneration,  with  nerve 
cells  which  send  their  axones  to  the  erector  muscles  of  the  hairs. 

And  it  appears  that  the  post-ganglionic  nerve  fibres  ending  in 
any  one  tissue  can,  if  an  opportunity  be  afforded  them  during  re- 
generation, readily  form  nerve  endings  in  connection  with  any  other 
visceral  tissue,  so  that  for  example  pilo  motor  fibres  may  form  nerve 
endings  in  the  iris,  and  become  pupillo-dilator  fibres.  Jelliffe. 


64  PERISCOPE- 

PHYSIOLOGY. 


Considering  first  the  pathology  of  the  recurrent  laryngeal 
the  author  formulates  the  following  questions: 

1.  Does  the  recurrent  contain  centripetal  fibres? 

2.  Ought  the  classic  scheme  tor  the  distribution  of  the  lar 
nerves  to  be  retained? 

3.  Does  the  recurrent  laryngeal  arise  from  the  pneumogas 
from  the  spinal  accessory? 

4.  What  is  the  bulbar  representation  of  the  larylix? 

5.  What  is  the  cerebral  representation  of  the  larynx? 

6.  Why  do  incomplete  lesions  of  the  recurrent  fix  the  vocal 
in  a  median  position? 

These  questions  he  answers  as  follows: 

1.  Negatively. 

2.  The  classic  scheme  of  distribution,  while  not  explain! 
observed  pathological  facts,  should  be  presented  in  default  of  a 

3.  Is  a  question  of  inlerprelation.  All  are  agreed  th; 
larynx  is  innervated  through  nerve  roots  arising  from  the  bulb 
region  between  the  tenth  and  eleventh  nerves,  but  some  authc 
sign  these  roots  to  the  pneumogastric,  others  consider  them  : 
longing  to  the  spinal  accessory. 

4.  The  larynx  is  represented  in  the  bulb  by  two  centres,  o 
respiration,  the  other  for  phonation,  and  each  of  these  is  bilaters 
the  cat,  the  centre  for  respiration  has  been  shown  to  be  situated 
superior  part  of  the  floor  of  the  fourth  ventricle,  while  that  for  p 
tion  is  in  the  inferior  part.  Anatomical  and  pathological  facts 
to  their  similar  location  in  man. 

5.  Respiration  and  phonation  have  most  likely  separate  c( 
representation.  The  cortical  respiratory  centre,  though  demons 
by  Russell  in  the  cat  and  in  the  dog,  is  as  yet  not  satisfactorily  sti 
The  centre  for  phonation  has  been  located  by  Krause  in  the  dof 
by  Horsley  and  Seinon  in  the  monkey:  in  the  latter  about  the  ft 
the  ascending  frontal  convolution.  Each  vocal  cord  is  repres 
on  both  sides,  and  destruction  of  the  centre  on  one  side  alone  doi 
produce  paralysis.  In  man  there  are  recorded  4  cases  which  point  1 
foot  of  the  ascending  frontal  as  the  seat  of^liis  centre,  but  they 
tradict  in  a  measure  the  experimental  observations,  since  lesii 
one  centre  was  followed  by  paralysis  of  the  op^iositc  vocal  cord, 
author  does  not  think  a  definite  conclusion  can  yet  be  drawn. 

6.  The  median  position  of  the  vocal  cord  in  partial  lesion  a 
urrcnt.  Is  best  explained  by  the  theory  of  Semon.  that  the  di 
scles  are  inherently  weaker  than  the  constrictors,  hence  the  fii 
affected. 

Passing  to  the  location  of  the  lesions  producing  the  paralysis 
hor  studies  their  causation,  in  the  recurrent  ilsclf.  in  the  pnei 
trie  and  spinal  accessory  nerves,  in  the  medulla,  and  in  tlie 
im.  He  concludes  that,  while  paralysis  of  the  recurrent  i,i  a  se 
uptom,  it  does  not  necessarily  indicate  a  fatal  issue,  but  mus 
isidered  in  connection  with  the  other  symptoms  present.  He  re 
es  three  principal  types  of  recurrent  laryngeal  paralysis:  i.  G 
1  fatal.     2.   Incurable  but  benign.     3,  Curable  and  benign. 

C.  L.  .^LLt 


PERISCOPE.  65 

5.    UeBER  ELEKTRISCHE    ReIZUNG    DER    ERSTEN    DoRSALWURZEL    BEIM 

Menschen    (Electrical   Stimulation   of  the   First   Dorsal    Root). 
H.  Oppenheim.    Berlin  klin.  Wochenschrift,  33,  1896,  p.  753. 

In  order  to  decide  the  question  whether  the  oculo-pupillar  fibres 
are  in  part  derived  from  the  first  dorsal  root  or  not,  the  author  made 
use  of  a  gunshot  wound  case  in  which  the  spinal  canal  was  opened. 
exposing  from  the  first  to  the  fourth  dorsal  segment.  Electrical 
irritation  of  the  second  dorsal  root  was  negative;  while  immediately 
after  irritaton  of  the  first,  dilatation  to  a  marked  degree  followed. 
This  dilatation  disappeared  on  removing  the  electrode.  The  author 
concludes,  from  his  experiments,  that  the  dilator  pupillaris  muscles 
receive  their  nerve  supply  from  the  first  dorsal.  Jelliffe. 

6.  Comparative  Effects  of  Different  Alcoholic  Drinks  on 
Man  (Lanceraux.)    Bull.  Med.  de  Paris:  10,  1896,  p.  979. 

Lanceraux  has  investigated  the  changes  taking  place  in  the  nerv- 
ous system,  due  to  abuse  of  different  alcoholic  drinks,  wine,  beer, 
absinthe,  essences,  etc. 

In  excessive  use  of  alcoholic  drinks  of  high  percentage  of  alcohol, 
the  tactile  and  thermal  sensibilities  do  not  seem  to  be  greatly  altered, 
while  sensibility  to  pain  seems  exaggerated.  In  those  that  use  absinthe 
and  similar  drinks  to  excess,  the  plantar  reflexes  are  increased,  light 
tickling  causing  movement,  while  slight  stroking  of  the  knees,  legs, 
or  abdomen  causes  pain  severe  enough  to  cause  the  patient  to  com- 
plain. 

Similar  results,  although  less  marked,  are  to  be  observed  in  the 
upper  extremities.  In  wine-drinkers,  this  sensitiveness  of  the  skin 
is  much  less  in  the  lower  exremities;  above  there  may  be  a  zone  of 
hyperesthesia;  while  still  higher  in  the  body,  normal  skin  sensation 
is  the  rule.  Psychical  symptoms  by  absinthe  drinkers  are  stated  to 
be  fewer  than  is  generally  supposed  and  taught  in  the  ordinary  text- 
books. Wine  and  alcohol  drinkers  are  prone  to  attacks  of  acute 
delirium,  while  in  those  that  drink  alcoholic  essences,  forms  of  de- 
mentia arc  more  liable  to  follow.  Jelliffe. 

PATHOLOGY. 

?■  BeitRAEGE  ZUR  KeNNTNISS  DER  multiplen,  allgemeinen 
Neurom  (Contributions  to  a  Knowledge  of  General  Multiple 
Neuromata.)  Karl  ^tren.  Sonderabdruck  aus  dem  Nordiskt 
Medicinskt  Arkiv. 

In  this  brochure  the  author  presents  an  exhaustive  study  of  a 
well-observed  case  of  multiple  general  neuroma.  The  histological  work 
^^'as  done  at  the  Pathological  Institute  of  the  University  of  Lund.  A 
complete  review  of  the  literature  is  given.  The  patient  was  a  tailor, 
aged  thirty-two.  There  was  a  high  degree  of  neuro-pathological 
hereditary  taint,  but  not  as  is  generally  the  case,  of  a  type  similar  to 
the  disease.  The  patient's  father  was  a  man  of  good  intelligence,  but 
of  violent  temper,  and  immoderately  addicted  to  alcohol.  A  paternal 
wncle  was  also  intemperate.  The  mother  was  eccentric  and  of  low 
dfgree  of  intelligence.  One  of  her  sisters  was  insane.  A  brother  and 
sister  of  the  patient  was  feeble-minded,  and  another  brother  actually 
insane.  A  maternal  aunt  and  cousin  were  at  times  under  treatment 
for  mental  disease.  The  tumors  were  very  numerous  and  widely  dis- 
tributed over  the  trunk  and  limbs,  corresponding  to  the  distribution 
of  the  nerves  aflfected.  They  varied  in  size  from  a  pea  to  a  pigeon's 
«gg  and  could  be  distinctly  felt  under  the  skin.  Where  multiple  neuro- 
mata do  not  undergo  sarcomatous  degeneration,  there  have  generally 
been  no  special   nerve  symptoms   observed.      Here,   however,   these 


66  PERISCOPE, 

tumors  caused  widespread  motor  and  sensory  disturbances  of  the 
kind  as  are  occasioned  by  a  very  chronic  and  benign  neuritis.     S 
ptosis,  nystagmus,  inequality  of  the  pupils,  sluggish  reaction  for 
and  accommodation,   diminished  tactile  sensibility,   and   temper 
sense  were  observed.    There  was  a  considerable  paresis  of  the  left 
and  the  reflexes  of  the  arm  were  distinctly  increased.     Motion 
in   the   upper  and  lower  extremities   was   distinctly   ataxic,    and 
"muscle  sense"  showed  considerable  diminution.    Romberg's  symj 
was  present.     Patellar  and  plantar  reflexes  were  increased.     The 
pression  of  his  face  and  conversation  evidenced  distinct  mental 
pairment. 

In  the  case  here  presented  there  was  in  all  probability  compre? 
of  the  spinal  cord  due  to  tumor  formation  on  the  roots  of  origi 
the  spinal  nerves.  Cases  of  such  compression  have  been  observe 
Sibley,  Riesenfeldt,  Gerhardt  and  Sieveking.  The  oculo-pupillary 
turbances  have  been  observed  but  twice  before  and  have  been  repc 
by  Riesenfeldt  and  Herczel.  Their  cause  is  not  known  with  certa 
The  clinical  picture  corresponds  very  closely  to  that  occurrinj 
neuritis  of  the  Dejerine  type,  except  that  in  the  latter  the  sympt 
are  all  more  strongly  developed. 

The  most  important  feature  of  the  microscopical  examinatio 
the  excised  neuromata  was  the  demonstration  of  a  new  formatio 
non-medullated  nerve  fibres  which  the  author  has  shown  for  the 
time.  It  is  in  entire  harmony  with  the  clinical  symptoms  that  a  < 
siderable  destruction  of  nerve  fibres  should  be  found  only  in  tl 
cases  which  undergo  sarcomatous  degeneration.  In  other  cases  i 
are  sometimes  no  changes  whatever  in  the  nerve  fibres,  sometimes tl 
are  slowly  developed  alterations  in  these  elements,  generally  a  pres: 
atrophy,  which  is  also  accompanied  by  a  diminution  in  their  num 
In  the  cases  here  reported  there  was  a  very  slow  but  undoubted 
struction  of  nerve  fibres  which  corresponded  fairly  to  the  clinical  m 
festations.  In  a  second  case  of  multiple  neuroma  the  author  succee 
in  demonstrating  in  all  probability  a  new  formation  of  medulh 
nerve  fibres.  The  appearances  corresponded  to  those  which  are 
served  in  the  proximal  stump  of  a  divided  nerve  when  regenerat 
occurs.  It  is  not  possible  to  say  whether  or  not  this  reproductior 
nerve  fibres  is  throughout  more  extensive  than  is  ever  the  case 
neuromata  and  can  even  go  on  to  complete  disappearance.  In 
former  the  place  of  the  nerve  fibres  is  taken  by  a  fibrous  connec 
tissue,  and  in  neuromata  one  often  finds  almost  the  same  form  of  c 
nective  tissue  surrounding  the  bimdles  of  nerve  fibres  which  f 
through  the  centre  of  the  tumor.  In  the  latter,  however,  there  is  i 
diffuse  connective  tissue  that  forms  the  principal  mass  of  the  tum< 
In  multiple  neuroma  as  in  the  above-mentioned  neuritis  there  is  of 
a  neuropathic  taint  which  in  both  may  assume  the  form  of  a  sim; 
heredity.  Both  diseases  are  generally  congenital  or  appear  in  chi 
hood  and  are  to  be  attributed  to  faulty  development.  In  both  t 
probably  consists  in  an  increased  energy  of  growth  of  the  connect 
tissue  of  the  nerves,  or  in  a  relative  diminution  of  the  same  for 
nerve  fibres.  As  regards  neuromata,  one  can  agree  with  Goldman  tl 
this  faulty  development  is  to  be  regarded  as  retarded  growth,  that 
a  persistence  of  the  connective  tissue  of  the  nerves  in  the  embryo 
stage. 

General  multiple  neuroma  and  neuritis  of  the  Dejerine  type  j 
to  be  considered  in  all  probability  as  related  diseases.  When  one  co 
pares  these  two  diseases  which  are  produced  by  increase  in  the  cc 
nective  tissue  of  the  nerves,  the  thought  occurs  that  the  dcvelopm< 
of  tumors  may  be  regarded  as  a  safety  valve  for  the  exuberance 


PERISCOPE,  67 

connective  tissue,  and  may  indeed  be  a  conservative  process  which  in 
certain  cases  protects  with  varying  effectiveness  the  nerve  fibres  from 
destruction.  In  neuritis  of  the  Dejerine  type  is  to  found  a  premonition 
even  if  a  slight  one,  of  tumor  formation.  Shively. 

8.  Lesions  de  la  moelle  epiniere  dans  un  cas  d*  amputation 
GONGENiTALE  DES  DOiGTS.  .(Lcsious  of  the  Spinal  Cord  in  a  Case 
of  Congenital  Amputation  of  the  Fingers.)  Longues  et  Marinesco 
La  Presse  Medicale,  No.  45,  1897. 

After  giving  a  short  description  of  a  case  of  congenital  absence 
of  the  first  and  middle  finger,  with  rudimentary  ring  finger  and  de- 
formity of  thumb  and  little  finger  of  the  right  hand  in  a  woman  who 
died  at  63  of  a  cancer,  the  authors  give  the  result  of  the  histological 
examination  of  the  spinal  cord  from  that  patient.    The  cervical  cord 
from  the  first  dorsal  segment  to  the  medulla  was  examined.     There 
was  diminution  in  size  of  the  right  half  of  the  cord,  most  marked 
about  the  eighth  cervical  and  first  dorsal  segments,  and  progressively 
less  marked  towards  the  higher  level.     On  the  right  side  both  an- 
terior and  posterior  roots  were  diminished  in  volume,  and  the  reflexo- 
motor  collaterals  which  traverse  the  posterior  horn  to  go  to  the  motor 
cells  of  the  anterior  horn,  as  well  as  the  collaterals  going  to  cells  of 
the  posterior  horn  were  reduced  in  number,  the  change  being  most 
pronounced  in  the  lowest  segments,  but  visible  as  high  as  the  fifth 
cemcal.    In  the  right  anterior  horn  the  changes  were  quite  marked, 
h  was  smaller  and  paler  than  the  left,  and  its  cells  showed  changes ; 
the  antero-internal   group   being  well   preserved,   the   postero-lateral 
group  partly   atrophied,   while   the   median    group   had    disappeared 
entirely.     The   cells   of  the   gray   matter   between   the   anterior   and 
posterior  horns  were  reduced  in  numbers.     Above  the  fifth  cervical 
these  changes  were  no  longer  visible.     There  was  an  atrophy  of  the 
column  of  Burdach,  most  marked  below,   but  traceable  up  to  the 
nuclei  in  the  medulla.     The  columns  of  Goll   showed  degeneration 
on  both  sides,  but  the  authors  do  not  think  this  explained  by  the 
lesion  of  the  hand.  The  paper  closes  with  a  consideration  of  the  origin 
of  the  disease  process,  which  the  authors  conclude  to  be  exogenous 
and  secondary  to  the  amputation  in  utero  of  the  fingers.  The  changes 
found  confirm  the  views  with  regard  to  the  distribution  of  the  col- 
laterals of  the    posterior    root   fibres,    held   by    Kolliker,    Ramon    y 
Cajal  and  others.  •     C.  L.  Allen. 

9.     UeBER      VeRAENDERUNGEN      DES      MENSCHLICHEN      RUCKENMARKS 

NACH  Wegfall  grosserer  Gliedmaasen.  (Concerning  Changes 
in  the  Human  Spinal  Cord  after  Removal  of  Large  Portions  of 
the  Limbs.)  By  E.  Flatau.  Deutsche  med.  Wochenschrift,  23, 
1897,  p.  278. 

Flatau  had  the  opportunity  of  examining  the  spinal  cord  in  two 
cases  a  short  time  after  amputation  had  been  performed.  He  found 
that  the  cells  in  the  parts  corresponding  to  the  amputated  limbs,  when 
stained  by  the  method  of  Nissl,  were  enlarged  and  tubular,  and  that 
the  protoplasmic  processes  were  decreased  in  number.  The  chromo- 
philic  elements  had  undergone  a  gradual  change,  and  the  nucleus  in 
some  cells  was  excentrically  situated.  These  findings  correspond  with 
those  obtained  experimentally.  He  states  an  important  fact,  acknowl- 
edged by  many,  viz.,  that  it  is  possible  to  detect  not  only  alteration 
of  the  cell  from  the  action  of  different  substances,  but  also  differences 
in  the  action  of  the  various  substances  on  one  and  the  same  cell  spec- 
ies. He  found  both  the  anterior  and  the  posterior  roots  degenerated 
after  amputation.  [There  is  a  suggestion  in  this  statement  in  regard 
to  the  possibility  of  a  peripheral  origin  of  tabes.  1         Spiller. 


68  PERISCOPE.      . 

10.  Paralysie  bulbaire  asthenique  descendante,  avec  auto 
(Descending  Asthenic  Bulbar  Paralysis,  with  Autopsy.)  (S; 
torn  complex  of  Erb.)  Bulletins  et  Memoires  de  la  So 
Medicale  des  Hospitaux  de  Paris. ^  By  Widal  and  Marinesc( 
1897,  P-  518. 

The    writers    give    a    succint    statement    of    the    symptom 
this  disease,  and  show,  by  a  very  important  case  of  their  own, 
contrary  to  the  opinion  of  Goldflam,  the  disease  may  be  acute  and  < 
occur  within  a  short  time. 

A  tuberculous  man  began  to  complain  of  headache.  This  wa 
lowed  by  unilateral,  atld  later  bilateral,  ptosis,  partial  bilateral 
paralysis,  noticed  especially  in  the  distribution  of  the  upper  bran 
the  right  seventh  nerve,  difficulty  of  speech,  mastication  and  de; 
tion,  convergent  strabismus  in  both  eyes,  rapid  exhaustion  of  c< 
ocular  muscles,  paralysis  of  the  tongue  and  muscles  of  the  neck 
weakness  in  the  upper  extremities.  There  was  no  positive  dis 
ance  of  objective  sensibility,  and  no  muscular  atrophy.  The  symj 
varied  from  time  to  time,  and  were  less  severe  in  the  morning.  1 
from  suffocation  occurred  about  three  weeks  after  the  beginning  < 
headache,  and  about  two  weeks  after  the  first  sign  of  paralysis  (pt 
The  unusual  symptoms  in  this  case  were  paralysis  of  the  external 
partial  paralysis  of  the  muscles  supplied  by  the  third  nerves,  an 
resis  of  the  iris. 

The  histological  examination  was  made  by  the  methods  of 
Marchi  and  Pal,  and  lesions  were  found  by  the  first  two,  cons 
of  disintegration  of  the  chromophilic  elements  in  the  nuclei  c 
cranial  and  cervical  nerves,  and  degeneration  of  the  myelin  sh 
in  the  third,  seventh  and  twelfth  nerves.  These  were  not  post-m« 
changes,  and  probably  were  not  due  to  the  tuberculous  conditi 
the  patient.  The  intensity  of  the  cellular  lesions  was  proporti 
to  the  intensity  of  the  symptoms.  There  was  nothing  peculiar  i 
alterations  of  the  chromophilic  elements;  they  were  such  as  are 
duced  by  intoxication,  and  the  asthenic  paralysis  may  be  the  res 
an  intoxication,  endogenic  or  exogenic. 

Widal  and  Marinesco  are  the  first  to  report  cellular  changes, 
pendent  of  perivascular  lesions  and  interstitial  inflammation,  in  a: 
ic  bulbar  paralysis.  They  believe  that  this  disease  and  the  polioer 
alomyelitis  may  be. due  to  nuclear  lesions,  though  of  different  1 
and  degree,  and  that  the  two  processes  should  be  regarded  as  di 
It  does  not  follow  from  one  examination  that  the  symptom-co: 
of  Erb  is  always  the  result  of  similar  lesions.  Spili 

CLINICAL  NEUROLOGY. 

11.  Vertigo  and  Ocular  Defects.  W.  Osier,  Montreal  M 
Journal,  25,  p.  12. 

The  author,  discussing  the  association  of  vertigo  and  ocuh 
fects,  cites  a  case  of  the  former  which  was  of  the  most  intense 
acter,  and  had  persisted  for  eighteen  months,  but  which   was 
pletcly  relieved  by  properly  adjusted  glasses. 

Mr.  H.,  aged  54,  consulted  the  doctor  on  the  4th  of  April, 
complaining  of  vertigo  and  stomach  trouble.  He  has  been  a  h 
man  with  the  exception  of  attacks  of  biliary  colic.  The  patien 
a  brick  maker  by  occupation.  His  habits  have  been  good.  H 
been  a  steady  smoker  until  about  a  month  ago. 

For  about  eighteen  months  he  has  had  attacks  of  severe  v« 
associated  with  flatulency.  The  first  one  occurred  while  he  was  s 
at  the  table  in  a  restaurant  drinking  claret  punch.  He  jumped  u 
said  to  his  wife,  **  Catch  me,  catch  me,"  and  had  to  get  hold  < 
tablf  to  steady  himself.     He  had  a  sensation  as  if  a  cannon-bal 


r 


PERISCOPE.  69 

burst  in  his  head,  and  as  if  everything  was  in  motion.  The  attack 
lasted  about  an  hour.  He  did  not  vomit  but  looked  pale,  and  broke 
into  a  profuse  perspiration.  He  has  had  only  two  attacks  of  similar 
severity,  one  while  in  his  carriage.  He  said  it  seemed  as  if  the  horse 
was  down  and  everything  was  turning  over.  This  attack  lasted  about 
an  hour.  He  had  to  go  to  bed,  and  felt  very  badly,  and  after  it  he  felt 
confused  in  his  head. 

The  milder  attacks  had  occurred  with  greater  frequency.  Scarcely 
a  day  passes  without  one  or  two;  thus,  one  day  after  breakfast  his 
stomach  felt  badly,  and  he  had  a  good  deal  of  belching.  Then,  as  he 
expressed,  it,  his  head  went  oflF  at  once,  and  he  generally  cried  to  his 
wife,  "come  and  catch  me!  "  Coming  home  just  before  dinner  he  had 
another  spell.  When  they  are  at  all  severe,  he  gets  pale  and  cool,  and 
perspiration  rolls  off  his  face  in  beads.  He  belches  all  the  time  during 
an  attack,  and  on  some  days  he  belches  continually.  He  had  no  pain 
whatever  in  the  chest  or  elsewhere.  The  attacks  did  not  come  on 
during  sleep,  but  he  had  several  of  them  while  in  bed. 

From  his  statement  the  vertigo  was  apparently  both  subjective 
and  objective.  Objects  went  to  the  right,  but  he  felt  that  he  turned 
also.  While  the  attack  lasted  walking  was  impossible.  If  the  head 
were  held  tight,  the  attacks  did  not  appear  to  be  so  severe.  Though  the 
patient  fainted,  yet  consciousness  was  always  preserved.  There  was 
no  throbbing  at  the  heart.  The  longest  interval  the  man  ever  passed 
without  an  attack  was  two  weeks. 

The  patient  attributes  his  condition  principally  to  his  stomach, 
as  the  distress  and  the  belching  were  incessant. 

Though  he  did  not  complain  of  difficult  hearing,  it  was  evident 
that  he  was  a  little  deaf,  and  on  questioning  him,  he  stated  that  the 
deafness  had  been  coming  on  for  several  years  past,  particularly  in 
the  right  ear  in  which  there  is  a  ringing  noise  almost  constantly.  In 
the  spells  it  is  much  lower,  and  sometimes  there  is  an  explosive  burst. 

On  examination  there  was  found  deafness  in  the  right  ear,  due  to 
changes  in  the  auditory  nerve  or  its  expansion  in  the  labyrinth,  and 
that  there  was  slight  deafness  in  the  left  ear.  The  examination  of  the 
eyes  showed  a  rather  high  grade  of  hypermetropia  with  a  decided 
amount  of  astigmatism. 

The  change  in  the  patient  from  the  use  of  properly  adjusted  glasses 
was  most  remarkable.  The  severe,  as  the  mild  attacks,  wholly  disap- 
peared, and  even  his  stomach  troubled  him  less.  Two  months  after 
the  patient  suffered  a  severe  attack  of  uncontrollable  vomiting  which 
ended  fatally.  The  autopsy  revealed  an  acutely  developing  malignant 
disease  of  the  stomach. 

Dr.  Osier  concludes  this  interesting  report  with  the  following  sug- 
gestive remarks:  A  condition  of  irritation  and  instability  of  the  space 
nerve  centres  may  possibly  be  kept  up  by  serious  accommodation 
errors.  Physiological,  clinical,  and  well-established  anatomical  data 
show  the  association  between  the  labyrinth  and  the  oculo-motor 
mechanism.  The  case  which  was  reported  bears  on  a  practical  aspect 
of  the  question,  inasmuch  as  the  patient  obtained  complete  relief  from 
a  vertigo  of  the  most  intense  and  persistent  character  by  the  use  of 
carefully  adjusted  glasses.  Abrahams. 

12.     Friedreich's  Ataxia.    E.  Riggs:  Northwestern  Lancet,  16,  1896, 
p.  264. 

The  author  reports  two  cases.  The  first  patient,  a  boy,  aged  16 
years,  had  had  difficulty  in  w^alking  for  a  year,  which  had  rapidly  in- 
creased before  the  date  of  examination.  He  had  some  difficulty  in 
articulation,  the  gait  was  spastic  and  staggering,  all  voluntary  move- 


70  PERISCOPE. 

ments  were  very  slow,  and  he  had  had  two  attacks  of  profuse 
ing  without  apparent  cause.    There  was  slight  transverse  nysta 
ankle  clonus  and  rectus  clonus  on  both  sides,  but  the  knee  jei 
absent  (!).    There  was  also  well-marked  gluteal  clonus. 

The  second  case  was  a  girl,  nine  years  old,  who  had  suffere< 
increasing  ataxia  for  some  months.  A  brother  had  died  of  a  i 
affection  at  the  age  of  twenty  years.  She  had  transverse  nysta 
but  the  pupil  reflexes  were  normal.  As  in  case  one  there  was  < 
marked  lateral  curvature  of  the  spine.  It  might  be  noted  that  t 
ing  of  the  head  and  neck  was  present,  and  tremor  of  the  hands  a 
panying  voluntary  effort.  There  was  well-marked  ataxia,  the 
ficial  reflexes  were  present,  but  the  knee-jerks  were  absent. 

Patric 

13.  Friedreich's  Disease.    Moyet:  Northwestern  Lancet,  17 

No.  2. 
The  author  reports  two  brothers,  aged  respectively  16  ai 
both  of  healthy  parents,  affected  with  Friedreich's  disease.  Re 
(16  years)  has  it  for  four  years,  and  Carl,  the  younger  one,  fc 
years.  In  Reinhold  the  affection  followed  an  attack  of  diph 
and  in  Carl  it  developed  without  any  preceding  illness.  The 
was  much  aggravated  in  tl?e  latter  after  a  fracture  of  the  leg. 
symptoms  in  both  boys  are  identical  save,  perhaps,  that  they 
little  less  severe  in  the  younger  child.  They  are  as  follow 
feet  in  walking  are  placed  widely  apart  and  the  toes  somewh 
verted.  The  gait  is  shuffling  and  unsteady  with  some  swayi 
the  body.  Cannot  walk  a  straight  line.  Sudden  turnings 
duces  staggering  and  falling.  If  unsupported,  will  fall  whei 
are  closed.  Ataxia  is  very  marked  in  both  hands.  No  sensoi 
turbances;  no  trunk  anesthesia;  no  nystagmus  nor  muscular  ti 
The  pupils  and  eye-grounds  normal;  knee  jerk  absent:  no  p; 
paresthesia.  All  the  rest  of  the  children  in  the  family,  six  in  nu 
enjoy  good  health.  Abrah^ 

14.  Three  Cases  of  Friedreich's  Disease  with  Increased  1 
Jerks.    (Hodge,  Brit.  Med.  Jour.,  June  1897,  p.  1,405.) 

The  three  patients,  two  sisters  and  a  brother,  aged  44.  40  a 
years  respectively,  presented  practically  the  same  clinical  histor 
condition.  About  the  age  of  12  they  began  to  have  difficulty  in 
ing,  which  disability  gradually  increased  and  ultimately  the  t 
club-foot  of  Friedreich's  disease  developed.  All  were  found  to 
marked  incoordination,  nystagmus  and  speech  defect,  but  the 
jerks  were  distinctly  exaggerated. 

French  authors  would  probably  class  these  cases  as  here 
cerebellar  ataxia.  Patrici 

15.  Maladie  de  Friedreich  a  debut  tardif.  (Friedreich's  D 
with  Late  Onset.)  Gaston  Bonnus.  Bulletins  de  la  Societe 
tomique  de  Paris,  10,  1897,  p.  18. 

The  author  presented  a  case  of  Friedreich's  disease  with 
upon  the  autopsy  and  microscopical  findings. 

The  case  occurred  in  a  man  thirty-nine  years  of  age,  alth 
the  earliest  signs  came  on  about  his  fourteenth  year. 

The  hereditary  factors  were  marked,  one  sister  being  mar 
ataxic  in  the  lower  extremities  without  sensory  disturbances  s 
brother  of  thirty-one  had  had  typical  signs  of  the  disease  for  s 
seven  years. 

The  results  of  the  histo^oorical  examination  is  of  interest  by  r 
of  the  rarity  of  such  examinations. 

The  cerebellum  was  said  to  be  absolutely  intact. 


PERISCOPE,  7 1 

Spinal  Cord:  At  level  of  third  lumbar,  the  posterior  columns  were 
degenerated  save  in  the  region  of  Flechsig's  centrum  ovale  and  West- 
phal's  zone.  A  certain  amount  of  degeneration  was  found  in  the 
crossed  pyramidal  tracts. 

Ninth  Dorsal:  Here  the  posterior  columns  were  markedly  degen- 
erated. The  crossed  pyramidal  tracts  were  degenerated,  also  Gowers 
bundle  and  the  direct  cerebellar  tract  to  a  less  extent.  The  cells  of 
Clark's  colunms  were  somewhat  atrophied  and  were  fewer  in  number. 

Eighth  Cervical:  The  entire  peripheral  region  was  involved,  but 
the  degeneration  was  most  apparent  in  the  columns  of  Turck,  and 
Goll,  and  Burdach. 

Medulla:  The  sensory  columns  were  involved  as  high  as  the 
nucleus  gracilis  and  cuneatus,  but  the  degeneration  did  not  extend  be- 
yond these  nuclei. 

The  meninges  were  intact,  the  anterior  roots  were  normal,  but 
the  posterior  roots  were  markedly  degenerated.  The  median,  ant. 
tibial,  sciatic  and  musculo  cutaneous  nerves  were  affected. 

Jelliffe. 
i6.    Ueber     Friedreichsche     Krankheit      (Hereditare    Ataxia). 

Concerning  Friedreich's  Disease  (Hereditary  Ataxia).    G.  Rosen- 

baum.    Deutsche  med.  Wochenschrift,  22,,  1896,  p.  471. 

Two  children  respectively  10  and  13  years  old,  showed  the  first 
symptoms  of  this  disease  6  years  ago.  A  brother  of  15  is  healthy, 
as  are  also  the  closely  related  parents,  the  father's  two  brothers  and  a 
sister,  and  a  cousin  of  the  mother  died  of  diabetes.  The  first  symptoms 
appeared  in  the  elder  girl  soon  after  an  attack  of  whooping-cough, 
the  younger  showed  signs  of  the  affection  shortly  after.  A  further 
exposition  of  their  present  status  is  unnecessary,  as. both  cases  present 
the  typical  picture  of  pure  FriQd,i;^h's  Ataxia. 

Pierre  Marie  differentiated  a  particular  form  of  the  original  Fried- 
reich's disease,  the  so-called  "cerebellar  hereditary  ataxia,"  in  which 
the  lesion  is  to  be  sought  in  the  cerebellum,  while  spinal  changes  are 
either  altogether  absent  or  so  slight  as  to  be  inappreciable.  The 
characteristics  differentiating  this  form  from  the  true  Friedreich's 
ataxia  are  its  later  manifestation,  (20th,  30th  year),  the  fact  that  the 
upper  extremities  are  not  attacked  until  the  disease  is  well  advanced, 
and  that  patellar  reflexes  are  either  normal  or  above  normal,  and  the 
absence  of  sensory  disturbances  and  scoliosis.  On  the  other  hand, 
visual  disturbances,  impaired  sensitiveness  of  the  pupil,  etc.,  are  in- 
variably present.  Although  transition  forms  are  unquestionably  to  be 
found,  the  author  thinks  that  spinal  and  cerebellar  sub-groups  should 
be  introduced  under  the  general  heading  of  hereditary  ataxia. 

VOGEL. 

I/-  Paraplegie  Spasmodique  Familiale.  (Hereditary  Spasmodic 
Paraplegia.)  C.  Achard  et  H.  Fressonn.  Gaz.  hebdom.  de  med. 
et  de  Chir.,  i,  1896,  p.  1225. 

Two  cases  of  hereditary  spastic  spinal  paralysis  affecting  sisters, 
are  reported.  Although  as  a  rule  this  disease  manifests  itself  between 
the  ages  of  3  to  12  years,  or  still  later,  in  the  present  instance  the  first 
symptoms  were  remarked  in  both  children  at  the  time  when  they 
commenced  to  walk.  In  the  one  case  it  was  at  the  age  of  16  months, 
after  an  attack  of  some  acute  disease,  the  nature  of  which  it  was  im- 
possible to  learn  about  definitely,  in  the  other  at  the  12th  month, 
sfter  an  attack  of  smallpox,  that  the  disturbances  first  took  place. 
The  disease  was  remarkable  for  the  slowness  of  its  course,  although 
steadily  increasing  in  severity.  Both  parents  were  entirely  sound, 
l>^t  a  sister  of  the  patient  had  an  epileptic  history. 

^lliffe. 


72  PERISCOPE. 

i8.    Hereditary  Ataxia — Friedreich's  Disease,  D.  Brower 
nal  of  the  American  Medical  Association,  28,  1897,  p.  871. 
Three  cases  of  Friedreich's  disease  are  reported  from   the 
of  the  author.    All  the  cases,  two  boys  and  a  girl,  were  of  th< 
family,    and   all  exhibited   marked    stigmata   of    degeneration, 
symptoms  obser\'ed  were: — ist,   the  ataxia  beginning    in    the 
limbs  and  extending  to  the  arms  and  tongue;  2d,  the  spinal 
ture,   double  scoliosis;  3d,   gradual  development  of  paraplegic 
loss  of  knee-jerk;  5th,  the  development  of  the  condition  in  chile 
6th,  the  absence  of  Argyll-Robertson  pupil,  of  anaesthesia,  of 
symptoms,  of  severe  pains,  of  intention  tremor,  of  spasticity 
gait.     These  several  symptoms  readily  differentiate  the  disease 
posterior  spinal  sclerosis  and  multiple  sclerosis.    The  seat  of  th< 
bid  changes  is  at  first  the  posterior  and  lateral  columns  of  the 
later  the  anterior  cornua  and  finally  the  nerve  structure.      In 
cases  there  is  developmental  failure;  in  others,  an  inflammati( 
suiting  in  a  steady  encroachment  of  the  connective  tissue  on  the 
elements.  Shivel 

PSYCHIATRY. 

19.    Acute   Delirium. 

Two  recent  contributions  to  the  subject  of  acute  delirium  d« 
notice.  Coston  (Nashville  Jour,  of  Med.  and  Surg.,  Aug.,  1896)  d 
it  as  **a  very  acute  febrile  disease  of  the  brain,  usually  fatal,  attend 
wild  delirium,  hallucinations,  and  great  disturbance  of  motor 
tions."  The  cause  is  obscure,  writings  on  the  etiology  being  sc 
more  than  speculations.  It  affects  both  sexes,  is  more  frequent 
30,  and  apparently  bears  no  relation  to  heredity.  The  onset  is  u 
sudden  and  the  first  symptoms  mental.    Three  cases  are  detaile< 

Case  I.  A  girl  of  15,  with  unimportant  family  and  negative 
sonal  history  was,  when  first  seen,  "  restless  and  slightly  deli 
using  uncouth  language  and  complaining  of  pain  in  her  head  anc 
of  pains  in  her  hips  and  back;  this  latter  seemed  but  insignifica 
character,  but  she  complained  bitterly  of  the  headache.  There 
great  motor  excitability,  the  patient  desiring  to  be  in  constant  mc 
and  occasionally  cursing  and  abusing  those  about  her."  Mor] 
and  bromides  failed  to  quiet  her,  and  the  next  day  she  was  r 
worse;  temperature,  loi;  pulse,  100;  and  she  constantly  talked  irra 
ally,  using  the  foulest  language,  but  recogized  everyone.  There 
absolute  anorexia,  no  vomiting,  and  the  urine  was  normal.  She 
very  destructive.  After  30  grains  of  chloral  she  slept  five  hours 
awoke  more  restless  and  destructive  than  before.  Fifteen  graii 
the  same  drug  induced  comparative  quiet,  but  she  was  soon  as  bs 
ever.  Sulphonal,  trional,  paraldehyde  were  tried,  but  large  dos< 
hyoscine  hydrobromate  were  most  successful,  1/20  grain  produ 
six  to  eight  hours  sleep.  She  gradually  became  weaker  and, 
passu,  the  delirium  less  violent,  and  died  on  the  thirteenth  day. 
highest  temperature  was  102,  the  lowest  100.5.  and  for  a  few  days 
ceding  death  she  seemed  to  be  blind;  the  pupils  were  widely  dilat< 

Case  II.  was  a  girl  of  13,  with  good  family  and  negative  pers 
wildly  delirious,  violently  and  constantly  agitated,  very  pro! 
who  had  never  menstruated,  but  showed  signs  of  approacl 
puberty.  The  character  of  onset  is  not  stated.  When  first  seen 
complained  bitterly  of  headache.  The  temperature  was  100.5;  P' 
no.  It  was  thought  at  first  to  be  hysteria,  but  she  did  not  imp] 
and  died  suddenly  in  the  beginning  of  the  fifth  day  while  sitting 
a  commode.    There  was  no  autopsy  in  either  of  these  cases. 

Case  III.     A  stout  country  girl,  aged  20,  of  good  heredity, 


PERISCOPE,  73 

with  unimportant  personal  history,  was  taken,  while  at  church,  with  what 
was  thought  to  be  a  chill,  but  the  shaking  tremor  and  slight  delirium 
continued,  and  she  was  seen  on  the  third  by  the  reporter.  She  recog- 
nized acquaintances  but  "  drifted  into  all  kinds  of  foolish  talk,"  and 
could  not  remember  having  seen  a  person  a  few  minutes  before;  tem- 
perature, loi;  pulse,  100.  The  body  and  extremities  were  in  constant 
motioir.  The  physical  agitation  was  in  some  degree  controlled  by 
morphine,  but  it  had  no  effect  on  the  delirium  unless  it  were  to  make 
it  worse.  She  continued  in  statu  quo,  except  that  she  lost  weight  rap- 
idly. She  was  given  sedatives  and  hypnotics,  but  hydrobromate  of 
hyoscine,  never  less  than  1/50  grain,  produced  the  best  results.  At 
the  end  of  the  week  the  physical  agitation  was  somewhat  better,  but 
she  continued  to  lose  strength  for  about  three  days  longer,  the  tem- 
perature varying  ffom  100  to  103,  with  pulse  from  100  to  150.  At  this 
time  she  was  found  to  be  totally  blind,  though  hearing  and  smell  re- 
mained very  acute.  The  amaurosis  lasted  four  days  and  then  gradually 
improved.  Mental  improvement  began  a  week  later  than  the  physical 
betterment,  both  gradual,  and  so  continued  until  complete  recovery, 
with  the  exception  of  one  slight  relapse;  but  there  was  still  some 
jerking,  especially  of  the  right  arm  and  hand  under  excitement. 

The  author  calls  special  attention  to  the  great  physical  agitation, 

rapid  exhaustion,  hyper-acuity  of  hearing  and  smell,  the  occurrence  of 

blindness  and  the  vesical  weakness  which  often  required  the  use  of  a 

catheter.    The  patient  recognized  persons,  but  talked  irrationally  and 

{orgot  immediately  having  seen  one. 

As  to  differential  diagnosis  from  acute  mania,  the  author  has  the 
following  to  say: 

"Acute  delirium  and  acute  mania  are  more  frequently  mistaken 
for  each  other,  and  their  diagnosis  from  each  other  is  more  difficult 
to  make,  but  with  care  we  may  differentiate  them.  The  symptoms  of 
acute  delirium  are  much  gjraver,  the  course  briefer  and  more  definite, 
the  temperature  is  elevated  in  acute  delirium  and  lowered  in  mania; 
the  exhaustion  is  very  rapid  in  acute  delirium,  while  the  maniac  will 
continue  to  rave  for  months  with  little  perceptible  loss  of  strength; 
mania  is  a  conscious  delirium,  the  patient  being  aware  of  what  he  is 
doing  and  taking  every  advantage  of  you;  acute  delirium  is  an  un- 
conscious delirium,  the  patient  never  trying  to  take  any  advantage 
of  you,  and  although  he  recognizes  you,  five  minutes  later  he  does  not 
remember  to  have  spoken  to  you.  In  mania  the  appetite  is  often 
enormous;  in  acute  delirium  it  is  always  absent;  mania  is  preceded  by 
marked  prodromata;  the  prodromata  of  acute  delirium  are  never  very 
marked  and  often  absent;  in  mania  the  face  is  often  flushed  and  the 
sclerotic  injected;  in  acute  delirium  the  face  is  pallid  and  no  injection 
of  the  sclerotic;  acute  delirium  will  terminate  in  death  or  recovery 
in  two  or  three  weeks,  mania  will  require  months." 

Babcock  (Medical  Record,  Aug.  ist,  1896)  first  calls  attention  to 
the  very  great  discrepancy  in  the  percentage  of  cases  of  acute  delirium 
admitted  to  different  asylums  for  the  insane.  This  varies  from  about 
one-seventh  of  one  per  cent,  to  4.7  per  cent.,  which  enormous  differ- 
ence the  author  rationally  attributes  to  the  diagnostic  tendency  of 
individual  institutions.  The  paper  is  essentially  devoted  to  a  consider- 
ation of  the  nature  of  acute  delirium,  particularly  its  possible  bacterial 
origin.  The  author  accepts  the  classification  of  Wood  into  acute  peri- 
encephalitis, and  cases  in  which  no  lesion  can  be  demonstrated,  but 
in  which  the  affection  is  assumed  to  be  one  primarily  of  the  cortical 
cells.  The  case  reported  is  placed  in  the  first  of  these  two  categories. 
The  patient  was  a  man,  46  years  of  age,  of  good  family  history,  but 
addicted  to  the  excessive  use  of  alcohol  and  tobacco.  Ten  days  before 
admission  he  became  restless,  sleepless  and  talkative,  and  later  was  at 


74  PERISCOPE. 

times  violent.    On  admission  he  talked  almost  constantly  and 
incoherently,  was  physically  agitated,  and  it  was  impossible  t< 
his  attention.     The  temperature  was  99.6;  pulse,  80;  urine  pr 
normal.     Patellar  reflexes  were  absent.     After  the  administr 
20  grains  of  sulphonal,  he  slept  seven  hours  and  awoke  with 
perature,  but  as  delirious  as  before.     He  continued  in  much  tl 
condition,  the  temperature  being  usually  normal,  until   the 
second  day  of  the  disease,  when  the  delirium  increased.     The 
ature  arose  to  100.2,  pulse  to  100,  and  a  trace  of  albumin  app< 
the  urine.    Sulphonal  failed  to  produce  sleep  and  hyoscine  was 
tuted  with  good  results.     He  remained  in  the  same  condition 
twenty-ninth  day  when  lumbar  puncture  was  performed  with 
ently  some  transitory  relief.    The  patient  then  gradually  grew 
passed  into  a  typhoid  state,  and  died  on  the  forty-sixth  day 
disease,  greatly  emaciated.    Eight  minutes  after  death  spinal  p 
was  again  done,  and  66  c.c.  of  turbid  fluid  collected.    The  post-: 
examination  showed  mascroscopic  and  microscopic  signs  of 
mation  in  the  membranes  of  the  brain  and  in  the  cervical 
The  fluid  from  the  first  puncture  contained  2/25  per  cent,  of  a 
and  that  removed  after  death  3/5,  which  is  exceedingly   hi| 
would  indicate  acute  inflammation.    Bacteriologic  examination 
fluid  showed  the  micrococcus  of  pneumonia  and  streptococc 
oculation  of  rabbits  caused  symptoms  of  infection,  but  the  expi 
was  not  conclusive  Patri 

THERAPY. 

20.  Traitement  des  douleurs  de  l*  ataxie  i^ar  le  bleu  DE  ] 
LENE  (Ataxia  Pains  Treated  by  Methylen  Blue),  M.  G.  L€ 
Gazette  Hebdomadaire,  2,  1897,  p.  570. 

The  author  reported  the  use  of  methylen  blue  in  nine  cj 
ataxic  pain.     In  two  there  was  no  improvement;  in  five  there 
great  lessening  of  the  intensity  and  frequency  of  the  crisis,  and 
a  long  period  of  complete  ease.     The  author  believes  that  the 
which    yield   the   most   readily   are   the   severe   lancinating   pa 
the  legs,  and  girdle  pains;  the  most  difBcult,  those  which  are 
in  the  intestines,  the  stomach  or  the  gastric  crises  without  other 
The   effect   sometimes   lasted   for   days,   and   occasionally  for 
Methylen  blue  seems  to  have  a  wide  range  of  usefulness,  if  the 
peutic  optimism  of  the  French  observers  does  not  mislead  thei 
sides*  the  valuable  property  of  relieving  ataxic  pains,  diabetic 
toms  have  disappeared  under  its  use,  and  even  the  final  eliminat 
sugar  from  the  urine  has  been  ascribed  to  it.     It  is  indeed  almc 

useful.  MlTCHEI 

21.  Pathogenese  und  Behandlung  der  Chorea,  (Patholog 
Treatment  of  Chorea).  P.  Cheron.  Allg.  Wiener  Zeitur 
1896,  p.  429. 

Cheron  recommends  methodically  used  massage,  which  he 
to  have  used  with  much  success.  Massage  and  passive  move 
should  be  employed  several  times  daily,  together  with  cold  bath: 
douches,  cold  packs,  and  notably  cold,  violent  sprays  against  th 
tebral  column  of  a  temperature  of  from  8  to  10  deg.  C.  for  about 
Yi  minute.  Heart  complications  form  no  contra-indication  to  the 
cold  water,  as  children  usually  have  few  signs  of  circulatory  dif! 
But  the  patients  should  never  be  frightened  by  hydriatic  mea 
else  the  psychic  excitement,  restlessness  and  pathologic  move 
become  increased.  The  heart  should  be  examined  daily,  and  itj 
dition  forms  a  guide  to  the  choice  of  whatever  form  of  cold-tF 
seems  indicated.  Stern 


PERISCOPE.  75 

22.  L'antipirina  contro  la  corea,  (Antipyrin  in  Chorea  Minor). 
Negro.    Gaz.  deg.  ospedal^,  J7,  1896,  p.  308. 

This  drug  was  exhibited  with  marked  success  in  chorea.  Dose 
for  children  of  from  five  to  seven  years,  018  to  i.o  gm.  pro  die:  from 
eight  to  ten  years,  up  to  2.0  gm.  Older  children  he  gave  up  to  3.0 
gm,  pro  die.  The  drug  was  usually  readily  taken,  with  few  ill  effects, 
if  a  pause  of  from  3  to  4  days  was  allowed  to. follow  the  day  upon 
which  antipyrin  was  used.    His  formula  is 

3  Antipyrin lO.o 

Aquae 200.0  ^ 

Syr.  Cort.  Aurant So.o 

M.  D.  Sig.  as  directed. 
The  antipyrin  was  given  for  about  one  month,  and  was  followed 
by  arsenic  and  iron  until  complete  cure  resulted. 

Sterne. 

23.  Treatment  of  Neurasthenia  by  Psychotherapy.     Dr.  Valen- 
tine (Medical  Week,  July  31st,  1896). 

The  extent  to  which  physicians  possessed  of  one  idea  will  go  is 
illustrated  in  the  report  of  the  remarks  of  Dr.  Valentine  at  a  meeting 
vf  the  Hypnologrical  and  Psychological  Society,  July  20th,  1896,  at 
Paris.  He  describes  the  treatment  by  hypnotic  suggestion  of  three 
patients,  only  one  of  whom  really,  according  to  his  own  description, 
was  in  deep  sleep;  the  third  case,  he  says,  was  treated  for  three  months 
by  "  suggestion  without  hypnotization."  This  apparently  means  that 
he  encouraged  the  patient  and  told  her  she  .would  get  well.  Other 
physicians,  who  do  not  pretend  to  hypnotize  their  patients,  have  no 
doubt  done  the  same  thing,  without  knowing  that  they  were  qualified 
for  members  of  the  society  with  the  imposing  name.  Mitchell 

24.  Treatment  of  the  Insomnia  of  Insanity  by  Trional  and 

Tetronal. 

M.  a.  Bohn  (These  de  Paris,  1896)  in  a  study  of  the  treatment  of 
the  insomnia  of  insanity  by  trional  and  tetronal,  concludes  that  both 
drugs  are  powerful  hypnotics  and  that  their  actions  are  practically 
identical.    He  thinks  that  either  is  preferable  to  chloralose  on  account 
of  the  accidents  which  occasionally  follow  its  employment,  and  on  ac- 
count of  the  wide  difference  in  doses  required  by  different  patients. 
(The  reporter  has  twice  seen  very  alarming  symptoms;   prolonged 
iinconsciousness,  breathing  as  slow  as  if  the  patient  had  taken  a  large 
dose  of  opium,  fixed  pupils  half  dilated  and  mental  confusion  for  some 
liours  on  waking,  as  the  result  of  the  use  of  15  grains  of  chloralose  in 

one  neurasthenic  case  and  of  10  grains  in  another.]  Mitchell. 

• 

25.  Sedatives  and  Hypnotics  in  the  Treatment  of  Insanity.  Dis- 
cussion before  the  British  Medical  Association  (British  Medical 
Journal,  Sept.  26th,  1896,  p.  807.) 

Oswdd  regarded  failure  of  strength  as  the  most  important  synip- 
1om  making  it  urgent  to  procure  sleep  in  acute  cases.  In  such  cases 
lie  preferred  paraldehyde;  it  did  not  depress  and  had  no  bad  effect. 
He  thought  in  the  rush  after  new  remedies  that  old  and  meritorious 
ones  were  apt  to  be  forgotten,  and  instanced  as  such  conium  juice, 
digitalis,  and  chloral,  especially  when  combined  with  bromide.  This 
last  drug,  combined  with  hyoscyamus  and  cannabis  indica,  could  be 
siven  in  much  larger  doses  than  were  usually  employed.  He  was 
opposed  to  the  use  of  sulphonal,  as  it,  in  many  cases,  destroyed  the 
Ted  blood  corpuscles  and  produced  mild  dementia.  It  cut.short  periods 
of  excitement,  but  the  patient  did  not  regain  mental  clearness.  Mor- 
l)nine  was  not  so  useful  as  opium,  and  his  impression  of  hyoscine  and 


76 


PERISCOPE. 


hyoscyamine  was  not  favorable.  The  best  hypnotics  and  s< 
he  thought,  were  exercise,  work,  distraction  of  thoughts,  atnui 
etc. 

J.  A.  Campbell  thought  that  hypnotics  and  sedatives  had 
ative  influence,  and  that  the-  continued  use  of  such  drugs  for  an; 
of  time  had  a  tendency  to  retard  recovery. 

McLeod  said  that  in  discussing  sucn  subjects  there  was 
too    much    generalization.      Such    drugs    should    be    given 
any  class  of  disease,  but  with  a  strict  attention  to  the  individ 
his    constitutional    peculiarities      Sulphonal    had    a    distinct 
tizing    effect.        He    never    saw    any    real    harm    result     fr 
proper    use.      It    usually    did    harm    in    cases    of    circular    i 
It  might  shorten  the  excitement,  but  it  prolonged  the  depress] 
clouded  the  quiescent  period.    He  used  fewer  drugs  of  that  cla 
he  used  to  do.    The  most  efficient  hypnotic  he  had  found  was 
tion  composed  of  chloral  hydrate,  potassium  bromide,   hyos 
and  cannabis  indica.    He  had  used  no  preparation  of  opium  as 
tive,  only  as  an  anodyne.     Hyoscyamine  was  occasionally  of  u 
in  moderate  doses  allayed  the  restlessness  of  certain  organic 
such  as  those  of  brain  tumor,  more  effectually  than  any  other  d 

Yellowlees  summed  up  his  convictions  regarding  hypnotics 
phrase  **  The  less  the  better."  There  should  be  a  definite  dist 
drawn  between  the  extent  to  which  such  drugs  were  given  in 
able  cases  and  in  cases  in  which  there  was  a  reason  to  belie' 
recovery  might  take  place.  We  should  put  up  with  a  great  dej 
a  curable  patient  before  we  ran  the  risk  of  the  brain  cell  injury 
these  drugs  were  so  apt  to  inflict.  They  always  retarded  and 
times  even  prevented  recovery. 

McDowall  said  that  he  used  to  give  hypnotics  very  freely,  bi 
very  rarely  indeed.  He  still  uses  them  extensively  in  one  c 
cases,  however,  namely  melancholia.  He  had  been  told  by  p 
that  physicians  did  not  properly  understand  the  great  misery  of 
lessness.  To  diminish  this  he  gave  his  melancholiacs  chloral,  s 
nal  or  other  hypnotic.  He  never  used  such  drugs  in  cases  of  : 
excitement.    He  practically  never  gave  morphine  or  hyoscine. 

Carlyle  Johnstone  said  that  in  prescribing  sedatives  and  hyp 
in  the  treatment  of  insanity  he  would  be  guided  by  the  same  g 
principles  as  those  which  would  guide  him  in  treating  other  dij 
He  would  ask  himself,  in  the  first  place,  is  a  sedative  or  hy 
really  required  in  this  particular  case?  Is  it  necessary  that  the  i 
should  be  put  to  sleep  or  that  his  excitement  should  be  suppr 
Is  our  object  being  attained?  Has  sleep  been  obtained?  Has 
ness  been  procured?  If  our  object  has  been  attained,  has  it  be 
tained  at  too  great  a  cost?  In  a  word,  is  the  patient  the  better  < 
worse  in  body  and  mind?  If  the  drug  was  interfering  with  any  n 
function,  if  recovery  was  not  being  promoted  under  its  use,  if  tl 
tient  could  not  be  said  to  be  better  than  he  was  before,  he  woui 
that,  even  although  sleep  and  quietness  had  been  produced,  they 
in  their  purpose. 

Gairdner  condemned  opium  and  stimulants  in  the  treatme 
delirium  tremens. 

Urquhart  did  not  see  that  it  was  permissible  that  a  chronic  i 
able  melancholiac  should  be  left  in  misery  day  and  night  without 
relief  being  given  him.  Certainly  great  care  was  necessary  in  th 
of  hypnotics.    The  moral  of  the  discussion  seemed  to  him  to  be 


ware." 


TurnbuU  said  he  thought  these  drugs  were  very  useful  in  t 
over  an  emergency.  He  had  found  sulphonal  most  useful,  and  h 
never  seen  any  ill  effects  from  it. 


PERISCOPE,  7^ 

Douglas  said  that  the  most  valuable  use  of  hypnotics  was  to  be 
found  in  that  period  which  preceded  the  state  in  which  a  patient  could 
be  certified.  They  could  often  tide  over  a  crisis  at  such  a  time  by 
means  of  drugs.  He  had  found  croton  chloral  and  bromide  of  the 
greatest  value.  He  also  recommended  tetronal  in  lo-grain  doses  as  a 
hypnotic.  Patrick. 

2d.    Saturnine   Encephalopathy  Treated  by  Venesection  and 

Serum  Injection. 
M.  Desplats  (Journal  dc  M^d^cine,  Nov.  loth,  1896)  recommends 
the  injection  of  serum  associated  with  bleeding  in  this  trouble,  and 
mentions  the  case  of  a  man  who  had  had  two  attacks  of  colic,  followed 
hy  an  epileptiform  crisis  characteristic  of  saturnine  encephalopathy. 
The  urine  contained  no  albumen.     After  the  patient  had  been  bled, 
(xxy  cubic  centimetres  of  artificial  serum  was  injected  subcutaneously. 
There  were  no  further  attacks,  and  in  a  few  days  the  case  was  dis- 
charged cured.     The  author  considers  it  legitimate  to  attribute  the 
cure,  in  this  instance,  to  the  association  of  the  two  means,  which  he 
says,  have  never  before  been  employed  in  eclampsia,  either  puerperal 
or  renal.     He  believes  that  whatever  may  be  the  pathology  of  this 
condition,  whether  due  to  deficient  urinary  elimination,  or  the  pres- 
ence  of  too  much  lead  in  the  blood,  or  to  functional  derangement  of 
the  liver,  or  some  other  gland,  under  the  influence  of  a  toxic  agent, 
it  is  certain  that  when  the  attacks  occur,  the  constitution  of  the  blood 
is  abnormal,  and  it  contains  noxious  principles  which  should  be  elim- 
inated.    If  we  wait  for  the  organism  to  relieve  itself  by  the  natural 
emunctories,  the  attacks  continue  and  may  terminate  in  a  fatal  man- 
ner.    The  most  energetic  purgations,  diuretics  and  diaphoretics  act 
too  slowly,  while  the  treatment  suggested  by  Desplats  is  more  prompt 
and  sure.    By  the  latter  means  elimination  takes  place  rapidly,  and  the 
serum  injected  modifies  the  compositon  of  the  blood.     He  considers 
this  method  also  applicable  in  puerperal  or  renal  eclampsia,  and  in 
other  affections  where  toxines  play  the  principal  role.       Freeman 

^-    Epilepsy;  Its  Surgical  Treatment.    McGrew.    (Medicine,  May, 

'97.) 

A  man  of  2l^y  received,  in  1882,  an  injury  to  the  head,  about  which 
little  could  be  learned  except  that  he  was  not  trephined.    A  half  hour 
after  the  accident  he  had  a  convulsion,  and  from  then  to  the  time  of 
the  operation,  except  for  one  short  period,  he  had  at  least  one  fit  a 
day.     In  1894  he  was  operated  upon,  with  unsatisfactory  result.    When 
first  seen  by  the  author,  later  in  that  year,  he  was  having  numerous 
fits,  preceded  a  few  minutes  by  a  peculiar  headache  as  an  aura.    Exami- 
nation showed,  on  the  left  side  of  his  head,  two  scars,  one  linear,  the 
other  horseshoe-shaped,  commencing  about  2  cm.  laterally  from  the 
junction  of  the  posterior  and  middle  thirds  of  the  line  joining  the 
glabella  and  the  mion,  and  passing  forwards  and  downwards.     These 
were  sensitive  on  pressure.     On  March  28,  1895,  the  patient  had  a  fit, 
and  lost  the  power  of  speech  and  hearing,  but  could  read  and  express 
his  wishes  in  writing.    This  condition  persisting,  on  Dec.  5,  1895,  the 
author  exposed  the  bone  in  the  left  parietal  area  by  a  large  horseshoe 
flap.     The  dura  was  found  adherent  to  the  bone  about  the  margins  of 
a  semilunar  opening,  2  cm.  long  by  8  mm.  wide  at  its  widest  part, 
left  from  the  earlier  operation.     The  opening  was  rounded  and  en- 
larged to  the  size  of  a  silver  dollar,  the  dural  adhesions  separated  and 
clipped  away,  and  the  edges  of  the  bone  made  smooth.    The  dura  was 
tvot  opened.    The  outer  table  of  the  skull  was  beveled,  a  thin  silver 
p^Mc  shaped  like  a  watch  glass  was  fitted  over  the  opening,  and  the 
ftap  closed  over  it.    The  patient  made  a  good  recovery.    Ae  soon  as  he 
came  from  under  the  anesthetic  he  could  speak  and  hear,  and  during 
the  fifteen  months  which  have  elapsed  during  the  operation  he  has  had 
no  fits.  C.  L.  Allen. 


§aah  "^z^^izws. 


Normal  and  Pathological  Circulation  of  the  Central  Ner 
System.  By  Wm.  Browning,  Ph.B.,  M.D.  J.  B.  Lippi 
Co.     Philadelphia,  1897. 

Dr.  William  Browning's  work  on  the  normal  and  patholo 
circulation  in  the  central  nervous  system  is  a  welcome  additio 
our  knowledge  of  a  subject  so  difficult  of  investigation.  The  ai 
fully  recognizes  these  difficulties  which  lie  in  the  fact  that  the 
ditions  of  the  circulation  by  the  very  process  of  the  experimental  s 
are  changed  from  those  existing  intra  vitam. 

The  author  scarcely  gives  sufficient  importance  to  the  com] 
tively  free  passages  of  the  cerebrospinal  fluid  from  the  brain  intc 
spinal  cord,  and  vice  versa,  thus  relieving  within  certain  limits  un( 
pressure  on  the  brain  as  a  whole  either  in  hyperaemia  or  ansemix 

There  seems  little  doubt  that  this  is  an  important  factor  in 
altered  cerebral  pressure  which  must  follow  in  cerebral  hemorrl 
or  softening,  or  in  cerebral  growths. 

Many  interesting  and  unusual  cases  of  internal  hydrocephalus 
symmetrical  central  lesions  are  related  in  more  or  less  detail.  F 
the  careful  investigation  of  the  literature  double  lesions  are  fc 
to  be  more  common  than  is  usually  supposed.  The  usual  cans 
cerebral  hemorrhage  or  thrombosis  is  disease  of  the  cerebral  ve 
which  is  general  and  not  localized  unless  following  some  local  in* 
It  is  easily  supposable  that  one  part  of  this  chain  of  diseased  ve 
might  be  more  affected  than  another,  thus  leading,  as  is  more 
quently  the  case,  to  a  unilateral,  rather  than  a  multiple  or  symniet 
lesion.  The  exciting  cause  of  cerebral  hemorrhage  is  said  to  be  "n 
action,  most  probably  vasomotor."  The  muscular  coat  of  the  cere 
arteries  is  subject  to  some  influence  leading  to  contraction  and  • 
tation,  but  whether  this  is  accomplished  by  the  direct  influence 
the  circulatory  fluid  altered,  as  it  may  be,  in  disease,  or  by  nerve 
the  cerebral  vessels,  is  still  a  question  for  further  elucidation. 

The  author  relates  two  cases  of  interest,  in  which  hemorrl 
probably  followed  a  previous  softening  in  some  area.  This  condi 
is  not  always  easy  of  proof.  In  these  studies  of  Dr.  Browning  we  1 
many  suggestions  of  great  importance.  £.  D.  Fishe 

Traumatic  Injuries  of  the  Brain  and  its  Membranes.  Wit 
Special  Study  of  Pistol  Shot  Wounds  of  the  Head  in  their  Med 
legal  and  Surgical  Relations.  By  Charles  Phelps,  M.D.,  Surg 
to  Bellevue  and  St.  Vincent's  Hospitals.  8vo,  582  pages.  \ 
49  illustrations.    Cloth,  $5.    New  York:  D.  Appleton  &  Comp; 

1897. 

This  contribution  to  regional  surgery,  neurology  and  legal  m 
cine  is  based  upon  the  study  of  five  hundred  intracranial  traumati 
which  were  observed  in  the  author's  own  hospital  services  and 
those  of  his  colleagues,  and  upon  the  results  of  experimental  pi 
shot  wounds  of  the  head  made  during  the  past  three  years  in 
city  morgue.  The  work  is  composed  of  three  parts.  The  first  descr 
the  pathology,  symptomatology,  diagnosis  and  treatment  of  gen 


BOOK  REVIEWS,  79 

brain  lesions,  and  the  second  has  to  do  with  the  surgical  and  medico- 
legal relations  of  pistol-shot  wounds  of  the  head.  The  last  hundred 
and  ninety  pages  are  taken  up  by  the  histories  of  the  clinical  cases, 
two  hundred  and  twenty-five  of  which  are  amplified  by  reports  of  the 
gross  appearances  found  at  autopsy.  The  whole  is  preceded  by  a 
consideration  of  fractures  of  the  skull,  and  in  this  part  are  to  be  found 
valuable  statistics  as  to  the  most  frequent  seats,  with  the  attendant 
mortality,  of  the  bone  lesions,  together  with  such  symptoms  as  are 
characteristic  of  each  class. 

In  the  section  on  pathology  objection  is  made  to  the  continuance 
of  the  term  "concussion  of  the  brain,"  although  the  author  proposes 
ng  satisfactory  substitute  to  designate  the  losses  of  consciousness,  in- 
cident to  head  injuries  of  moderate  severity,  from  which  the  patient 
quickly  recovers  without  ever  presenting  subsequent  symptoms  of  a 
character  to  indicate  any  actual  disturbances  of  brain  structure.  Con- 
siderable prominence  is  given  to  meningeal  contusion  as  a  cause 
of  general  cerebral  symptoms.  In  it  is  found  the  explanation  of  the 
peculiar  circumscribed  sub-pial  collections  of  clear  fluid  which  seem 
to  be  the  only  discoverable  causes  of  death  in  some  cases.  The  author 
does  not  believe  that  this  condition  can  be  diagnosticated  during  life, 
since  "when  the  edema  is  considerable  in  amount,  it  is  still  insufficient 
to  occasion  symptoms  of  compression."  It  may  be  said,  however, 
that  at  the  last  meeting  of  the  American  Neurological  Association, 
circumscribed  edema  was  accepted  as  an  occasional  cause  of  focal 
symptoms  (see  this  Journal,  August,  1897). 

The  chapters  on  symptomatology  contain  many  interesting  ob- 
sen'ations  as  to  the  distinctive  clinical  features  of  the  different  kinds 
of  brain  lesions  (classified  as  i.  Hemorrhages;  2.  Diffuse  and  limited 
contusions;  3.  Laceration;  4.  Secondary  inflammations),  and  as  to 
such  symptoms  as  result  from  affections  of  definite  cerebral  territories. 
The  cases  of  injury  to  the  frontal  lobes  are  so  noteworthy  that  they 
may  be  referred  to  in  some  detail.  Twenty-eight  cases,  confirmed  by 
autopsy,  are  considered  as  permitting  an  estimate  of  the  direct  results 
of  frontal  lesions.  The  laceration  involved  the  left  frontal  lobe  in 
eleven,  the  right  in  seven,  and  both  lobes  in  ten  of  the  cases.  "In 
the  eleven  cases  in  which  frontal  laceration  was  confined  to  the  left 
lobe,  there  was  •  mental  aberration  or  deficiency,  apart  from  mere 
stupor  or  delirium,  in  every  one;  while  in  the  seven  in  which  laceration 
was  confined  to  the  right  lobe,  it  was  observed  in  none.  In  the  ten 
cases  in  which  frontal  laceration  involved  both  lobes  .  .  specific 
mental  disturbance  .  .  .  was  observed  in  eight."  The  two  others 
were  not  clinically  available  for  statistics.  The  importance  of  these 
results  is  self-evident.  If  subsequent  and  more  extended  observations 
confirm  them.  Dr.  Phelps  will  have  succeeded  in  pointing  the  way  to 
the  solution  of  knotty  psychological  problems.  The  discussion  of  the 
symptomatology  of  brain  lesions  is  continued  by  the  consideration 
of  the  diagnostic  significance  of  paralysis,  morbid  movements,  con- 
jugate deviation  of  the  head  and  eyes,  the  condition  of  the  sphincters, 
P'l^,  temperature,  etc.  These  are  again  referred  to  under  "  Dia- 
gnosis." The  first  part  concludes  with  a  chapter  devoted  to  the 
principles  of  treatment. 

The  chief  interest  in  Part  II.  attaches  to  the  medico-legal  rela- 
tions of  pistol  shot  wounds  of  the  head.  Dr.  Phelps  has  long  been 
interested  in  this  subject,  and  the  present  systematic  exposition  of 
the  results  of  his  investigations  is  a  valuable  contribution  to  this 
branch  of  forensic  medicine.  He  shows  the  inferences  as  to  the  size 
of  the  ball,  the  length  of  range,  etc.,  which  may  be  drawn  by  exami- 
nation of  the  wound  of  entrance  and  exit,  the  burning  of  the  skin  and 
bair,  the  deposit  of  powder  grains  in  the  skin  or  in  the  track  of  the 


8o  BOOK  REVIEWS. 

bullet.    This  part  of  the  book  is  fully  illustrated  with  excellent 
graphs  of  the  cases. 

The  work  as  a  whole  merits  the  serious  attention  of  all  wh 
to  do  with  encephalitic  traumatisms.  It  embodies  the  results 
dious  analysis  of  a  very  large  number  of  cases  and  consequent 
tains  a  fund  of  useful  information.  The  neurologist,  howeve 
find  the  histories  deficient  in  points  of  detailed  examination,  ai 
regret  that  the  specimens  from  some  of  the  especially  interesting 
were  hot  examined  by  means  of  the  microscope.  The  part  of  th< 
which  treats  of  pistol  shot  wounds  fills  a  hitherto  conspicuoi 
in  our  literature  and  will  at  once  be  accorded  the  place  of  au 
on  this  class  of  injuries. 

There  are  places  in  the  text  where  the  style  might  hav< 
easier  and  more  clear,  and  the  book  would  have  had  a  more  c< 
ient  usefulness  had  it  been  indexed.  Pearce  Bai 

Twentieth  Century  Practice.     Vol.  xi.     Diseases  of  the  N< 
System.     Edited  by  Thomas  L.  Stedman,  M.  D.    William 
&  Company,  New  York,  1897. 

An  article  by  Lloyd,  of  more  than  four  hundred  pages,  01 
eases  of  the  Cerebrospinal  and  Sympathetic  Nerves,  is  the  firs 
series  of  excellent  papers.  The  author  has  drawn  largely  on  tl 
perience  gained  in  an  active  practice,  and  on  the  best  literature 
ing  to  the  peripheral  nerves.  The  Trophoneuroses  are  treat 
Mills  and  Dercum.  Bruns  and  Windscheid  write  on  Diseases 
Spinal  Cord;  Mobius  on  Tabes  Dorsalis;  Striimpell  on  Con: 
System  Diseases  of  the  Spinal  Cord;  and  Witmer,  from  the  ! 
point  of  the  psychiater,  on  Pain.  The  volume  will  prove  usefu 
only  to  the  neurologist,  but  to  the  general  practitioner  an 
student. 

BOOKS  RECEIVED. 

"An  Epitome  of  the  History  of  Medicine,"  by  Roswell  Par 
D.    F.  A.  Davis  &  Co. 

"  Die  Darstellung  krankhafter  Geisteszustande  in  Shakesp 
Dramen."    Von  Dr.  Hans  Laehr.    Paul  Neff  Verlag.  Stuttgart. 

"Index  Catalogue  of  the  Library  of  the  Surgeon  General's  Oi 
U.  S.  Army,  Vol.  ii.     B  to  By  water.    Washington,  1897. 

"System  Nerveux  Central,  photo  gravures,"  Dr.  J.  Dagonet, 
raire.    J.  B.  Baillerriet  Fils,  Paris,  France. 

"  Die  Akromegalie."    Von  Dr.  Maximilian  Sternberg. 

"  Sulla  Opportunite  ed  Efiicacia  della  Curra  Chirurgico,  Ge 
logica  Nella  Nevosi  Isterica  E  Nella  Alunazione  Mentale,"  D 
Angelassi  and  Dr.  A.  Pieraccini. 

"Dyskinesias  Arsenici^s,"  (Nova  Cortribuicas  E  Estado  Actu 
Questas.)     Dr.  Deslinde  Galvas. 

"Sitzungsberichte  der  kaiserlichen  Akademie  der  Wissenschai 
3  numbers. 

"L  Hysteric  Aux  xvii  et  xviii  Sieclcs,"  Mme.  G.  AbricosofF 
Steinheil,  Paris. 

"Iowa  State  Medical  Society  Transactions,"  Vol.  xv. 

"  Die  Bedeutung  der  Augenstorungen  fiir  die  Diagnose  der 
imd  Riickenmarkskrankheiten."        Dr.   Otto  Schwartz.       S.  Kr; 
Berlin. 

"Studies  Gummos."  (Tertian)  Syfilis,  by  Kristian  Grou.  Stee 
Bogtrykkerj,  Kristiania. 


Its 
Bacteriolog:y 

The  crucial  test  of  the  efficacy  of  an  anti 
fluid  is  the  bacteriological  one.  When  we  stat< 
BoROLYPTOL  is  equal  in  germicidal  potency  to  a  i 
solution  of  Corrosive  Sublimate  without  the  irrifc 
toxic  properties  of  the  latter  drug,  we  base  our 
upon  the  results  of  careful  laboratory  experiment 
with  the  different  varieties  of  germ  life.  We 
full,  complete  and  conclusive  reports  from  the 
teriologists  of  the  N.  Y.  Post-Graduate  M( 
School,  City  Hospital  at  Boston,  and  the  Ga 
Memorial   Hospital  at  Washington. 

These  will  be  sent  upon  request. 


V 


BOROLYPTOL  is  palatable,  fragrant,  and 
slightly  astringent  It  does  not  staSa  linen  or 
clothes.  It  shouid  be  employed  in  Gynecology 
and  Obstetrics,  Rhino-Laryngolojgyi  Surgery  and 
Dentistry.  Also  internally  in  the  treatment  of 
Typhoid  Fever,  and  in  the  gastro-intestinal  dis- 
oraers  of  children. 

Send  for  •*  Expert  Evidence." 


THE  PALI8ADI  M'FH 
YONKIR8,  N.  Y 


VOI^.   XXV. 


February,   1898. 


No.  2. 


THE 


Journal 


OF 


Nervous  and  Ment 


^^viQiwxl  ^trtt 


ON  ARRESTED  DEVELOPMENT  AND  LITTLE'S 

DISEASE.^ 

By   WILLIAM    G.  SPILLER.  M.D., 

With  Remarks  by  W.  W.  Keen,  M.D.,  On  the  Advisability  of  Opera- 
tion in  Microcephaly. 

The  diagnosis  of  arrested  development  is  so  frequently 
made  that  the  desire  naturally  arises  to,  know  the  facts 
obtained  by  actual  examination  of  brain  and  cord  in  such 
cases,  and  in  this  paper  an  attempt  is  made  to  present  a 
few  of  these,  especially  those  relating  to  arrested  devel- 
opment of  the  motor  tracts.  The  clinical  notes  have  in 
gfreat  part  been  taken  from  the  casebook  of  Prof.  Keen, 
at  the  Philadelphia  Orthopedic  Hospital  and  Infirmary 
for  Nervous  Diseases.  I  am  deeply  indebted  to  him  for 
the  liberality  he  has  manifested  in  placing  them  at  my  dis- 
posal. Use  has  also  been  made  of  the  paper  published  by 
Prof.  Keen  in  the  American  Journal  of  the  Medical 
Sciences,  June,  1891.  The  case  K.  K.  is  from  the  Pennsyl- 
vania Training  School  for  Feeble  Minded  Children. 

The  parents  of  the  child  K.  K.  were  first  cousins,  and 
of  moderate  intelligence.  One  child,  still  living,  has  hydro- 
cephalus; another  died  in  his  fourth  month  in  convulsions. 

*  From  the  Wistar  Institute  of  Anatomy  and  Biology.  One  of  two 
papeK  presented  for  membership  in  the  American  Neurological 
Association. 


82  WILLIAM   G.  S FILLER, 

K.  K.  had  a  very  small  head  at  birth,  and  the  ant 
fontanelle  was  closed.  She  was  born  in  difficult  labc 
full  term,  without  the:  use  of  instruments,  and  was  the 
ond  child  in  the  family.  The  mother  fell  down  ten  j 
and  hurt  her  side  in  the  seventh  month  of  pregnancy 
history  of  venereal  disease  in  the  parents  could  be  ob 
ed.  At  the  age  of  nineteen  months,  K.  K.  w^as  ur 
to  sit  erect  without  support,  though  she  could  hold 
jects  in  her  hands.  She  had  moderate  contracture  ol 
flexor  muscles  of  the  feet,  but  her  legs  were  not  paral} 
The  knee-jerks  were  absent,  possibly  on  account  of 
tracture,  and  ankle-clonus  was  not  observed.  The  < 
presented  the  appearance  of  an  idiot,  and  her  atten 
could  only  be  obtained  momentarily.  Convuls 
occurred  in  the  teething  period.  The  measurement 
the  age  of  nineteen  months  were  as  follows: 

Biparietal   10.3  cm.  (4  1-16  in.) 

Biauricular 10.2  cm. 

Bitemporal   8.3  cm.  (3  1-2  in.) 

Occipito-frontal 11.9  cm.   (4  3-4  in.) 

Circumference 36     cm.  {14  1-4  in.) 

By  comparison  with  average  measurements  it  will  be  ; 
that  the  head  was  not  much  larger  than  that  of  a  f 
at  full  term.    Craniotomy  was  performed  when  the  pat 
was  nineteen  months  old.     The  description  by  Dr.  K 
of  the  operation  is  as  follows:     "An  incision  was  n* 
one  inch  to  the  left  of  the  middle  line,  parallel  to 
sagittal  suture,  and  six  inches  in  length.    A  curved  incij 
was  then  made  from  the  anterior  end  of  this  line  downw 
so  as  to  lift  a  frontal  flap, the  scar  of  which  would  be  hid 
by  the  hair.     A  half-inch  button  of  bone  was  remo 
by  the  trephine,  and  from  this  anteriorly  and  posteri< 
a  furrow,  a  quarter  of  an  inch  wide,  was  cut  out  of 
bone,  extending  to  within  an  inch  of  the  supraorbital  ri 
and  an  inch  above  and  to  the  left  of  the  inion.    The  len 
of  the  furrow  was  five  inches.    The  amount  of  hemorrh 
from  the  scalp  was  very  slight,  much  less  than  I  h 


LITTLE'S   DISEASE.  83 

found  in  adults.  The  bone  was  very  thin,  about  one  to 
one  and  a-half  mm.  thick  only,  but  bled  freely.  Opposite 
the  parietal  boss  the  dura  was  very  adherent  to  the  bone, 
but  at  all  other  points  was  separated  easily.  When  the 
point  of  a  pair  of  scissors  was  put  under  the  flap  of  bone 
thus  loosened,  and  the  handle  of  the  scissors  let  down 
gently,  the  simple  weight  lifted  the  flap  perceptibly.  The 
periosteum  corresponding  to  the  bone  removed  was  cut 
away.  The  dura  had  not  been  opened,  and  appeared 
normal.  A  few  strands  of  horsehair  were  placed  in  the 
furrow,  and  the  wound  dressed.  The  oj>eration  lasted 
half  an  hour.    The  temperature  at  its  close  was  98  deg." 

Three  months  later  a  linear  craniotomy  was  performed 
in  precisely  the  same  manner  on  the  other  side  of  the  head. 
The  condition  of  the  child  was  thought  to  be  improved 
to  some  slight  degree  after  the  operation,  though  this 
improvement  may  have  been  due  to  the  attention  she  re- 
ceived at  the  Children's  Hospital  from  the  chief  nurse. 
Miss  Hogan.  When  two  and  a  half  years  old,  K.  K.  could 
only  say  "Mammy."  The  arms  and  legs  were  freely  mov- 
ed, but  incoordinately,  and  motion  was  greater  in  the 
former.  She  could  sit  up  without  support,  but  if  placed 
upon  her  feet  she  fell  at  once  to  the  floor.  Her  intelligence 
was  of  very  low  grade. 

In  Dr.  Llewellyn's  report  of  her  condition  during  her 
residence  at  the  Pennsylvania  Training  School  for 
Feeble-Minded  Children,  and  just  before  her  death,  the 
statements  are  made  that  K.  K.  could  not  stand;  could 
not  feed  herself,  and  had  little  use  of  her  hands,  though 
she  could  understand  many  things  said  to  her. 

She  died  suddenly  at  the  age  of  six.  When  seen 
after  death  the  feet  .were  in  the  position  of  marked  talipes 
equino-varus,  and  the  toes  were  flexed.  The  thenar  and 
hypothenar  eminences  of  the  hands  were  of  nearly  normal 
development;  the  thumbs  were  not  flexed;  the  first  pha- 
langes of  all  the  fingers  were  extended,  and  the  second  and 
third  moderately  flexed.    Her  form  was  very  slight.    The 


84  WILLIAM    G.  SPILLER, 

circumference  of  the  head  through  the  glabella  and  i 
was  sixteen  inches.    In  removing  the  calvarium  the 
was  found  to  be  very  adherent  near  and  along  the  sag 
suture.    The  brain  was  small,  and  weighed  sixteen  ou 
avoirdupois.    The  pia  was  not  adherent     There  wer- 
abnormal  depressions,  and  no  sclerotic  areas,  and  the 
and  fissures  were  well  developed.       There  was  not 
slightest  indication  of  microgyria.       The  cord  was 
small. 

From  the  clinical  description,  which  has  been  < 
firmed  by  several,  as  the  child  was  studied  by  a  nun 
of  physicians,  the  affection  was  not  unlike  the  dis 
described  by  Little,  which  in  France  and  German; 
more  frequently  called  by  his  name  than  in  England, 
labor  was  difficult,  but  neither  this  nor  premature  b 
was  the  cause  of  the  child's  condition.  The  defini 
which  Brissaud^  gives  of  Little's  disease,  which  is 
reality  merely  a  symptom-complex,  is  as  follows:  "Spa 
and  congenital  paraplegia  of  the  four  limbs,  more  ] 
nounced  in  the  inferior,  occurring  especially  in  chile 
born  before  full  term,  characterized  by  spasm  more  t 
by  paralysis,  and  not  associated  with  convulsions  or 
turbance  of  intellect,  and  capable  of  progressive  ameli< 
tion,  if  not  of  complete  cure."  Little,^  however,  sp 
of  impairment  of  the  intellect.  Freud*  says  there  are  a 
of  diplegia  in  which  premature  birth  and  difficult  la 
are  not  the  causes  of  the  paralysis,  but  that  there  i 
predisposition  to  paralysis  in  these  children  which,  if  si 
ciently  strong,  may  develop  into  diplegia,  without  the 
currence  of  trauma.  The  majority  of  children  bom  bef 
full  term,  or  in  a  condition  of  asphyxia  resulting  fr 
dystocia,  do  not  present  diplegia.  This  case  of  K.  K 
of  unusual  interest,  for  Marie**  states  that  there  has 

■  Brissaud:  Maladies  Nerveuses,  p.  no. 

*  Little:  Transactions  of  the  Obstetrical  Society  of  London, 
iii.,  pp.  306,  307. 

*  Freud:  Revue  Neurologique,  1893,  p.  183. 

*  Marie:  Traite  de  Medecine,  vol.  vi.,  p.  457. 


r 


LITTLES   DISEASE.  85 

yet  been  no  autopsy  in  a  case  of  Little's  disease.®     He 
thinks  dystocia  or  disease  of  the  mother  or  fetus  in  cer- 
tain cases  may  possibly  produce  spastic  dorsal  tabes  (Lit- 
tle's disease)    in  children  born  at  term,  but  the  most 
common  cause  is  premature  birth,  and  the  condition  is 
one  of  imperfect  development  of  the  pyramidal  fibres,  as 
IS  seen  in  the  case  K.  K.    Emphasis  must  be  laid  on  the 
statement  that  there  was  no  macroscopic  lesion  in  my  case. 
It  is  impossible  to  state  the  degree  of  spasticity  which 
was  manifested  by  the  child  K.  K.,  inasmuch  as  I  never 
saw  her  in  life,  but  the  contractures  of  the  flexor  muscles 
of  the.  feet  at  the  age  of  nineteen  months  and  after  death 
indicate  that  the  muscular  tonus  was  exaggerated.    The 
child  also  was  not  paralyzed.    To  those  who  object  to  the 
title    of  Little's  disease  for  this  case  on  account  of  the 
birth   at  full  tenn,  the  presence  of  microcephaly,  and  the 
insufficient   degree   of  spasticity,    the   name   of   cerebral 
</iplegia  in  the  sense  used  by  Freud,*^  or  of  ^'infantile 
spastic  state  of  cerebral  origin  (etats  spasmodiques  in  fan- 
Hie^  d'origine  cerebrale)  suggested  by  Van  Gehuchten,®  may 
be   more  acceptable. 

Sections   from   the   superior   part    of   the   ascending 

fro  ratal  convolution  of  the  right  and  left  sides  of  the  brain 

of  IC,  K.,  in  the  portions  which  contain  the  centres  for  the 

lower  extremities,   and   especially   from   the  paracentral 

lobiale^  show    an    absence    of    the    very    large    ganglion 

<^^lls,    (Riesenzellen),  which  are  found  in  a  normal  mptor 

cortex.    The  cells  of  the  third  layer  (Cajal)  are  a  little 

larger  than  those  of  the  second,  and  some  are  of  very  good 

^^^^  ;  but  there  is  great  diminution  of  the  giant  cells  which 

are  present  in  sections  from  a  normal  brain  of  a  child  of 

about  the  same  age,  taken  from  the  same  portions  of  the 

cortex  for  comparison.     It  may,  however,  be  possible  to 

^^"^d  one  or  two  cells  of  unusuaj  size  in  a  field,  but  they 

The  cases  of  Dejerine  reported  to  the  Societe  de  Biologie  were 
Published  after  this  paper  was  written. 

Freud:  Zur  Kenntniss  der  cerebralen  Diplegien  des  Kindesalters. 
'  Van  Gehuchten:  Revue  Neurologique,  Feb  15,  1897. 


86  WILLIAM    G.  SPILLER, 

are  always  much  smaller  than  the  largest  of  the  g 
cells  of  a  normal  cortex.  The  condition  can  hardly 
attributed  to  the  age  of  the  child.  Some  of  the  few  ( 
present  in  the  anterior  horns  of  the  cord  are  large, 
pyramidal  cells  of  Betz*-*  are  said  to  be  the  largest  cell 
the  entire  nervous  system,  excepting  some  in  the  sp 
gangHa,  and  are  found  in  the  motor  cortex.  They 
semble  the  cells  of  the  spinal  cord.  Betz  stated  that  t 
are  found  chiefly  in  the  fourth  of  his  five  cortical  lay 
that  they  are  less  numerous  in  the  lower  half  of  the  ai 
rior  central  gyrus,  and  are  most  abundant  in  the  parac 
tral  lobule.  He  has  found  them  in  the  brain  of  id 
(Riesenpyramideiu  Neruenriesenzellcn) .  V.  Monakow^^ 
the  fibres  of  the  inner  capsule  of  a  cat.  The  histolog 
examination  of  the  motor  cortex  was  most  astonishi 
according  to  his  statements.  Betz's  giant  cells  had  ent 
ly  disappeared,  while  the  other  layers  presented  no  nc 
worthy  changes.  Mahaim^^  says  that  the  connection 
the  giant  cells  with  the  pyramidal  fibres  has  also  h\ 
demonstrated  by  v.  Gudden  and  Moeli  in  the  rabbit  c 
guinea  pig,  and  by  Moeli  and  Henschen  in  man. 

The  apical  processes  of  the  pyramidal  cells  in  the  ce 
bral  cortex  of  K.  K.  point  toward  the  surface,  and  do  i 
cross  one  another  in  the  irregular  arrangement  descrit 
by  some  writers.  The  anterior  pyramids  of  the  oblong; 
are  small,  but  present  no  evidences  of  degeneration, 
has  not  been  possible  to  obtain  an  oblongata  or  cord  fn 
a  child  of  exactly  the  same  age  for  comparison,  but  t 
whole  central  nervous  system  is  much  smaller  than  i\ 
from  another  child  of  seven  years.  There  are  vc 
few  cells  in  the  anterior  horns  of  the  cervical  swellir 
though  those  which  are  present  have  a  normal  appej 
ance.  The  horns  are  small.  The  crossed  pyramidal  trac 
and  columns  of  Goll  are  decidedly  less  intensely  stain 

"  Betz:  Centralblalt  fiir  die  medicinischen  Wissenschaften,  1874  a 
1881. 
**V.  Monakow:  Neurologisches  Centralblatt,   1883. 
"  Mahaim:  Archiv  fiir  Psychiatrie,  xxv. 


V 


LITTLE'S   DISEASE.  87 

by  the  method  of  Weigert.  In  carmin  sections  an  increase 
of  the  neuroglia  is  very  evident  in  the  cokimns  of  GolK  and 
while  the  fibres  of  the  anterior  and  lateral  columns  are 
small,  those  in  the  crossed  pyramidal  tracts  are  of  unusual- 
ly fine  calibre,  and  are  smaller  than  those  in  Goll's  col- 
umns. The  thoracic  portion  of  the  cord  is  very  small. 
The  anterior  horns  of  the  lumbar  region  contain  a  few 
cells  of  normal  appearance.  The  anterior  and  posterior 
spinal  roots  are  normal.  Serial  sections  have  been  made 
of  the  central  nervous  system  from  the  oblongata  into 
the  thalamic  region,  but  they  have  not  revealed  anything 
further  worthy  of  special  note.  This  case  K.  K.  seems  to 
be  similar  to  the  one  described  by  Mya  and  Levi  (quoted 
by  Van  Gehuchten).  Their  patient  was  born  in  difficult 
labor  at  full  term,  was  of  feeble  intellect,  and  presented 
general  muscular  rigidity.  Partial  agenesia  >  of  the  pyra- 
midal tracts  in  the  cord,  and  incomplete  development  of 
the  pyramidal  cells  of  the  motor  cortex  were  found. 

Ganghofner^^  has  reported  a  case  of  what  was  appar- 
ently general  spasticity.  Sections  from  the  upper  part 
of  one  anterior  central  gyrus  appeared  normal,  but  a  scar- 
city of  fibres  in  the  crossed  pyramidal  tracts  of  the  cord 
was  noticed.  Macroscopically  the  brain  and  cord  were 
normal,  and  yet  he  believes  that  the  cortex  could  not  really 
have  been  perfectly  developed.  In  two  other  cases  of 
spasticity  in  which  no  peculiar  findings  were  observed  by 
the  microscope  he  thinks  there  may  have  been  a  moderate 
decrease  of  the  pyramidal  fibres  which  eluded  detection. 

Otto^^  has  reported  two  cases  of  idiocy.  One  of  his 
patients  was  unable  to  walk  or  stand,  but  could  move 
the  limbs  feebly  while  in  bed.  He  could  neither  speak  nor 
understand  anything  said  to  him.  The  other  child  pre- 
sented contractures  in  all  the  extremities.  Microgyria 
was  found  in  both  cases  at  the  autopsy,  and  in  the  micro- 
scopical investigation  decided  anomalies  were  observed  in 

"Ganghofner:  Zeitschrift  fiir  Heilkunde,  vol.  xvii.,  1896. 
"Otto:  Arvhiv  fiir  Psychiatric,  vol.  xxiii.,  p.  153. 


S8  LITTLE'S    DISEASE. 

the  cellular  elements,  although  the  fibres  of  the  cer. 
cortex  presented  no  great  variation  from  the  normal, 
cells  were  quite  numerous,  well  developed,  and  regu 
placed  in  the  layer  of  small  pyramidal  cells.  The  1 
pyramidal  cells  were  almost  entirely  absent,  and  t 
that  were  present  were  little  larger  than  the  small  f 
midal  cells.  There  were  no  giant  pyramidal  cells  a 
in  the  frontal  and  central  lobes,  but  there  were  n 
round  ganglion  cells.  In  his  cases  the  pyramidal  trac 
the  oblongata  contained  fewer  fibres  than  normal, 
they  were  not  degenerated,  and  this  deficiency  of  fibre 
''ttributes  to  the  scarcity  of  cortical  ganglion  cells, 
anglion  cells  of  the  cord,  contrary  to  the  condition  in 
ase,  were  well  developed.  In  Anton's  case  the  pyram 
racts  were  very  small,  and  the  central  gyri  were  affet 
s  in  Otto's  case  (Otto).  Otto  states  that  these  g 
ells  of  the  cerebral  cortex  are  developed  in  normal  bn 
t  the  time  of  birth.  He  found  also  pale  gray  area: 
he  white  matter  of  the  hemispheres  which  were  forr 
y  collections  of  ganglion  cells  between  the  fibres  of 
bfhite  matter.  They  were  evidently  nerve  cells,  for  m; 
/ere  pyramidal  in  shape  and  had  processes. 

Binswanger'''  also  has  reported  a  case  of  microgy 
'he  child  was  unable  to  stand,  walk,  speak,  or  understj 
.hat  was  said  to  him.  The  limbs  were  contractured,  1 
entral  gyri  in  both  hemispheres  were  absent.  In  secti( 
rom  the  left  frontal  lobe  near  the  defect  the  giant  c( 
Ricsenccllen  of  Betz),  were  absent.  There  was  no  secor 
ry  degeneration  of  the  pyramidal  tracts  of  the  cord,  a 
he  cells  of  the  anterior  horns  showed  no  pathologii 
hanges.  The  fibres  in  the  white  matter  of  the  cord  we 
ossibly  a  Httle  smaller.  The  anterior  horns,  especia 
1  the  lower  part  of  the  cord,  were  relatively  small,  ai 
he  cells  seemed  to  be  less  numerous. 

In  the  case  of  idiocy  with  microcephaly,  reported  1 
*opoff,^''  the  cortical  nerve  cells  were  unequally  distri 
f,  1882,  n.  +i7. 


LITTLES   DISEASE.  89 

iited,  and  in  some  places  had  an  irregular  arrangement. 
The  apical   processes  of  the  pyramidal   cells  in  normal 
brains  are  parallel  to  one  another;  but  in  Popoff's  case, 
they  crossed  at  an  acute  angle.     In  some  portions  there 
was  a  decrease  in  the  number  of  nerve  cells,  and  most  of 
the  cells  were  small  and  occasionally  their  contour  was 
abnormal.    The  cortical  vessels  were  more  or  less  thicken- 
ed.   In  the  frontal  and  paracentral  lobes  the  giant  cells 
were  quite  hard  to  find,  and  had  not  attained  a  large  size. 
The  left   cerebral   hemisphere   was   more   flattened   and 
smaller  in  its  anterior  portion  than  the  right.    During  life 
the  right  upper  limb  was  adducted,  and  the  forearm,  hand 
and  fingers  were  flexed. 

Koster^®  in  the  brain  of  an  idiot  found  thickening  of 
the  neuroglia,  enlargement  of  the  pericellular  and  perivas- 
cular spaces,  decrease  in  nerve  cells  in  certain  parts,  and, 
in  some,  deposits  of  pigment.  In  some  shrivelled  cells 
there  was  no  nucleus.  He  also  found  the  irregular  arrange- 
ment of  the  pyramidal  cells.  Some  of  these  were  paral- 
lel to  the  surface  of  the  cortex,  lying  on  their  side.  Kos- 
ter  gives  a  brief  review  of  some  of  the  earlier  investigations 
on  idiotic  brains. 

Oppenheim^^  observed  an  increased  number  of  the 
small  round  cells  of  the  cortex  in  microgyria;  the  pyra- 
midal cells  in  places  were  entirely  absent,  or  imperfectly 
formed  and  abnormally  placed. 

Friedmann^®  describes  a  case  of  infantile  spastic  para- 
plegia associated  with  idiocy.  One  hand  was  contractured. 
The  brain  and  spinal  cord,  With  the  exception  of  the  pos- 
terior columns,  were  smaller  than  normal.  The  pyramidal 
cells  of  the  cortex  were  reduced  to  about  half  the  usual 
number,  the  pericellular  spaces  were  enlarged,  the  small 
vessels  were  distended,  and  their  walls  had  undergone 
hyaline  degeneration.    The  number  of  the  vessels  was  less 

"Koster:  Neurologisches  Centralblatt,  1889,  No.  10. 
"Oppenheim:  Neiirologisches  Centralblatt,  1895,  p.  131. 
Friedmann:  Deutsche  Zeitschrift  fiir  Nervenheilkunde,  vol.  iii. 


90  WILLIAM   G.  SPILLER. 

than  normal.  Some  of  the  cortical  pyramidal  eel 
altered  in  shape.  Dififuse  areas  of  sclerosis  were  fo 
through  both  hemispheres.  The  mass  of  white 
was  greatly  diminished.  The  pyramidal  tracts  and 
white  columns  of  the  cord,  except  the  posterior 
small.  Friedmann  is  inclined'  to  attribute  the  coi 
in  this  case  primarily  to  the  changes  in  the  small  ves 

B.  Sachs^®  has  reported  a  case  which  is  not  s 
known  in  the  foreign  literature  as  it  deserves  to  b 
claims  that  it  is  the  first  case  of  congenital  spastic 
plegia  examined  microscopically.  In  this  case  the 
was  difficult,  and  the  child  was  asphyxiated  when 
Convulsions  were  frequent  in  early  infancy.  Conv 
strabismus  was  present.  The  deep  reflexes  were  inci 
The  mental  development  was  deficient,  but  the  chil 
not  absolutely  idiotic.  It  was  one  year  old  at  the  t: 
death.  Sachs  found  thickening  of  the  pia,  charact 
by  general  cellular  infiltration;  its  blood  vessels  si 
marked  cellular  proliferation,  and  the  pia  was  adher 
the  cortex.  In  the  cortex  itself  there  were  few,  i 
normal  pyramidal  cells.  In  the  outer  layers,  and  pa 
larly  in  what  would  correspond  to  Meynert's  thin 
fourth  layers,  there  was  an  enormous  profusion  of 
glia  cells.  The  blood  vessels  were  in  part  norma! 
many  of  them  showed  marked  small  cell  proliferati 
the  walls.  There  was  unquestionably  a  thickening  < 
neuroglia.  The  anatomical  diagnosis  was  chronic  n 
go-encephalitis.  Sachs  considered  the  case  to  be  du< 
wide-spread  effusion  of  blood  between  the  pia  an( 
cortex  at  the  time  of  birth.  The  spinal  cord  revea 
most  distinct  degeneration  of  both  lateral  columns 
ondary  to  the  cortical  lesion.  This  degeneration  < 
be  recognized  in  all  parts  of  the  motor  tracts.  Th< 
no  degeneration  of  the  lateral  tracts  in  the  case  K 
but  the  condition  is  one  of  partial  agenesia. 

In    his   work    on    the   nervous    diseases   of  chil 


19 


Sachs:  New  York  Medical  Journal,  1891,  vol.  i. 


LITTLES   DISEASE.  9 1 

Sachs^*^  speaks  again  of  this  case  and  states  that  the  upper 
extremities  were  less  paralyzed,  but  somewhat  rigid.  What 
at  first  he  supposed  to  be  secondary  degeneration  of  the 
pyramidal  tracts  he  later  concluded  was  a  primary  and 
congenital  defect.     In  another  case  of  arrested  cerebral 
development  published  by  him,-*^the  cortical  ganglion  cells 
were  very  imperfectly  formed,  and  were  not  numerous. 
There  was  no  trace  of  a  previous  encephalitic  process,  and 
no  change  in  the  blood  vessels.     He  speaks  again  of  this 
case  in  his  paper  on  amaurotic  family  idiocy.^^     In  the 
brain  from  the  sister  of  this  patient  similar  findings  were 
obser\-ed,  and  in  the  lower  part  of  the  cord  (the  upper  por- 
tion was  lost),  the  lateral  columns  presented  a  degenera- 
tion that  "was  very  diflferent  in  character  and  extent  from 
an  ordinary  secondary  degeneration/'   Sachs  regarded  the 
condition  of  the  pyramidal  cells  of  the  cortex  as  a  sign 
of  arrested  development  and  not  of  inflammation.     King- 
don^*  also  noted  changes  in  the  cortical  pyramidal  cells 
in  his  case  of  amaurotic  family  idiocy,  as  well  as  "well- 
marked  descending  degeneration''  in  the  cervical  region 
of  the  cord. 

SchiiF*  found  that  after  removal  of  the  sigmoid  gyrus 
in  a  dog  twelve  days  old,  the  pyramidal  tract  of  the 
opposite  side  in  the  cervical  region  stained  more  deeply 
with  the  carmine  than  normally,  when  examined  seven- 
teen weeks  after  the  operation.  On  the  same  side  of  the 
cord  there  was  a  small  red  patch  in  the  pyramidal  tract. 
He  was  much  surprised  to  find  that  there  was  no  true 
secondary  degeneration,  but  instead  of  this  the  pyramidal 
tracts  were  filled  with  thin  nerve  fibres  with  very  small 
axis  cylinders.  He  later  observed  this  diminution  in  the 
size  of  the  pyramidal  fibres  in  six  cases,  and  in  all  these 

*  Sachs:  Nervous  Diseases  of  Children,  p.  399. 

Sachs:  Journal  of  Nervous  and  Mental  Disease,  1887. 

''Sachs:  New  York  Medical  Journal,  May  30,  1896. 

Kingdon:  Transactions  of  the  Ophthalmological  Society  of  the 
United  Kingdom,  vol.  xii.,  1892. 

Schiff:  Centralblatt  fiir  Physiologic,  1893,  p.  7. 


t 


92  WILLIAM   G.  SPILLER, 

the  area  occupied  by  the  small  fibres  was  not  th 
In  none  of  these  cases  did  he  find  any  true  degen 
even  when  the  animal  had  lived  five  months  ai 
operation.  In  one  case  the  greater  part  of  both 
columns  was  involved,  and  in  another  small  fibr 
found  in  nearly  all  the  white  columns.  Schiflf 
might  be  imagined  that  true  secondary  degenera 
young  animals  does  not  occur.  This  idea  is  in< 
for  Lowenthal^*  has  shown  that  this- may  be.foui 
kitten  fourteen  days  after  section  of  the  posteri< 
of  the  lateral  column.  SchifF  has  obtained  this  resi 
in  young  dogs.  However,  six  cases  prove  the  frei 
of  simple  atrophy  of  motor  fibres  after  a  cortical 
in  early  life.  These  fine  fibres  are  present  in  the  c 
K.,  but  we  must  not  forget  that  in  a  child  the  nerv< 
are  smaller  than  in  an  adult,  and  do  not  attain  th< 
development  for  a  long  time,  as  Hosel^®  has  stated 
making  allowance  for  this  fact,  there  is  no  doubt  th 
pyramidal  fibres  are  of  uniformly  finer  calibre  than 
of  any  other  part  of  the  cord,  and  much  smaller  tl 
the  child  of  seven  years.  They  probably  represent  a  < 
tion  of  agenesia. 

It  will  be  noticed  in  Otto's  case  (1.  c.)  that  there  v 
degeneration  of  the  fibres  of  the  pyramidal  tract* 
merely  a  diminution  in  the  number  of  fibres.  It  canr 
said  that  there  is  a  diminution  in  the  number  of  fib 
the  case  K.  K.  They  are  very  small  and,  therefore, 
are  crowded  together  in  a  given  area.  Oppenheim^ 
reported  atrophy  of  the  direct  and  crossed  pyramidal 
from  porencephaly.  There  was  no  true  degeneratio 
though  a  slight  increase  of  neuroglia,  and  possibly  ; 
generation  of  scattered  fibres.  There  are  many  sii 
cases  in  the  literature.  Gierlich^®  examined  a  case  in  v\ 


"Lowenthal:    Recueil   zoolog.   Suisse,  vol.   iv.,   p.   in,  quot< 
Schiff. 
'"'Hosel:  Archiv  fiir  Psychiatric,  vol.  xxiv.,  p.  480. 
"Oppenheim:  Neurologisches  Centralblatt,   1895,  p.  132. 
**  Gierlich:  Archiv  fiir  Psychiatric,  vol.  xxiii. 


LITTLE'S    DISEASE.  93 

the  motor  tract  had  been  affected  within  the  internal  cap- 
sule very  early  in  childhood.  The  pyramidal  tract  was 
smaller,  but  the  fibres  were  not  of  diminished  calibre,  al- 
though their  number  was  less  than  in  the  corresponding 
tract  of  the  opposite  side.  There  were  no  evidences  of 
degeneration.  His  explanation  for  the  paucity  of  nerve 
fibres  and  absence  of  sclerosis  is  that  either  a  downward 
growth  of  motor  fibres  from  the  cortex  did  not  take  place, 
or  else  reactive  inflammation  did  not  develop  after  de- 
struction and  absorption  of  the  young  fibres.  Hervouet^® 
also  thought  that  there  was  a  deficiei\cy  of  development  of 
the  nerve  fibres  of  the  lateral  columns,  without  sclerosis, 
in  his  case  of  idiocy.  In  Popoff's^^  case  of  idiocy  the  gyri 
of  both  hemispheres  were  thin,  but  the  left  hemisphere  was 
smaller  than  the  right  in  its  anterior  part.  The  lateral 
column  and  horns  of  the  right  side  of  the  cord  were  small- 
er than  normal,  and  above  the  motor  decussation  the  left 
pyramidal  tract  was  small.  This  diminution  in  size  of 
the  right  horns  and  lateral  column  was  due  to  imperfect 
development,  for  there  was  no  sclerosis,  and  the  nerve 
fibres  had  probably  never  developed  as  in  a  normal  cord. 
It  has  been  known  for  a  long  time  that  micromyelia  may 
be  associated  with  microcephaly  (Aeby,  Thiele,  Flesch, 
Schattenberg:  quoted  by  Popoff). 

Anton^^  has  reported  four  cases  of  fetal  or  early  cere- 
bral disease  which  caused  deficient  development  of  the 
pyramidal  tracts.  In  one  of  his  cases  there  was  absence 
of  the  pyramidal  tracts,  and  yet  the  gray  matter  of  the 
cord  was  well  developed.  He  believed  that  in  complete 
agenesia  of  these  tracts  the  spinal  gray  matter  suffers  very 
little  or  not  at  all,  and  states  that  no  writer  has  reported 
changes  in  the  anterior  horns  in  micromyelia.  This  view 
is  not  tenable.     In  Popoff's  case  the  right  anterior  horn 

^Hervouet:  Archives  de  Physiologic,  1884. 

"  Popoff:  Archiv  fiir  Psychiatric,  vol.  xxv. 

"Anton:    Ueber    angcborene    Erkrankungen    dcs    Ccntralnerven- 
systems,  1890,  quoted  by  Popoflf. 


94  WILLIAM   G.  SPILLER, 

in  the  cord  was  much  smaller  and  there  were  pre 
ally  fewer  cells  within  it,  although  the  cells  pres' 
neither  sclerosed  nor  atrophied.  One  side  of  t 
including  the  anterior  horn,  was  smaller  also  in  H< 
case  (1.  c),  although  the  cells  of  the  anterior  hoi 
normal.  In  this  case  the  columns  of  Goll  presei 
appearance  of  a&cending  degeneration,  as  in  my  < 
yet  there  was  no  lesion  to  be  detected  which  coi 
caused  an  ascending  degeneration.  Hervouet  r 
this  condition  of  the  cord  as  one  of  arrested  devel 
The  case  K.  K.  also  is  contrary  to  Anton's  vie^ 
anterior  horns  of  the  cervical  swelHng  are  under- 
contain  very  few  nerve  cells.  In  Muratoflf's^^  case 
eral  porencephaly  there  were  atrophied  cells  in  th 
rior  horns  of  the  cervical  cord,  and  in  the  thora 
lumbar  portions  scattered  atrophic  cells  were  foun 
pyramidal  tracts  were  degenerated,  and  this  probj 
plains  the  condition  of  the  ganglion  cells  of  the  cc 
abnormal  condition  of  these  cells  probably  frequei 
curs  when  the  pyramidal  fibres  are  imperfectly  de 
in  the  child.  In  Muratoff's  case  No.  VI.,  (an 
microcephalic  child),  there  was  imperfect  devel 
of  the  pyramidal  fibres,  total  atrophy  of  the  cortic 
of  the  central  lobe,  and  absence  of  the  tangential 
The  motor  cells  of  the  anterior  horns  of  the  cor 
atrophied;  the  cellular  processes  were  indistinct;  c 
cells  though  small  were  present  in  normal  ni 
Rail  t on ,^^  in  a  case  of  double  spastic  hemiplegia, 
the  pyramidal  tracts  normal,  and  in  the  motor  are 
tex?)  there  was  a  diminution  in  the  number  of  th 
ganglion  cells  and  some  increase  in  neuroglia.  Marc 
says  the  nervous  elements  are  in  normal  arrang 
though  lessened  in  number,  in  uncomplicated  cj 
microcephaly. 

^"  MiiratofT:  Deutsche  Zcitschrift  fiir  Nervenheilkunde,  vol. 
■"Railton:  British  Medical  Journal,  1892,  vol.  i.,  p.  441. 
**  Marchand:  Abstract  in  Centralblatt  fiir  allgemeine  Patholc 
pathologische  Anatomic,  1892,  p.  780. 


LITTLE'S    DISEASE.  95 

Steinlechner-GretschischnikofP**  in  two  cases  of  micro- 
cephaly observed  imperfect  development  of  the  cord, 
chiefly  in  the  pyramidal  tracts,  anterior  columns  and  col- 
umns of  GoU,  and,  in  one  case,  in  the  direct  pyra!midal 
tracts.  In  one  of  these  cases  there  were  fewer  ganglion 
cells  in  the  gray  matter  of  the  cord.  The  statement  by 
this  authoress  that  the  normal  development  of  the 
columns  of  Goll,  as  well  as  of  the  pyramidal  tracts,  is  de- 
pendent upon  the  development  of  the  cerebrum,  is  in  ac- 
cordance with  the  findings  in  the  case  K.  K.  The  experi- 
ments of  Ceni^®  (of  Milan)  in  hemisection  of  the  posterior 
columns  with  the  remarkable  resulting  changes  in  the 
cortical  cells  of  the  sigmoid  gyrus  and  occipital  lobe,  chief- 
ly of  the  side  opposite  to  the  hemisection,  as  seen  by  the 
silver  method,  would  seem  to  show  a  connection  between 
the  fibres  of  the  posterior  columns  and  the  cortical  cells. 
The  number  of  the  cells  in  the  anterior  horns  in  micro- 
cephaly is  usually  less  than  in  normal  cords,  according 
to  Steinlechner-Gretschischnikoff. 

Van  Gehuchten^"^  has  found  that  the  pyramidal  fibres, 
even  the  axis  cylinders,  are  entirely  absent  in  the  cord 
of  a  normal  fetus  of  seven  months,  but  are  present  in  and 
above  the  anterior  pyramids.  Spastic  rigidity  in  children 
born  before  full  term,  according  to  him,  is  not  due  to  the 
absence  of  the  myelin  sheaths,  nor  to  deficiency  of  the 
pyramidal  tracts  in  their  entire  length,  but  to  an  arrest  of 
the  downward  growth  of  these  fibres.  Flechsig  claimed 
that  the  pyramidal  tracts  develop  from  above  downward, 
and  Starr^^  has  offered  a  forcible  argument  in  favor  of  this 
view  from  the  study  of  a  most  extraordinary  case  of 
microcephaly  in  which  the  cerebral  hemispheres  were  ab- 
sent, and  the  pyramidal  tracts  had  not  developed. 

Hervouet  (1.  c.)  has  shown  that  the  pyramidal  tracts 

•  

'  Steinlechner-Gretschischnikoff:  Archiv  fiir  Psychiatric,  vol.  xvii., 

'Ceni,  quoted  by  Marinesco:  Semaine  Medicale,  No.  48,  1896. 

"Van  Gehuchten:  Journal  de  Neurologic,  1896. 

*  Starr:  Journal  of  Nervous  and  Mental  Disease,  1884,  p.  343. 


96  WILLIAM    G-  SPILLER. 

are  not  fully  developed  until  about  the  fourth  y£ 
extrauterine  life.  Perhaps  here  is  the  explanation  < 
fact  that  the  tendency  to  bilateral  cerebral  paralysis  ; 
to  cease  in  early  childhood.  The  extrauterine  cei 
paralysis  in  childhood  is  usually  unilateral  (Hig 
Sachs*"  has  seen  no  case  of  cerebral  diplegia  or  paraj 
which  had  begun  after  the  fourth  year,  and  he  says 
the  tendency  to  bilateral  cerebral  affections  seems  to 
early  in  life.  If  the  pyramidal  fibres  are  so  imper 
formed  in  the  first  few  years  of  the  extrauterine  pt 
they  are  more  exposed  to  injury,  and  especially  in 
distal  ends.  It  is  not  .impossible  that  the  degener 
seen  in  combined  systemic  disease,  as  for  examp 
Striimpell's*'  case  or  in  many  others,  may  be  expl 
by  the  direction  of  the  growth  of  the  fibres.  The  sei 
fibres  grow  upward  in  the  cord,  in  the  same  way  tha 
motor  fibres  develop  downward.  In  combined  sysl 
disease  the  pyramidal  tract  is  usually  most  degene: 
in  the  lower  regions  of  the  cord,  and  the  posterior 
umns  in  the  upper  portion,  i.  e.,  in  the  parts  last  for 
Erb*^  has  expressed  the  opinion,  held  now  by  many 
ers,  that  the  most  distant  part  of  the  neuron  may  b< 
first  to  degenerate.  In  K.  K.  the  paresis  was  i 
evident  in  the  lower  limbs.  Van  Gehuchten's  views 
sibly  offer  the  best  explanation  for  this  condition,  fo- 
lumbar  cord  in  K.  K.  seems  possibly  proportionally  si 
er  than  the  cervical,  as  though  many  of  the  cervical  f 
had  not  developed  downward  into  the  lumbar  regie 
In  examining  some  patients  at  the  New  Jersey  T 
ing  School  for  Feeble-Minded  Children,  during  the 
6,  the  following  cases  seemed  of  sufficient  import 
:onnection  with  this  subject  to  be  briefly  describe 

Higier:  Deutsche  Zeitschrift  fur  Nervsnheilkunde,  vol.  ix.,  p. 
Sachs:  Volkniann's  Sammlung  klin.  Vortrage,  46-47,  1892,  p 
Striimpeli;    Archiv  fiir  Psychiatric,  vol.  xvii. 
Erb:  Deutsche  Zeitschrift  fiir  Nervenheilkunde,  vol,  i,.  p,  Z+c 
rologisches  Ceiitralblatt,  i88j,  p.  481. 


LITTLE'S    DISEASll. 


A.  S.  (Little's  disease). 

The  patient  A.  S.  presents  great  similarity  in  his  ap- 
pearance to  the  case  K.  K.,  which  has  been  examined 
microscopically.  The  circumference  of  the  head  measures 
17  1-2  inches.  His  intellectual  powers  are  very  feeble, 
and  he  never  speaks.  The  saliva  dribbles  constantly.  The 
entire  body  is  covered  with  a  papular  eruption.  The  hands 
and  feet  are  always  cold.  He  has  no  power  of  motion 
in  the  lower  limbs,  and  makes  no  attempt  to  stand.  When 
placed  upon  his  feet  he  sinks  at  once  to  the  ground.    Both: 


98      •  WILLIAM   G.  SPILLLR, 

legs  are  much  flexed  at  the  knees,  and  cannot  be  extei 
by  passive  movement.     The  feet  are  in  the  positio 
talipes  equinus,  and  can  only  be  extended  and  flexe 
a  very  slight  degree  by  passive  movement.    The  resist; 
in  the  thighs  to  passive  movement  is  considerable, 
patellar  reflex  is  increased,  but  owing  to  the  rigidity  oi 
limbs  the  full  degree  of  exaggeration  is  not  percept 
Ankle  clonus  and  Achilles  tendon  reflex  cannot  be  obt 
ed  on  account  of  rigidity.    In  striking  one  patellar  ten 
slight  adduction  is  observed  of  the  opposite  thigh  (cr 
ed  reflex).    The  limbs  and  trunk  are  well  nourished, 
fingers  are  held  flexed  upon  the  thumb,  but  can  be 
tended  passively.     The  patient  can  very  awkwardly  i 
up  a  large  object  with  either  hand.     The  reflexes  of 
upper  limbs  (at  wrist,  elbow,  and  biceps  tendon),  are  ex 
gerated,  but  are  partially  checked  by  the  muscular  s] 
ticity.       The  patient  has  some  power  of  motion  in 
upper  limbs.     Strabismus  is  not  present.       As  tlie  1 
understands  a  few  simple  commands,  the  sense  of  hear 
cannot  be  destroyed.    His  vision  apparently  is  good.    T 
pupils  are  equal.     He  cannot  sit  alone,  and  unless  s 
ported  he  falls  upon  the  bed.    The  child  was  born  at 
seventh  month,  in  ordinary  labor.     As  a  baby  he  \ 
strong,  but  '*two  years  after, birth  he  simply  stopped 
veloping,  without  any  apparent  cause."    The  mother  \ 
only  seventeen  when  this  child  was  born.-  One  sister 
the  patient  is  living  and  healthy.  It  is  stated  in  the  histc 
that  the  bov  has  said  some  words.     He  has  never  h 
^epilepsy.     He  was  born  May  23,  1887. 

This  is  a  case  of  Little's  disease,  and  is  due  to  the  cai 
which  certain  neurologists  consider  the  only  one  whi 
should  be  recognized, i.e.,  premature  birth,  and  could  I 
nervous  system  be  examined  lesions  similar  to  those 
K.  K.  might  be  found. 

There  are  undoubtedlv  cases  of  arrested  cerebral  dev< 
>opm£Jit   which  assume  a   paraplegic   type.      Sachs  ga 


LITTLES   DISEASE.  99 

the  proof  of  this  in  1891.  I  have  found  three  feeble-mind- 
ed children  at  the  New  Jersey  Training  School  in  whom 
the  lower  limbs  were  alone  affected.  One  is  selected  as 
an  example. 

R.  C,  eight  years  old,  is  a  paraparetic  idiot.  He  has 
never  spoken,  dpes  not  understand  what  is  said  to  him, 
and  takes  no  notice  of  anything.  The  limbs  and  trunk 
are  well  nourished.  He  cannot  walk,  and  makes  no 
attempt  to  take  a  step.  In  the  erect  position  he  inclines 
backward,  and .  has  to  be  supported  or  would  fall.  He 
can  move  his  legs  when  in  the  sitting  posture.  Knee-jerk 
and  ankle-jerk  are  exaggerated,  and  slight  ankle  clonus 
is  present.  Above  the  hips  the  movements  are  good.  The 
reflexes. in  the  upper  extremities  are  not  notably  exag- 
gerated. Strabismus  is  not  observed,  and  the  pupils  are 
equal.  The  head  is  well  developed.  This  child  was  born 
at  full  term  in  easy  labor. .  A  few  months  after  birth  he 
had.  convulsions.  As  a  babe  he  was  said  to  be  strong. 
His  condition  was  congenital.  Other  children  in  the  fam- 
ily arq  healthy. 

Three  or  four  months  after  the  above  description  was 
written  the  patient  died  in  status  epilepticus,  and  fortu- 
nately a  necropsy  was  obtained,,  and  microscopic  examina- 
tion of  brain  and  cord  \yas  made,  .Within  a  few  days 
previous  to  death  the  patient  was  s,aid  to  have  had  many 
convulsions.  The  body  was  much  emaciated.  The  dura 
was  somewhat  adherent  to  the  calvarium,  and  ^the  pia, 
especially  over  the  left  parieto-oc.cipital  lobe,  was  congest- 
ed.   1  am  indebted  tq  Dr.  C.  W.  Burr  for  the  material. 

The  brain,  especially  in  the  left  hemisphere,  presents 
a  low  type  of  fissuration*  In  the  left  hemisphere  the  paral- 
lel fissure  unites  with  the  Sylvian,  the  ascending  frontal  is 
almost  fully  united  with  the  Sylvian,  the  first  frontal  is  so 
distinct  that  it  forms  almost  a  straight  line,  and  the 
Sylvian  fissure  extends  almost  to  the  upper  border  of 
the  hemisphere.  .  . 

in  sections  from  the  superior  part  of  the  right  ascend- 


lOO  WILLIAM   G.  S FILLER, 

ing  frontal  convolution,  there  is  a  diminution  in  the  ni 
her  of  the  pyramidal  cells,  and  all  are  much  smaller  t 
the  giant  cells  (Riesenzellen)  of  the  normal  cortex  u 
for  comparison.  The  nerve  cells  also  present  an  app< 
ance  of  imperfect  development,  though  some  are  of 
size.  In  the  paracentral  lobule  a  few  giant  cells 
present,  but  these  cells  are  not  nearly  as  numerous  as 
a  normal  cortex. 

Within  thre  cord  all  parts  seem  to  stain  equally  w 
and  it  is  impossible  to  note  any  diminution  in  the  num 
of  the  fibres  in  the  crossed  pyramidal  tracts,  and  th 
tracts  do  not  contain  the  many  fine  fibres  observed 
the  case  K.  K.  In  this  respect  the  contrast  is  strikii 
The  cells  of  the  cervical  enlargement  are  numerous  a 
well  formed.  In  the  lumbar  region  the  motor  cells  i 
also  large  and  abundant,  and  if  there  is  diminution 
the  number  of  these  it  cannot  be  excessive. 

How  shall  we  explain  the  paraplegia?  It  is  probab 
as  Ganghofner  suggests  in  regard  to  his  cases,  that  t 
fibres  of  the  pyramidal  tracts  are  really  fewer  in  numb< 
although  the  microscope  is  too  poor  an  instrument  to  d 
tect  this.  Everyone  who  has  studied  the  nervous  syste 
will  acknowledge  that  it  is  difficult,  or  even  impossibl 
to  detect  a  moderate  decrease  in  the  number  of  fibres  in 
given  tract.  The  condition  of  the  cortex  justifies  tl 
opinion  advanced.  It  is  possible  that  proportional 
more  motor  fibres  in  growing  downward  reached  tl 
cervical  region  than  the  lumbar.  ' 

There  are  other  cases  of  undoubted  arrested  develof 
ment  in  which  the  power  of  motion  is  not  greatly  affectec 
There  is  a  picture  of  the  following  case  in  Mills'  paper  i 
Starr's*'  book  on  the  diseases  of  children. 

J.  M.  is  a  microcephalic  idiot  of  low  grade,  and  no 
taller  than  a  child  of  four  or  five  years.  He  was  bon 
January  31st,  1870.  The  circumference  of  the  head  i 
16  1-4  inches.     He  can  talk,  but  his  words  convey  m 


••  An  American  Text- Book  of  the  Diseases  of  Children.     Edited  bj 
Louis  Starr,  M.D. 


h 


LITTLE'S   DISEASE.  lOI 

meaning.  He  has  epilepsy,  and  may  have  as  many  as  two 
or  three  attacks  in  a  night,  though  on  an  average  he  has 
two  or  three  in  a  week.  He  is  very  bow-legged,  and  this 
condition  is  evidently  due  to  rachitis.  He  scratches  and 
bites,  and  it  is  impossible  to  attract  his  attention.  He 
does  not  understand  anything  said  to  him.  He  can  walk, 
usually  slowly,  although  he  can  be  made  to  run.  The 
right  foot  is  planted  firmly  on  the  ground,  but  the  left  is 
kept  elevated.  His  gait  is  not  spastic.  He  moves  the 
upper  extremities  freely,  but  slowly.  The  color  of  the  irides 
is  different;  in  one  eye  it  is  gray,  in  the  other  hazel. 
The  right  pupil  is  slightly  larger  than  the  left,  and  is  ir- 
regular. Movement  of  the  eyeballs  is  free.  Sensation  for 
pain  is  well  preserved.  The  knee-jerk  and  ankle-jerk  are 
exaggerated,  and  there  is  slight  ankle  clonus.  Strabismus 
is  not  present.  The  reflexes  in  the  upper  extremities  at  the 
wrist,  olecranon,  and  biceps  tendon  are  exaggerated  on  both 
sides,  but  not  so  much  as  those  in  the  lower  extremities. 
One  might  be  surprised  to  find  motion  in  the  extremities 
so  good  in  a  case  of  microcephaly  of  high  grade,  but 
paralysis  is  in  no  way  due  to  small  size  of  the  head. 
Pubertv  has  been  attained.  It  is  difficult  to  test  the  re- 
action  of  the  pupils  to  light  and  accommodation,  as  it  is 
impossible  to  make  the  man  (?)  keep  his  eyes  open  and 
fix  an  object.  He  was  the  third  in  the  family,  and  was 
born  at  full  term  in  normal  labor.  The  father  kept  a 
saloon,  and  was  inclined  to  indulge  in  alcoholic  bever- 
ages. The  patient  had  four  sisters  living  and  healthy  in 
1888.  Six  children  have  died  from  infectious  diseases, 
and  one  from  marasmus.  There  were  no  other  malformed 
children. 

After  this  paper  was  written  my  attention  was  called 
by  Dr.  Adolf  Meyer,  of  the  Worcester  Lunatic  Hospital, 
to  the  work  of  Hammarberg"*^  which  is  of  so  great  import- 
ance that  a  brief  abstract  must  be  given.  The  chief  aim 
of  this  paper  has  been  the  investigation  of  the  causes  of 

**Carl    Hammarherg:    Studien    iiber    Klinik    und    Pathologic    der 
Idiotie,  etc. 


I02  WILLIAM    G.  SPILLRR, 

paresis  and  paralysis  in  cases  of  idiocy  and  micro- 
cephaly, and  considerable  evidence  of  the  important  part 
the  giant  cells  (Riesensellen)  of  the  motor  cortex  have  in 
the  function  of  motion  has  been  obtained.  Hammarberg's 
work  is  confirmative  of  this  view,  and  the  abstract  relates 
chiefly  to  his  investigations  on  the  ascending  frontal 
gyrus.  The  results  of  his  examination  of  the  cerebral 
cortex  must  be  read  in  the  original.  No  abstract  can  do 
justice  to  a  work  of  this  magnitude. 

While  the  chief  aim  of  this  paper  has  been  the  in- 
vestigation of  the  causes  of  paralysis,  the  causes  of  im- 
becility have  also  in  part  been  mentioned,  for  it  must 
follow,  that  if  the  cortical  zones  which  form  the  pro- 
jection centries  are  arrested  in  their  development  dur- 
ing the  embryologic  period,  or  even  the  first  month  of 
extrauterine  life,  that  this  arrest  will  cause  a  correspond- 
ing arrest  in  the  development  of  the  association  centres, 
as  an  inevitable  consequence,  and  in  this  way  an  arrest 
in  the  development  of  the  intellectual  faculties  (Flechsig, 
as  quoted  by  Van  Gehuchten.)"*^ 

The  giant-cells  (Hammarberg)  measure  35-40x50x80 
microns  in  the  anterior  central  gyrus.  These  have  been 
called  '^ganglionic  cells*'  by  Bevan  Lew^is  and  Clarke. 

Under  the  title  of  Blddsinnigc  (dements)  four  ca^es  are 
reported  by  Hammarberg.  .  The  first  child  was  twenty- 
two  months  old.  During  the  first  year  of  life  it  made 
no  spontaneous  movements.  In  the  medial  and  upper 
half  of  th^  lateral  aspect  of  the  anterior  central  gyrus, 
as  well  as  in  the  adjoining  part  of  the  frontal  convolutions, 
the  cells  were  arranged  in  one  layer.  They  resembled 
the  undeveloped  cells  of  a  fetus  of  five  months,  although 
they  were  larger  than  these,  and  yet  smaller  than  normal 
cells,  and  they  represented  about  one-fifth  the  normal 
number.     A  few  undeveloped  spindle  cells  were  noticed. 

Case  2.  14  years  old.  The  child  could  not  walk  or 
sit  erect,  and  there  was  paresis  in  the  upper,  and  paralysis 
in   the  lower  extremities.     The  anterior  central  gyrus, 

**  Van  Gehuchten:  Journal  de  Neurologic,  January  5,  1897. 


LITTLE'S   DISEASE.  103 

the  posterior  half  of  the  lateral  aspect  of  the  inferior 
frontal  gyrus,  and  the  superior  and  inferior  parietal  gyri 
were  the  least  developed.  The  cells  were  arranged  in  a 
single  layer,  and  resembled  embryonal  cells,  and  were 
smaller  than  in  normal  persons  of  the  same  age. 

Case  3.  10  years  old.  The  cells  in  the  anterior  central 
g}'nis  were  somewhat  smaller  and  fewer  than  in  normal 
brains.  Groups  of  giant  cells  in  normal  number  were 
observed.  This  case  diflfered  from  the  other  two  in  that 
mobility  w-as  greater. 

Cas^  4.  3  years  old.  The  child  could  sit  alone  and 
walk,  very  insecurely,  on  level  ground.  In  the  right 
anterior  central  gyrus  the  pyramidal  cells  did  not  amount 
to  one-fifth  the  usual  number,  and  they  were  mingled 
w'ith  undeveloped  cells.  There  were  also  cells  which  pre- 
sented a  hyaline  appearance.  In  the  lower  part  of  the 
g>'rus  more  large  cells  were  noticed. 

The  larger  part  of  the  cerebral  cortex  in  these  four 
cases  represented  the  normal  degree  of  development  in 
the  latter  half  of  fetal  life.  The  different  clinical  symp- 
toms could  be  explained  by  the  cortical  findings. 

Two  feeble-minded  children  of  low  grade  are  de- 
scribed : 

Case  5.  26  years  old.  Movements  were  slow,  but  the 
patient  could  walk,  although  was  soon  exhausted.  In  the 
anterior  central  gyrus  the  cells  and  layers  were  somewhat 
smaller  than  in  a  normal  person  of  the  same  age.  The 
giant  cells  measured  25-30x50  microns.  The  slow  move- 
ments could  not  be  explained  by  the  findings  in  the  motor 
region.  Possibly  the  decrease  in  the  cells  of  the  vermis 
was  connected  with  the  slow  movements. 

Case  6.  i  year,  10  months  old.  The  child  could  not 
walk  or  sit  erect.  The  imperfect  mobility  was  not  only 
due  to  the  undeveloped  condition  of  the  cortex  in  the 
motor  region,  as  this  corresponded  merely  to  the  degree 
of  development  seen  at  the  end  of  the  first  year,  but  also 
to  the  fact  that  the  cells,  and  especially  the  giant  cells, 
were  much  fewer  than  normal. 


I04  ll'JLLIAM    G.  SPILLER. 

In  these  two  cases  the  greater  part  of  the  cerebral  cor- 
tex corresponded  to  the  degree  of  normal  development 
in  the  first  years  of  life. 

Three  cases  of  moderate  and  slight  grades  of  mental 
development  are  described: 

Case  7.  14  years  old.  There  was  complete  paralysis 
of  the  lower  extremities  and  paresis  of  the  upper.  This 
was  explained  by  the  fact  that  the  corresponding  parts  of 
the  motor  cortex  were  not  more  developed  than  in  the 
first  year  of  normal  life,  and  the  giant  cells  in  the  upper 
part  of  the  anterior  central  gyrus  were  absent.  In  the 
lower  parts  of  the  gyrus  the  cells  were  larger  and  the 
appearance  more  like  the  normal. 

Case  8.  12  years  old.  Mobility  was  not  impaired. 
In  the  anterior  central  gyrus  the  cells  were  normal,  al- 
though fewer.  The  giant  cells  were  relatively  most  num- 
erous. 

Case  9.  16  years  old.  Both  lower  extremities  were 
paretic,  and  the  patient  could  not  stand.  The  movements 
in  the  upper  limbs  and  trunk  were  normal.  The  medial 
and  upper  sixth  of  the  lateral  aspect  of  the  anterior  cen- 
tral gyrus,  the  posterior  central  gyrus,  and  the  inferior 
frontal  gyrus  were  most  altered,  and  the  cells  presented 
an  undeveloped  appearance.  In  the  rest  of  the  cortex 
the  cells  were  normal,  but  fewer  than  in  normal  brains. 
There  were  no  giant  cells  in  the  upper  part  of  the  anterior 
central  gyrus. 

In  these  three  cases  the  number  of  the  nerve  cells  in 
the  greater  part  of  the  cerebral  cortex  Wcis  much  less  than 
the  normal,  and  in  a  small  area  they  represented  the  de- 
gree of  development  in  the  first  years  of  life. 

From   the  results  of  these  important   examinations 
Hammarberg  concluded  that  the  mental  condition  de- 
pends on  the  degree  of  development  of  the  brain  as  repre- 
sented by  the  cortical  cells. 

Surely  in  view  of  the  testimony  which  has  been  pre- 
sented by  macroscopical  and  microscopical  examination 
of  the  central  nervous  system  in  cases  of  microcephaly. 


LITTLES  DISEASE.  105 

one  must  acknowledge  that  the  operation  of  craniotomy 
is  one  which  deserves  most  careful  consideration.  Perls 
and  Edinger*®  have  shown  that  hydrocephalus  of  mild  de- 
gree occurring  in  childhood  and  not  progressing,  or  rach- 
itis involving  the  skull,  have  seemed  to  favor  the  mental 
development  by  lessening  the  resistance  to  the  growth  of 
the  brain,  but  in  these  cases  nerve  cells  were  already  pres- 
ent. It  may  be,  as  Starr*^  suggests,  that  operation  stim- 
ulates the  growth  of  cerebral  tissue,  but  probably  it  can 
never  cause  the  production  of  new  nerve  cells.  We  can 
never  be  perfectly  sure  of  the  nature  of  the  lesion  in  any 
case  of  microcephaly.  Dr.  Keen  has  most  kindly  consented 
to  give  his  views  on  the  advisability  of  the  operation  of 
craniotomy  in  microcephaly,  and  the  results  obtained  from 
his  experience  of  many  years  are  of  inestimable  value. 
I  thank  him  most  heartily  for  this  important  addition  to 
my  paper.*® 

REMARKS  BY  W.  W.  KEEN,  M.D..  ON  THE  ADVISABILITY 
OF  OPERATION  IN   MICROCEPHALY. 

I  am  glad  that  Dr.  Spiller  has  been  so  fortunate  as  to 
be  able  to  make  a  very  careful  post-mortem  examination 
of  the  little  girl  K.  K.  reported  in  this  paper.  I  cheerfully 
consent,  at  his  request,  to  give  my  views  on  the  present 
status  of  the  operation  of  linear  craniotomy. 

My  views  are  based  not  only  on  what  I  have  learned 
from  the  experience  of  others,  but  upon  a  personal  experi- 
ence covering  eighteen  cases.  Of  these  eighteen  cases 
five  died,  a  mortality  of  21.7  per  cent.  The  youngest  was 
ttghteen  months  old,  the  oldest  six  and  a  half  years.  As 
to  their  later  history  I  can  report  of  the  thirteen  who 

Edinger:  Vorlcsungen  iiber  den  Bau  der  nervosen  Centralorgane. 
P"th  edition. 

"Starr:  Medical  Record,  1892,  vol.  i. 

.  Since  this  paper  was  written  important  works  bearing  on  the  sub- 
ject of  microcephaly  and  idiocy  have  been  published  by  Pfleger  and 
Pilcz  (Arbeiten  aus  dem  Institut  fur  Anatomic  und  Physiologic. 
^Dcrsteiner.  No.  v.)  and  by  Kaes  (Monatsschrift  fiir  Psychiatric  und 
i^curologie,  No.  i..  1897.) 


I06  WILLIAM  G.  SPILLER. 

recovered  that  six  were  slightly  improved,  seven  were- 
not  benefited. 

On  the  whole  the  prospect  for  improvement  after  the 
operation  of  linear  craniotomy  for  microcephalus  is  not 
bright.  Sometime  since  a  patient  called  upon  me  who 
had  sought  advice  as  to  her  child,  and  when  I  told  her 
that  nothing  could  be  done,  the  boy  being  simply  an  idiot 
with  an  average  sized  head  and  not  the  slightest  indica- 
tion favorable  to  operation,  she  was  astonished  to  the 
last  degree,  and  more  than  that  she  was  heart-broken. 
She  had  been  encouraged  to  believe  that  even  in  hundreds 
of  operations  not  a  death  had  taken  place,  and  she  stated 
that  the  very  words  used  to  her  were  that  if  she  would 
allow  an  operation  to  be  done  "the  result  would  be  a 
revelation  to  her."  Two  specific  instances  of  great  im- 
provement were  cited  to  her.  When  I  investigated  these 
two  cases  I  found  that  both  were  again  in  an  asylum  in  a 
worse  condition  than  before  the  operation.  One  can 
imagine  what  a  crushing  blow  it  was  for  a  fond  mother, 
who  had  anticipated  a  speedy  cure  for  her  idiot  boy  and 
a  restoration  to  a  normal  intellectual  life,  to  be  told  that 
such  statements  were  not  borne  out  bv  facts,  and  that 
in  my  opinion  absolutely  no  good  could  result  from  opera- 
tion. 

I  do  not  consider  that  a  child  with  an  average  sized 
head  is  a  suitable  case  for  operation,  nor  secondly  that  in 
cases  older,  we  will  say,  than  about  seven  years  of  age,  im- 
provement can  be  expected.  Nor  do  I  regard  the  opera- 
tion justifiable  in  those  suflfering  from  extreme  micro- 
cephaly in  which  the  head  is  excessively  small.  Only  the 
cases  showing  a  moderate  degree  of  .microcephaly  are 
suitable  for  operation.  The  cases  with  very  small  heads,, 
as  the  child  K.  K.  reported  in  this  paper  by  Dr.  Spiller, 
as  he  has  shown,  have  a  very  imperfect  development  of 
the  nerve  cells,  which  are  essential  for  a  normal  or  even 
approaching  a  normal  life.  In  less  extreme  cases  where 
probably  the  cells  are  more  perfect  we  may  hope  for  more. 
As  I  have  said  elsewhere  (Medical  News,  November  29th^ 


LITTLES   DISEASE.  lOJ 

1890,  p.  558)  '*The  inherent  cause  of  microcephalus  we  do 
not  know.  Formerly  it  was  supposed  to  be  due  to  pre- 
mature ossification  of  the  cranial  sutures,  but  the  exam- 
ination of  several  such  skulls  has  shown  that  while  this 
may  sometimes  be  the  case,  yet  in  the  cases  examined 
there  was  no  abnormality  in  the  bony  development  of  the 
cranium.  On  the  other  hand,  we  know  that  the  growth 
of  the  skull  keeps  pace  with  the  growth  of  the  brain  within 
it;  and  if  the  growing  power  of  the  brain  be  weak,  a  slight 
resistance  on  the  part  of  its  osseous  envelope  may  be  suf- 
ficient to  check  and  stunt  it." 

The  benefit  so  far  as  my  observation  goes  is  but  slight. 
When  the  American  Surgical  Association  met  in  Buffalo 
about  three  years  ago.  Dr.  Roswell  Park  showed  a  boy, 
I  think  about  twelve  years  of  age,  who  had  been  very 
greatly  benefited  by  the  operation,  so  that  he  had,  one 
might  say,  three-quarters  of  a  normal  intellectual  develop- 
ment. I  have  never  seen  in  any  of  my  own  cases  any  such 
improvement,  and  this  case  surprised  me  the  more  in  view 
of  the  boy's  age,  which  I  think  was  about'  ten  when  he  was 
operated  on.  Any  real  improvement,  however,  would  justi- 
fy the  operation  in  my  opinion.  One  of  my  cases  for  in- 
stance, was  the  child  of  a  poor  washer-woman  with  several 
other  children.  He  was  as  restless,  and  as  mischievous  as 
a  monkey.  At  night  he  was  almost  constantly  crying, 
and  so  disturbed  his  mother  that  she  had  scarcely  had  one 
good  night's  rest  since  he  was  born.  The  operation  trans- 
formed him  into  a  quiet,  fairly  sleepfiil  child,  and  was  well 
worth  any  risk  which  attended  the  operation. 

In  fact,  if  any  one  may  speak  of  risk,  we  can  honestly 
only  wish  that  in  all  the  cases  which  should  not  be  bene- 
fited the  risk  would  be  far  greater  than  it  is,  since  if  such 
children  cannot  be  helped  it  is  far  better  for  thein,  their 
parents  and  other  caretakers  and  their  companions  that 
they  should  die. 

I  suppose  I  have  declined  to  operate  on  at  least  one 
hundred  cases  which  in  my  opinion  were  entirely  unsuit- 
able for  operation. 


Io8  WILLIAM  G.  SPILLER. 

My  present  conclusions,  therefore,  are: 

(i)  That  in  a  moderate  number  of  selected  cases  of 
medium  degrees  of  microcephaly  the  operation  will  hap- 
pily be  followed  by  death  in  about  fifteen  to  twenty  per 
cent,  of  the  patients. 

(2)  In  a  small  number  of  cases  benefit  to  a  slight  ex- 
tent will  be  observed,  but  in  the  majority  no  results,  good 
or  bad,  will  follow  the  operation. 

Were  we  to'  judge  from  the  microscopic  results  in  the 
case  Dr.  Spiller  has  so  ably  investigated,  we  should  un- 
questionably say  that  no  good  result  could  ever  follow, 
but  we  must  remember  that  this  child  had  an  extremelv 
small  head,  and  was  a  case  in  which,  with  a  now  larger 
experience,  I  should  absolutely  decline  to  operate,  and 
also,  that  this  child  did  actually  improve  to  some  extent, 
whether  as  the  result  of  the  operation,  or  of  the  later 
excellent  training  and  care  that  she  had,  we  cannot 
judge  positively.  CHnically  there  is  no  question  about  a 
moderate  improvement  in  a  small  number  of  cases. 

After  operation  the  greatest  attention  should  be  paid 
to  developing  the  child's  faculties  by  education.  This  can 
hardly  be  done  in,  or  by  any  family.  It  is  best  done  in  a 
school  such  as  that  of  the  Misses  Bancroft  and  Cox  in 
Haddonfield,  N.  J.,  where  a  long  familiarity  with  such 
cases  enables  them  to  adopt  means  to  ends,  to  develop 
better  methods  of  education  which  result  from  a  wide  ex- 
perience, and  to  provide  an  individual  teaching  which 
neither  in  a  family  nor  in  a  large  school  is  practicable.  How 
much  improvement  comes  from  the  education  and  how 
much  from  the  operation  is  often  a  matter  of  great  uncer- 
tainty. 

In  all  cases  a  clear  statement  of  the  mortalitv  should 
be  made  to  the  parents  and  they  should  be  prepared  for 
a  very  probable  disappointment  in  seeing  only  very  slight 
good  results  or  none  at  all,  and  then  they  must  decide 
whether  they  are  willing  to  accept  the  risk  of  death  and 
the  risk  of  disappointment. 


; 


GLIOMA  OF  THE  RIGHT  FRONTAL  LOBE  OF 

THE  BRAIN. 

By  WILLIAM    C.  KRAUSS,    M.D., 

Buffalo,  N.  T. 

H.  S. — Single,  aet.  thirty-one;  height,  five  feet  eight 
inches;  weight,  one  hundred  and  fifty-five  pounds;  occu- 
pation, architect  and  carpenter;  complexion,  dark. 

Family  History:  Grandparents  lived  to  old  age. 
Parents  are  living  and  healthy  at  the  age  of  fifty-six. 
There  is  no  history  of  consumption  or  syphilis  obtainable. 
One  aunt  on  the  mother's  side  died  of  cancer. 

Early  History:  He  passed  through  the  usual  diseases 
of  childhood  without  any  sequelae;  grew  rapidly  and  be- 
came an  expert  workman  at  his  trade. 

Present  History :  About  a  year  and  a  half  ago  he  no- 
ticed, while  stooping  over  at  his  work,  a  little  dizziness 
which  soon  passed  off.  Occasionally  he  would  notice  the 
vertigo  when  in  an  upright  position,  but  on  account  of  its 
transitory  character  he  paid  little  attention  to  it.  These 
dizzy  spells  continued  without  increasing  any  in  intensity, 
and  without  further  disturbances  until  February,  1896, 
whenfiebegan  to  have  dull  headaches  with  periods  of  exac- 
erbation. The  dull  pain  seemed  to  encompass  the  whole 
head,  but  during  the  exacerbation  the  pain  became  more 
acute  and  intense,  and  extended  from  the  forehead  to  the 
nape  of  the  neck;  afterwards  it  became  more  intense  and 
more  fixed  at  the  occiput,  and  was  more  or  less  continuous, 
so  that  he  was  obliged  to  discontinue  his  work  (Sept.  20th, 
1896.)  When  the  pains  were  at  their  acme  of  intensity 
he  would  feel  his  head  drawn  backwards. 

In  May,  1896,  while  he  and  his  brother  were  bicycling, 
they  ran  into  each  other,  and  he  was  thrown  violently  to 


■i 
i 

i 

i 
{ 

»;  no  ly.c.KRAuss. 

i 

.» 


*} 


'1 


the  pavement  and  received  quite  an  extensive  injury  over 
the  left  eye,  necessitating  several  stitches    to  close    the 
d  .  wound.     This  accident  did  not  seem  to  affect  the  head- 

^  aches  to  any  extent,  but  to  another  brother  (a  physician) 

seemed  the  probable  cause  of  the  head  pains.  It  may  be 
stated  here  that  the  patient  was  a  rather  quiet,  uncom- 
municative man,  especially  in  regard  to  his  own  feelings 
and  sensations,  and  up  to  the  time  of  the  injury  hardly  ever 
spoke  of  his  head  pains.  During  the  following  three 
months  he  had  but  five  severe  spells  of  head  pains. 

About  September  ist,  1896,  he  began  to  have  spells  of 
nausea  and  vomiting,  generally  in  the  morning  when  the 
stomach  was  entirely  empty.  These  occurred  at  first 
about  once  a  month,  but  increased  in  frequency  until  they 
occurred  almost  every  other  day.  The  vomited  matter 
always  consisted  of  a  watery  flfuid,  which  he  says  had  a 
very  pleasant  taste.  The  vomiting  came  on  with  a  sort  of 
hiccough  and  never  prostrated  him.  During  the  summer 
(1896)  the  dizziness  became  more  severe,  and  instead  of 
having  a  dizzy  spell  about  once  a  week  he  would  feel  dizzy 
every  time  he  laid  dow^n  or  arose.  When  he  tried  to  walk 
after  having  had  one  of  these  spells  he  staggered  for  two 
or  three  steps,  but  did  not  swerve  to  either  side,  never  fell 
down,  and  noticed  no  other  peculiarity  about  his  loco- 
motion.  The  eyes,  he  said,  felt  as  if  red  hot  irons  were 
being  thrust  into  them,  also  at  times  it  seemed  as  if  a  white, 
mist  were  hanging  before  the  eyes;  this  would  clear  up 
and  vision  would  become  again  good.  He  stated  that  his 
bowels  were  nearly  always  regular;  that  his  appetite  was 
variable;  that  he  slept  pretty  well  of  late,  though  formerly 
he  was  disturbed  by  the  head  pains;  that  ther^  was  no 
difficulty  in  urination,  no  numbness  or  any  other  abnormal 
sensation,  and  that  if  it  were  not  for  the  headaches  and 
dizziness  he  would  be  able  to  work  as  hard  as  ever. 

Status  Praesens.     Sept.  26th,  1896. 

Mental  condition:     Conversation  with  him  shows  that 


GLIOMA.  1 1 1 

the  mental  faculties  are  intact,  although  he  talks  very  little 
on  any  subject  unless  specially  interrogated.     He  is  in 
good  humor,  answers  all  questions  promptly,  and  does  not 
seem  to  take  his  sickness  and  enforced  idleness  much  to 
heart.    He  reads  the  papers,  does  copying  and  makes  him- 
self useful  about  his  brother's  pharmacy.     His  actions  and . 
demeanor  here  show  po  change  from  his  normal  healthy 
conditioi>,  so  his  brother  informs  me. 

His  face  is  emaciated;  the  face  lines  are  prominent; 
the  complexion  is  dark,  dull  and  ashen^  the  expression  is 
somewhat  apathetic.  A  very  faint  scar  ,is  seen  over  the 
left  eye,  the  result  of  the  bicycle  accident  in  May,  1896; 
the  scalp  reveals  no  scars,  no  tender  spots  and  no  promi- 
nence of  the  sutures. 

Percussion  of  the  skull  reveals  no  tenderness. 

Eyes:  The  pupils  are  widely  dilated,  with  no  apparent . 
difference,  betweeji  the  two,  and  react  to  light  and  ac- 
commodation. The  muscles  of  the  orbits  functionate 
normally  in  all  directions.  Ophthalmoscopically,  a  double 
optic  neuritis  is  seen,  and  is,  perhaps,  a  little  more  pro- 
nounced in  the  right  disc.  Hemorrhages  have  taken  place 
about  the  fundus.  Vision  is  subnormal,  with  no  history 
of  double  vision. 

The  tongue  and  uvula,  show  no  deviation.  No  dis- 
tur])ance  of  audition,  olfaction  or  gustation  is  found.  The 
tendon  reflexes,  as  well  as  the  muscular,  are  normal.  Sen- 
sation of  the  face,  body  and  extremities  is  unimpaired. 
Dynamometric  test  gives  the  following  results:  Right 
hand.  140;  left  hand,  145;  right  leg,  i82;.left  leg,  175. 

Pulse  shows  eighty  to  eighty-five  beats  per  minute  and 
Js  reo^ular  and  uniform.  Urine  contains  no  traces  of  sugar 
or  albumin.  •        ' 

The  persistent  headaches,  with  dizziness,  nausea,  vom- 
iting, and  above  all,  choked  discs,  suggested  a  cerebral  • 
growth  of  some  kind  situated  in  some  ''silent''  portion  of 
the  brain  or  else  so  small  as  not  to  call  forth  anv  locali- 
zing  symptoms.     Although  he  strenuously  denied  having 


•  t 


I 


,1 


112  IV.C.KRAUSS. 

had  syphilis,  it  was  deemed  prudent  to  put  him  on  mer- 
cur>^  and  iodide,  and  to  watch  the  effect  of  treatment;  and 
to  be  prepared  for  the  appearance  of  focal  symptoms,  so 
that  if  advisable  surgical  measures  could  be  undertaken. 

I  saw  him  repeatedly  after  this,  and  apparently  a 
change  for  the  better  was  going  on,  as  he  complained  less 
of  his  head  pains;  the  vomiting  and  dizziness  seemed  to 
have  lessened  in  frequency  and  severity,  and  he  appeared 
more  active  and  interested  in  his  environment.  This  im- 
provement was  also  observed  by  his  brother,  the  physician, 
and  the  mercur}^and  iodide  were  given  with  renewed  vigor. 

On  October  17th,  1896,  he  rceived  a  letter  from  his 
former  employer  asking  him  if  he  were  able  to  work  again, 
and  if  so  to  write  immediately.  This  pleased  him  greatly, 
and  he  could  not  understand  why  he  was  not  able  to  re- 
sume work,  inasmuch  as  he  was  feeling  so  much  better. 
The  optic  neuritis,  however,  remained  stationary,  and  was 
regarded  more  as  an  index  of  the  condition  in  the  brain 
than  the  subjective  symptoms. 

Between  Oct.  17th  and  Dec.  8th,  he  thought  he  was 
so  much  improved  that  he*  refused  to  take  any  more  medi- 
cine and  did  not  come  to  see  me.  He  also  absented  him- 
self from  his  brother's  office,  and  it  was  with  some  diffi- 
culty that  he  was  persuaded  to  come  this  day. 

On  Dec.  8th,  1896,  he  reported  as  follows:  He  said 
his  headaches  had  nearly  disappeared;  that  he  had  not 
vomited  in  two  weeks;  that  the  dizziness  was  also  disap- 
pearing; that  the  appetite  was  good  and  the  bowels  reg- 
ular; that  he  slept  well  and  "felt  more  like  getting 
around."  The  papillitis  of  the  left  eye  was  receding,  so 
that  the  outlines  of  the  nerve  were  distinguishable  The 
right  eye  showed  small  hemorrhages  about  the  optic  disc 
which  was  much  swollen.  Vision  of  right  eye  was  20/30, 
left  eye  15/30.  Dynamometric  test:  Right  hand,  145; 
left  hand,  145;  right  leg,  180;  left  leg,  175. 

Sensation,  audition,  gustation  and  olfaction  were  not 


GLIOMA.  113 

disturbed.  Pulse  was  eighty,  regular  and  uniform.  His 
mind  was  clear,  although  he  acted  as  if  somewhat  de- 
pressed and  seemed  to  fall  into  a  state  of  mental  hebetude 
when  no  questions  were  asked  him. 

Believing  him  somewhat  improved,  it  was  decided  to 
continue  the  anti-syphilitics  up  to  the  point  of  intoxica- 
tion,  especially  as  no  localizing  symptoms  had  appeared. 
It  seemed-  from  the  subjective  symptoms,  the  exami- 
nation of  the  eyes  and  strength  of  the  extremities  that  the 
growth  was,  perhaps,  diminishing  in  size. 

Soon  thereafter  reports  came  to  me  through  his  father 
and  brother  that  the  pains  were  becoming  more  intense, 
and  were  somewhat  more  paroxysmal,  and  that  during 
these  attacks  he  would  say  nothing,  and  even  refused  to 
answer  questions,  and  was  in  a  dazed  condition.  Pulse 
during  a  paroxysm  ranged  from  forty-five  to  fifty-five. 

On  December  25th,  he  took  dinner  with  his  brother's 
family  and  seemed  to  be  in  the  best  of  health  and  spirits. 
He  played  with  the  children,  laughed,  talked  freely  and 
enjoyed  himself  very  much.     The  next  day,  Dec.  26th,  he 
came  to  my  office  and  denied  having  had  any  severe  at- 
tack, and  said  the  pains  were  in  no  way  comparable  to  the 
pains  he  formerly  endured.     He    also    reported    feeling 
pretty  well,  although  his  expression  was  not  as  cheerful 
as  on  former  visits.     Dynamometric    test  showed    some 
diminution  of  power  of  the  left  hand.     It  was  as  follows: 
Right  hand,  145;  left  hand,  135. 

From  this  time  on  I  received  word  from  the  brother 
that  the  paroxysms  of  pain  were  becoming  so  intense  that 
he  would  be  obliged  to  go  to  bed,  and  that  in  his  opinion 
the  patient  was  failing  rather  than  improving.  After  one 
of  these  paroxysms  (Feb.  ist,  1897),  he  urinated  in  the 
•'^oap  dish  and  into  the  bureau  drawer,  and  was  unable  to 
find  his  way  down  stairs.  This  was  the  only  time  when 
the  patient  appeared  at  all  irrational,  and  he  recovered 
from  this  condition  in  twenty  to  thirty  minutes.     During 


r 

1 


i 

I 

r 

I 

I 
!  I 


t  J  ; 


114  IV.C.KRAUSS. 

the  intervals  he  would  stay  at  the  pharmacy  writing  labels, 
reading,  and  doing  light  work,  and  was  possessed  of  all 
his  mental  faculties. 

On  February  4th,  1897,  accompanied  by  his  brother, 
he  appeared  at  my  office,  and  on  first  glance  it  was  appar- 
:■  ent  that  a  change  for  the  worse  had  taken  place.     The  face 

j^ ,  was  pale,  ashen,  dull  and  expressionless,  the  pupils  of  the 

pj  eyes  were  widely  dilated  and  his  strength  was  evidently 

'  declining.     He  remembered  nothing  about  the  urination 

t  episode,  nor  of  the  several  paroxysms,  but  knew  about 

r  •  everything  that  had  transpired  during  the  time  w-hen  his 

head  was  free  from  pain.     He  answered  all  questions  in- 
'  telligently,  but,  as  on  a  former  visit,  lapsed  into  a  dreamy, 

Hstless  condition  when  left  alone. 

I  was  firmly  resolved  to  locate  the  growth  to-day  if 
possible,  and  made  a  thorough  examination. 

Again  the  head  was  not  sensitive  to  percussion;  the 
eyes  were  in  practically  the  same  condition  as  before;  audi- 
tion, olfaction,  gustation,  and  the  various  forms  of  sensa- 
tion were  likewise  unaltered.  Dvnamometric  test  re- 
suited  as  follows:  Right  hand,  135;  left  hand,  120;  right 
leg,  170;  left  leg,  165. 
;  There  was  no  history  of  spasms  or  of  periods  of  par- 

esis of  the  extremities,  while  the  face,  tongue  and  uvula 
r  functionated  normally.     The  pulse  was  eighty,  regular  and 

"  uniform.     I  informed  the  brother  that  in  all  probability 

:'  the  growth  was  not  located  in  the  parietal,  temporal  or 

j  occipital  lobes,  nor  at  the  base,  and  was  not  affecting  the 

i|  basal  ganglia,  and  that  only  by  exclusion  could  it  be  lo- 

cated in  one  of  the  frontal  lobes.  And  yet,  even  if  here, 
it  had  not  so  far  called  forth  anv  of  the  mental  disturb- 
ances  often  met  with  in  disease  of  the  frontal  area. 
Whether  it  was  on  the  right  or  left  side  was  also  diffi- 
cult to  determine,  and  if  on  the  left  side,  certainlv  did  not 
atYcct  the  caudal  part  of  the  third,  or  of  the  second  convo- 
hui«  n  near  theRolandic  area.  It  did  not  affect  the  centres  of 


GLIOMA. 


115 


motor  speech  and  writing,  as  neither  aphasia  jior  agraphia 

was  present.     If  the  tumor  were  located  on  the  right  side 

of  the  brain  it  might  have  invaded  certain  areas  whose 

functions  are  as  vet  undetermined,  these  '^silent"  areas  be- 

ing  more  extensive  on  the  right  side  than  on  the  left,  and 

causing  no  definite  symptoms  w^hen  destroyed,  as  far  as 

we  know;  or  the  cortex  at  the  base  of  the  brain,  as  that  of 

the  orbital  convolutions,  might  have  l)een  diseased,  and 

no  recognizable  symptoms  have  been  present.     This  was, 

liowever,  mere  speculation,  and  the  frontal  lobes  were 

thoug-lit  to  be  the  seat  of  the  growth  more  than  any  of  the 

other    areas  whose  functions  are  unknown.     The  patient 

had  several  very  severe  attacks  of  head  pain  during  the  next 

few  da.Ts  and  an  unusually  severe  paroxysm  on  Feb.  loth, 

J897,     necessitating  heroic  doses   of  morphia.     Following 

this  at:  tack  he  declined  rapidly  and  died  on  the  same  day, 

Feb.    I  oth,  1897,  at  ten  o'clock,  P.  M. 


^'^^<J7, 


Fig.  I. 

On  Feb.  9th  he  was  at  the  pharmacy  copying  labels,  a 

sample  of  which  is  here  presented.     He  had  not  changed 

any  since  Feb.  4th,  either  physically  or  mentally,  and  no 

new     symptoms  had  presented  themselves.     During  the 

^^y    Vie  played  whist,  had  on   the  boxing  gloves,  read, 

\augVied,  and  felt  better  than  for  a  month  past. 

The  autopsy  was  made  by  Dr.  Sayles  and  myself  on 
F^b.  nth,  1897.  ^h^  frontal  bone  over  the  left  eye 
s\^owe(l  no  traces  of  any  injury  which  the  bicycle  accident 


ii6 


ir.  C.  KRAUSS. 


might  liave  .inflicted.  The  calvarium  was  of  the  usual 
thickness,  and  not  adherent  to  the  dura.  The  dura  was 
not  injected,  and  over  the  right  frontal  lobe  fluctuated  and 
showed  an  area  of  depression  as  compared  with  that  of  the 
left  side.  It  was  soft  superficially  to  the  touch,  but  dense 
and  hard  under  pressure.  The  left  lobe  felt  firm  and  re- 
sistant, and  it  was  evident  that  the  right  lobe  was  the 
seat  of  disease.  On  removing  the  dura  a  large  cyst,  about 
the  size  of  a  walnut,  the  ectal  wall  of  which  was  evidently 
the  pia,  was  found  in  the  right  lobe  at  the  surface.  The 
cystic  contents  were  collected  in  a  bottle, and  the  collapsed 
walls  brought  into  view  a  large,  dense,  firm  tumor.  The 
brain  was  removed  and  placed  in  a  five  per  cent,  solution  of 
formalin  for  hardening,  so  as  to  facilitate  a  careful  ana- 
tomical and  pathological  examination  of  the  affected  lobe. 


^ 


The  tumor  occupied  the  middle  and  caudal  portion  of 
the  first,  second  and  third  frontal  convolutions,  extending 
as  far  caudad  as  the  ascending  frontal  convolution, thus  oc- 
cupying about  one-half  of  the  convex  surface  of  the  frontal 
lobe.     Entad,  the  tumor  extended  to  the  lateral  ventricle. 

This  cystic  opening  communicated  with  the  lateralven- 
tricle.  Histologically  the  growth  appeared  to  be  a  glioma 
with  con.siderable  connective  tissue  stroma  present. 


GLIOMA.  117 

While  the  brain  was  in  process  of  hardening  an  area  of 
softening  was  felt  over  the  angular  convolution  of  the  left 
lobe,  and  thinking  that  the  formalin  had  not  infiltrated  the 
brain  thoroughly,  and  that  this  portion  was  beginning  to 
soften  and  break  down,  I  cut  into  this  region  and  found  a 
cystic  cavity  about  the  size  of  a  pigeon's  egg.  The  fluid 
was  similar  to  that  which  had  escaped  from  the  cyst  in 
connection  with  the  gfioma.  The  cystic  fluid  from  the 
tumor,  which  was  about  two  ounces,  was  of  a  pale  straw 
<^olor,  rich  in  albumin,  and  under  the  microscope  revealed 
1^0  traces  of  echinococci. 

Two  important  questions  arise  in  the  study  of  this 

^^e:    First,  were  the  symptoms  sufficient  to  warrant  a 

/  ^^sitive  focal  diagnosis,  and  secondly,  was  it  a  mistake  to 

/  /^C^stpone  and  eventually  deprive  the  patient  of  the  bene- 

y  jf^S  of  an  operation. 

It  is  now  almost  universally  conceded  that  the  right 
irontial  and  right  temporal  lobes  contain    no  distinctive 
foca.1  centres,  and  they  are  known  as  the  "silent"  or  "la- 
tent: "  lobes  or  areas,  in  contradistinction  to  the  corre- 
spoinding  lobes  on  the  left  side,  which  are  the  centres  of 
motor  speech  and  writing,  and  of  hearing.     The  frontal 
lol>es,  perhaps  equally,- except  for  mott)r  speech  and  writ- 
irig,  are  supposed  to  be  the  seat  of  the  intelligence  and  the 
psyohicaLattributes  which  characterize  mankind.     Experi- 
trients  on  animals  and  clinical  study  have  thus  far  failed 
to   show  just  how  much  responsibility  each  lobe  assumes 
in  preserving  the  proper  mental  balance  of  the  individual, 
and   when  the  posterior  portion  of  the  second  and  third 
^'"^ntal  convolutions  of  the  left  side  are  not  involved,  it 
^^  almost  impossible  to  say,  from  the  subjective  symptoms, 
"which  lobe   is  the   seat    of   disease.     When    along    with 
tnarked  mental  decadence,  aphasia  or  agraphia  is  present 
with  the  symptoms  denoting  brain  tumor,  then  it  is  safe 
to  localize  the  disease  at  least  in  the  left  frontal  area,  but 
^till  unsafe  10  say  whether  or  not  the  right  frontal  area  is 
^Iso  involved.  1 


Jl8  W.  C.  KRAUSS. 

Inasmuch  as  the  left  side  of  the  brain,  especially  the 
frontal  and  temporal  lobes,  contain  important  centres  not 
present  on  the  right  side,  may  not  the  centres  presiding- 
over  reason,  memory,  intelligence,  or  the  higher  psychical 
states  be  more  localized  in  the  left  frontal  lobe  close  to  the 
centres  of  speech  and  writing,  which  are  the  two  great 
channels  through  which  the  intelligence  of  the  being  is 
made  manifest  to  the  external  world?  The  close  proxim- 
ity of  the  centres  of  speech  and  the  centres  presiding  over 
those  organs  (articulatory)  by  means  of  which  speech  is 
possible;  also  the  proximity  of  the  centres  of  writing  and 
those  presiding  over  the  movements  of  the  fingers  by 
which  writing  is  possible,  might  suggest  a  like  proximity 
of  the  centres  of  intelligence,  and  those  centres  through 
which  the  intelligence  of  the  individual  is  expressed,  name- 
ly, of  speech  and  writing  >all  these  are  located  in  the  left 
frontal  lobe  of  the  brain. 

The  symptoms  presented  by  my  patient  would  certain- 
ly tend  to  corroborate  this  view,  and  also  to  prove  quite 
conclusively  that  the  writing  centre  is  not  situated  in  the 
right  frontal  region.  In  my  opinion,  the  areas  presiding 
over  the  functions  just  mentioned  enjoy  much  closer  com 
munion  than  we  have  as  yet  pretended  to  grant  them. 
The  same  is  true  of  the  centres  presiding  over  motion  and 
sensation.  In  the  motor  areas,  for  instance,  the  layer  of 
large  cortical  ganglion  cells  is  interested  in  the  move- 
ments of  the  various  extremities,  while  the  laver  of  small 
ganglion  cells  in  the  same  cortical  area  could  very  prop- 
erly preside  over  sensation.  This  view  is  not  so  very  ex- 
traordinary, inasmuch  as  cases  are  on  record  of  paralysis 
of  motion  and  sensation  where  the  lesion  was  found  whollv 
in  the  motor  areas.  In  like  manner  the  centres  of  intelli- 
gence, inhibition  and  judgment  -might  be  located  in  the 
smaller  ganglion  cells  of  the  whole  frontal  lobe  of  the 
left  hemisphere,  the  centres  of  speech  and  writing  occupy- 
ing localized  areas  in  the  deeper  layer  of  ganglion  cells. 


GLIOMA.  119 

In  fifty  cases  of  tumor  of  the  prefrontal  area  analyzed 
by  Williamson,*  the  mental  symptoms  were  generally  well 
marked,  and  in  many  cases  were  the  most  prominent  and 
earliest  symptoms.     His  results  are  as  follows: 

There  w^as  a  condition  of  mental  decadence  with  a  dull 

mental  state,  a  loss  of  power  of  attention,  a  loss  of  mem- 

orv,   a  loss  of  spontaneity;  the  patient  took  no  notice  of 

his   surroundings  and  slept  during  the  greater  portion  of 

the  clay,  or  was  semi-comatose  in  thirty-two  of  the  cases. 

There  was  loss  of  memory,  mental    failure,  but    the 
patient  w^as  cheerful  in  six  cases. 

The  patient  was  suspicious  and  suffered  from  delusions, 
wliicli  were  occasionally  violent  in  one  case. 

nPhe  patient  was  irritable  and  violent  in  one  case. 
The  patient  w-as  "generally  asleep   and    irritable   when 
awalce  in  two  cases. 

The  patient  was  ambitious,  excitable,  and  had  loss  of 
nieiTiory  in  one  case. 

There  was  slowness  of  mental  processes,  and  the  pa- 
tiei^ii:  was  simple  and  childish  in  one  case. 

There  were  mental  anxiety,   childishness,   hallucina- 
tions, suicidal  tendencies  in  one  case. 

The  mental  condition  was  not  stated  in  five  cases. 
Seventeen  of  these  lesions  involved   the  right   lobe, 
twenty-two  the  left,  and  eleven  both  lobes. 

Perrier'  states  the  symptoms  of  disease  of  the  frontal 
lobes  as  follows:     Mental  inactivity,  forgetfulness,  lack  of 
jvidgment,  decided  change  in  character,  irritability  of  tem- 
per and  unusual  stupidity,  an  inability  to  concentrate  the 
attention,  to  think  connectedly  and  continuously,  to  learn 
^sily,  to  exercise  self-control,  and  lastly,  a  state  approach- 
ing  mild  dementia  without  delusions,  in  which  the  patient 
^^y  become  dirty  and  disregard  all  restraints  of  decency. 


^Brain,  1896,  p.  346. 

'Ferrier,  quoted  from  Starr,   Dercum's  System   of  Nervous   Di- 
s<^ases. 


1 


I20  IV,C,KRAUSS. 

Starr"  says:  "A  decided  mental  change  in  character 
and  disposition,  a  mental  apathy  and  a  mental  somnolence 
must  be  regarded  as  a  local  sign  of  frontal  lobe  disease." 

Mills*  says  that  in  cases  of  disease  of  the  prefrontal  re- 
gion, mental  disturbances  of  a  peculiar  character  occur, 
such  as  mental  slowness  and  uncertainty,  want  of  atten- 
tion and  control,  and  impairment  of  judgment  and  reason; 
closely  studied  the  inhibitory  influence  of  the  brain  both 
upon  psychical  and  physical  action  is  found  to  be  dimin- 
ished. 

It  must  also  be  borne  in  mind  that  a  brain  tumor  af- 
fecting any  portion  or  lobe  of  the  cerebrum  causes  mental 
changes,  which  are,  however,  not  as  pronounced  as  when 
the  frontal  lobe  is  affected. 

In  an  atialysis  of  fifty-six  cases  of  brain  tumor,  I  found 
mental  indifference  or  apathy  present  in  thirty-five  cases, 
not  present  in  one  case,  and  not  mentioned  in  twenty  cases. 
In  an  analysis  of  forty-two  cases  of  brain  abscess  or 
1  cyst,  I  found  mental  symptoms  present  in  twenty-seven 

J  cases,  absent  in  four  cases,  and  not  mentioned  in  eleven. 

I  Oppenheim*considers  mental  apathy  or  somnolence  of 

?!  great  importance  in  cases  of  brain  tumor.     The   patient 

5  appears  to  be  in  a  dreamy,  sleepy  state,  and  falls  asleep 

i  while  eating,  or  is  even  filthy  in  his  habits,  owing,  of 

\  course,  to  the  mental  hebetude.    The  symptoms  here  nar- 

rated do  not  include  those  produced  by  pressure  of  the 
\  growth  upon  the  neighboring  areas  as,  for  instance,  the 

motor  regions. 

The  mental  condition  of  our  patient  was  not  such  as  to 
attract  particular  attention,  until,  perhaps,  after  the  uri- 
nation episode.  It  might  then  have  been  decided  that  the 
frontal  area  was  involved,  although  the  mental  peculiarity 
at  this  time  could  have  been  attributable  to  the  severe  par- 

"Starr,  Dercum's  System  of  Nervous  Diseases. 
*Mills,  Dercum's  System  of  Nervous-  Diseases. 
*Lehrbuch  der  Nervenkrankheiten. 


GLIOMA.  121 

■ 

oxysm  of  pain.     That  none  of  the  marked  mental  states 

found  in  prefrontal  disease,  such  as    those  observed  by 

different  writers  were  present,  was  evident  to  us,  and  the 

symptoms  w^hich  were  observed  were  not  different  from 

those  I  have  seen  in  cases  where  the  tumor  was  located  in 

the  parietal  or  temporal  lobe.     It  was,  therefore,  only  by 

exclusion  that  a  problematical  diagnosis  was  possible,  and 

then  it  was  not  of  sufficient  accuracy  to  warrant  a  surgical 
operation. 

In  Williamson's  collection  of  fifty  cases,  four  cases  of 

abscess  were  all  suitable  for  surgical   interference.       One 

case,  MacEwen's,  was  operated  on  with  success.     Seven 

cases  of  tumor  of  the  prefrontal  lobes  were  so  suitable  and 

of  such  a  moderate  size  that  they  could  have  been  easily 

removed.     In  twenty  other  cases  a  tumor  was  removed; 

in  one  case  successfully  (Durante),  in  the  others  unsuccess- 
fully. 

Had  an  operation  been  undertaken  the  removal  of  so 
largeaportion  of  the  brain  and  the  drainage  of  the  cerebro- 
spinal fluid  would  doubtless  have  produced  a  fatal  termi- 
nation soon  after  the  completion  of  the  operation.  If  it 
had  been  successfully  .removed  the  cyst  in  the  left  angular 
g>'rus  would  still  have  been  present  and  would  have  pro- 
duced the  same  general  symptoms,  but  perhaps  not  as 
severe.  It  would  seem,  therefore,  that  here,  at  least,  was 
a  frontal  lobe  tumor  which  would  not  have  permitted  a 
successful  operative  procedure. 


^  Traitement  des  Neurasthenies  Graves  par  la  Psychother- 
APiE  (The  Treatment  of  Grave  Neurasthenia  by  Psychotherapy). 
Dr.  P.  Valentine.  (Bull.  Gen.  dc  Then,  Nov.  15.  '96.) 
It  has  already  been  proved  by  many  authors  that  the  mental 
treatment  of  neurasthenic  subjects  is  most  beneficial,  especially  in 
Jj^llious  cases,  which,  as  is  well  known,  resist  the  usual  methods. 
Tne  author,  considering  the  morbid  psychical  condition  as  the  patho- 
genic element  of  the  disorder,  advocates  treatment  by  hypnotic  sug- 
&sdon  as  the  most  reliable  means,  and  enumerates  three  cases  ap- 
Foaching  the  degenerative  type  of  neurasthenia  successfully  treated. 
"C  concludes  that  psychotherapy  in  any  form,  with  or  without  hyp- 
nosis, is  the  most  successful  method  in  obstinate  cases,  and  that  hyp- 
notic suggestion  never  aggravates  the  cerebral  disorder,  but,  on  the 
<^ontrary,  invariably  inspires  the  patients  with  stronger  will  power, 
^ore  judgment  and  application.  Macalester. 


^ociettj  ^tpoxts. 


^ 


PHILADELPHIA  NEUROLOGICAL  SOCIETY. 

November  22d,  1897.  The  President,  Dr.  Charles  W. 
Burr,  in  the  chair. 

ON  TABES  DORSALIS  "ARRESTED  BY  BLINDNESS/ 

This  was  the  title  of  a  paper  read  by  Dr.  Spiller.  He 
ij  stated  that  he  used  the  word  "arrested''  because  it  had  l)e- 

come  well  known  in  this  connection  through  the  writings 
of  Dejerine,  and  had  been  applied  to  those  cases  in  which 
the  symptoms  cease  to  progress,  and  even  diminish  in  in- 
tensity after  blindness  appears.  He  quoted  extensively 
from  the  statements  of  Dejerine  on  this  subject,  and  re- 
ported two  cases  of  this  form  of  tabes,  in  one  of  which^ 
however,  the  diagnosis  was  somewhat  doubtful. 

One  patient  had  been  gradually  losing  his  eyesight 
during  a  period  of  eight  years  and  had  complained  of  pain 
in  the  lumbar  region  and  shoulders.  His  gait  was  not 
truly  ataxic,  and  Romberg's  sign  was  not  very  evident. 
The  patellar  reflex  in  the  right  leg  was  much  diminished 
in  intensity,  and  in  the  left  it  was  scarcely  perceptible.  Dr. 
Hansell  reported  that  the.  patient  had  tabetic  atrophy  of 
both  optic  nerves.  Argyll-Robertson's  sign  was  not  pres- 
ent,  but  the  pupils  were  unequal.  The  case  was  interest- 
ing on  account  of  the  long  duration  of  the  gradually  de- 
veloping optic  atrophy,  without  complete  blindness  even 
at  the  present  time;  the  absence  of  distinct  ataxia;  the 
greater  involvement  of  one  side  of  the  lumbar  cord,  as  in- 
dicated by  the  difference  in  the  knee-jerks;  and  the  ab- 
sence of  Argyll-Robertson's  sign. 

The  second  patient,  a  negro,  gave  a  clear  history  of 
syphilitic  infection  eight  years  ago.  He  had  complained 
of  pain  in  the  lumbar  region  and  one  thigh,  had  been  los- 
ing his  vision  for  two  years,  and  had  a  girdle  sensation  and 
disturbance  of  micturition.  There  was  no  incoordination 
of  gait.  The  knee-jerks  at  the  first  examination  were  ab- 
sent, but  became  visible  after  the  administration  of  iodide 
of  potassium.  Dr.  de  Schweinitz  found  reflex  iridoplegia. 
myosis,  and  divergence  of  the  left  eyeball.  The  optic 
nerves  presented  the  signs  of  primary  atrophy. 


rUlLADELPHlA  NEUROLOGICAL  SOCIETY.  123 

Dr.  Spiller  spoke  of  the  difficulty  of  excluding  cerebro- 
spinal syphilis  in  this  second  case,  and  of  his  inability  to 
understand  in  what  way  Edinger's  substitution  theory 
could  be  applied  to  this  form  of  tabes.  He  thought  it 
would  be  well  to  avoid  the  name  of  locomotor  ataxia  as  it 
is  very  awkward  to  speak  of  locomotor  ataxia  without 
locomotor  ataxia. 

Dr.  William  Osier: — I  well  remember  that  Dejerine  called 
special  attention  to  this  very  point,  namely,  the  absence  of 
ataxic  symptoms  in  those  cases  affected  with  early  optic  at- 
rophy, but  I  think  that  it  is  not  quite  correct  to  say  that  we  do 
not  see  other  instances  of  preataxic  phenomena  persisting  for 
a  long  period,  even  years,  without  the  development  of  ataxia; 
for  instance,  a  localized  paralysis  of  the  ocular  muscles.  I 
have  recently  seen  an  exceptional  case  in  which  a  diagnosis 
of  locomotor  ataxia  was  made  in  Paris  in  1876.  The  patient 
has  had  lightning-like  pains  at  intervals  ever  since.  He  has 
the  Argyll-Robertson  pupil  and  absence  of  patellar  reflex, 
but  he  has  no  ataxia.  In  this  case  a  diagnosis  of  locomotor 
ataxia  in  the  preataxic  stage  has  been  made  by  most  of  the 
neurologists  of  Europe. 

Dr.  James  Hendrie  Lloyd: — Such  cases  are,  of  course,  not 
unobserved.  I  have  seen  one  or  two,  and  I  think  that  there  is 
a  case  somewhat  of  this  type  at  oresent  in  the  Philadelphia 
Hospital.  This  man  has  complete  optic  atrophy,  and  so  far  has 
not  the  symptoms  of  posterior  sclerosis.  Four  or  five  years 
ago  he  had  several  very  curious  congestive  crises,  much  like 
what  we  see  in  dementia  paralytica.  Of  recent  years  he  has 
not  had  even  these.     He  has  a  distinct  history  of  syphilis. 

Brissaud  has  divided  locomotor  ataxia  into  sensory  and 
motor  types,  and  has  recorded  one  or  two  cases  of  the  sensory 
type.  I  think  he  claims  that  the  fulgurant  pains  are  a  common 
accompaniment  of  optic  atrophy,  and  also  that  cases  of  the 
sensory  type,  with  optic  atrophy  and  fulgurant  pain,  without 
ataxia,  are  the  cases  most  likely  to  present  spinal  arthropath- 
ias. This  is  a  point  which  I  am  not  prepared  to  confirm 
from  my  own  observation. 

Wfth  reference  to  theories,  it  may  possibly  be  worth  while  to 
recall  that  the  optic  nerve-tract  is  not  an  ordinary^  peripheral 
nerve.  It  is  analogous  rather  to  a  tract  of  the  central  nervous 
system.  As  Monroe  has  pointed  out,  it  is  allied  in  this  way  to 
the  posterior  columns  of  the  spinal  cord.  It  is  probably  for 
this  reason  that  we  find  it  degenerated  along  with  the  posterior 
columns  in  ordinary  cases  of  tabes.  It  seems  that  in  some 
persons  the  optic  nerve-tract  suffers  first  and  more  than  the 
posterior  columns  of  the  cord  from  the  same  poison, — syphi- 
lis.  The  reason  is  obscure,  but  the  fact  remains.     The  only 


124  PHILADELPHIA  NEUROLOGICAL  SOCIETY. 

• 
trouble  in  reaching  an  explanation  is  that  we  do  have  some 
spinal  symptoms,  such  as  abolition  of  reflexes  and  fulgurant 
pains  in  these  cases  of  the  so-called  sensory  type. 

Dr.  Francis  X.  Dercum: — I  think  that  the  title  ^'arrested  by 
blindness  "  is  objectionable.  The  facts  would,  perhaps,  be 
better  expressed  by  saying  that  after  optic  nerve  atrophy  ap- 
I)ears  the  symptoms  progress  very  slowly. 

The  second  case  which  Dr.  Spiller  reported  looks  very  much 
like  a  case  of  spinal  syphilis;  especially  the  return  of  the  knee- 
jerk  after  the  use  of  iodide  is  very  suggestive.  In  the  negro, 
further,  locomotor  ataxia  is  excessively  rare.  I  have,  ho>yever, 
had  one  case  where  the  diagnosis  was  confirmed  by  autopsy. 
It  is  strange  that  the  negro  should  enjoy  such  immunity  from 
ataxia,  w^hile  he  does  not  enjoy  a  corresponding  immunity 
from  paresis. 

Dr.  Frederick  A.  Packard  showed  two  brothers,  aged 
ten  and  eleven  years,  respectively,  out  of  a  family  of  seven 
otherwise  healthy  children,  with  pseudo-hypertrophic 
muscular  paralysis,  changes  in  the  thyroid  gland  and  men- 
tal deficiency.  The  family  history  was  unimportant,  save 
for  the  existence  of  goitre,  with  nervousness  and  tachy- 
^  cardia — but  without  exophthalmos — in  the  mother,  and 

the  normal  condition  of  the  remaining  members  of  their 
generation. 

Dr.  Francis  X.  Dercum: — Ever>'  now  and  then  we  see  other 
types  of  nervous  disease  in  children,  which  are  either  ac- 
centuated or  first  make  their  appearance  after  an  attack  of 
some  infectious  disease,  such  as  measles.    The  three  cases  of 
\  cerebral  spastic  paralysis,  shown  by  me  before  this  Society 

last  winter  were  an  illustration  of  this  fact.  This  appearance 
of  accentuation  after  an  infection  is  extremely  interesting.  It 
seems  as  though  the  power  of  resistance  is  occasionally  so 
low  in  the  nervous  tissues — ^perhaps  owing  to  some  morpho- 
logical peculiarity — that  under  so  slight  a  cause  as  the  toxicity 
of  measles  they  undergo  degeneration. 


■ 
4 


Dr.  William  Osier  read  a  paper  on  paralysis  of  the 
hypoglossal  nerve. 


•;  Dr.  Charles  K.  Mills: — There  is  one  point  in  Dr.  Osier's 

'  paper  which  seems  to  me  to  be  of  special  interest,  and  if  I 

correctly  understand  the  matter,  it  is  doubtful  whether  his 

method  of  reference  to  accessorius  paralysis  is  correct.    In  the 

-  lig^t  of  recent  observations,  it  seems  to  me  questionable  wheth- 

]  er  the  nerve  supply  of  the  palatal  and  lar\'ngeal  muscles  can 


PHILADELPHIA  NEUROLOGICAL  SOCIETY.  i  25 

be  regarded  in  any  sense  as  from  the  spinal  accessory  nerve. 
The  spinal  accessory  nucleus  has  been  separated,  and  probably 
correctly,  from  the  vagal  nucleus  and  only  supplies  those  mus- 
cles regarded  as  connected  with  the  spinal  portion  of  the  nerve. 
The  laryngeal  paralysis  would  not  then  be  referable  to  the  ac- 
cessorius. 

Dr.  Francis  X.  Dercum: — In  this  connection,  I  would  al- 
lude to  the  morphological  fact  that  in  the  orang-outang,  the 
vagus  supplies  the  larynx  without  fusing  with  the  spinal  ac- 
cesson'  at  all. 

Dr.  Charles  W.  Burr  exhibited 

A  porencepha;.ic  brain. 

The  man  from  whom  the  specimen  was  removed  was 
a  negro,  thirty-five  years  of  age.  Little  is  known  of  his 
previous  history,  except  that  he  is  said  to  have  been  an 
idiot  and  epileptic  all  his  life.  He  came  to  the  Philadel- 
phia Hospital  some  years  ago.  He  suffered  from  general 
convulsions  and  had  a  spastic  gait  and  spastic  rigidity  of 
both  arms,  and  such  marked  spasm  of  the  tongue  and  lips 
that  he  could  not  talk.  He  remained  in  that  condition 
some  years.  During  the  past  summer  he  developed  typhoid 
fever,  from  which  he  died. 

At  the  necropsy  tw^o  large  symmetrical  cavities  were 
found  in  the  brain,  one  in  each  hemisphere.  Dr.  Burr  be- 
lieved that  these  were  of  post-natal  origin  and  regretted 
that  the  term  porencephaly  is  used  so  indiscriminately  for 
cavities  in  the  cerebrum. 

Dr.  Purves  exhibited  for  Dr.  Mills,  the  brains  from  two 
cases  of  intraventricular  hemorrhage.  No  convulsions  had 
been  observed  in  these  cases  at  the  time  of  the  apoplectic 

seizure. 

Dr.  Charles  K.  Mills: — These  are  two  interesting  cases,  al- 
though not  erf  an  unusual  type.  The  first  was  of  interest  as  re- 
gards diagnosis  in  connection  with  the  history  of  the  condition 
of  the  kidneys.  Dr.  Dercum  and  others  in  various  papers,  have 
called  attention  to  the  subject  of  hemiplegia  in  nephritis  with- 
out gross  brain  lesion.  This  case  presented  many  features 
thatmig-ht  have  been  explained  in  this  way,  but  mv  experience 
has  been  that  when  such  cases  come  to  autopsy,  it  is  rare  not 
to  find  a  lesion.  The  cases  are  also  of  interest  from  the  ab- 
sence of  convulsions. 

The  post-mortem  notes  are  worthy  of  special  remark.     It 


126  PHILADELPHIA  NEUROLOGICAL  SOCIETY. 

is  just  as  important  in  many  of  these  cases  to  record  the  other 
vascular  lesions  that  are  present  as  it  is  to  record  the  gross 
hemorrhage.  In  many  cases  of  large,  sudden,  intracerebral 
hemorrhage  lesions  are  found  similar  to  those  which  are  pres- 
ent in  cases  of  concussion  without  gross  hemorrhage.  The 
symptoms  which  obscure  the  diagnosis  in  some  cases  are  un- 
doubtedly due  to  the  numerous  extravasations  in  various  parts 
of  the  brain  and  membranes,  and  the  secondary  lesions  which 
result  in'  association  W'ith  these. 

A  word  with  regard  to  autopsies  in  brain  cases.  My  atten- 
tion was  called  to  the  method  of  Dejerine  by  Dr.  Sailer 
and  Dr.  Spiller,  a  year  or  two  ago,  and  since  then  I  have  chief- 
ly followed  this  method.  In  many  necropsies,  the  methods 
adopted  rentier  the  brain  uaeless  for  subsequent  microscopic 
and  even  macroscopic  study.  An  old,  and  for  many  pur- 
poses, gocKl  method  is  that  of  Virchow.  In  this,  after  opening 
the  ventricles,  transections  of  the  brain  are  made.  This  is  a 
useful  method  for  rapidly  determining  the  conditions  present, 
and  if  carefully  pursued  is  a  good  one,  especially  for  locating 
lesions  in  the  fresh  state. 

Another  method  to  which  I  first  called  attention  is  that  of 
entering  the  brain  from  below,  through  the  great  transverse, 
calcarine  and  other  fissures  and  keeping  the  callosum  and  parts 
above  intact.  • 

The  method  of  Meynert  is  w^ell  known.  In  this  citv  a  meth- 
od is  sometimes  used  which  seems  to  be  a  modification  of  that 
of  Meynert.  After  the  ganglia  are  exposed,  an  incision  is  car- 
ried around  them  deeply  through  the  brain  substance  and 
necessarily  through  the  temporal  lobes.     Horizontal  or  verti- 

•J  cal  sections  are  then  made  through  the  ganglia.    This  method 

'  is  open  to  the  objection  of  destroying  the  relation  of  the  parts, 

V  making  it  impossible  to  subsequently  examine  the  brain  satis- 

\         ^  facto  rily. 

!j  The  method  of  Dejerine,  which  was  described  in  the  post- 

mortem notes  of  these  two  cases,  is  for  many  purposes  a  good 

r*  one.  A  vertical  incision  is  made,  cutting  of?  the  occipital  lobe.. 

\  Another  vertical  incision  may  or  may  not  be  made  in  front 

of  the  basal  ganglia.     Then  an  incision  is  made  about  on  a 

S  level  with  the  callosum   and  the  two  hemispheres   may   be 

;  separated.     In  the  method  of  Dejerine  the  cerebellum,  pons 

and  oblongata  are  removed  as  a  separate  specimen  by  an  in- 

"  cision  through  the  pons  above  the  fifth  nerve.    One  advantage 

j  of  this  is  that  the  separate  parts  can  be  easily  placed  together. 

A  good  method  of  examininq^  the  cerebellum  is  to  cut  oflf 
the  lateral  lobe  on  one  side,  and  subsequently  the  lobe  on  the 

!  other  side,  keeping^  the  middle  lobe  ps  a  separate  specimen. 

Dr.   Spiller: — These  two  cases  of  intraventricular  hemor- 

!  rbape  are  further  proof  of  what  I  recently  had  occasion  to 


PHILADELPHIA  NEUROLOGICAL  SOCIETY.  127 

• 

speak  of  at  the  Pathological  Society,  viz.,  that  convulsions  are 
not  always  observed  when  hemorrhage  into  the  ventricle  oc- 
curs, and  that  they  are  of  doubtful  value  in  diagnosticating 
.such  hemorrhage. 

Dr.  J.  P.  Arnold,  by  invitation,  exhibited  a 
TUMOR  OF  THE  CEREBRAL  DURA. 

The  growth  had  its  origin  in  the  dura  at  the  lon;>;itu- 
diiial  fissure.  It  had  displaced  the  cerebral  tissue  and  inter- 
fered with  the  functions  of  the  leg,  arm  and  face  centres. 

Dr.  James  Hendrie  Lloyd: — I  saw  this  case  in  consultation 
with  Dr.  Stryker  at  the  Presbyterian  Hospital.  A  diagnosis  of 
brain  tumor  had  been  made,  but  the  question  was  as  to  the 
exact  location.  Looking  at  the  specimen  now,  it  is  easy  to 
regret  that  the  man  was  not  operated  on.  My  own  belief  was 
that  the  tumor  was  in  the  antero-frontal  region.  The  absence 
of  convulsions,  considering  the  location,  is  an  interesting  poir.t. 
In  the  absence  of  distinct  localizing  symptoms  1  did  not  feel 
justified  in  recommending  operation.  There  had  been  no  dis- 
tinct focal  or  signal  epileptodd  symptoms  at  any  time.  I  in- 
quired particularly  into  this  point,  and  in  the  absence  of  such 
localizing  symptoms  I  did  not  feel  justified  in  concluding  that 
the  ^row-th  was  in  the  motor  zone.  The  mere  hemiplegia  was 
not  enough  to  indicate  this,  because  hemiplegia  is  seen  in  cases 
of  brain  tumor  in  the  most  widely  separated  regions.  The 
patient  had  the  peculiar  mental  inhibition  that  is  sometimes 
set  n  in  cases  of  brain  tumor,  especially  in  those  of  the  frontal 
lobes. 

T)r.  F.  X.  Dercum: — I  understand  that  the  arm  and  face 
were  more  markedly  affected  than  the  leg.     Tf  so,  it  is  prob- 
ably to  be  'explained  by  the  way  in  which  the  tumor  invaded 
the  brain,  i.e.,  from  the  mesial  surface  outward,  cutting  across 
the  fibres  for  the  face  and  arm  passing  to  tlie  internal  capsule. 
This  case  reminds  me  of  one  which  I  exhibited  before  this 
Society  some  years  ago,  in  which  the  tumor  had  grown  down- 
Avard  from  the  membranes,  had  separated  the  frontal  from  the 
motor  convolutions,  and  had  produced  profound  symptoms  of 
a  general  character,  but  no  convulsive  seizures. 

Dr.  Spiller: — The  condition  of  lock  spasm  which  Dr.  Arnold 
lias  described  in  this  case,  as  an  inability  on  the  part  of  the 
patient  to  relax  his  hold  on  an  object  and  a  tightening  of  the 
?Tasp  when  he  attempted  to  relax  it,  is  like  a  symptom  of 
Thomsen's  disease.  Schlesinger,  of  Vienna,  told  me  that  he 
had  seen  this  sign  in  a  case  of  syrinp'omyelia,  and  Patrick  has 
recently  observed  a  similar  form  of  muscular  contraction  in 
this  same  disease. 


NEW  YORK  NEUROLOGICAL  SOCIETY. 

Stated  Meeting,  December  7,  1897. 

B.  Sachs,  M.  D.,  President. 

TOXIC  TREMOR  AND  HYSTERIA  IN  A  MALE. 

Dr.  J.  Arthur  Booth  presented  a  man  whom  he  had 
seen  one  week  ago  at  the  French  Hospital.  The  patient, 
sixty-one  years  of  age,  had  been  engaged  up  to  1885  as  a 
mirror  polisher,  using  mercury,  and  since  then  in  the  same 
occupation,  but  using  silver  instead.  His  family  history 
was  negative  as  regards  nervous  disease.  At  the  age 
of  twenty-tw^o,  he  contracted  syphilis,  and  w^as  treated  for 
this  for  some  time.  He  then  enjoyed  goo.d  health  up  to 
thirteen  years  ago.  At  this  time  he  fell  on  the  street  with 
both  lower  and  upper  extremities  in  a  state  of  clonic  spasm. 
He  was  taken  to  the  Boston  City  Hospital.  Some  years 
later  was  under  the  care  of  Professor  Charcot  for  sev- 
eral months.  He  returned  to  this  country  in  1887,  and 
resumed  his  work  of  mirror  polishing,  using  silver.  He 
has  had  three  or  four  attacks  of  tremor.  The  present  ill- 
ness began  November  17,  after  having  worked  very  hard 
for  some  time  previously.  The  tremors  presented  by  the 
patient,  the  speaker  said,  certainly  resembled  those  ob- 
served in  cases  of  mercurial  poisoning.  A  very  slight  tap 
on  the  body  would  set  up  a  pitiable  degree  of  reflex  trem- 
or. There  was  no  nystagmus,  but  there  was  slight  ataxia. 
It  was  found  that  the  tremor  was  greatly  increased  when 
attention  was  drawn  to  him,  and  for  this  reason  it  seemed 
not  improbable  that  there  was  an  hysterical  element  in 
the  case.    There  were  no  bladder  or  rectal  symptoms. 

Dr.  W.  M.  Leszynsky  said  that  the  case  looked  to  him  to 
be  a  functional  one,  added  to  the  evident  tqxic  tremor.  The 
fact  that  he  had  such  attacks,  and  had  recovered  from  thent, 
would  seem  to  confirm  this  view. 

Dr.  Peterson  and  Dr.  B.  Sachs  concurred  in  the  opinion 
that  there  was  marked  hysteria  imposed  upon  a  mercurial 
tremor. 


NEH^  YORK  NEUROLOGICAL  SOCIETY.  129 

NEURITIS  FOLLOWING  AN  INFECTED  VACCINATION. 

Dr.  W.  B.  Noyes  presented  a  baby.    It  had  been  vac- 
cinated last  spring,  and  the  wound  had  become  infected. 
IVhen  the  bandages  had  been  removed,  it  had  been  found 
that   the  child  could  not  move  the  arm.     Examination 
showed  that  the  deltoid,  biceps  and  the  muscles  supplied 
by  the  ulnar  nerve  were  ivolved.    They  did  not  react  to 
faradism,  and  gave  the  reaction  of  degeneration.  The  case 
seemed  to  him  at  the  time  to  be  a  neuritis  resulting  from 
an  infected  wound,  but  two  other  opinions  had  been  of- 
fered, viz.,  that  it  was  the  result  of  tight  bandaging;  and 
that  the  child  had  an  attack  of  anterior  poliomyelitis.    The 
condition  had  developed  within  two  weeks  after  the  vac- 
cination, and  the  motion  of  the  arm  had  been  largely  re- 
covered.   There  was  no  history  of  constitutional  disturb- 
ance.    His  own  opinion  was,  that  the  case  was  one  of 
ascending  neuritis  involving  the  circumflex,   ulnar  and 
musculo-cutaneous  nerves. 

Dr.  Peterson  thought  that  poliomyelitis  could  hardly  be 
considered.  The  diagnosis  offered  by  Dr.  Noyes  might  be 
correct,  or  else  the  condition  was  due  to  pressure.  He  inclined 
rather  to  the  latter  view. 

PULMONARY  TUBERCULOSIS  AND  TABES  COMBINED. 

Dr.  Fraenkel  presented  a  man  thirty-nine  years  of  age, 
unmarried,  whose  family  history  was  negative.    About  ten  - 
years  ago  he  contracted  syphilis,  but  enjoyed  fairly  good 
health  up  to  two  years  ago.    Then  he  had  repeated  hemor- 
rhages from  the  lungs,  and  developed  rapidly  the  signs  and 
symptoms  of  pulmonary  tuberculosis.     On  admission  to 
the  Montefiore  Home  in  May,  1896,  there  were  pronounc- 
ed physical  signs  of  pulmonary  tuberculosis,  and  of  a  large 
cavity  at  one  apex,  and  death  seemed  near.    The  left  pupil 
was  but  slightly  responsive  to  light.     The  temperature 
never  rose  above  98.5  degrees  Fahrenheit,  and  the  pulse 
above  eighty.     He  steadily  improved  up  to  May,  1897, 
at  which  time  his  sputum  still  contained  tubercule  bacilli, 
hut  his  condition  was  in  every  way  better.    The  signs  of 
the  cavity  had  disappeared.    His  pupils  were  unequal  and 
the  left  vyras  myopic.    The  scapular,  abdominal,  gfluteal  and 
plantar  reflexes  were  exaggerated  on  both  sides.     The 
left  patellar  knee-jerk  was  markedly  diminished.     There 


130  NEW  YORK  NEUROLOGICAL  SOCIETY. 


u 


was  no  evidence  of  ataxia  or  inco-ordination.    On  Novem- 
3  ber  18,  1897,  physical  examination  showed  the  thoracic 

:]  organs  in  the  same  condition.  The  patient  then  complain- 

jl  ed  for  the  first  time  of  occasional  shooting  pains  in  the 

y.  left  lower  extremity.    The  sexual  appetite  was  markedly 

diminished.    The  left  knee-jerk  was  greatly  reduced.    The 

three  points  of  interest  were:    (i)  The  marked  unilateral 

character  of  the  symptoms;  (2)  the  combination  of  tuber- 

{;  culosis  and  tabes — a  very  rare  condition;  and  (3)  the  mild- 

i  ness  of  both  diseases. 

Dr.  Leszynsky  said  that  he  had  seen  a  number  of  cases 
with  various  forms  of  disease,  both  of  the  lungs  and  abdomen, 
*  with  but  slight  change  of  pulse  and  temperature,  even  in  neu- 

;  rotic  individuals.    He  had  in  mind  a  patient  who  showed  very 

;  markedly  unilateral  pupillary  symptoms  such  as  had  been  re- 

ferred to. 

Dr.  Noyes  said  that  the  case  appeared  to  be  one  of  fibroid 
':  phthisis.     Non-progressive  tabes  is  due  rather  to  a  collection 

,  of  connective  tissue  than  to  any  actual  degeneration  of  the 

posterior  columns.     These  two  conditions  were  occasionally 
associated,  and  the  case  presented  was  probably  an  example 
,  of  this. 


I  TIC  CONVULSIF. 

1 


Dr.  Willam  Hirsch  presented  a  young  man  having  Tic 
convulsif.  He  first  saw  him  about  a  year  ago.  and  the  symp- 
toms had  not  changed  materially  since  then.  The  object 
in  bringing  the  patient  was  to  demonstrate  a  certain  re- 
lation between  his  symptoms  and  the  psychical  condition 
present.  On  tapping  the  cheek,  the  patient  made  a  num- 
ber of  grimaces.  The  fact  that  the  symptoms  had  not  un- 
dergone change  was  in  marked  contrast  with  what  was 
observed  in  hysteria.  This  patient  had  had  articular  rheu- 
matism, followed  by  endocarditis  and  the  development 
of  mitral  insufficiency.  Shortly  afterward  he  had  develop- 
ed this  neurosis. 


WRY-NECK  AND  ASYMMETRY  OF  FACE. 

Dr.  Graeme  M.  Hammond  presented  for  Dr.  Meiro- 
witz,  a  boy  of  sixteen,  who  had  come  under  observation 
for  the  relief  of  what  appeared  to  be  a  wry-neck.  As  far 
back  as  could  be  remembered  the  neck  had  been  deflected 


NEIV  YORK  NEUROLOGICAL  SOCIETY.  131 

to  the  left,  but  he  had  never  experienced  any  pain  in  the 
neck  or  elsewhere.  There  had  been  no  twitching  or  jerk- 
ing. Examination  showed  that  the  head  deviated  to  the 
left ;  the  left  half  of  the  face  exhibited  a  perceptible  slope 
iroin  above  downward;  the  left  eyebrow,  ala  nasi,  angle 
of  mouth  and  angle  of  jaw  were  all  higher  than  the  cor- 
responding points  on  the  right  side.  The  muscles  of  the 
neck  were  distinctly  hypertrophied.  The  skull  over  the 
parietal  region  showed  a  perceptible  flattening,  not  observ- 
ed on  the  other  side.  The  movements  of  the  head  were 
free  in  all  directions.  The  hair  curved  to  the  left  side. 
There  was  no  disturbance  of  the  cranial  nerves,  and  no 
hemiatrophy,  and  the  intelligence  was  normal.  There 
was  no  family  history  of  similar  defects. 

Dr.  Fraenkel  remarked  that  cases  of  congenital  wry-neck 
had  been  explained  as  resulting  from  a  lessened  developmental 
resistance  on  one  side. 

Dr.  Peterson  remarked  that  it  was  unusual  to  find  so  good 
an  example  of  the  unequal  development  of  the  ear. 

Dr.  Onuf  said  that  in  most  cases  of  congenital  wry-neck 
there  was  this  asymetry  of  the  face.  He  was  not  sure  that  the 
pressure  was  alone  responsible  for  the  unequal  development; 
it  would  hardly  explain  the  asymetrical  development  of  the 
ear.  The  atrophy  seemed  to  him  possibly  the  result  of  twist- 
ing of  the  carotid  artery  on  one  side,  with  a  consequent  inter- 
ference with  the  nutrition  on  that  side. 

ENORMOUS  HYDROCEPHALUS. 

Dr.  F.  Peterson  presented  the  brain  from  such  a  case, 
one  of  the  largest  for  many  years  at  the  Randall's  Island 
institution.     The  patient  was  a  woman  of  twenty  who, 
in  the  early  stages,  had  had  a  left  hemiplegia  and  imbecil- 
ity.   As  the  disease  progressed,  she  became  diplegic  and 
completely  idiotic.    The  following  are  the  measurements 
of  the  head :    Circumference  63.5cm. ;  approximate  volume 
I7H  cc;  naso-occipital  arc  47  cm.;  naso-bregmatic  arc 
16.5  cm.;  bregmatic-lamboid  arc  19cm.;  binauricular  arc 
50  cm.;  antero-posterior  diameter  19.5;  greatest  trans- 
verse diameter  18.5  cm.;  length-breadth  index  94.8  per 
cent.;  binauricular  diameter  12  cm.;   auriculo-bregmatic 
radii  20  cm.;  facial  length   11.2  cm.;  empirical  greatest 
height  17.7  cm.;  height  Beta-x  19.2  cm.    At  the  autopsy 
the  sutures  were  found  fully  united  and  the  fontanelles 
perfectly  closed.    The  skull   bones   averaged   8   mm.   in 


1 


i 

«, 


132  NEIV  YORK  NEUROLOGICAL  SOCIETY, 

thickness.  The  dura  was  not  adherent  at  any  part.  There 
was  a  very  little  fluid  in  the  dura.  All  of  the  fluid  was  in 
the  ventricles  of  the  brain,  more  on  the  right  side  than 
the  left,  for  the  cortex  of  the  right  hemisphere  had  become 
in  part  membranous.  Five  pints  of  clear  serum  were  re- 
moved from  the  ventricles.  The  third  and  fourth  ventri- 
cles partook,  to  some  extent,  in  the  dilatation.  It  was 
unfortunate  that  through  a  mishap  the  brain  was  so  in- 
jured that  the  patency  of  the  foramen  of  Magendie  could 
not  be  determined.  Dr.  Peterson  said  that,  in  his  exper- 
ience, it  was  difficult  to  examine  this  foramen,  and  ap- 
parently impossible  to  demonstrate  the  presence  in  any  hu- 
man being  of  the  foramina  of  Mierzejewsky.  It  was  very 
important  in  all  cases  of  chronic  hydrocephalus  to  exam- 
ine, if  possible,  the  foramen  of  Mierzejewsky.  It  was  much 
easier  to  determine  the  patency  of  the  aqueduct  of 
Sylvius  and  of  the  foramen  of  Monroe.  He  had,  with 
3  Dr.  Blake,  at  the  Anatomical  Laboratory  of  the  College 

^  of  Physicians  and  Surgeons,  examined  the  brain  of  a  ten- 

year-old  hydrocephalic  of  Randall's  Island,  and  in  this  in- 
stance, at  least,  had  determined  definitely  the  permeabil- 
ity of  the  foramina  mentioned,  and  the  aqueduct. 


■ 

h 


"i 


r 


ABSCESS  OF  THE  BRAIN. 

Dr.  Peterson  presented  a  specimen  showing  an  abscess 
of  the  brain  that  had  been  operated  upon.  The  case  had 
been  seen  on  September  3,  1897,  in  the  service  of  Dr. 
Brown,  of  the  Mountainside  Hospital,  at  Montclair,  N.  J. 
The  patient  was  a  male,  forty-one  years  of  age,  who,  in  an 
attempt  at  suicide,  had  struck  his  head  upon  a  rusty  spike 
and  had  sustained  a  compound  depressed  fracture  in  the 
right  occipital  region,  very  near  the  middle  line.  He  was 
trephined,  and  the  depressed  bone  removed.  The  dura 
was  found  uninjured,  and  was  left  untouched.  The  wound 
became  slightly  infected,  but  aside  from  slight  fever  no 
symptoms  of  importance  appeared  until  two  days  before 
he  had  seen  the  man,  that  is,  for  about  two  weeks  after 
operation.  He  then  gradually  developed  in  twenty-four 
hours  a  left  hemiplegia,  with  left  hemianaesthesia.  Ex- 
amination showed  complete  paralysis  of  the  left  arm  and 
leg,  with  considerable  anaesthesia  over  the  paralyzed 
limbs;  slight  analgesia  in  places,  and  hyperalgesia  in  oth- 


1 


NEW  YORK  NEUROLOGICAL  SOCIETY.  133 

crs.    The  plantar  and  cremasteric  reflexes  were  normal. 
The  knee-jerks  were  subtypical,  slightly  greater  on  the  left 
side.    The  mind  was  clear.    There  was  no  aphasia,  no  in- 
volvement of  the  face  or  tongue.     There  was  no  evid- 
ence, in  pupils  or  pulse,  of  intra-cranial  pressure,  and  no 
symptom  of  cortical  irritation.    The  temporal  half  of  the 
field  of  vision  of  the  left  eye  was  lost.    The  right  seemed 
normal.    He  heard  a  watch  at  only  half  the  distance  with 
the  left  ear  as  compared  with  the  right.    Taste  was  normal 
on  both  sides  of  the  tongue.    The  fundus  seemed  slightly 
cloudy.     A  diagnosis  was  made  of  abscess  deep  in  the 
brain,  in  the  region  of  the  posterior  limb  of  the  internal 
capsule.    The  surgeon  was  advised  to  trephine  in  the  par- 
ietal region,  considerably  back  of  the  motor  area,  and  in- 
sert an  exploring  needle  down  into  the  supposed  site  of  the 
abscess,  should  the  patient  grow  worse.    Two  days  later 
this  was  done.     The  abscess  was  found  at  the  site  sug- 
gested, and  was  drained.     The  temperature  became  nor- 
mal, the  anaesthesia  disappeared  and  the  patient  moved 
his  left  hand,  but  a  few  days  later  he  suddenly  became 
worse,  and  died.    The  brain  was  sent  to  Dr.  Peterson  for 
examination.    He  found  the  dura  very  sclerotic  over  the 
site  of  the  original  injury  close  to  the  superior  longitud- 
inal  sinus.       The  convolutions  of  the  right  hemisphere 
were   considerably  flattened.     There  was  no  meningitis. 
Deep  in  the  interior  of  the  right  hemisphere  was  an  ab- 
scess, about  the  size  of  a  hen's  egg. 


HEMIATROPHY  OF  THE  BRAIN. 

Dr.   Peterson  then  presented  a  specimen  showing  ap- 
parent hemiatrophy  of  the  brain.    The  brain  was  that  of 
a  Randall's  Island  patient,  a  man  of  thirty  years,  who  had 
been  in  the  idiot  asylum  for  several  years.     A  history  of 
the  origin  of  his  trouble  could  not  be  obtained.    He  was 
a  large,  heavy  man,  with  a  hemiplegia  (the  arm  being 
much  worse  than  the  leg),  and  with  frequent  and  severe 
general  epileptic  convulsions.    While  able  to  be  about,  he 
was  dull  and  stupid,  and  in  intelligence  would  be  placed  in 
the  grade  of  moderate  idiocy.     He  died  in  an  epileptic 
ftt.    There  was  nothing  abnormal  in  the  other  organs  of 
his  body,  but  the  brain  presented  the  condition  of  mark- 
ed right  hemiatrophy.    There  was  very  slight  evidence  of 


134 


NEW  YORK  NEUROLOGICAL  SOCIETY. 


microgyria,  the  convolutions  differing  as  regards  normal^ 
ity  from  those  of  the  opposite  side  in  being  somewhat 
smaller.  The  membranes  over  the  right  hemisphere  were^ 
perhaps,  somewhat  thicker  than  over  the  left.  An  exam- 
ination of  the  vessels  at  the  base  of  the  brain  showed  that 
the  blood  supply  was  apparently  equal  for  the  two  sides. 
It  was  undoubtedly  a  lack  of  development  through  some 
obscure  and  early  pathological  process. 


.   * 


¥. 


A  CASE  OF  AMYOTROPHIC  LATERAL  SCLEROSIS— SUP- 
PLEMENTARY REPORT. 

Dr.  William  Hirsch  said  that  on  October  i,  1895,  he 
had  presented  to  the  Society  a  case  of  this  kind.  The 
patient  was  forty-three  years  of  age  and  had  had  poliomye- 
itis  at  the  age  of  twenty.  The  clinical  symptoms  were 
such,  that  at  that  time  he  had  traced  them  from  the  old 
scar  in  the  left  anterior  horn  in  the  cervical  region.  The 
process  must  have  approached  the  left  pyramidal  tract, 
and  then  after  affecting  the  right  horn,  spread  over  to  the 
right  side.  That  was  his  opinion  at  that  time,  and  a  few 
such  cases  had  already  been  presented.  In  the  discussion, 
it  was  claimed  that  the  case  was  one  of  ordinary  progres- 
sive muscular  atrophy.  But  further  clinical  observation  of 
the  case  showed  that  this  was  not  the  case.  The  man  died 
on  June  3,  1897,  and  Dr.  Hirsch  was  now  able  to  pre- 
sent microscopical  specimens  of  the  spinal  cord  in  differ- 
ent regions,  proving  the  correctness  of  his  diagnosis.  He 
said  that  in  these  specimens  one  could  see  the  connective 
tissue  spreading  from  the  anterior  horn  to  the  left  pyra- 
midal tract,  and  the  latter  converted  into  connective  tis- 
sue. The  cells  in  the'  anterior  horns  had  been  destroyed, 
the  connective  tissue  had  formed  all  tfirough  the  lateral 
tract.  In  the  cervical  region  one  bundle  of  connective  tis- 
sue had  spread  backward  into  the  posterior  columns,  as 
he  had  previously  diagnosticated.  Deep  degeneration  of 
the  pyramidal  tracts  could  be  followed  down  to  the  lum- 
bar region. 

Dr.  Hammond  asked  how  he  would  differentiate  these 
specimens  from  progressive  muscular  atrophy. 

Dr.  Hirsch  replied  that  the  specimens  showed  that  the  case 
was  not  one  of  ordinary  degeneration  of  the  lateral  tracts,  but 
that  the  connective  tissue  grew  horizontally  from  the  anterior 


NEW  YORK  NEUROLOGICAL   SOCIETY.  135 

horn  to  the  side.    Furthermore,  the  ordinary  progressive  mus- 
cular atrophy  is  a  symmetrical  disease. 

Dr.  G.  M.  Hammond  said  that  in  three  unquestioned  cases 
of  progressive  muscular  atrophy  that  had  been  under  his  ob- 
servation, there  had  been  a  typical  degeneration  of  the  pyra- 
midal tracts.  On  looking  up  the  subject,  he  had  found  that 
Cowers  made  the  statement  that  he  had  not  seen  a  case  of  pro- 
gressive muscular  atrophy  in  which  the  pyramidal  tracts  had 
not  been  extensively  affected.  It  was  true  that  in  the  specimen 
presented,  one  horn  was  affected  more  than  the  other,  never- 
theless both  horns  were  involved. 

Dr.  C.  L.  Dana  thought  these  sections  looked  very  much 
like  specimens  from  a  case  of  progressive  muscular  atrophy. 
If  the  pathological  change  were  not  one  of  degeneration  of 
the  horns  and  lateral  columns,  he  would  like  to  know  what  Dr. 
Hirsch  thought  it  really  was? 

Dr.  B.  Sachs  thought  the  main  point  was  as  to  whether  the 
degeneration  was  strictly  bilateral  in  the  lateral  columns,  or 
mare  marked  on  the  side  of  the  old  poliomyelitis. 

Dr.  Dana  thought  that  at  the  time  of  the  poliomyelitis  there 
had  been  considerable  hemorrhage  in  the  neighborhood  of  the 
anterior  horns,  and  the  lateral  column  might  have  been  injured 
and  a  scar  formed.  The  degeneration  would  then  be  secondary 
to  this  scar. 

Dr.  C.  A.  Herter  said  that  the  fact  that  the  degeneration 
of  the  lateral  tract  was  chiefly  on  one  side  pointed  very  strongly 
to  the  local  nature  of  the  trouble,  and  opposed  the  idea  of  the 
case  being  one  of  progressive  muscular  atrophy. 

Dr.  Hirsch  said  that  it  was  not  a  descending  degeneration, 
l^ut  a  growing  out  of  connective  tissue  from  the  anterior  horns 
peripherally  and  laterally  in  the  direction  of  the  pyramidal 
tracts;  and  the  series  of  sections  that  he  had  made  enabled 
one  to  follow  this  branching  out  of  the  bundles  of  connective 
tissue.  This  was  quite  different  from  an  ordinary  case  of 
progressive  muscular  atrophy  complicated  by  a  secondary  de- 
generation of  the  lateral  tracts.  The  specimen  presented  show- 
ed that  an  old  focus  in  the  anterior  horn  had  set  up  a  second- 
^^  inflammation.  It  was  difficult  to  form  a  correct  conception 
01  the  case  without  a  careful  examination  of  the  whole  series 
of  specimens.  The  case  represented  one  of  those  processes 
^'  inflammation  characterized  by  the  formation  of  connective 
tissue. 

^r.  M.  Allen  Starr  asked  Dr.  Hirsch  if  the  focus  of  inflam- 
niation  in  one  anterior  horn  and  extending  into  the  adjacent 
columns  might  not  produce  a  secondary  sclerosis  downward 
through  the  cord,  and  so  explain  the  condition. 

^r.  Hirsch  replied  that  it  extended  laterally  as  well  as  up- 
^'^rd.    He  had  not  yet  examined  the  medulla  oblongata.    The 


ft 


136  NEW  YORK  NEUROLOGICAL  SOCIETY. 

poliomyelitis  was  in  the  cervical  region  of  the  cord,  about  the 
region  of  the  left  arm. 

UNILATERAL  ATROPHY  OF  THE  BRAIN. 

Dr.  Pearce  Bailey  reported  a  case  of  this  kind  occur- 
ring in  a  carpenter  who  was  fifty-seven  years  of  age  at  the 
time  of  his  death.  He  had  been  perfectly  healthy  up  to 
the  forty-seventh  year,  and  had  then  had  an  attack  of 
apoplexy.  At  this  time  he  awoke  to  find  one  side  power- 
less, and  this  power  he  never  regained.  The  picture  was 
that  of  extreme  left  hemiplegia.  The  atrophy  in  the  par- 
alyzed limbs  was  not  unusual  in  degree.  There  was  no 
disturbance  of  psychical  sense  functions  or  general  in- 
tellectual capacity  Speech  was  clear.  In  the  summer  of 
1897,  he  died  of  acute  lobar  pneumonia.  At  the  autopsy, 
the  dura  mater  was  found  adherent  at  the  right  anterior 
!g|  portion  of  the  cranial  border,  and  in  the  adhesions  between 

the  dura  and  pia  was  a  collection  of  clear  serum. 
The  left  hemisphere'  was  normal  in  size.  The  wjiole 
right  hemisphere  was  much  smaller  than  the  left. 
The  unilateral  atrophy  involved  also  the  brain  stem 
and  spinal  cord.  The  right  internal  carotid  arter\ 
was  less  than  half  the  size  of  the  left.  The  forward 
portion  of  the  right  hemisphere  was  in  a  state  of  advanced 
chronic  softening.  Sections  from  the  pre-central  gyrus 
and  from  the  occipital  lobe  contained  few  ganglionic  ele- 
ments. The  cuneus  was  affected  similarly,  though  to  a 
lesser  degree.  Although  the  frontal  lobes,  which  are  sup- 
posed to  be  intimately  connected  with  mental  processes, 
were  almost  completely  obliterated  on  one  side,  mental- 
ity had  not  been  impaired.  It  was  believed  that  the  lesion 
occurred  after  complete  cerebral  and  bodily  growth 
had  been  attained.  It  was  assumed  that  the  orig- 
inal lesion  was  a  thrombus  in  the  right  internal  carotid 
i|  artery,  at  or  near  its  bifurcation.     This  case  emphasized 

the  necessity  for  caution  in  regarding  any  single  region 
of  the  brain  as  indispensable  to  mental  action. 

Dr.  Herter  said  that  he  had  no  doubt  that  the  extreme  de- 
gree of  atrophy  was  the  result  of  extensive  arterial  lesion; 
possibly  the  very  slow  development  of  the  vascular  lesion 
in  the  frontal  region  w^ould  go  far  towards  explaining  the 
absence  of  marked  cerebral  symptoms.  In  his  experience, 
comprising  cases  of  acute  softening  and  abscess,  where  there 


^^V 


f 


NEIV  YORK   NEUROLOGICAL   SOCIETY.  137 

had  been  extensive  destruction  of  the  frontal  lobe  on  one  side, 
there  had  been  considerable  interference  with  the  mental 
functions. 

Dr.  Dana  said  that  it  was  remarkable  how  the  faculty  of 
language  could  be  maintained^notwithstanding  extensive  des- 
truction of  the  right  side  of  the  brain. 

Dr.  Sachs  said  it  seemed  to  him  very  evident  that  Dr.  Bail- 
ey's case  was  distinctly  vascular  in  origin,  which  was  in  sharp 
contrast  wnth  Doctor  Peterson's  case. 

Dr.  Bailey,  in  closing,  said  that  there  seemed  to  be  no  doubt 
that  the  entire  half  of  the  brain  in  his  case  had  been  affected. 

« 

A    NEW  DEVICE   FOR  ADAPTING  THE   INCANDESCENT 
ELECTRIC  CURRENT  TO  THERAPEUTIC  PURPOSES. 

Dr.  A.  D.  Rockwell  demonstrated  the  action  of  an  ap- 
paratus which,  he  said,  comes  under  the  head  of  shunt 
<^ontrollers,  but  is  of  novel  construction.     It  ranges  from 
I  to  75  volts,  and  can  be  varied  one  volt  at  a  time  up  to  30 
^'^Its,  and  then  3  volts  at  a  time  for  the  balance.     The 
^^U'anic  current  in  this  w^ay  can  be  readily  superimposed 
^\>Oti  the  faradic,  giving  most  interesting  therapeutic  re- 
^aA\s.   The  movement  of  the  milliamperemeter  during  the 
simultaneous  passage  of  the  two  curents  is  somewhat 
greater  than  when  only  the  galvanic  current  passes,  prob- 
ably owing  to  a  lowering  of  the  resistance  of  the  body  by 
the  faradic  current.    This  combined  application  had  been 
found  by  him  particularly  useful  in  cases  of  exophthalmic 
goitre.  • 


Neurological  Fragments.     Hughlings  Jackson   (Lancet,  Jan.   2d, 

1897). 

In  this  continuation  of  his  series  of  papers,  termed  *'  Neurological 
Fragments,"  Hughiings  Jackson  gives  us  a  consideration  of  cervical 
fracture-dislocation.  It  is  an  extremely  interesting  article  dealing  with 
symptoms  **at  the  seat  of  lesion"  and  "below  the  seat  of  lesion,"  and 
the  effects  upon  the  four  systems,  namely,  the  thermal,  the  respiratory, 
the  circulatory  and  the  digestive.  Incidentally  certain  symptoms  from 
the  side  of  the  sexual  system  are  also  considered.  Jackson  indulges 
in  speculation  concerning  the  severance  of  intrisic  and  extrinsic  fibres, 
in  observations  on  extremely  high  temperatures  resulting  from  lesions 
in  this  regions  (cervical)  and  upon  the  eflFects  of  the  cutting  off  from 
the  highest,  middle  and  lowest  levels  (centres). 

It  is  almost  impossible  to  adequately  review  the  paper  in  question 
without  entering  into  details,  which  would  involve  long  quotations 
■from  the  original.    It  would  be  better  to  read  the  article  in  toto. 

Sterne. 


"Sevlscopt. 


With  tlte  Assistance  of  the  Following  Collaborators: 

ChasXewis  Allen. M.D.. Wash., D.C.R.  K.  Macalester,  M.D.,  N.Y. 
J.  S.  Christison,  M.D.,  Chicago,  III.  J.  K.  Mitchell.  M.D..  Phila..  Psr 
A.  Freeman,  M.D..  New  York.  H.  Patrick,  M.D.,  Chicago,  111. 

S.  E.  Jelliffe,  M.D.,  New  York.        Joseph.  Sailer,  M.D.,  Phila.,  Pa, 
Wm.C.Krauss.M.D.,  Buffalo,  N.Y.      Hknry  L.  Shively,  M.D.,  N.  Y^ 
W.  M.  Leszynsky,  M.D.,  New  York  A.  Sterne,  M.D.,  Indianapolis 

.      ANATOMY. 

28     NOUVELLHS  RfeCHERCHES  SUR  LA  STRUCTURE   FINE  DE  LA  CELULLIv 

NERVEUSE      (New  Researches  upon  the  Minute  Anatomy  of  the 
Nerve  Cell.)     S.  Marinesco  (La  Presse  Medicale,  1897,  No.  49)- 

In  this  article,  a  continuation  of  one  previously  reviewed,  the 
author  describes  the  lesions  produced  in  the  cells  of  the  spinal  ganglia 
and  anterior  horns,  by  alcohol,  arsenic,  and  the  hydrophobic  virus. 
These  lesions  consist  of  a  chromatolysis,  most  generally  peripheral^- 
but  sometimes  diffuse,  differing  somewhat  with  the  different  poisons. 

Basing  his  conclusions  upon  the  results  of  examination,  and 
comparison  of  normal  with  pathological  cells,  he  discusses  the  fine 
anatomy  and  probable  physiology  of  the  nerve  cell.  The  nerve  cell 
is  composed  of  three  essential  elements — i.  the  chromophile  sub- 
stance; 2.  an  incolorable  "figured"  substance;  3.  an  incolorable 
amorphous  substance,  which  binds  the  chromophile  granules  to- 
gether. To  the  second  of  these,  attention  is  specially  called.  It  con- 
sists of  a  number  of  very  fine  fibrils,  which  cross  and  recross,  making 
up  a  network,  in  whose  interstices  the  chromophile  granules  arc 
placed.  The  meshes  of  this  network  vary  in  fineness.  To  it  the  name 
of  "spongio-plasma"  is  applied.  Its  structure  is  best  shown  in  cells^ 
which  have  undergone  chromatolysis.  As  to  the  relation  of  the  fibrils 
of  the  axis  cylinder  process  and  the  protoplasmic  processes  with  the- 
fibrils  of  the  spongio-plasma,  the  author  thinks  that  they  are  directly 
continuous.  With  regard  to  the  chromophile  substance  he  takes^ 
issue  with  the  authors  who  tegard  it  as  having  only*  a  nutritive  func- 
tion. For  him  it  is  an  unstable  chemical  compound,  and  serves  as  a 
reservoir  for  the  storage  of  nerve  energy.  "  Kineto-plasm"  he  calls 
it.  Being  unstable,  it  breaks  up  easily  to  enter  into  new  combinations^ 
and  in  so  doing  liberates  energy,  which  reinforces  the  current  which 
has  caused  the  explosion.  It  may  also  be  caused  to  liberate  energy 
by  the  direct  action  upon  it  of  poisons,  as  strychnine,  etc.  Other 
poisons  destroy  it  at  once,  producing  paresis  or  paralysis. 

Allen. 

29.  ZuR  Kenntniss  der  Cerebrospinal  Flussigkeit  (The 
Cerebrospinal  Fluid.)  H.  Nowvatzki.  (Deutsche  med.  Wochen- 
schrift,  1897,  No.  2.) 

Nowvatzki  has  made  a  study  of  the  cerebrospinal  fluid,  and  states- 
that  in  healthy  calves  the  chemical  constituents  are  as  follows:  .04S 


PERISCOPE.  139 

per  cent,  grape  sugar,  .01 — .03  per  cent,  albumen,  .28  per  cent,  organic 
constituents,  1.07 — i.i  per  cent,  of  dry  residuum,  .7 — .8  per  cent.  ash. 
There  were  no  albumoses  or  peptones  in  the  organic  constituents, 
and  the  albumenoid  was  a  globulin. 

In  the  cerebrospinal  fluid  of  paralytics,  .5  per  cent,  grape  sugar 
was  found,  which  amount,  however,  diminished  rapidly  after  death. 

Jelliffe. 

30.  Uber  die  Anwendung  ei^kktivkr  FXrbenmbthoden  am  in 
PoRMOi«  gehXrteten  Centrai^nervensystem  (Formaline  as  a 
Fixative  for  Nervous  Tissues. )  Gudden  (Neurologisches  Central- 
blatt,  16,  1897,  p.  24). 

Gudden  gives  the  results  of  experiments  on  staining  nervous  tis- 
sues which  have  been  hardened  in  formaline.  With  such  he  uses  the 
Nissl  staining  methods.  The  material  to  be  used  for  the  Weigert 
methods  requires  a  preliminary  placing  in  J/^  per  cent,  chromic  acid 
for  ten  hours,  at  the  temperature  of  the  room  to  prepare  it. 

Jelliffe. 

3L  A  Modified  Fixing  Fluid  for  General  Histological  and 
Neuro-histological  Purposes.  A.  P.  Ohlmacher  (Journal  of 
Experimental  Medicine,  2,  1897). 

After  experimenting  with  various  modifications  of  Carnoy's  fluid, 
which  is  so  highly  recommended  by  Van  Gehuchten,  the  author  pre- 
sents the  following  modifications: 


ft 


Anhydrous   alcohol 80  pts. 

Chloroform    15 

Glacial  acetic  acid 5 

Corrosive  sublimate to  saturation. 

The  alcohol  employed  is  made  by  dehydrating  95  per  cent,  alcohol 
with  anhydrous  copper  sulphate.  About  twenty  grammes  of  powdered 
corrosive  sublimate  are  required  to  slightly  over-saturate  100  ccm.  of 
the  fluid. 

Ordinary  pieces  of  tissue  are  sufficiently  fixed  in  fifteen  minutes 
to  half  an  hour.  For  the  brain,  after  subdivision,  eighteen  to  twenty- 
four  hours  are  usually  sufficient.  Penetration  is  rapid,  and  the  cyto- 
logic details  are  said  to  be  excellent.  Jelliffe. 

32.  Eine  neue  Methode  zuR  Farbung  desCentralnervensystbms 
(A  New  Method  of  Staining  the  Nervous  System.)  J.  Allerhand 
(Neurolog.  Centralblatt,  16,  1897,  p.  727). 

The  author  describes  a  method  whereby  materials  which  have 
been  hardened  in  a  great  variey  of  fixative  fluids,  including  alcohol, 
can  be  used  in  the  Weigert-Pal  technic.  He  uses  the  Liquor  ferri 
sesquichloratis  of  the  German  Pharmacopoeia  and  a  preparation  of 
tannic  acid: 

Thin  sections  are  stained  for  from  fifteen  to  twenty  minutes  in  a 
fifty  per  cent,  solution  of  the  iron;  after  some  washing  in  water  the 
specimens  are  transferred  to  a  twenty  per  cent,  solution  of  tannin, 
which  is  specially  prepared;  the  tannin  being  dissolved  in 
distilled  water  and  boiled,  and  then  left  in  an  open  flask  in  the  sun- 
light where,  after  a  lengfth  of  time,  moulds  develop;  after  two  or 
three  weeks  the  fluid  is  filtered  and  is  then  ready  for  use.  The  speci- 
mens, after  treatment  in  the  iron,  are  placed  in  the  tannin  solution,  and 
for  from  one  to  two  hours,  stay  at  a  temperature  of  about  50  deg.  C. 
They  can  be  differentiated  by  the  regulation  Pal  methods. 

Jelliffe. 


I40  PERISCOPE. 

PATHOLOGY. 

33.      UBER    DSGKNBRATIONSHBRDB    in    DKR    WEISSBN    SUBSTANZ  DBS 

RiJCKBNMARKS   BY  LbukXmib    (The  Spinal  Cord  in  Leukemia). 
M.  Nonne    (Deutsche  Zeitschr.  f iir  Nervenheilk. ,  10,  1897,  p.  167). 

To  Nonne  we  are  already  indebted  for  much  valuable  information 
regarding  the  changes  in  the  spinal  cord  induced  by  pernicious  anemia 
and  the  symptoms  resulting  therefrom.    He  now  contributes  two  cases 
!  of  cord  disease  caused  by  leukemia,  a  knowledge  of  which  seems  here- 

\  tofore  to  have  been  confined  to  a  single  case  reported  by  W.  Mtiller 

J  (Inaugural  Thesis,  Berlin,  1895). 

.  The  first  case  was  a  man  aged  59,  whose  symptoms  began  six 

I  months  before  death  with  general  debility,  dizziness  and  anorexia.    On 

1  examination  two  months  after  the  inception  of  .the  disease,  the  liver 

and  spleen  were  found  to  be  greatly  enlarged,  the  red  blood  corpuscles 
numbered  1,896,006,  the  white  630,000  to  the  cubic  millimeter,  and 
the  percentage  in  hemoglobin  was  only  40.  The  bones  were  nowhere 
tender  to  pressure,  and  glandular  enlargement  was  limited  to  a  few 
I  glands  in  the  groin  and  axillae,  some  of  which  were  as  large  as  a  filbert. 

'  Sensation,  motion  and  the  reflexes  were  normal.     While  under  ob- 

j  servation.  the  number  of  red  blood  corpuscles  increased  slightly,  and 

'  the  spleen  diminished  in  size,  but  the  patient  suffered  from  large  inter- 

s  muscular  hemorrhages  and  died  of  marasmus  and  catarrhal   pneu- 

monia.   Miscroscopic  examination  of  the  cord  revealed  small  myelitic 
■}  foci  or,  more  strictly  speaking,  foci  of  acute  or  subacute  nerve  degen- 

eration, scattered  through  the  white  substance  from  the  upper  lumbar 
region  to  the  medulla  oblongata.     Some  of  these  degenerated  points 
,  were  large  enough  to  be  seen  by  the  naked  eye,  and  all  the  stages  of 

•:  degeneration  were  to  be  observed  from  a  simple  puffed-up  appearance 

V  of  the  myeline  sheath  and  swelling  of  the  axis  cylinder,  to  segmenta- 

tion, breaking  up  and  disappearance  of  the  nerve  fibres  with  com- 
pensatory hypertrophy  of  the  neuroglia.  Changes  in  the  vessels,  hem- 
orrhages, cellular  infiltration  and  extravasation  of  leucocytes  were 
entirely  wanting,  and  the  gray  matter  throughout  with  the  nerve 
loots  was  absolutely  normal. 

The  second  patient,  a  man  aged  31,  noticed  first  some  enlargement 

of  the  abdomen,  and  during  the  next  two  months  marked  general 

!  weakness  developed.     Irregular  febrile  movement  then  appeared,  and 

I  the  patient  was  admitted  to  the  hospital  where  he  was  found  to  have 

an   enormous   spleen,   reaching  to   the   right  inguinal   region.      The 
lymphatic  glands  were  not  enlarged,  and  the  bones  were  not  notice- 
j  ably  tender,  but  examination  of  the  blood  showed  a  great  increase  of 

-  white  corpuscles,  viz.,   1,940,000  red,  -and  910,000  white,  to  the  cubic 

.  *  millimeter.   Objective  symptoms  of  involvement  of  the  nervous  system 

•  I  were  wanting.     The  patient  died  eight  days  after  admission  to  the 

I  hospital  and  four  after  the  appearance  of  the  first  symptoms  noticed. 

A  careful  microscopic  examination  of  the  spinal  cord  revealed  lesions 
i  identical  in  character,  size  and  distribution  with  those  of  the  first  case, 

/  the  gray  matter,  ner\'e  roots  and  vessels  being  intact.     It  should  be 

added,  however,  that  the  Nissl  method  was  not  employed  as  the 
material  was  hardened  in  Miiller's  fluid,  and  hence  minute  changes 
in  the  nerve  cells,  were  not  to  be  positively  excluded.  Patrick. 

'  34.      EiN    BbiTRAG    ZUR    KENNTNISS    DER  IM  VBRI.AUFB  DER  PERNI- 

CIOSEN  AnAMIB  BBOBACHTETEN   SpINALERKRANKUNGEN     (Chang- 

.j;  es  in  the  Gray  Matter  of  the  Spinal  Cord  in  Pernicious  Anemia). 

jj  Teichmiiller    (Deutsche  Zeitschr.  fur  Nervenheilk..  8,  1896  p.  385). 

The  author   reports   a   case   of  pernicious   anemia   with   arterio- 


■ 


PERISCOPE.  141 

sclerosis,  chronic  enteritis,  paresthesia,  and  increased  knee-jerk.  On 
post'^^^^^»  small  hemorrhages  were  found  in  the  corpora  quadri- 
.^0iina  and  corpora  striata.  Microscopic  examination  showed  changes 
sach  a^s  have  been  described  in  the  posterior  columns,  and,  in  addition, 
hemorrhages  in  both  the  white  and  gray  matter,  with  degeneration 
in  the  anterior  and  lateral  columns.  The  author  combats,  the  idea 
that  the  changes  in  the  cord  in  pernicious  anemia  represent  a  com- 
bined system  of  disease,  and  looks  on  the  changes  of  the  gray  matter 
as  of  chief  importance. 

The  paper  is  illustrated  with  photo-micrographs,  and  a  biblio- 
graphy is  included.  Vogel. 

35.    The  Spinal  Cord  in  Pernicious  Anemia.    Clarke  (British  Med- 
ical Journal,  1897,  p.  325). 

The  author  reports  two  cases.     In  the  first,  the  patient  being  a 
woman  of  46  years,  th^  changes  in  the  cord  were  substantially  those 
hitherto  described  as  occurring  in  pernicious  anemia;  i.  e.,  degener- 
ation  of  the  posterior  columns  with  some  involvement  of  the  lateral 
columns.    The  posterior  column  degeneration  was  very  intense,  in- 
cluded most  of  the  columns  of  Goll  and  Burdach  and  extended  from 
the  highest  to  the  lowest  point  of  the  cord.     Lateral  column  changes 
^^re  limited  to  the  pyramidal  tract  of  one  side  in  the  lower  dorsal 
^<i  upper  lumbar  regions;  the  direct  cerebellar  tract  remained  intact. 
.^      Changes  in  the  second  case,  a  man  of  38,  were  decidedly  except- 
'  '^^K  the  degeneration  of  white  matter  being  restricted  to  small  sym- 
^^\t\cal  patches  just  external  to  the  gray  matter  between  the  anterior 
teA.  posterior  horns.     These  areas  were  also  limited  in  longitudinal 
extent,  corresponding  to  about  one  cord  segment.    In  the  gray  matter 
were  marked  changes  which  seemed  to  be  contrary  to  the  rule. 

"  The  vessels  were  intensely  injected,  and  there  were  many  hemor- 
rhages, varying  in  size,  but  all  microscopic,  into  the  grey  matter. 
These  hemorrhages  were  distributed  chiefly  about  the  central  parts  of 
the  gray  matter,  posterior  part  of  the  anterior  cornua  and  neighbor- 
hood of  the  commissure.  Besides  the  hemorrhages  there  were  in 
places  small  areas  ui  which  the  gray  matter  was  granular,  partly  dis- 
integrated or  sclerosed.  The  nuclei  of  the  glia  cells  were  either  normal 
or  slightly  increased  in  number. 

Certain  of  the  nerve  cells  of  the  anterior  cornua  were  swollen, 
opaque  and  homogenous,  their  nuclei  obscured;  others  were  highly 
granular  and  deeply  pigmented,  and  a  few  appeared  small  and  shrunk- 
en, but  the  large  majority  appeared  normal.  The  walls  of  the  small  ves- 
sels were  much  thickened,  and  very  many  showed  hyaline  change.  In 
places  the  anterior  fissure  was  broadened  by  the  distended  arterial 
branches.  The  central  canal  was  blocked.  These  changes  in  the 
gray  matter  were' judged  to  be  of  fairly  recent  occurrence,  and  not 
of  old  standing,  and  were  most  marked  in  the  upper  dorsal  region. 
No  hemorrhages  were  noticed  in  the  other  organs  oost  mortem." 

Patrick. 

36.  Anatomischb  und  sxpsrimkntbi«i.b  Untersuchungen  uber 
DIB  RuckbnmarksverXnderungen  by  AnXmie.  (Anatomical 
and  Experimental  Studies  in  the  Changes  of  the  Spinal  Cord  in 
Anemia).  G.  V.  Voss  (Deutsches  Archiv  fiir  klin.  Med.,  58,  1896, 
P-  489). 

By  the  injection  of  such  agents  as  pyrodin,  glycerin,  pyrogallol, 
and  tolylendiamin,  the  author  induced  an  artificial  anemia,  which, 
although  not  of  the  genuine  pernicious  form,  still  presented  the  fol- 


■4 


142  PERISCOPE. 

^  lowing  symptoms;  diminished  number  of  red  blood  cells,  decreased 

amount  of  hemoglobin,  poikilocytosis,  fatty  hemorrhage.  Although 
the  animals  were  maintained  in  this  condition  for  some  time,  no 
typical  lesion  of  the  spinal  cord  could  be  discovered.  The  negative 
results  reached  inclined  the  author  to  the  belief  that  the  disease  in 
man  is  due  to  as  yet  unknown  chemical  poisons.  Vogel. 

37.  Le  Sci^erosi  Combinatb  del  Midollo  Spinale  NelleAnemib 
Perniciose.  (Combined  Sleroses  of  the  Spinal  Cord  in  Pernicious 
Anemia).  G.  Bastianelli  (Bulletino  della  R.  Accademica  Medica 
di  Roma,  22,  1896). 

The  author  groups  the  observations  that  have  been  made  on 
combined  scleroses  of  the  cord  in  pernicious  anemia  under  two  head- 
ings. The  first  class  embraces  those  cases  in  which  the  anemia  is 
the  most  prominent  factor,  and  the  nervous  symptoms  are  slight,  the 
disease  running  its  course  in  a  comparatively  short  time.  The  cord 
presents  irregular  lesions,  situated  principally  in  the  posterior  columns. 
Into  the  second  class  are  put  those  forms  in  which  the  nervous  mani- 
festations are  the  predominating  feature  of  the  clinical  picture,  and 
the  pernicious  anemia  is  a  supervening  complication.  Here  the  spinal 
lesions  are  the  same  as  those  found  in  other  primary  combined  scler- 
oses, and  are  quite  in  accord  with  the  nervous  symptoms.  The  author 
does  not  believe  in  a  direct  relation  between  the  anemia  and  the 
spinal  lesions,  for  the  changes  of  the  chord  induced  by  anemia  alone 
are  simple  swelh'ng  of  neuroglia  and  nerve  fibres  and  not  a  form  of 
degeneration.  The  theory  of  Minnich  that  vascular  lesions  are  capable 
of  producing  degeneration  of  the  white  matter  of  the  cord,  is  not 
satisfactory,  for  similar  conditions  are  present  in  other  affections  of 
the  cord,  and  the  author  also  found  perfectly  normal  vessels  in  in- 
stances of  this  disease.  The  most  likely  explanation  is  the  presence 
of  some  toxic  agent  capable  of  producing  both  diseases,  and  which 
the  author  believes  frequently  to  be  of  interstitial  origin.        Vogel. 

38.  Drs  accidents  nkrveux  observes  dans  l'anemie  pernici- 
EUSE  ET  LHUR  PATHOGENiE.  (Nervous  Lesions  in  Pernicious 
Anemia  and  their  Pathology).  Annales  et  Bulletin  de  la  Societe 
de  Medicine  de  Gand,  1897,  pp.  139-147. 

This  article  contains  a  short  resume  of  the  more  recent  work  that 
has  been  done  in  pathological  lines  upon  nervous  tissues  in  this  disease. 

39.  CONTRIDUTION  A  l'ETUDE  DES  LESIONS  MEDULLAIRES  DANS 
l'anemie     PERNICIEUSE     PROGRESSIVE     PROTOPATHigUE     ET     DANS 

LES  l'anemies  symptom atiques  de  l'adulte  (Medullary  Le- 
sions in  Pernicious  Anaemia).  E.  LeNoble  (Revue  de  Medicine, 
1897,  p.  425). 

The  author  considers  two  cases  of  pernicous  anaemia,  the  first 
occurring  in  a  young  man  of  twenty-six  years  of  age,  whose  blood 
showed  typical  changes.  The  nervous  symptoms  were  vertigo,  tin- 
nitus, ocular  disturbances,  frequent  headaches,  slight  tremor  of  the 
hands,  a  marked  hyperesthesia  of  the  skin  and  greatly  increased  knee- 

:\  jerks. 

The  pathological  changes  observed  in  the  nervous  tissues  were 
old  hemorrhages  in  the  bulb,  and  disseminated  and  extensive  hem- 
orrhages in  the  cord.  The  second  case  was  one  of  symptomatic  sec- 
ondary anaemia  without  any  marked  clinical  disturbances.    The  patho- 

•J  logical   findings  were  negative.  Jelliffe. 


A 


I  PERISCOPE,  143 

CLINICAL   NEUROLOGY. 

-40.       L'EXAG^RATION     DES     REFLEXES     ET     LA     CONTRACTURE     CHEZ 

l'hemipleGIQUK.  (The  Exaggeration  of  the  Reflexes  and  the 
Contracture  in  the  Spastic  and  the  Hemiplegic):  A.  Van  Ge- 
huchten  (Journal  de  Neurologic  et  d'Hypnologie,  2,  1897,  p.  621). 

A  lesion  of  the  pyramidal  tract  in  its  cerebral  portion  causes  flac- 
cid paralysis  and  loss  of  voluntary  movements,  whereas  a  lesion  in  its 
spinal  portion  causes  spasticity  without  paral3^is,  but  with  impair- 
ment of  voluntary  movements.  According  to  Van  Gehuchten,  the 
motor  cortex  is  connected  by  two  tracts  with  the  cells  of  the  peripheral 
motor  fibres;  by  a  direct  corticospinal  tract,  and  by  a  corticoponto- 
cerel>ellospinal  tract.  These  two  tracts  are  united  from  the  cerebellar 
cortex  to  the  louver  part  of  the  pons,  and  in  the  latter  region  they 
separate,  one  passing  to  the  cord  as  the  pyramidal  tract,  and  the  other 
to  the  cerebellar  cortex,  from  which  point  other  fibres  descended  into 
the  anterior  part  of  the  lateral  column  of  the  cord.  The  flaccid  pa- 
ralysis and  the  loss  of  voluntary  motion  in  the  hemiplegic  are  the 
results  of  destruction  of  both  tracts.  The  spasticity  and  partial  preser- 
vation of  voluntary  motion  in  the  spastic  are  the  result  of  interruption 
of  the  corticospinal  tract,  with  preservation  of  the  corticopontocere- 
hellospinal  tract.  The  interruption  of  the  corticospinal  tract  within  the 
cord  suspends  the  inhibitory  action  of  the  cortical  cerebral  cells  upon 
the  motor  spinal  cells,  and  is  the  immediate  cause  of  the  exaggeration 
f*^  the  reflexes,  whereas  the  motor  tract,  passing  through  the  ccrebel- 
^^^'^i,  preserves  the  connection  with  the  cerebral  cortex  and  prevents 
^ralysis.  It  has  been  thought  that  interruption  of  the  pyramidal  tract 
^^ses  paralysis,  and  that  the  degeneration  of  these  fibres  causes  spas- 
^^^VV  or  contracture.  Van  Gehuchten  disputes  these  statements,  and 
^W^Tnpts  to  show  that  the  theories  advanced  in  regard  to  the  effects  of 
secondary  degenerations  cannot  satisfactorily  explain  the  contractures. 
\  Babinsky  has  recently  stated  that  there  is  impairment  of  the  mus- 

cular tonus  in  hemiplegia,  t.  e.,  that  the  passive  movements  of  exten- 
sion and  flexion  are  greater  in  the  paralyzed  limbs.  This  hypotonicity 
has  been  noticed  not  only  in  recent  cases,  in  which  there  had  been  no 
exaggeration  of  the  tendon  reflexes,  but  also  in  cases  of  hemiplegia 
which  had  lasted  several  months,  and  in  which  there  had  been  exag- 
geration of  the  tendon  reflexes. 

The  muscular  tonus  is  the  outward  expression  of  the  condition  of 
the  stimulation  of  the  spinal  cells,  and  this  condition  is  the  result  of 
stimulation  and  inhibition  by  means  of  the  posterior  spinal  roots,  and 
the  pyramidal  and  descending  cerebellar  fibres.  The  muscular  tonus 
is  exaggerated  in  the  spastic  because  of  the  stimulation  through  the 
cerebellospinal  and  posterior  root  fibres,  and  the  loss  of  inhibition 
through  the  pyramidal  fibres.  Complete  transverse  lesions  of  the  cord 
destroy  the  cerebellospinal  and  the  corticospinal  fibres  and  cause  hy- 
potonia. The  hypertonia  produced  by  destruction  of  these  two  tracts 
in  cerebellar  hemiplegia  proves  that  the  hypotonia  in  complex  lesions 
of  the  cord  is  not  due  merely  to  destruction  of  fibres  from  the  cere- 
hcllum,  together  with  the  pyramidal  fibres,  but  to  destruction  of  the 
corticopontocerebellospinal  tract,  together  with  the  pyramidal.  The 
exaggeration  of  the  reflexes  in  both  the  hemiplegic  and  the  spastic, 
and  the  impairments  of  the  muscular  tonus  in  the  former  and  the 
f^ggeration  in  the  latter,  prove  that  the  condition  of  the  reflexes  is 
independent  of  the  muscular  tonus.  This  Van  Gehuchten  believes, 
hccause: 

I.  In  the  hemiplegic  there  is  impairment  of  the  muscular  tonus 
and  exaggeration  of  the  reflexes. 


144  PERISCOPE. 

2.  In  the  spastic  there  is  exaggeration  of  the  muscular  tonus  and 
exaggeration  of  the  reflexes. 

3.  In  the  cerebellar  lesions  there  is  exaggeration  of  the  reflexes 
and  normal  muscular  tonus. 

4.  In  complete  transverse  lesion  of  the  cervicothoracic  cord  there 
is  diminution  of  the  muscular  tonus  and  abolition  of  the  reflexes. 

The  cerebellum  seems  to  have  an  important  influence  on  the  con- 
dition of  the  reflexes,  if  not  on  the  tonus,  for  lesions  which  destroy 
both  motor  tracts  in  the  cerebrum  cause  an  exaggeration  in  the  reflex- 
es, whereas  lesions  which  destroy  both  tracts  in  the  cord  cause  an  abo- 
lition of  the  reflexes. 

The  contracture  of  the  hemiplegic  is  not  comparable  with  the 
contracture  of  the  spastic.  In  the  former  there  is  a  lesion  of  both 
motor  tracts,  in  the  latter  only  of  the  corticospinal  fibres.  The  con- 
tracture of  the  hemiplegic  is  late  in  its  manifestation;  it  is  always  pre- 
ceded and  accompanied  by  paralysis;  it  presents  a  variable  location 
in  the  muscles  of  a  limb;  the  muscular  tonus  is  impaired,  and  the  con- 
tracture is  persistent  in  repose  as  well  as  in  activity.  The  extensors 
of  the  upper  limb  are  usually  more  paralyzed  than  the  flexors,  and  all 
voluntary  efforts  to  move  the  paralyzed  member  affect  the  flexors. 
The  posthemiplegic  contracture  is  the  result  of  muscular  contraction, 
not  of  retraction.  The  variations  of  type  of  the  contracture  depend 
on  the  fibres  destroyed  in  the  internal  capsule. 

The  contracture  of  the  spastic  begins  as  soon  as  there  is  destruc- 
tion of  the  spinal  portion  of  the  pyramidal  tract;  it  is  not  associated 
with  complete  paralysis.  It  involves  all  the  muscles  of  the  affected 
limbs;  the  mucular  tonus  is  exaggerated  and  the  degree  of  the  con- 
tracture is  increased  by  motion.  The  contracture  of  the  spastic  is  the 
clinical  expression  of  the  exaggeration  of  the  muscular  tonus. 

Van  Gehuchten  makes  the  following  brief  statements; 
\  I.    The  secondary  degeneration  of  the  pyramidal  fibres  and  the 

consecutive  sclerosis  are  not  manifested  by  any  outward  signs. 

2.  The  exaggeration  of  the  reflexes  and  the  .contracture  in  the 
hemiplegic  and  in  the  spastic,  are  independent  of  the  pathological  con- 
ditions. 

3.  The  condition  of  the  reflexes  is  entirely  independent  of  the  con- 
dition of  the  muscular  tonus. 

4.  The  normal  condition  of  muscular  tonus  depends,  at  least- in 
I                                        great  part,  on  the  connection  of  the  spinal  with  the  cortical  cerebral 
I                                        cells.    Complete  separation  of  these  causes  diminished  tonicity. 
f                                               5.    The  normal  condition  of  the  reflexes  also  depends  on  this 

connection  of  the  spinal  with  the  cortical  cerebral  cells,  and  complete 
separation  of  these  causes  exaggeration  of  reflexes.  The  condi- 
tion of  the  reflexes  in  complete,  transverse  spinal  lesions  (Bastian) 
cannot  be  satisfactorily  explained. 

6.  The  contracture  of  the  hemiplegic  is  very  different  from  the 
contracture  of  the  spastic. 

7.  The  contracture  of  the  spastic  is  of  central  origin  and  is  due  to 
}  exaggeration  of  the  muscular  tonus.  This  exaggeration  is  due  to 
'•:  interruption  of  the  corticospinal  tract  with  preservation  of  the  cortico- 
*                                         pontocerebellospinal  tract. 

4  8.    The  posthemiplegic  contracture  is  of  peripheral  origin,  and  is 

f  due  to  a  minor  degree  of  paralysis  in  the  flexor  muscles  of  the  upper 

.'  limb  and  to  the  contraction  of  these. 

J  There  are  fibres  in  the  anterolateral  columns  which  degenerate 

t^  downward  after  lesions  of  the  cerebellum. 

Spiller. 


'I 


■X 


1 


PERISCOPE.  145 

PSYCHOLOGY  AND  PSYCHIATRY. 

41.  Comparative  Observations  on  the  Involuntary  Movements 
OF  Adults  and  Children.  M.  A.  Tucker  (American  Journal  of 
Psychology,  8,  1897,  p.  394). 

The  author,  during  his  experiments,  made  the  thought  of  the 
reagent  a  "constant"  by  some  simple  exercise  of  the  mind.  A  slight 
modification  of  Jastow's  automatograph  was  used,  the  finger  tip  rest- 
ing slightly  upon  it.  A  circle  being  regarded  as  the  field  of  motion 
for  the  hands,  it  was  divided  into  an  upper  half,  or  positive  field,  and 
a  lower  half,  or  negative  field;  and  the  right  and  left  halves  were 
called  the  right  and  left  fields. 

In  the  first  series  of  experiments  the  reagent's  (adults  i8,  children 
13)  attention  was  directed  to  some  stationary  object.  It  was  found 
that  for  adults  55.5  per  cent,  of  the  movements  were  into  the  positive 
or  forward  field,  while  48.5  per  cent,  were  in  the  negative  field.  For 
children  the  entire  movements  in  the  positive  field  were  only  26.9  per 
cent.,  while  those  in  the  negative  field  were  73.1  per  cent. 

In  those  whose  constant  attention  (18  adults,  25  children)  was 
not  directed  to  any  external  object,  the  moventents  for  adults  in  the 
positive  field  were  53.8  per  cent.,  while  those  in  the  negative  field 
were  46.2  per  cent.  For  children  the  corresponding  movements  were 
27.8  per  cent.,  and  72.2  per  cent,  respectively.  The  two  forms  of  ex- 
periment thus  give  about  the  same  results.  Combined  they  show 
the  movements  of  adults  in  the  positive  field  52.5  per  cent.,  and  in 
the  negative  field  49.5  per  cent.,  while  for  children  in  the  same  respect- 
ive fields  the  movements  are  27.3  per  cent,  and  72.7  per  cent. 

A  comparison  of  movements  in  the  right  and  left  fields  (reagents 
74-  cases  1,054)  gives,  for  adults  and  children  taken  separately  a  result 
nearly  alike.  For  both  together  the  right  hand  moves  in  the  left 
field  64  per  cent.,  versus  36  per  cent,  to  the  right;  while  the  left  hand 
Jjoves  in  the  right  field  66  per  cent.,  versus  34  per  cent,  to  the  left. 
This  means  that  normally  the  hand  moves  inwardly  toward  the  median 
plane  of  the  body. 

As  to  the  relative  directness  of  movements  it  was  seen  that  adults 
*fe  much  more  direct  than  children.  In  adults  71  per  cent,  were  fairly 
direct,  and  25  per  cent,  were  irregular.  In  children  21  per  cent,  were 
u  "^'^  direct,  and  66  per  cent,  were  very  irregular.  The  changes  of 
the  original  direction  in  adults  were  32  per  cent,  in  children  68  per 
cent. 

Of  right-handed  persons,  75  movements  were  to  the  left,  and  100 
^^  the  right.  Of  left-handed  persons,  10  movements  were  to  the  left, 
*^<i  15  to  the  right. 

It  was  also  found  in  adults  87.9  per  cent,  of  the  movements  imitate 
^«e  direction  of  an  object  followed  in  motion,  while  12.1  do  not.     In 
children  81  per  cent,  imitate,  while  19  per  cent,  do  not. 

With  the  eyes  shut,  while  the  object  is  moving,  98.2  per  cent, 
^oved  in  the  direction  of  the  object.  Some  even  moved  the  body. 
•Repetition  increased  the  susceptibility.  In  all  the  experiments  there 
4oes  not  seem  to  be  any  sex  or  age  difference  in  children. 

Christisov. 

» 

4.'.  The  Force  and  Rapidity  of  Reaction  Movements.     Delabarre 
(Psychological  Review,  4,  1897,  p.  615). 

The  author  made  two  series  of  experiments  on  fifteen  subjects. 
A  complicated  and  ingenious  method  was  adopted,  the  subject  being 
*^eated  comfortably    in  a  chair-and  told  to  react  to  a  given  signal.     He 


146 


PERISCOPE. 


was  instructed  to  think  only  of  making  a  quick  reaction,  allowing  the 
force  to  take  care  of  itself,  while  his  right  forefinger  and  thumb  were 
in  touch  with  a  pair  of  '*jaws"  connected  by  an  electrical  machine  with 
a  revolving  drum  and  a  column  of  mercury.  With  his  eyes  closed,  the 
subject  reacted  to  the  sound  of  a  signal  key. 
These  experiments  showed: 

1.  Dividing  pressure  inde^  by  the  duration  time,  the  resulting 
quotient  representing  the  rapidity  of  contraction  of  the  reacting  mus- 
cles tends,  for  the  same  individual  and  the  same  series,  to  be  con- 
stant. 

2.  There  are  well-marked  diflFerences  between  the  different  in- 
dividuals and  the  two  series  of  the  same  individual.  They  differ  ab- 
solutely and  in  range  of  variation. 

3.  Although  the  two  series  overlap  each  other  a  great  deal,  yet 
in  no  case  is  the  maximum  value  of  the  quotient  of  the  pressure  di- 
vided by  duration  greater  in  one  series  than  in  another. 

4.  The  degrees  of  pressure  exerted  and  the  range  of  its  variation 
are  characteristic  of  the  individual. 

5.  In  every  case  but  one  the  average  pressure  was  greater  in  the 
second  series,  while  the  rapidity  was  greater  in  the  first  series. 

Christison. 

43.  A  Study  in  the  Psychology  of  Religious  Phenomena.     J. 
Leuba  (American  Journal  of  Psychology,  7,  1896.  p.  309.) 

The  fundamental  resistance  to  conversion  is  self-assertion,  and  so 
self-surrender  is  the  turning-point  in  conversion;  that  is,  what  we  call 
will  weakens  as  delivery  approaches  and  resignation  to  God  ensues. 
The  land,  so  to  speak,  passes  under  a  new  rule  and,  henceforth,  all 
strife  ceases;  harmony,  a  sense  of  unity  and  corresponding  joy  per- 
vades the  organism;  everything  becomes  new  and  a  new  organic  life 
begins.  Pride  is  often  the  centre  of  the  residual  resistance.  The 
diversity  of  feelings  apparent  in  the  conversion-experience  of  various 
persons  are  (i)  desire  for  humility,  (2)  sense  of  impotency  and  un- 
utterable woe,  (3)  prostrate  in  complete  self-surrender,  (4)  confidence 
and  expectancy,  (5)  love  impulse  to  faith  in  God  and  Christ.  The 
following  are  the  usual  stages  in  conversion:  conviction  of  sin,  humil- 
ity, impotency,  utter  wretchedness,  despair,  self -surrender,  hope,  trust, 
love,  faith.  Leuba  quotes  Col.  H.  H.  Hadley,  for  many  years  superin- 
tendent of  the  Jerry  McCauley  Water  Street  Mission,  New  York,  in 
reference  to  conversions,  and  his  own  experience  thirteen  years  ago. 
He  says,  "  men  have  been  converted  in  the  delirium  tremens.  It 
knocks  all  the  theology  higher  than  a  kite.  I  don't  understand  it.  but 
it  is  so.  Take  my  own  case:  A  big,  bloated  drunkard — had  fifty-three 
drinks  the  day  before  I  was  converted,  most  of  them  brandy  cocktails, 
and  before  me  I  saw  my  Lord  crucified."  He  had  previously  listened 
to  the  "  experiences  *'  of  25  or  30  converts.  Christison. 

44.  The  Relation  of  Diabetes  to  Insanity.    C.   Hubert  Bond. 
(Jour,  of  Ment.  Science,  42,  1896,  p.  36). 

The  author  studied  268  consecutive  admissions  of  male  patients, 
makini?  an  examination  of  urine  in  175  cases  and  finding  sugar  in  12 
cases.  With  these  12  cases  he  placed  four  found  among  the  women, 
making  16  for  analytical  study. 

His  conclusions  seem  to  be  that,  though  usually  quite  rare  among 
the  insane,  the  proportion  is  increased  by  taking  the  recent  cases.  He 
finds  no  very  clear  relationship  of  the  glycosuria  to  the  form  of  insan- 
ity to  the  age  or  seemingly  to  the  bodily  health.  Half  of  the  cases  had 
a  history  of  alcoholic  excesses.  Two  cases  followed  by  autopsy  had 
cirrhotic  liver  and  kidneys. 


PERISCOPE.  147 

45.  iJBER  DiK  Veranderung  der  Pupillenreaction  bei  Geistes- 
KRANKEN  (Concerning  the  Changes  in  the  Reaction  of  the  Pupils 
in  Persons  with  Mental  Diseases.  E.  Siemerling  (Berliner  kli- 
nische  Wochenschrift,  33,  1896,  p.  973)- 

A  difference  in  the  pupils  may  be  found  in  normal  persons.  The 
Argyll-Robertson  pupil  is  rightly  regarded  as  an  early  sign  of  paresis. 
Persistent  unilateral  rigidity  of  the  pupil  is  exceedingly  rare.  Siemer- 
ling has  found  in  few  cases  of  paresis  the  peculiar  reaction  of  the 
pupil  described  by  Gowers.  The  pupil  contracted  to  light  but  soon 
resumed  its  former  size,  notwithstading  the  illumination  of  the  eye. 
The  paradoxical  reaction — dilatation  of  the  pupil  to  light  and  con- 
traction in  darkness — is -exceedingly  rare.  The  difference  In  the  size 
of  the  pupils,  often  associated  with  rigidity,  may  vary.  This  is  especi- 
ally true  of  paresis.  Hippus  has  been  observed  in  different  forms  of 
nervous  disease. 

Siemerling  reports  the  condition  of  the  pupils  in  9,160  cases  of 
mental  disease  observed  at  the  Charite  during  ten  years.  Reflex  rigid- 
ity was  noted  in  1,639  cases.    The  report  is  as  follows: 

Paralysis  progressiva i»524 

Tabes  with  psychoses •. 29     . 

Dementia  senilis 19 

Syphilis  of  the  central  nervous  system 17 

Focal  lesions 19 

Alcoholism    15 

Injuries  of  the  head i 

Epilepgy  4 

Hysteria   4 

Paranoia 7 

Siemerling  has  found  cerebral  changes  in  dementia  senilis.  The 
pupils  in  the  aged  are  narrow,  and  the  reaction  may  be  slow. 

The  explanation  of  pupillary  rigidity,  due  to  injuries  of  the  head, 

w  difficult,  but  the  writer  will  not  deny  the  existence  of  rigidity  from 

traumai.    The  period  of  observation  was  short  in  the  cases  of  epilepsy 

^nd  hysteria,  and  rigidity  as  a  sign  of  hysteria  remains  to  be  proven. 

In  two  of  the  seven  cases  of  paranoia  there  was  a  suspicion  of 

tabes.     The  period  of  observation  in  the  cases  of  paranoia  was  also 

wort.     The  reflex  rigidity  may  be  the  only  sign  of  paresis  for  many 

years. 

.  Siemerling  has  observed  variations  in  the  size  of  the  pupils  pre- 
wdingr  or  succeeding  epileptic  attacks.  In  one  case  rigidity  of  the 
pupils  persisted  several  hours  after  the  attack.  The  rigidity  of  the 
Pjipils  in  a  convulsive  attack  is  a  diagnostic  sign  of  great  value  in 
distingr^iishing  between  epilepsy  and  hysteria. 

It.  is  probable  that  centripetal  pupillary  fibres  are  to  be  found 
within  the  optic  nerve,  and  that  there  is  a  partial  decussation  of  these 
"^res.  Spiller. 

4^-     Syphilis     and     Paralytic     Dementia     in     Iceland.     Ehlers. 
TJgeskr.  fur  Lager,  I.,  41. 

The  much-discussed  relationship  of  syphilis  and  general  paresis 
receives  some  new  light  from  the  author's  studies  from  Iceland. 

Syphilis   is   there  a  rare   disease;   the  general   idea   of  immunity 
is  not,  however,  a  correct  one.    The  relative  infrequency  of  the  disease 
being  related  to  the  isolation  of  the  various  families  at  great  distances 
irom  each  other,  rather  than  a  result  of  any  moral  factor. 

General  paresis  is  unknown.  The  only  case  that  the  author  was 
able  to  find  having  occurred  in  a  sailor  who  had  lived  a  number  of 
years  in  foreign  countries  and  had  acquired  syphilis  there. 


1 48  BOOK  REVIEWS. 

THERAPY. 

47.    Die   Ergkbmsse   der   Lumbal   Puxktion     (Lumbar   Puncture). 
Fleischmann.     (Deutsche  Zeitschr.  fiir  Nervenheilk.,  10,   1897,  p. 

The  author  reports  on  the  himbar  puncture  of  54  patients  (ac- 
cording to  the  table  55)  in  the  service  of  Lichtheini  at  Koenigsberg. 
It  agrees  with  nearly  all  others  that  the  procedure  is  without  serious 
therapeutic  value.  Even  in  so-called  serous  meningitis  only  one  of 
the  four  cases  upon  which  it  was  practiced  showed  any  good  results 
from  the  operation.  In  accord  with  previous  observers,  however, 
is  the  conclusion  that  the  technique  is  simple  and  facile,  and  the  few 
unpleasant  results  of  no  serious  import,  and  not  to  be  regarded  as  a 
contraindication.  Together  with  most  other  investigators  of  the  sub- 
ject, he  lays  most  stress  on  the  diagnostic  importance  of  the  abstracted 
fluid. 

Puncture  was  done  15  times  in  12  cases  of  tubercular  meningitis 
and  the  bacilli  were  found  nine  times  in  eight  patients,  while  of  five 
punctures  in  two-  cases  of  epidemic  cerebro-spinal  meningitis  only 
one  yielded  the  Weichselbaum  coccus. 

Four  cases  of  purulent  meningitis  are  recorded.  Pus  corpuscles 
aind  streptococci  were  found  in  the  fluid  of  two,  streptococci  without 
pus  in  one,  and  many  white  blood  corpuscles  without  micro-organ- 
isms in  the  fourth;  that  is,  a  positive  finding,  more  or  less  conclusive, 
in  all. 

In  studying  this  report,  as  indeed  all  others  on  this  subject,  the 
thought  is  inevitable  that  even  when  lumbar  puncture  is  a  1  undoubted 
diagnostic  aid,  the  information  thus  obtained,  considering  the  present 
status  of  therapeutics,  is  not  of  great  practical  value.  As  between 
tubercular  meningitis  and  purulent  meningitis,  or  even  as  between 
tubercular  meningitis  and  serous  meningitis,  it  must  be  acknowledged 
that  a  positive  diagnosis  is  really  of  not  very  great  value  in  directing 
the  treatment  or  affecting  the  result  of  the  disease. 

Of  the  cases  reported  in  detail,  we  may  mention  three  of  serous 
meningitis,  as  the  disease  is  not  very  well  known,  and  the  cases  il- 
lustrate some  of  the  difficulties  of  diagnosis  by  means  of  lumbar  punc- 
ture. 

A  young  woman  of  24  years  was  taken  suddenly  ill  with  violent 
headache,  nausea  and  vomiting.  There  were  soon  added  attacks  of 
general  convulsions,  with  loss  of  consciousness  and  moderate  cervical 
pain.  Seven  days  after  the  onset  examination  showed  elevation  of 
temperature,  a  dicrotic  pulse  of  44,  pain  on  bending  the  head  for- 
ward, and  double  optic  neuritis.  The  following  day  the  patient  vom- 
ited several  times  and  had  a  general  convulsion  lasting  about  two 
hours.  Afterward  she  was  quite  rational  and  without  fever.  The  next 
day  there  were  removed  by  lumbar  puncture  2.^  cubic  centimetres  of 
fluid,  which  contained  one  part  per  thousand  of  albumin,  and  in 
which  a  slight  coagulum  formed  spontaneously.  No  immediate  good 
effects  of  the  puncture  were  discernible,  but  the  patient  gradually  im- 
proved, and  four  weeks  after  the  beginning  of  her  illness  was  com- 
pletely well,  the  persisting  optic  neuritis  (which  also  rapidly  im- 
proved) being  the  only  sign  of  disease.  The  percentage  of  albumin 
in  the  fluid,  as  well  as  the  spontaneous  formation  of  coagulum,  pointed 
to  an  inflammatory  affection.  As  the  patient  belonged  to  a  tuber- 
culous family,  and  had  herself  suffered  from  scrofula  and  bone  tuber- 
culosis, tubercular  meningitis  was  suspected,  but  examination  of  the 
fluid  for  tubercle  bacilli   was  negative,   and  purulent  meningitis   was 


PERISCOPE.  149 

excluded  on  account  of  the  low  percentage  of  albumin,  the  absence 
of  pus  corpuscles  and  micro-organisms.  The  rapid  recovery  of  the 
patient  was  considered  to  verify  the  diagnosis  of  serous  meningitis. 

The  second  patient,  a  sailor  aged  22,  who  had  also  had  tuber- 
culous osteitis,  was  taken  with  headache,  nausea,  vomiting,  cervical 
rigidity  and  sleeplessness.    The  pulse  was  only  34.    After  a  couple  of 
weeks  he  rapidlj'  improved,  but  four  weeks  after  the  beginning  of  the 
trouble  the  same  symptoms  returned,  with  a  pulse  of  48  and  double 
optic  neuritis.     Three  months  later  lumbar  puncture  was  made  and 
fluid  removed  which  contained  only  3-10  of  one  part  of  albumin  per 
i.ooo  and  did  not  coagulate.    Afer  four  weeks  a  second  puncture  drew 
fluid  of  the  same  character.    There  was  no  perceptible  effect  from  the 
operation,  but  the  patient  improved,  and  was  discharged  cured  four 
months  from  the  first  onset  of  his  sickness.     In  this  case  the  small 
amount    of  albumin  in  the  fluid  and  its  failure  to  show  coagulation 
indicated  a  non-inflammatory  affection,  and  yet  the  course  and  ter- 
mination of  the  disease  seemed  to  prove  it  a  serous  meningitis. 

In  the  third  case  autopsy  confirmed  the  diagnosis.     A  child  of 
three  years  who  had  had  eclampsia  at  10  days  suddenly  became  ill 
with  high  fever,  headache,  vomiting,  loss  of  consciousness  and  rigid- 
ity of  the  entire  body,  but  remained  sick  only  a  short  time.     Three 
weeks  later  she  had  a  fit,  with  loss  of  consciousness,  clonic  spasm, 
folJowed  by  loss  of  speech  and  paralysis.     On  admission  there  were 
rigidity  of  the  spine,  impaired  consciousness,  rotatory  movement  of 
the  head,   continual   grinding   of   teeth,   slight   paresis   of   right   side 
and  double  optic  neuritis.    During  the  period  of  observation  the  pulse 
remained  high,  the  temperature  occasionally  high  but  generally  nor- 
^3l.     The  spinal  canal  was  punctured  twice,  the  fluid  containing  only 
3  trace  of  albumin  and  developing  no  cloudiness.     Three  weeks  after 
admission  the  child  developed  pneumonia,   which  was  quickly  fatal. 
The  autopsy  revealed  internal  hydrocephalus,   spinal   meningitis,  ca- 
tarrhal pneumonia  and  swelling  of  the  internal  follicles.    This  case,  as 
*'ell  as   others,  goes  to  show  that  the  serous  meningitis  of  Quincke 
«  probably  not  a  perfect  entity,   but  that  approximately   the   same 
symptom-complex  may  be  developed  by  a  variety  of  conditions.     It 
will  also  be  noted  that  the  quality  of  the  fluid  indicating  inflamma- 
tion,  viz,,  large  proportion  of  albumin  and  spontaneous  coagulation 
were   wanting,  although  distinct  inflammation  was  present. 

^n  another  case,  in  which  the  diagnosis  lay  between  tumor  and 
abscess,  the  high  pressure,  equal  to  45  millimetres  of  mercury,  de- 
cided the  observer  in  favor  of  tumor — a  conclusion  shown  to  be  cor- 
rect by  operation  and  autopsy. 

Another  interesting  case  may  be  mentioned  in  brief.     A  boy  of 

8  became  rapidly  sick  with  all  the  principal  symptoms  of  meningitis, 

but  a  few  days  later  the  condition  seemed  somewhat  anomalous,  and 

a  lumbar  puncture  was   made   for   diagnostic   purposes.       The   fluid 

was  clear,  contained  only  a  trace  of  albumin  and  showed  no  sign  of 

cloudiness  on  standing;  hence  an  inflammatory  affection  of  the  cere- 

bro-spinal  meninges  was  excluded.     This  being  done,  typhoid  fever 

seemed  the   most  probable   disease,   and   the   serum   test  being  used 

gave  a  positive  result — the  correctness  of  which  was  fully  confirmed 

by  the  subsequent  course  of  the  case,  as  well  as  by  the  diazo  test  of 

the  urine.  Patrick. 


I 


.1 . 


1 50  PERISCOPE. 

48.  Un  Caso  di  Guarigione  di  Meningite  Cerebro-Spinale  da 
DiPLOCOCCO  DI  Fraenkel  (A  Cure  of  Cerebro-Spinal  Meningi- 
tis). Ibid:  Un  2  Caso  di  Guarigione,  etc.,  Contributo  ad  valore  di- 
agnostico  e  Terapeutico  della  Puntura  Lombare.  A  Second  Cure, 
etc.  Contribution  to  the  Diagnostic  and  Therapeutic  Value  of 
Lumbar  Puncture).  Jemma  (Riforma  Med.,  1896,  pp.  259  and 
260). 

The  author  reports  two  cases  of  cures  of  cerebro-spinal  meningitis, 
believing  the  feasability  of  a  certain  diagnosis  by  means  of  lumbar 
puncture.  From  the  first  patient  20  cc.  and  from  the  second  40  and 
35  cc.  of  a  sero-purulent  fluid,  rich  in  pus  corpuscles  and  diplocci, 
were  withdrawn.  He  has  always  found  the  operation  a  safe  one,  and 
thinks  it  to  have  facilitated  recovery  in  both  of  the  above  cases.  In 
his  second  case  attenion  is  called  to  the  favorable  results  obtained  by 
the  use  of  15-minute  hot  (40°)  baths.  Judging  from  his  cultures  and 
experiments  on  animals,  the  author  concludes  that  the  cerebro-spinal 
fluid  has  the  property  of  diminishing  the  virulence  of  the  carriers  of 
infection,  and  promises  another  communication  on  this  subject. 

VOGEL. 

49.     La  ponction  lombe-sacrEe     (Lumbo-Sacral   Puncture).     Chi- 
pault  (Journal  de  Medecine,  1897,  p.  253). 

Instead  of  making  the  puncture,  as  do  most  operators,  between 
the  third  and  fourth  lumbar  vertebrae,  this  author  introduces  the  needle 
between  the  last  lumbar  vertebra  and  the  sacrum,  but  his  results  have 
been  very  simlar  to  those  of  other  operators.  He  agrees  with  them  that 
the  operation  is  not  difficult  or  dangerous,  and  is  of  decided  advantage 
in  diagnosis,  particularly  in  the  detection  of  tubercular  menigitis.  He 
goes  so  far  as  to  assert  that  the  examination  of  the  cerebrospinal  fluid 
thus  obtained  in  cases  of  suspected  tubercular  meningitis  is  as  imper- 
ative as  the  examination  of  sputum  in  cases  of  suspected  pulmonary 
phthisis.  Therapeuticaly,  his  results  have  been  far  from  brilliant, 
but  still  we  think  better  than  those  of  most  previous  investigators.  Of 
19  cases  operated  upon,  in  10  the  result  was  absolutely  negative; 
namely,  4  cases  of  infantile  hydrocephalus,  one  probably  caused  by 
cerebellar  tumor;  one  case  of  tubercular  meningitis  in  the  adult;  4  of 
general  paralysis  of  the  insane,  and  one  of  idiopathic  epilepsy.  In  4 
cases  the  result  of  the  operation  was  insignificant,  namely,  3  cases  of 
tubercular  meningitis  in  infants  and  one  of  idiopathic  epilepsy.  In  5 
cases  the  procedure  accomplished  more  or  less  good.  In  one  case  of 
cerebral  tumor  in  an  infant  three  punctures  at  intervals  of  eight  days 
relieved  the  headache  and  hebetude  for  a  month  and  diminished  the 
intensity  of  the  choked  disk.  The  fourth  puncture  in  this  case  was 
without  effect.  In  one  case  of  congenital  hydrocephalus  the  patient 
at  the  time  of  adolescence  had  begun  to  have  attacks  of  severe  head- 
ache with  mental  hebetude.  At  the  time  of  the  first  puncture  he  had 
been  suffering  for  8  days  and  was  relieved  in  12  hours.  Later  attacks 
were  aborted  by  puncture,  and  the  patient  Nvas  enabled  to  continue  his 
occupation.  In  two  cases  of  syphilitic  meningitis  with  involvement  of 
the  cranial  nerves,  choked  disk,  mild  delirium  and  attacks  of  stupor, 
a  single  puncture  sufficed  to  cause  a  disappearance  of  the  pressure 
symptoms  and  allowed  time  for  active  specific  treatment  which  ac- 
complished in  one  an  entire  cure  and  in  the  other  almost  a  cure.  One 
case  of  idiopathic  epilepsy  was  relieved  to  a  certain  extent  by  punctures 
made  every  two  weeks,  the  patient  having  during  the  3^2  months  of 
treatment  one  attack  a  week  instead  of  8  or  10  in  24  hours.  After  ces- 
sation of  the  punctures  he  had  2  or  3  a  week,  which  had  been  his 
u.sual  number  before  the  exacerbation  for  which  puncture  was  done. 


•j 


PERISCOPE.  I  s  I 

In  conclusion  the  author  states  that  in  his  opinion  the  future  suc- 
cess of  lumbo-sacral  puncture  must  rest  not  upon  the  simple  evacua- 
tion of  the  liquid,  but  upon  its  evacuation  followed  by  the  mjection  of 
an  artificial  serum  which  shall  act  either  by  the  direct  action  of  some 
contained  medicament  on  the  seat  of  the  disease  or  by  its  inoculation 
effect  analogous  to  that  of  anti-diphtheritic  serum,  and  promises  an 
early  contribution  to  this  method  of  treating  infectious  diseases  of  the 
cercbro-spinal  meninges.  Patrick. 

50.  Lumbal  Punktion  (Lumbar  Puncture).  S.  Bull  (Norsk.  Mag. 
for  Lagevid,  11,  1896,  p.  498). 

The  author  has  performed  lumbar  puncture  in  four  cases  of  tuber- 
cular meningitis.  In  one  instance  only  8  cc.  were  withdrawn  and  no 
tubercle  bacilli  found,  while  in  the  three  other  cases  they  were  pres- 
ent, the  quantity  of  fluid  taken  being  43-57  cc.  Injection  of  this 
serum  into  the  abdominal  cavity  of  guinea  pigs  in  one  instance  was, 
and  in  another  was  not,  followed  by  results.  Therapeutically  consid- 
ered, the  puncture  has  a  temporary  palliative  eflFect,  but  is  of  diag- 
nostic importance.  The  author  urges  the  necessity  for  caution,  es- 
pecially in  private  practice.  Vogel. 

51.  SuL  Valork  Diagnostico  e  Curativo  della  Puntura  Lom- 
BARE  (The  Diagnostic  and  Curative  Value  of  Lumbar  Punc- 
ture).   G.  Mya  (Settimana  Med.,  1897,  pp.  4  and  5). 

G.  Mya  has  performed  80  lumbar  punctures  in  23  cases,  15  of 
which  were  tubercular  meningitis  and  encephalitis.  Only  in  two 
instances  were  tubercle  bacilli  found  in  the  fluid.  His'bpinion  is  that 
when  the  serum  is  sterile  and  exudate-like  (containing  moderate  num- 
bers of  leucocytes,  flecks  of  ependyma,  and  clotting  slightly)  tuber- 
culosis is  probably  present,  while  in  serous  meningitis  the  fluid  gen- 
erally contains  staphylococci,  and  in  chronic  cases  is  "transudate- 
like."  He  reports  that  in  tubercular  meningitis  a  distinct  alleviation 
of  the  cerebral  symptoms  took  place  after  the  puncture.  In  two 
-cases  where  clinically  a  diagnosis  of  the  tubercular  form  had  been 
made,  the  presence  of  staphylocci  in  the  fluid  pointed  to  an  "early" 
meningitis,  which  the  outcome  showed  to  be  the  case.  In  cases  of 
tumor  the  demonstration  of  a  secondary  hydrocephalus  may  be  of 
greatest  importance.  Diagnostically,  the  author  thinks  highly  of 
lumbar  puncture;  therapeutically,  it  may  be  of  much  value  in  some 
cases  of  acquired  hydrocephalus.  Jelliffe. 

52.  SuL  Valore  Diagnostico  e  Terapeutico  della  Puntura  Lom- 
BARE  (The  Diagnostic  and  Therapeutic  Value  of  Lumbar  Punc- 
ture). Jemma  and  Bruno  (Estratto  del  Arch.  Ital.  di  Clin.  Med., 
1896). 

The  authors  give  a  very  complete  bibliography  of  the  subject,  in- 
cluding French,  German  and  Italian  works.  Then  follow  reports  on 
their  own  cases,  25  in  number,  as  well  as  a  thorough  discussion  of  the 
operation  itself  and  possible  complications  through  the  alteration  of 
intracranial  pressure.  The  physical,  chemical,  microscopical  and  bac- 
teriological properties  of  the  liquor  are  all  of  diagnostic  importance. 
Gear  or  only  slightly  turbid  fluid  is  found  in  tubercular  meningitis; 
that  of  the  infectious  or  epidemic  forms  is  turbid  or  purulent.  Of  the 
chemical  characteristics  the  most  valuable  is  the  percentage  of  albumen. 
In  cases  of  tubercular  meningitis  it  rises  to  i  per  cent. ;  in  acute  forms 
of  meningitis  it  is  higher  than  in  chronic,  and  where  brain  tumors  are 


''.ii 


152  PERISCOPE. 

present  may  reach  3  per  cent,  and  over.  Of  the  greatest  importance, 
however,  is  the  bacteriological  examination,  and  especially  the  proof 
of  the  presence  of  the  tubercle  bacillus,  which,  together  with  a 
clear  fluid  resembling  the  normal,  was  found  in  every  one  of  four 
cases  of  tubercular  meningitis  under  observation.  The  diagnostic 
value  of  the  procedure  is  further  upheld  by  the  fact  that  negative  re- 
sults were  invariably  obtained  in  meningitis-like  affections  where 
some  other  disease  was  the  source  of  trouble.  Although  the  authors 
consider  lumbar  puncture  an  excellent  palliative  in  many  instances,  its 
therapeutic  usefulness  is  still  to  be  determined*  Vogel. 

53.  DiAGNOSTISCHER  UND  ThERAPEUTISCHER  WeRTH  DER  LuMBAL 
PUNKTION.        DrUCKBESTIMMUNG    MIT    QUECKSILBER    MaNOMETER 

(Diagnostic  and  Therapeutic  Value  of  Lumbar  Puncture).  Wilms 
Miinchener  med.  Wochenschrift,  1897,  No.  3). 

Wilms  presents  the  results  of  30  lumbar  punctures  performed  for 
various  affections  on  23  patients  in  the  Augusta  Hospital  of  Cologne. 
In  epidemic  cerebro-spinal  meningitis  the  presence  «)f  the  diplococcus 
intracellularis  was  demonstrated  in  three  out  of  four  cases,  but  tu- 
bercle bacilli  were  found  only  once  in  five  cases  of  tubercular  menin- 
gitis. The  author  prefers  a  Hg.  manometer  to  the  customary  HaO 
manometer  on  account  of  its  compactness  and  readier  manipulation. 
According  to  his  observations  the  normal  cerebro-spinal  pressure  av- 
erages 10  mm.  Hg.,  while  Quincke's  figures  arc  40-60  mm.  H20=3-5 
mm.  Hg.,  but  many  factors,  such  as  the  patient's  posture,  position  of 
the  head,  outcries,  breathing,  etc.,  may  influence  the  tension.  The 
amount  of  fluid  abstracted  varies  in  different  cases,  and  is  not  at  all 
proportional  to  the  pressure;  100  cc.  were  taken  with  good  results 
from  a  case  of  cerebro-spinal  meningitis,  25-60  cc.  in  cases  of  tuber- 
cular and  epidemic  meningitis;  in  non-inflammatory  disorders  the 
quantities  range  from  5-20  cc.  Vogel. 

54.  Die  diagnostische  Bedeutung  der  Punktion  des  Wirbel- 
KANALS  (The  Diagnostic  Significance  of  Lumbar  Puncture).  F. 
Strauss  (Deutches  Archiv.  f.  Klin.  Med.,  57,  1896,  p.  328). 

In  reporting  the  lumbar  punctures  performed  in  Ziemssen's  clinic 
Strauss  gives  a  detailed  resume  of  the  present  state  of  knowledge  re- 
garding the  diagnostic  and  therapeutic  significance  of  this  operation. 
A  noteworthy  point  is  the  fact  that  in  cases  of  epidemic  cerebro-spinal 
meningitis  communication  is  frequently  cut  off  between  the  cerebral 
l]  and  spinal  sub-arachnoideal  spaces.     The  bacteriological  examination 

of  fluid  obtained  from  such  cases  revealed  the  diplococcus  of  pneu- 
monia and  the  staphylococcus  pyogenes  albus  and  aureus.  In  the 
pathological  cerebro-spinal  fluid  of  a  case  of  serous  meningitis  a 
chtMiiical  substance  was  found,  which  was  either  globulin  or  mucin. 

Vogel. 


Borak  IRjexiiews. 


HyPKOTISM   AND  ITS  APPLICATION  TO  PRACTICAL  MeDICINE.      By  OttO 

George  Wetterstrand,  M.  D.  Translated  from  the  German  edition 
by  Henrick  G.  Petersen,  M.D.  Together  with  Medical  Letters  on 
H^rpno-Suggestion,  Etc.,  by  Henrick  G.  Petersen,  M.D.  G.  P. 
p*utnam's  Sons. 

THis  little  volume,  which  is  dedicated  to  Dr.  Liebeault,  the  founder 
of  the  Nancy  School  of  Hypnotism,  is  not  to  be  regarded  as  a  treatise 
on  hypnotic  suggestion,  for  it  consists,  as  its  author  states,  "of  un- 
pretentious notes  by  a  physician  who,  under  the  pressure  of  a  fatiguing 
and  engrossing  practice,  has  not  been  able  to  develop  his  rich  material 
into  a.  more  complete  form;" — and  the  work  should  be  judged  accord- 
ingly. 

The  117  pages  of  which  the  book  consists  are  devoted  very  largely 
to  the  description  of  individual  instances  of  disease  in  which  hypnotic 
sug^gfestion  has  been  used  for  its  therapeutic  effects,  together  with 
comments  on  the  results.  The  book  is  thus  of  an  essentially  practical 
chara.cter,  and  its  value  to  practitioners  depends  mainly  on  the  ac- 
curacy of  the  observations  that  are  described,  and  on  the  pc)ssibility 
that  similar  therapeutic  results  can  be  obtained  by  other  practitioners. 
If  it  be  true  that  the  writer's  experience  is  the  record  of  cases 
observ-ed  with  painstaking  care  and  the  insight  which  comes  from 
broad  clinical  culture,  this  record  of  experience  is  sufely  of  value  to 
medical  men.  If,  however,  the  author  has  approached  his  subject 
along-  a  narrow  path  and  with  more  enthusiasm  than  judgment,  we 
can.  ha.rdly  be  congratulated  on  having  another  book  of  a  kind  already 
too    i>l€ntiful. 

The  basis  of  successful  use  of  hypnotism  for  therapeutic  purposes 
*s  necessarily  the  ability  to  render  patients  succeptible  to  suggestion. 
Wetterstrand  has  had  a  large  measure  of  success  in  the  induction  of 
sug^gestible  states,  for  of  3148  persons  hypnotized  only  97  failed  to  res- 
pond   to  his  suggestion. 

The  author  agrees  with  Liebault,  Bernheim  and  Forel  that  nearly 
every    one  is  succeptible.     He  finds  that  age  is  an  important  factor  in 
^^"^^rmining   suggestibility,   that  persons   under  thirty  are   especially 
s^SKestible.  and  that  all  children  from  three  or  four  to  fifteen  years 
^Y^^ee  are  without  exception  hypnotizable.     In  the  case  of  persons 
who    cannot  be  rendered  susceptible  by  the  usual  methods  of  hypno- 
tizing   Wetterstrand  recommends  the  inhalation  of  chloroform,  which 
was    first  used  by  Rifat  of  Salonika,  for  the  purpose  of  overcoming 
s^*^^^   voluntary  or  involuntary  resistance  as  the  subject  may  offer,  and 
u  ^^^^€"n&  him  somnambulistic.     There  seems  to  be  good  evidence 
that    the  susceptibility  to   suggestion  may  in   some   instances  be   in- 
^^^^sed  by  the  use  of  chloroform,  but  it  is  questionable  whether  the 
^sc   of  an  anaesthetic  for  this  purpose  is  likely  ever  to  meet  with  the 
approval   of   representative    English-speaking   practitioners,    however 
it  may  be  regarded  on  the  continent.    In  connection  with  the  question 
ot  susceptibility  it  may  not  be  out  of  place  for  the  reviewer  to  give 
^?^Pression  to  the  belief,  based  upon  some  experience  with  hypnotism 
that      the     average      American      citizen     of      American     parentage. 
oviing   perhaps    to    greater    curiosity    and  greater  independence   of 
Iriought  and  action,  is  considerably  more  difficult  to  hypnotize  than 
the  average  continental  citizen  of  corresponding  social  status. 

\yhile    it    is    not    within    the    scope    of    this    review    to    present 
or    discuss    Wetterstrand    views    as    to    the     numerous     symptoms 


I 


15-1  BOOK  REVIEWS. 


and    types    of    disease    in    which    he    has    made    use    of    hypnotisnr 
as    a    therapeutic    agent,    it    is    desirable    to    indicate    the    author's, 
attitude  toward  representative  forms  of  disease.     We  may  select  for 
this  purpose  some  of  the  statements  that  are  made  with  reference 
to  insomnia,   habitual  headache,   organic   paralyses,   hysteria,   incon- 
tinence of  urine,  and  external  diseases.     There  can  be  no  doubt  that 
hypnotism  is  sometimes  of  great  service  in  the  production  of  slee;> 
in  nervous  but  healthy  persons  who  are  suffering  from  insomnia  as 
the  consequence  of  unusual  nervous  influences,  such  as  worry,  grief,, 
etc.     But  it  is  surprising  to  hear  that  a  woman  who  for  seven  years 
had  been  in  the  habit  of  lying  awake  for  a  large  part  of  the  night 
should  be  cured  by  an  hypnotic  seance  with  the  aid  of  a  few  drops- 
of  chloroform.     We  do  not  wish  to  question  the  accuracy  of  this 
and  similar  observations,   but  think  the  author  sometimes  displays- 
undue  readiness  to  believe  in  the  efficacy  of  his  treatment, — for  ex- 
ample as  when  he  says,  speaking  of  a  case  of  insomnia  cured  by  him: 
"I  have  not  heard  from  him  (the  patient)  since  he  returned  home,  but 
I  have  every  reason  to  believe  that  his  sleep  continues  satifactory." 
In  the  section  on  habitual  headaches  a  number  of  cases  are  described, 
in  which  the  head  pains  of  neurotic  individuals  were  greatly  benefited. 
Here  again  the  author  seems  to  have  been  rather  surprisingly  suc- 
cessful.    The  reviewer  is   quite  committed  to  the  belief  that  most 
headaches  ought  to  be  treated  by  means  directed  against  their  cause, 
but  that  hypnotism  should  be  tried  where  other  means  have  failed,., 
and  that  it  occasionally  is  distinctly  helpful  in  the  relief  of  pain.    The 
section  on  hysteria,  though  shorter  than  could  be  desired,  is  perhaps 
the  best  in  the  volume,  in  the  sense  that  it  displays  the  critical  faculty 
in  higher  degree  than  it  is  elsewhere  to  be  seen.     In  the  pages  on 
paralyses  of  organic  nature  we  are  startled  by  reading  that  an  old 
hemiplegic  who  "could  not  lift  the  arm,  which  hung  down  power- 
less," was  "completely  cured  almost  after  the  first  treatment!"    "The 
paralysis   had   disappeared   completely   after   six   treatments   and   no- 
difference  could  be  discovered  in  the  muscular  strength  of  the  left 
and  the  right  arm."     Neurologists  are  familiar  with  the  spontaneous- 
variations  which  occur  from  time  to  time  in  the  power  of  hemiplegic 
patients,  and  there  is  some  reason  to  think  that  suggestion  may  at 
times  be  capable  of  temporarily  improving  some  paralyses,  perhaps 
through   altering   the   conditions   of  the   circulation   about   the   des- 
tructive lesion;  but  conservative  men  are  not  yet  prepared  to  admit 
that  a  paralysis  dependent  on  a  lesion  in  the  motor  path  can  be  even 
temporarily  abolished  by  any  form  of  psychic  influence.     In  this  par- 
ticular instance  we  cannot  but  suspect  that  Wetterstrand  either  de- 
ceived himself  in  regard  to  the  results  of  his  treatment  or  erred  in 
diagnosis. 

In  the  section  on  incontinence  of  urine  several  instructive  instances- 
of  improvement  or  cure  are  described  as  the  result  of  suggestive  thera- 
peutics, together  with  some  failures  and  relapses.  The  reviewer  ^re- 
gards incontinence  of  urine  in  children  as  one  of  the  conditions  best 
adapted  to  the  therapeutic  use  of  hypnotism,  and  believes  that  practi- 
tioners will  come  in  time  to  recognize  the  advantages  of  using  sug- 
gestion for  this  purpose.  In  the  author's  short  section  on  external 
diseases  may  be  detected  further  indications  of  undue  faith  in  the 
efficacy  of  suggestion  directed  against  structural  pathological  con- 
ditions. A  boy  whose  knee  had  been  painful  and  swollen  for  about 
a  month,  as  the  result  of  a  blow,  limped  into  the  author's  office  on 
October  13th,  1887.  "The  leg  was  in  a  semi-flexed  position,  and  he 
(the  patient)  could  not  bend  nor  extend  it.  The  joint  was  swollen 
considerably,  with  strong  fluctuation."  After  hypnotization  the  pati- 
ent could  walk  without  limping;  "all  sensitiveness  and  pain  had  dis- 
appared,  and  the  joint  could  be  bent  and  extended  without  any  in- 


*. 

k 


BOOK  REVIEWS,  I  55 

convenience."  On  October  14th  "the  effusion  had  ahnost  disapperad, 
iut  was  still  visible."  It  is  within  the  limits  of  possibility  that  all  this 
happened  exactly  as  described,  but  the  writer  unfortunately  makes  the 
impression  that  he  is  unintentionally  exaggerating  his  therapeutic  re- 
sults. 

EnouRh  has  been  said  to  show  that  the  observations  contained 
in  this  little  volume  are  marred  by  indications  of  excessive  credulity 
or  loose  observation  on  the  part  of  the  author.    The  histories  of  re- 
markable therapeutic  results  in  organic  cases  would  certainly  have 
come  nearer  to  convincing  us  of  their  accuracy  had  the  clinical  con- 
ditions   been    minutely   and    scientifically    described.      Although    the 
looseness  of  description   which   characterises   some   of  the   histories 
detracts  materially,  in  the  reviewer's  opinion,  from  the  scientific  value 
of  the  volume,  it  by  no  means  destroys  its  interest.     The  book  con- 
tains   many   observations   which    are    probably    truthful    descriptions 
of  the  author's  experience,  and  are  well  worth  examination  by  those 
who   are  interested  in  determining  the  therapeutic  value   of  hypno- 
tism.    It  is  just  because  the  book  contains  so  much  that  is  interesting 
that   we  regret  its  shortcomings.     The  subject  of  hypnotism  seems 
to  attract  especially  persons  of  the  artistic  temperament,  in  whom  the 
imagination  often  has  undue  sway.     The  writings  of  such  persons, 
through  their  exaggerations,  repel  many  sober-minded  men,  and  thus 
the  facts  of  hypnotism  are  being  admitted  more  slowly  by  the  med 
ical   public  than  might  otherwise  be  the  case.     Krafft-Ebing  in  his 
recent   "Psychiatrischen  Arbeiten"  shows  how  satisfactorily  hypnotic 
observations  may  be  presented  by  one  who  is  a  tTioroughly  trained 
observer.  We  still  need  in  this  field  the  mature  and  original  judgment 
oi  men  who  have  had  long  years  of  training  in  the  methods  of  modern 
and  scientific  internal  medicine. 

The  last  quarter  of  the  volume  before  us  is  devoted  to  medical 
letters  on  hypno-suggestion,  etc.,  by  the  translator.    These  letters  treat 
of  hypnotic  subjects  in  a  general  and  rather  diffuse  manner,  and  can 
nardly  be  said  to  contain  any  information  not  already  at  our  disposal, 
yi^     section   entitled,    "Music,    not   Sermons   in    Insane    Hospitals," 
Elaborates  a  good  idea,  but  unless  the  lyres  of  *  Orpheus  are  more 
tuneful    than  they  usually  are  in  public  institutions,  it  may  be  ques- 
tioned  whether  the  frigid.-  grey-toned  sermon  is  not  the  lesser  of  two 
Ev^ls,  The   translator's   attitude   toward    thought   transference   and 

V.  ^^^^'^^^ST  up  of  "  molecular  action  "  in  one  brain  by  another  is 
rattler  amusingly  illustrated  in  the  first  letter.  This  does  not  detract 
ironi  such  general  interest  as  his  letters  may  possess,  but  it  cannot 
lail  to  make  us  call  in  question,  whether  justly  or  unjustly,  the  ac- 
curacy of  any  personal  views  the  writer  mav  hold  on  the  therapeutic 
'^alue  of  hypnotism.  The  difficulty  with  the  mental  attitude  of  the 
^^  >vho  firmly  believes  some  things  that  have  not  been  proved,  is 
tnat   V|e  is  at  any  moment  liable  to  confound  fact  and  fancy. 

C.  A.  Herter. 

"'^sthria  and  Certain  Allied  Conditions,  Their  Nature  and 
T^Reatment  with  Special  Reference  to  the  Application  of 
T'He  Rest  Cure,  Massage,  Electrical  Therapy,  Hypnotism. 
Krr  By  George  J.  Preston,  M.D.  P.  Blakiston  &  Co.,  Phila- 
<ielphia,  Pa.     1897. 

^n  this  treatise  of  298  pages.  Dr.   Preston  has  given  a  very  full 

account  of  the  protean  manifestations  of  hysteria  and  of  the  various 

methods  that  have  been  suggested  for  the  treatment  of  the  disease. 

.The  historical   data  collected   in   Chapter   I.,   the   review   of  the 

various  theories  regarding  the  aetiology  and  pathology  of  the  disease 

l^veri  in  Chapter  II..  are  well  calculated  to  give  the  special  student  such 

"Cts  as  he  needs  before  taking  up  the  further  study  of  this  interesting 


156 


BOOK  REVIEWS 


subject.  In  the  remainder  of  the  book  the  author  has  avowedly  kept 
the  needs  of  the  general  pratitioner  in  mind  rather  than  those  of  the 
specialist,  and  yet  every  specialist  who  reads  carefully  will  find  facts, 
though  familiar,  carefully  stated  and  described  in  clear  and  concise 
language. 

It  is  evident  that  the  author  has  given  the  subject  a  great  deal  of 
special  study,  so  that  the  book  is  not  merely  a  summary  of  the  writ- 
ings of  others.  That  he  has  lafgely  reproduced  the  statements  and 
even  the  illustrations  of  the  French  school  is  excusable,  and  in  as 
much  as  little  that  is  new  could  be  added  to  the  exhaustive  studies 
made  by  Charcot  and  his  followers,  the  author  has  on  the  whole  acted 
wisely  in  adopting  this  conservative  policy. 

In  the  chapter  on  Differential  Diagnosis  we  find  a  useful  sum- 
mary in  parallel  columns  of  the  characteristic  symptoms  of  epileptic 
and  hysterical  "spells."  The  difference  between  neurasthenia  and 
hysteria  is  brought  out  very  clearly,  but  we  think  the  author  under- 
rates the  difficulty  of  distinguishing  between  hypochondria  in  the 
female  and  hysteria.  The  former  is  a  much  more  common  affection 
than  it  is  generally  supposed  to  be. 

It  is  a  satisfaction  to  note  that  the  author  attaches  very  much 
more  importance  to  the  moral,  hydrotherapeutic  and  general  hygienic 
measures  than  to  the  treatment  by  drugs.  His  remarks  on  hypnotism 
are  also  to  be  commended  for  their  brevity  and  sobriety.  There  are 
few  books  from  which  the  general  practitioner  can  get  as  readily  the 
few  salient  points  regarding  hypnotism  as  he  can  from  this  mono- 
graph. We  are  in  accord  with  the  author  in  stating  that  the  great 
value  of  hypnotism  and  the  great  service  that  it  has  done  is  that  **it 
has  taught  us  how  to  make  our  treatment  of  hysterical  subjects  sug- 
gestive." Furthermore,  he  is  correct  in  stating  that  the  successful 
treatment  of  hysteria  consists  not  "in  a  suggestion  now  and  then, 
as  in  the  hypnotic  state,"  but  in  continuous  suggestion.  It  is  far 
better  to  give  the  general  practitioner  this  sober  view  of  the  matter 
than  to  praise  indiscriminately  the  good  effects  of  hypnotism  ami 
thus  to  encourage  tjie  practice  of  a  questionable  and  not  altogether 
harmless  therapeutic  method  at  the  hands  of  the  inexperienced. 

Dr.  Preston's  book  deserves  to  be  read  by  the  general  practitioner 
who  may  be  called  upon  to  treat  hysterical  patients.  But  we  commend 
it  also  to  the  specialist  as  a  convenient  work  of  reference  on  thib 
perennially  troublesome  subject.  B.  Sachs. 

Eye-strain  in  Health  and  Disea.se.  With  Special  Reference  to 
the  Amelioration  or  Cure  of  Chronic  Nervous  Derangements 
Without  the  Aid  of  Drugs.  By  Ambrose  L.  Ranney,  A.M.,  M.D. 
Illustrated  with  38  wood-cuts.  The  F.  A.  Davis  Co..  Publishers, 
1914  and  1916  Cherry  Street,  Philadelphia;  117  West  Forty-second 
Street,  New  York  City:   9  Lakeside  Building,  Chicago. 

Much  of  what  the  volume  contains  has  already  been  published 
during  the  last  ten  years  in  various  medical  journals.  The  subject  is 
one  that  has  always  proved  of  interest  and  about  which  many  a  wordy 
battle  has  been  waged. 

To  many  the  claims  made  by  Ranney  for  graduated  tenotomy  in 
the  various  conditions  comprised  under  the  collective  term  "hetero- 
phoria"  will  appear  to  be  far-fetched,  and  the  cures  by  him  in  chronic 
chorea,  epilepsy,  insomnia,  and  even  insanity  will  seem  to  be  no  less 
than  almost  marvelous. 

It  is  to  be  regretted  that  Dr.  Ranney  has  not  published  the  statist- 
ics of  all  of  his  heterophoric  cases,  including  the  failures  as  well  as 
the  cures.     That  he  must  have  had  many  failures  is  evident  when  he 


BOOK  REVIEWS.  157 

says  that  **one  radical  cure  of  epilepsy  without  the  aid  of  drugs  offsets 
a  thousand  failures  as  a  scientific  proof  of  a  discovery."  Such  a 
statement  may  be  considered  to  be  extremely  extravagant. 

In  spite  of  the  adverse  criticism  which  the  methods  of  Ranney 
have  evoked,  we  cannot  help  feeling  that  in  view  of  the  number  of 
apparently  severe  cases,  the  cure  of  which  is  corroborated  by  different 
physicians,  the  subject  deserves  impartial  investigation.  The  burden 
of  such  an  investigation  must,  of  course,  fall  upon  the  oculist,  who, 
if  not  already  entirely  familiar  with  the  technique  of  the  examination 
and  treatment  as  outlined  in  the  book  under  consideration,  could 
easily  perfect  himself  therein. 

It  must  be  said  that  the  claims  of  Ranney  and  of  Stevens  (his 
master  on  the  treatment  of  eye-strain)  were  investigated  some  weight 
or  nine  years  ago  by  the  New  York  Neurological  Society.  The  re- 
sults of  this  investigation  were  not  favorable  to  the  authors  of  the 
new  treatment.  This,  however,  does  not  prove  that  there  is  nothing 
of  value  in  the  discovery  and  treatment  of  anomalous  action  of  the 
muscles  of  the  eyeball.  Although  it  may  seem  incredible  that  the 
various  heterophoric  conditions  should  produce  reflexly  such  grave 
disorders  as  epilepsy  and  chronic  chorea,  it  must  be  bgrne  in  mind 
that  errors  of  refraction  may  cause  slighter  nervous  disturbances,  as 
headaches;  and,  furthermore,  that  severe  hysterical  phenomena  may 
be  engendered  by  comparatively  insignificant  traumatism.  The  re- 
lation of  eye-strain  to  intractable  nervous  affection  is  a  subject  which 
demands  further  investigation.  As  yet  the  data  which  we  possess 
are  too  insufficient  to  permit  us  to  draw  definite  conclusions. 

Meirowitz. 

Crime  and  Criminals.    By  J.  Sanderson  Christison,  M.D.,  Chicago. 
The  W.  T.  Keener  Co.     1897. 

This  little  book  of  117  pages  is  a  reproduction  of  a  series  of 
articles  contributed  to  the  Chicago  Tribune  under  the  title  of  "Jail 
Types."  The  mode  of  origin  explains  the  peculiar  make-up  of  the 
book,  and  the  occasional,  careless  and  even  incorrect  use  of  language. 
(Vid.  page  46,  eighth  line  from  bottom.)  The  author  promises  a 
larger  systematic  work  on  the  same  subject  in  the  near  future,  so  that 
the  present  volume  may  be  taken  to  be  a  mere  sketch  of  what  he  pro- 
poses to  offer  to  the  profession.  The  sketch  has,  however,  some 
points  of  interest  which  it  may  be  well  to  point  out.  The  author 
divides  the  delinquents  into  three  groups,  viz.,  the  insane  (defective 
in  reason);  the  moral  paretic  (defective  in  self-control);  and  the 
criminal  proper  (defective  in  conscience).  Even  the  last-named  de- 
linquent is  treated  as  the  product  of  his  ancestry  and  of  his  environ- 
ment; and  the  doctrine  of  degeneration,  although  the  author  makes 
no  reference  to  Lombroso  or  anyone  else,  receives  full  consideration. 

We  doubt  the  advisability  of  handling  such  a  subject  as  this  in 
an  ultra-popular  form.  After  all,  the  impression  is  created  that  there 
are  extenuating  circumstances  in  the  commission  of  almost  every 
crime,  and  just  by  so  much,  crime  is  made  less  abhorrent.  One  pur- 
pose of  the  author  in  writing  these  articles  appears  to  have  been  to 
enlist  the  interest  of  good  people  in  the  question  of  prison  reform; 
but  the  good  people,  hardly  need  such  incentives,  and  upon  others  not 
so  inclined,  such  articles  with  their  detailed  narrative  of  crime,  may 
have  a  very  different  effect.  Moreover,  the  question  of  prison  reform 
is  one  that  calls  for  the  exercise  of  sober  judgment  and  mature  delib- 
eration, qualities  which  the  ordinary  newspaper  reader  does  not  pos- 
sess to  any  serviceable  degree.  The  author  takes  an  advanced  stand 
in  advocating  the  abandonment  of  punishment  as  such  by  the  State, 


158 


BOOK  REVIEWS. 


and  favors  the  adoption  of  measures  so  as  to  turn  out  of  prisons 
"  better  citizens  than  they  receive." 

The  writer  of  "Crime  and  Criminals"  is  evidently  an  original 
thinker  on  the  subject  of  which  he  treats,  but  we  earnestly  hope  that 
he  will  hereafter  appeal  to  the  professional,  rather  than  to  the  lay, 
public.  B.  Sachs. 

Clinical  Lectures  on  Mental  Diseases.    By  T.  S.  Clouston,  M.D., 
Edinburgh.     Fourth  Edition.    Lea  Bros.  &  Co.     1897. 

There  is  probably  no  clinical  treatise  upon  insanity  in  the  English 
language  which  for  clearness  of  statement  surpasses  this  work  of 
Clouston,  which  has  now  reached  its  fourth  edition.  It  differs  but 
slightly  from  the  other  editions,  which  are  well  known  to  the  general 
practitioner  and  to  the  specialist,  and,  therefore,  does  not  require  any 
extended  notice.  The  symptoms  of  insanity  are  presented  in  such  a 
^ay  as  to  remove  much  of  the  obscurity  which  seems  to  pervade  the 
medical  mind  in  regard  to  the  clinical  features  of  the  disease,  and 
the  only  criticism  which  we  have  to  offer  is  that  the  more  recent 
investigations  in  regard  to  the  pathology  of  the  disease  are  not  ade- 
quately presented.  The  Be  van- Lewis  methods  of  investigation  arc 
adopted,  but- there  is  very  little  notice  of  the  revelations  in  the  pathol- 
ogy of  nerve  cells  due  to  the  methods  of  Nissl,  of  Andriezen  and  of 
Berkeley.  The  illustrations  are  hardly  of  a  character  to  commend 
themselves  to  the  pathologist  familiar  with  the  appearance  of  lesions 
under  the  microscope,  but  in  as  much  as  this  work  claims  to  present 
the  subject  from  the  clinical  standpoint,  and  in  that  respect  is  to  be 
in  every  way  commended,  it  is  possible  that  these  criticisms  with 
regard  to  the  pathological  descriptions  are  not  in  place.  For  a  student 
or  a  practitioner  there  is  no  work  which  can  be  more  highly  com- 
mended. M.  A.  Starr. 

BOOKS   RECEIVED. 

The  Physical  Correlation  of  Religious,  Emotional  and  Sexual 
Desire.  Jos.  Weir,  Jr.,  M.D.  The  Courier  Jour.  Job  Printing  Co., 
Louisille,  Ky. 

Rubiyat  of  Doc  Sifers.  By  James  Whitcomb  Riley.  Century 
Co.,  New  York.  ^ 

Hugh  Wynne.  2  vols.  S.  Weir  Mitchell,  M.D.,  Philadelphia. 
Century  Co.,  New  York. 

Eighth  Annual  Report  of  New  York  State  Commission  in  Lunacy, 
Oct.,  1895-Sept.  30th,  1896.     Also  Reprint  of  Second  Annual  Report. 

Vol.  XV.,  Transactions  of  the  Iowa  State  Medical  Society,  1897. 

Vol.  iv..  Transactions  of  the  Congress  of  American  Physicians 
and  Surgeons,  held  at  Washington,  D.  C.  May  4lh.  5th,  and  6th,  1897. 

Bulletin  of  the  Ohio  Hospital  for  Epileptics.    Gallipolis,  Ohio. 

Twenty-fifth  Annual  Report  of  New  York  State  Charities  Aid 
Association. 

The  Aphasias  and  their  Medico-legal  Relations.  By  F.  W.  Lang- 
\  don,  M.D.    The  Lansing  Printing  Co.,  i8q8. 

The  Psychology  of  Suggestion.  By  Boris  Sidis,  M.A.  D.  Apple- 
ton,  1898. 

These  Apresentada  a  Faculdade  de  Medicina  e  de  Pharmacia, 
em  30  de  Novembro  de  1897.  For  Julio  Atranio  Peixoto.  Disscr- 
tagao  Epilepsia  e  Crime,  Bahia,  Brazil. 

Festschrift  anlasslich  des  funfzigjahrigen  Bestehens  der  Provinzial- 
Irren-Anstalt  zu  Nietleben.    T.  C.  W.  Vogel,  Leipzig. 


1 


Wm.  R.  Warner  &  Company's 

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^    Pbotpharl,  I^IOOfr.;  Ext.ll■oltVo■lio«,K|f- 


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J 


^  mmt6 


^^'^c^ 


VOI^.  xxv. 


March,  1S98. 


No.  3^ 


THE 


Journal 


OF 


Nervous  and  Ment 


©vifliual  ^vticUs. 


THK  PSYCHICAL  MECHANISM  OF  DELUSIONS.^ 

By  WILLIAM  HIRSCH,  M.  D.. 

Of  all  clinical  symptoms  of  Psychiatry,  there  is  none 
which  even  to  the  laity  is  so  characteristic  of  mental  dis- 
ease as  delusions  and  still  it  is  more  difficult  to  explain  the 
psychical  mechanism  of  this  remarkable  phenomenon  thaa 
that  of  any  other  psychopathic  condition. 

Delusions  have  been  recognized  as  such  at  all  periods^ 
of  history,  and  in  fact  it  is  this  symptom  which  has  given. 
rise  to  the  popular  idea  of  crazy ness  and  madness.  Ini 
spite  of  this  fact,  however,  not  even  a  satisfactory  clin- 
ical definition  of  delusion  has  yet  been  offered.  The  lay- 
man is  generally  under  the  impression  that  the  contents* 
of  certain  ideas  decide  as  to  their  delusive  nature.  We: 
knoAV,  however,  that  while  on  the  one  hand  the  most  ab- 
surd and  incredible  thoughts  may  emanate  from  an  er- 
roneous, illogical,  but  nevertheless,  healthy  state  of  mind', 
on  the  other  hand  an  idea  may  correspond  to  real  facts  and! 
still  he  a  delusion.  It  is  therefore  much  less  the  nature 
of  the  contents  of  an  idea  which  leads  us  to  diagnosticate 
a  delusion  than  the  way  in  which  it  manifests  itself  clin- 
ically by  the  actions  and  remarks  of  the  individual. 

The  great  difficulty  of  explaining  the  psychical  mech-^ 

*  Read  before  the  section  on  neurology  on  the  New  York  Acad- 
etny  of  Medicine,  October  22.  1897. 


i6o 


WILLIAM    HIRSCH. 


anism  of  any  i)sychophatic  condition  we  will  appreciate,  if 
we  consider  that  our  knowledge  of  any  normal  psychical 
process  consists  only  of  hypotheses.  All  our  modern 
psychological  doctrines,  ingenious  and  evident  as  they  may 
appear,  including  the  generally  accepted  association 
theory,  are  after  all  more  or  less  speculations  without  ab- 
solute and  irrefutable  proof.  One  might  even  say,  that 
it  is  idle  work  to  try  to  explain  the  mechanism  of  a  dis- 
eased condition  as  long  as  we  do  not  possess  the  clear 
knowledge  of  its  physiological  analogue.  However,  the 
two  sciences,  psychology  and  psychiatry,  form  in  more 
than  one  respect  a  mutual  complement,  and  a  thorough 
and  accurate  study  of  any  psychopathic  symptom  is  apt 
to  throw  additional  light  on  the  corresponding  normal 
psychical  process.  In  this  way  the  study  of  psychiatrical 
phenomena  becomes  of  double  importance  to  general 
science. 

Ever  since  mental  diseases  have  been  made  the  subject 
of  special  study,  one  has  tried  to  explain  this  interesting 
phenomenon — the  origin  and  mechanism  of  delusions.  Up 
to  the  present  day,  however,  no  satisfactory  explanation 
has  been  gfiven.  a  fact  which  is  sufficientlv  well  shown  bv 
the  comparatively  large  number  of  theories  which  has 
been  offered  bv  various  authors. 

The  old  theory  of  a  partial  affection  of  the  mind,  which 
gave  rise  to  the  doctrine  of  monomanias,  according  to 
which  the  psychical  condition  of  an  individual  could  have 
been  perfectly  normal  apart  from  a  few  isolated  delusions, 
has  been  generally  rejected.  More  thorough  and  careful 
observation  has  shown  that  fhe  normal  condition  of  the 
miftd  was  seeming  rather  than  real  and  that  the  delusions 
formed  only  a  part  of  a  general  mental  disease. 

Another  more  recent  theory  sees  a  relation  between 
the  mechanism  of  delusions  and  imperative  ideas.  Both 
originate  from  a  certain  irritation  of  their  anatomical  loca- 
tion, and  delusions  often  develop  from  imperative  ideas, 
the  c:nly  difference  between  the  two  being,  that  the  form- 


rSYCmCAI.   MECHANISM    OF   DELUSIONS.  l6l 

crai  e  considered  as  real  by  the  individual,  thus  influencing 
his  whole  psychical  condition,  while  the  latter  appear  as 
foreigri  and  strange  to  the  otherwise  normal  process  of 
thinking,  the  patient  himself  trying  to  rid  himself  of  this 
unpleasant  disturbance. 

This  theory  also  has  met  with  but  little  sympathy.  In 
the  iirst  place  it  does  not  correspond  to  clinical  facts  to 
say  that  delusions  ever  develop  from  imperative  ideas,  and 
besides  this  the  whole  clinical  course  and  aspect  of  these 
two  classes  of  symptoms  are  so  different  from  each  other 
that  \jve  can  not  possibly  assume  the  same  or  a  similar 
meoha-iiism  for  both  phenomena. 

.\  theor}'  which  has  quite  a  number  of  adherents  among 
mcxlern  psychiatrists,  explains  the  origin  of  delusions  by  a 
priiiia.ry  disturbance  in  the  process  of  association,  by  ^ 
wliioh  the  personality  of  the  individual  becomes  changed.  | 
Parallel  with  the  normal  ego.  a  second  morbid  ego  is  form- 
etl,  which  latter  gradually  predominates  and  becomes  re- 
sponsible for  the  actions  of  the  individual. 

-Xpart  from  the  metaphysical  aspect  which  adheres  to 
2II  these  ideas  of  a  metamorphosis  of  the  soul  or  the  ego 
ar<l  -^vhich  is  in  fact  nothing  but  a  modernizing  of  anti- 
<iuated  metaphysical  views,  a  theory  based  on  a  primar}' 
(lisassociation  of  thoughts  could  not  by  any  means  give  a 
^3t  is  factory  explanation  for  the  nature  and  origin  of  de- 
'ii'^i^^ns.  There  exists  in  all  probability  a  mechanism  of 
coiiii^iiisory  associations,  but  such  a  condition  does  not 
prrxlvice  delusions,  but  rather  a  certain  class  of  impera- 
^*'^'e    ideas. 

-^    person,  who  in  a  compulsory  way,  associates  the  con- 
cept ion  of  a  sharp  pointed  object  with  a  certain  unpleasant 
^^    l>a.inful  sensation,  may  develop  a  symptom  known  as 
a^^hnophobia,  but  not  a  delusion.    The  condition  of  an  in- 
Aividtjal.  suffering  from  an  hysterical  psychosis,  who  is 
a^^aid  to  touch  certain  objects  because  there  is  a  morbid 
^^sociation   between    these   objects   and   the   conception 


l62 


WILLIAM    HIRSCH. 


"poison"  is  very  different  from  the  condition  of  a  paranoiac 
who  has  a  delusion  of  being  poisoned. 

Another  attempt  to  explain  the  mechanism  of  delusions 
starts  from  the  theory  that  every  conception  and  idea  is 
accompanied  by  a  certain  emotional  state,  which  has  been 
called  the  emotional  tonus,  and  which,  under  normal  con- 
ditions, stands  in  a  certain  proportion  to  the  tonus  of  all 
other  conceptions  and  ideas.  It  is  this  proportion  of  the 
intensity  of  the  tonus  of  the  different  ideas  to  one  another 
which  according  to  this  theory  forms  what  we  call  the 
individual's  character.  The  intensity  of  the  tonus  of  those 
conceptions  which  form  our  ideas  of  honor,  right,  and 
wrong,  etc'  determines  our  actions  and  modes  of  life. 
Under  pathological  conditions  certain  ideas  may  acquire 
an  abnormally  high  tonus  (iiberwertige  Ideen),  predom- 
inating over  all  other  ideas,  thus  becoming  delusions. 

Although  this  theory  is  ingenious  in  some  respects,  it 
does  not  corespond  to  clinical  facts.  The  author  of  this 
view  (Wernicke),  has  himself  carried  his  theory  to 
its  logical  consequences,  which  finally  led  him  to  the  as- 
sumption of  isolated  focal  diseases  of  the  mind.  This 
theory  bears  a  close  resemblance  to  the  old  doctrine  of 
monomanias. 

Another  theory,  which  has  perhaps  more  supporters 
than  any  of  the  others,  attributes  the  origin  and  nature  of 
delusions  to  an  intellectual  weakness.  Owing  to  the  de- 
fects in  his  intellect  the  individual  is  not  able  to  per- 
ceive and  judge  his  impressions  in  the  normal  way.  The 
lack  of  his  full  reasoning-power,  leads  him  to  misinterpret 
his  environment  and  the  actions  of  his  friends.  The  im- 
portant bearing  upon  general  psychiatrical  conceptions, 
whether  or  not  the  presence  of  delusions  necessarily  in- 
volves a  lack  of  intellectual  power,  and  the  strong  opposi- 
tion which  this  view  has  met  with  some  psychiatrists,  have 
caused  some  of  the  most  prominent  advocates  of  this 
theory,  to  attempt  to  prove  that,  in  the  affection  which 
we  might  call  the  disease  of  delusions  kat'  exochen,  i.  e, 


PSYCHICAL  MECHANISM   OF  DELUSIONS,  163 

clironic  paranoia,  there  is  always  an  impairment  of  the  in- 
tellect, and  that  there  is  not  a  single  paranoiac  with  a  nor- 
mal amount  of  reasoning-power. 

It  would  take  me  too  far  to  enter  into  a  discussion  of 
this  latter  question.  What  interests  us  here,  would  simply  be 
what  relation  does  the  impairment  of  the  intellect — if  it 
exists  at  all — bear  to  the  formation  of  delusions  in  cases 
of  chronic  paranoia?  I  think  that  everybody,  no  matter 
which  view  he  holds  regarding  the  condition  of  the  intel- 
lectual power  in  paranoia  must  admit,  that  intellectual 
weakness  alone  is  not  sufficient  to  produce  delusions. 
W  hile  we  see  on  the  one  hand  the  highest  degrees  of 
weakmindness,  imbecility  and  idiocy  without  any  delus- 

• 

ions,  we  find  on  the  other  hand  among  paranoiacs  individ- 
uals  with  an  intellectual  capacity  and  reasoning-power 
far  above  the  average.    Jean  Rousseau  for  instance,  who 
said  that  the  kings  of  Russia,  England  and  France,  all 
nobles,  the  women,  the  priests  and  mankind  in  general, 
"sJ  banded  themselves  together,  and  declared  a  dreadful 
war  upon  him,  was  a  paranoiac,  who  suffered  from  distinct 
delusions  of  persecution,  but  still  could  anybody  assert 
that  his  reasoning  power,  his  intellectual  capacity  was  too 
1^^^'  to  judge  properly  of  contemporaneous  events?     Do 
we  not  find  among  our  paranoical  patients  men  whose 
loii^ical  train  of  thoughts  and  acuteness  of  mind,  is  decid- 
c^lly  above  the  average?  There  is  one  symptom,  which  can 
DC  frequently  observed  among  paranoiacs  especially  in 
institutions,  and  which  in  itself  involves  a  compai^atively 
great  amount  of  reasoning-power,  i.  e.,  dissimulation.    A 
patient,  for  instance,  who  has  delusions  of  persecution, 
knows  that  certain  ideas  are  considered  insane  and  that 
on  their  account  he  is  kept  in  the  institution.    He  learns 
how  to  hide  these  thoughts  and  pretends  to  have  no 
enemies,  etc.    Is  it  logical  now  to  assume,  that    it  is  lack 
of  reasoning-power  which  produced  these  thoughts,  while 
there  is  sufficient  reasoning-power  and   self-control   to 
Wdethem?    If  there  is  an  intellectual  impairment  at  all  in 


1 64 


WILLIAM    HIRSCH. 


f 

I 

t 
l 


chronic  paranoia,  this  can  only  be  of  a  qualitative  nature. 
The  reasoning-power  may  be  changed  qualitatively,  but 
as  a  rule  is  not  diminished  quantitatively.  Apart  from  all 
these  considerations,  the  so-called  lowering  of  the  ability 
to  judge  critically  about  the  surroundings,  even  if  we 
would  admit  its  existence  in  paranoia,  could  only  form  one 
factor  in  the  production  of  delusions,  but  would  never 
be  suflScient  to  explain  the  entire  nature  of  this  pheno- 
menon. 

The  clinical  aspect  of  delusions  as  well  does  not  cor- 
respond to  this  theory.  A  weak  intellectual  capacity  can 
be  strengthened  by  training.  Everybody  knows  that  iin- 
beciles  and  idiots  can  in  some  degree  improve  their  intel- 
lectual capacity  by  the  systematic  training  of  their  mental 
faculties.  If,  therefore,  delusions  were  in  any  way  due 
to  an  intellectual  weakness,  they  ought  to  be  influenced 
beneficially  by  training  of  the  intellect,  by  advice  and  in- 
formation. But  just  the  reverse  is  the  truth.  While  we 
may  succeed  to  a  certain  extent  in  enlightening  an  imbec- 
ile person  concerning  his  erroneous  ideas,  it  is  generally 
admitted  that  it  is  not  only  impossible  to  convince  a 
paranoiac  of  the  real  nature  of  his  delusions  by  logical  ar- 
guments, but  that  such  a  measure  would  only  be  apt- to 
aggravate  the  morbid  condition  of  his  mind.  We  are  all 
iir  the  habit  as  soon  as  the  diagnosis  paranoia  is  made  to 
instruct  the  relatives  never  to  try  to  argue  logically  with 
the  patient  about  his  dehisions,  yet  this  would  surely 
benefit  him,  if  his  condition  were  in  any  way  due  to  a 
weakness  of  his  reasoning-power. 

In  close  relation  to  this  theory  are  all  attempts  to  ex- 
plain the  formation  of  delusions  in  a  purely  psychological 
way  comparing  the  mental  process  of  paranoiacs  with  that 
of  children  or  savages. 

The  principal  reason  why  prominent  psychiatrists  hold 
so  many  different  and  directly  opposite  views  con- 
cerning delusions,  lies  I  think  to  a  certain  extent  in 
the  erroneous  assumption  that  the  delusion  as  such  forms 


PSYCHICAL   MECHANISM    OF   DELUSIONS,  165 

a  pathological  entity,  that  the  psychical  mechanism  of  de- 
lusions  must  necessarily  be  the  same,  no  matter  of  what 
nature  they  are  and  under  what  circumstances  they  occur, 
Up  to  the  present  time  the  starting  point  for  any  psychia- 
trioa.1  investigation  can  only  be  clinical  observation,  and 
everybody  knows  how  widely  delusions  differ  clinically 
iroTTX  one  another  in  every  respect.  What  right  have 
yfc^  ttien  to  assume  that  one  and  the  same  mechanism  lies 
at  th^  bottom  of  all  these  different  symptoms? 

It  cannot  be  denied  that  there  are  certain  delusions, 
which  can  be  explained  by  one  or  the  other  theory,  men- 
tioned above.  The  typical  delusions  of  grandeur  in  gen- 
eral paresis  is  evidently  due  to  a  certain  extent  to  a  dis- 
turbance in  the  intellectual  power.  Corresponding  to  his 
pathological  euphoria,  the  patient  builds  castles  in  the  air, 
which  his  demented  intellect  is  not  able  to  correct  and 
which  are  therefore  taken  as  real.  There  is  in  these  cases 
a  direct  proportion  between  the  nature  of  the  delusion 
and  the  impairment  of  the  intellect.  In  the  initial  stages 
delusions  of  grandeur  are  confined  to  a  cer.tain  amount  of 
self-admiration.  The  more  the  dementia  progresses  the 
more  they  assume  the  true  character  of  insanitv.  The 
businessman  becomes  a  millionaire,  the  politician  a  great 
statesman,  etc. 

Iri     other  cases  delusions  might  develop  in  a  purely 
psychological  way,  to  explain  other  psychopathic  condi- 
tions.     So  for  instance  a  person  who  is  suffering  from  hal- 
lucinations may  try  to  explain  the  voices  or  sensations, 
and  thus  construct  ideas  which  bear  the  clinical  character 
01  delusions.    In  some  cases  of  melancholia  the  self-accus- 
ation  emanates  from  the  great  mental  depression  which 
^^Ices  everything,  above  all   the  ego  appear  dark   and 
gl^^omy  to  the  patient.    In  a  similar  manner,  delusions,  in 
^cute  mania,  might  be  explained  by  a  primary  change  of 
th^  moods  and  emotions. 

There  is,  however,  a  large  class  of  delusions,  which 
^ight  be  called  primary  delusions  or  delusions  proper. 


1 66 


WILLIAM   HIRSCH. 


which  can  not  be  satisfactorily  explained  by  any  of  the 
theories  offered.  Let  us  take  for  instance  a  person  with 
a  normal  amount  of  intelligence,  who  suddenly  refuses  to 
eat,  because  without  any  apparent  reason  he  susoects  his 
nearest  relatives  to  have  poisoned  his  food.  No  persua- 
sion, no  argument,  be  they  ever  so  clever  and  logical,  are 
able  to  correct  this  error,  to  remove  this  delusion.  As- 
suming that  there  are  no  hallucinations,  no  primary  im- 
pairment of  the  emotions  or  affections,  how  can  we  ex- 
plain the  psychical  mechanism  of  this  condition? 

Before  I  offer  mv  theorv  for  this  condition,  I  would 
like  to  call  attention  to  the  very  close  relation  which  exists 
clinically  between  delusions  and  hallucinations.  The  con- 
tents of  by  far  the  greatest  number  of  delusions  as  well  as 
hallucinations  refer  mainly  to  the  individual's  own  person. 
The  figures  and  faces  which  are  seen  have  either  a  threat- 
ening or  an  encouraging  look.  The  voices  may  abuse  the 
patient,  call  him  names,  threaten  him  or  they  may  an- 
nounce to  him  great  revelations,  tell  him  that  he  is  the 
son  of  a  crowned  person  or  something  similar.  In  an 
analagous  way  delusions  have  always  reference  to  the  ego. 
The  occurrence  of  these  two  cases  of  symptoms, 
delusions  and  hallucinations,  is  also  a  very  similar  one. 
They  occur  in  the  same  diseases  under  the  same  condi- 
tions. In  chronic  paranoia  these  two  symptoms  play  an 
equally  important  role.  According  to  the  preponderance 
of  the  one  or  the  other  set  of  symptoms,  we  distinguish 
between  paranoia  simplex  and  paranoia  hallucinatoria,  al- 
though cases  in  which  the  one  kind  is  missing  completely 
are  extremely  rare,  if  they  occur  at  all. 

In  view  of  this  evident  relation  which  these  two  phen- 
omena present  in  their  clinical  aspect,  it  should  appear 
but  natural  to  assume  that  there  exists  a  similar  relation 
in  their  psychical  mechanism.  That  the  hallucination 
as  such  is  not  a  clinical  entity  is  a  fact,  which  has  been 
recognized  and  generally  acknowledged  for  a  Jong  time. 


/ 


PSYCHICAL   MECHANISM    OF   DELUSIONS.  167 

Hailucinations  may  originate  by  a  peripheral  irritation, 
either  in  the  peripheral  organ  itself  or  at  any  place  of  the 
sensory  tract  from  the  peripheral  organ  to  the  centre  of 
perception.  Such  hallucinations  are  clinically  character- 
ized by  a  certain  intellectual  resistance  and  the  fact  of  their 
being-  limited  to  one  sense  only.  While  these  may  be  call- 
ed primary  hallucinations,  there  are  others  which  arise  sec- 
ondarily to  other  psychopathic  conditions,  such  as  emo- 
tions and  delusions.  The  well-known  question  of  Grie- 
singer,  which  he  left  unanswered  himself:  "  Why  does 
the  patient  believe  in  his  hallucinations?'*  for  instance  in 
a  voice  announcing  him  to  be  the  son  of  an  emperor,  can 
be  answered  for  many  cases:  The  patient  does  not  believe 
himself  to  be  the  son  of  the  emperor,  because  the  voice 
told  him  so,  but  he  heard  the  .voice  making  this  state- 
ment, because  he  believed  it.  The  morbid  idea,  the  de- 
lusion of  grandeur  was  the  primary  affection,  and  the 
hallucination  was  secondarily  produced.  The  realization 
of  t lie  fundamental  difference  between  these  various  kinds 
of  hallucinations  caused  some  authors  years  ago  to  speak 
about  contripetal  and  centrifugal  hallucinations.  Although 
at  that  time  these  terms  were  used  in  a  more  or  less  meta- 
phorical way,  they  were  based  on  perfectly  correct  clinical 
observation. 

M^odern  anatomical  investigation  has*  placed  the  fact 
'>^yoTid  any  doubt  that  there  exists  only  one  nervous  sys- 
tem and  that  all  vital  functions,  no  matter  whether  motor, 
sensory  or  psychical,  are  performed  by  the  same  kind 
^^  nervous  material.     It  is  therefore  perfectly  justifiable 
^^  assume,  that  all  psychical  disturbances  are  caused  by 
the  Same  disorders  which  we  are  accustomed  to  see  in  the 
peripheral  part  of  the  nervous  system.    Now  which  are  the 
tunctional  nervous  disturbances  known  to  us?    There  are 
^^  the  first  place  the  two  principal  symptoms,  spasm  and 
paralysis,  which  produce  in  the  motor  nerves  convulsions, 
V tonic  and  clonic),  and  loss  of  motion;  in  the  sensory  sys- 
tcw^,  hyperaesthesia,  (pain)  and  anaesthesia.    There  is  -be- 


i68 


WILLIAM    lllRSCH. 


sides  a  number  of  motor  disturbances  like  tremor,  ataxia, 
choreiform  movements  and  athetosis,  and  in  the  sensory 
sphere  we  recognize  many  varieties  of  paraesthesia.  If  we 
apply  these  disturbances  to  the  psychical  sphere  we  will 
be  able  to  explain  many  psychopathic  symptoms.  Paresis 
of  the  inhibitory  apparatus  will  cause  a  condition  of  ex- 
hilaration as  it  is  seen  in  maniacal  conditions  and  in  acute 
alcohol  intoxication,  while  a  spasm  of  the  inhibitory  ap- 
paratus might  cause  a  retardation  of  association  as  in  cer- 
tain cases  of  melancholia.  Psvchical  anaesthesia  and 
hyperesthesia  are  well  known  symptoms.  The  involuntary 
compulsory  movements  of  the  choreiform  or  athetoid 
nature  find  their  psychical  analogue  in  certain  morl)id  im- 
pulses, like  coprolalia  and  similar  phenomena  which  we 
are  used  to  see  especially  in  cases  of  psychical  degenera- 
tion. Psychical  ataxia  might  be  called  a  certain  disturb- 
ance in  association  as  it  is  often  seen  in  general  paresis. 

Besides  all  these  disturbances  there  is  a  phenomenon 
to  which  I  wish  to  call  your  special  attention.  Every 
practitioner  is  familiar  with  the  different  kinds  of  pain. 
Pain  may  be  produced  by  a  lesion  at  the  peripheral  end  of 
the  nerve,  in  the  peripheral  organ,  or  it  may  be  produced 
by  a  disease  of  the  nerve  itself,  as  in  genuine  neuralgia  or 
neuritis.  There  are  other  pains,  however,  of  which  hypo- 
chondriacal complaints  form  the  most  characteristic  illus- 
tration, which  originate  in  the  psychical  organ  itself.  How^ 
the  patient  explains  these  sensations  to  himself,  whether 
he  thinks  that  his  organs  are  destroyed  by  a  fatal  disease 
or  whether  he  attributes  these  sensations  to  external  in- 
fluences like  telepathy,  etc.,  makes  no  difference  as  to  the 
mechanism  of  the  phenomenon.  We  have  to  deal  in  all 
these  cases  with  sensory  hallucinations.  According  to  the 
theory  generally  offered  for  conditions  of  this  kind  there 
is  some  central  irritation,  which  by  force  of  habit  is  as- 
signed to  the  peripheral  organ.  This  theory  is  open  to  a 
good  many  objections,  so  that  it  might  be  necessary  in 
order  to  explain  fully  these  phenomena  to  assume  a  re- 


PSYCHICAL   MECHANISM    OF   DliLUSIOXS.     '      169 

verse,  i.  e.,  a  centrifugal  instead  of  a  centrigetal  action 
of  the  sensory  tract.^  Be  this  as  it  may,  the  fact  is  that 
there  are  cases  in  which  the  normal  relations  are  reversed, 
in  which  central  sensations  produce  the  conception  of 
peripheral  irritation  instead  of  being  produced  by  them. 
That  such  a  condition  also  takes  place  in  the  psychical 
sphere  in  the  production  of  hallucinations  I  have  previous- 
ly mentioned.  Now  let  us  go  one  step  further  and  consid- 
er  primary  delusions  from  this  point  of  view. 

The  normal  psychical  process  starts  from  the  simple 
sensation  of  the  different  organs  of  sense.  Sensations 
combine  with  other  sensations  and  form  a  perception. 
Through  the  combination  of  perceptions  and  the  action 
of  apperception  originate  conceptions,  which  by  the  pro- 
cess of  association  form  complicated  thoughts  and  ideas. 
Every  combined  conception  is  followed  by  a  certain  emo- 
tional state,  generally  called  mood,  which  persists  until  it 
is  replaced  by  another  emotional  state.  These  states  sur- 
vive their  underlying  conceptions,  their  duration  stand- 
ing in  a  certain  relation  to  their  intensity.  In  cases  of 
high  tension  they  may  influence  the  emotional  states  of 
the  following  conceptions,  shading  them  with  their  own 
colors.  The  complicated  ideas  and  thoughts  with  their 
emotional  states  thus  form  the  last  station  of  the  centri- 
petal psychical  process,  and  at  the  same  time  are  the  start- 
ing point  of  centrifugal  or  psychomotor  actions.  If  we 
analyse  the  psychical  process  into  its  components,  we  find 
as  the  fundamental  elements  the  sensations  of  sense,  from 
which  in  a  centripetal  way  the  process  starts  in  the  fol- 
lowing order:  Sensations  of  sense — perceptions — concefH 
tions — thoughts  and  ideas  (conchisions) — emotions  and 
moods. 


■  Shortly  after  this  paper  was  read  I  noticed  an  article  by  Benedikt 
(Die  doppelseitige  Leitung  der  Nerven.  Deutsche  medicinische 
Wochenschrift,  1897,  No.  41),  in  which  he  tries  to  explain  hypo- 
chrondriacal  and  hysterical  pains  by  a  centrifugal  action  of  the  sensory 
nerves. 


170 


H'lLUAM    HIRSCH. 


Now  let  us  apply  the  phenomenon  which  we  have  ob- 
served in  a  part  of  the  sensory  tract,  i.  e.,  the  retroaction, 
to  the  whole  psychosensory  sphere.  The  ultimate  link 
in  the  great  chain  of  the  process  of  thinking,  the  conclus- 
ion, the  ready  formed  idea,  either  produced  by  some  emo- 
tional state  or  some  other  internal  cause,  such  as  fancy, 
dreams,  etc.,  forms  the  origin  of  the  psychical  mechanism. 
In  a  centripetal  way  it  is  analyzed  into  its  components, 
is  transformed  into  various  conceptions,  which  may  go  on 
to  produce  real  perceptions,  i.  e.,  hallucinations.  Wo 
would  have  the  same  mechanism  for  the  delusion  as  we 
have  for  certain  hallucinations,  and  I  think,  it  would  fully 
correspond  to  clinical  facts  to  call  a  delusion  a  hallucina- 
tory idea.  The  morbid  condition  does  not  rest  with  the  forma- 
tion of  the  idea,  or  perhaps  a  primary  emotiofial  state  as  such — 
for  these  may  occur  under  perfectly  normal  conditions — 
it  lies  in  this  retroactive  mechanism,  by  zvhich  tlie  baseless 
conclusions  take  the  character  of  reality,  just  as  endogenic 
perceptions  are  transformed  into  real  images,  into  hallucirui- 
tions. 

Let  us  now  from  this  point  of  view  look  at  our  cases 
of  chronic  paranoia.  In  the  first  place  we  now  understand 
the  clinical  relation  between  delusions  and  hallucinations. 
We  see  why  under  certain  conditions,  i.  e.,  in  cases  of 
primary  delusions,  the  patient  believes  unreservedly  in  his 
hallucination,  while  under  other  circumstances,  i.  e.,  in 
centripetal  hallucinations  he  himself  considers  his  hallu- 
cinations as  morbid  symptoms  and  only  gradually,  because 
of  their  persistance,  begins  to  consider  them  as  true.  We 
see  (urther,why  delusions  always  bear  close  reference  to  the 
individual's  own  person.  For  it  is  clear  that  the  contents 
of  ideas  and  thoughts  which  are  not  formed  in  the  usuld 
way  by  observation  and  conclusions,  but  which  come  from 
within,  which  form  not  the  end,  but  the  starting-point  in 
the  process  of  thinking,  necessarily  must  possess  the  char- 
acter of  their  source.     We  can  also  account  now  for  the 


PSYCHICAL  MECHANISM   OF  DELUSIONS.  171 

characteristic  peculiarity  of  delusions,  not  only  to  with- 
stand all  logical  arguments,  but  to  be  aggravated  by  them 
instead  of  being  corrected.  It  is  clear  that  any  ideas 
which  have  not  originated  by  logical  conclusions  from  a 
consecutive  chain  of  thoughts,  cannot  be  corrected  by 
logical  arguments.  The  physiological  error  is  caused  by 
illogical  conclusions  or  incorrect  observation,  and  there- 
fore will  readily  yield  to  correction.  But  an  idea  which 
comes  from  within  can  not  be  influenced  from  without. 
To  try  to  correct  delusions  by  arguments,  must  therefore 
necessarily  be  just  as  fruitless  as  to  try  to  make  the  water 
in  SL  river  run  towards  its  source. 

It  will  be  now  of  special  interest  to  consider  the  gen- 
eral mental  condition  of  paranoiacs  from  the  standpoint  of 
the   theory  of  retroaction.     In  some  cases  of  acute  para- 
''oia,  where  the  retroaction  takes  place  more  or  less  in  the 
^hole  psychical  organ,  we  see  a  flood  of  delusions  break 
over   the  patient.    All  surrounding  events  are  interpreted; 
nc^mnal  perceptions  and  conclusions  seem  entirely  impos- 
sible^    If  the  retroaction  penetrates  down  to  the  centres 
°*  F^erception,  we  have  the  hallucinatory  form  of  paranoia. 
^he  surroundings  may  then  not  be  perceived  at  all  or  only 
J^  a.   fragmentary  way.    The  patient's  attention  appears  to 
"^  Entirely  absorbed  by  his  hallucinations  and  he  seems  to 
"^^    in  another  world. 

fiy  far  more  interesting  are  those  chronic  cases  of  para- 
^<^i^L  with  more  or  less  isolated  delusions  and  hallucina- 
*^^^i^s.  As  mentioned  already,  the  general  mental  condi- 
"^^*^,  especially  the  intellectual  power  of  paranoiacs  has 
^*  l«ite  years  been  made  the  subject  of  numerous  discus- 
^*^^^^s  and  controversies.  While  there  are  on  the  one  hand 
^^"vrocates  of  the  view  that  a  person  can  be  perfectly 
^^^^rnal  apart  from  one  or  a  few  isolated  delusions,  there 
on  the  other  hand  authors  who  think  that  in  every 
of  paranoia  there  exists  a  marked  diminution  of  the 
'intellectual  power.    The  former  view  is  evidently  due  to 


172 


li  ILLIAM    HIRSCH. 


in^urticient  observation.  There  is  not  one  paranoiac  whose 
mental  condition  beyond  his  delusions  can  be  called  nor- 
mal. Delusions  as  such  form  only  some  of  the  clinical 
manifestations  of  the  morbid  process  of  thinking,  and  if 
we  could  take  away  the  delusions,  the  person  would 
remain  just  as  insane  as  he  was  before.  As  to  the  latter 
view,  the  affection  of  the  intellect,  I  have  expressed  my 
opinion  before.  The  reason  that  even  excellent  observers 
and  men  of  vast  experience  believe,  that  a  certain  amount 
of  intellectual  weakness  forms  an  essential  part  of  every 
case  of  paranoia,  lies  to  a  certain  extent,  in  the  great 
contrast  which  the  contents  of  delusions  frequently  show 
to  conclusions  formed  in  the  normal  way,  and  in  the  in- 
ability of  the  patient  to  realize  the  morbid  nature  of  his 
delusions.  We  cannot  fail  to  understand  the  queer  actions 
and  the  peculiar  mental  condition  of  a  paranoiac,  if  we 
hear  in  mind  the  effect  which  a  retroactive  psychical  pro- 
cess must  necessarily  have  on  his  whole  psychical  condi- 
tion. A  baseless  idea,  a  judgment  without  logical  founda- 
tion forms  the  starting-point  of  a  long  chain  of  thought 
and  may  cause  the  individual  to  draw  from  it  all  sorts 
of  conclusions  which,  as  a  matter  of  course,  are  apt  to 
influence  the  moods  and  emotions,  which  in  their  turn 
mip^ht  again  become  the  source  of  new  retroactive  pro- 
cesses. But  the  strange  contents  of  delusions  must  by  no 
means  be  considered  as  evidence  of  a  weak  intellect.  All 
sorts  of  ideas,  even  highly  ingenious-looking  thoughts, 
might  be  produced  in  this  retroactive  manner,  a  fact  whidi 
is  sufficiently  shown  by  the  large  number  of  paranoiacal 
])rophets,  poets  and  artists  in  history.  This  theory  of  retro- 
action may  tlierefore  furnish,  perhaps,  another  clew  to  the 
alleged  relation  ])etween  genius  and  insanity,  although, 
as  I  have  always  held,  a  true  genius  is  just  as  Httle  insane 
as  a  paranoiac  is  weak-minded.  We  are  not  more  justified 
to  conclude  weak-mindedness  from  the  contents  of  de- 
lusion than  from  a  very  silly  dream,  which  as  everybody 
knows,   might   be  experienced  by   the  most   intellectual 


VSYCHICAL    MliCHAXISM    Of    DELUSIOXS.  J  73 

people-     Both  phenomena  stand  entirely  out  of  reach  of 
the  intellectual  reasoning  power. 

The  fact  that  this  disturbance  in  the  psychical  mechan- 
ism i^"*  most  cases  aft'ects  the  process  of  thinking  only  to  a 
certain  extent,  but  leaves  a  considerable  amount  of  normal 
thinking  and  logical  conclusions  undisturbed,  is  in  perfect 
harmony  with  the  analagous  process  in  hallucinations.  A 
person  may  suffer  from  hallucinations  in  one  or  the  other 
organs  of  sense,  but  at  the  same  time  have  perfectly  clear 
and  undisturbed  perceptions. 

The  fact  that  emotions  often  form  the  starting-point 
of  primary  delusions,  furnishes  an  important  indication  as 
to  the  treatment.  As  long  as  we  are  unable  to  exert  any 
direct  influence  on  the  functional  disorder  itself,  i.  e.,'on 
the  nervous  retroaction,  our  efforts  must  be  directed  to- 
wards the  possible  source,  the  emotion.  Every  one  who 
is  of>liged  to  deal  with  paranoiacs  knows  by  experience 
that  the  best  way  to  get  along  with  these  unfortunate 
patients  consists  in  a  careful  avoidance  of  all  exciting 
agents,  may  they  come  from  within  or  without,  and  that 
these  patients  will  do  best  if  their  mind  is  absorbed  by 
some  mechanical  occupation,  which  will  guard  the  moods 
from  injurious  rtuctuation.  The  beneficial  result  of  this 
purely  empirical  treatment  furnishes  therefore  a  further 
support  to  the  theory  of  nervous  retroaction. 

The  attem])t  to  explain  all  psychopathic  conditions  by 

«»sturl:>ances  known  to  us  in  the  so-called  peripheral  nerv- 

<^us  system,  stands  in  full  harmonv  with  modern  anatom- 

ical   research.      Modern   investigations  have  shown   that 

t"^  niysterious  psychical  organ  is  made  up  of  precisely 

the  sa.ine  material  as  the  peripheral  part  of  the  nerv^ous 

system.    There  is  no  difference  between  an  intracerebral 

and  a   cerebrospinal  or  spino-muscular  neuron,  and  what 

holds  good  for  the  one  must  hold  good  for  the  other.    In 

tne  same  manner  as  the  anatomical  difference  between  the 

central  and  the  peripheral  nervous  system  has  disappeared, 

^ve  nuist  learn  to  classify  all  disturbances  of  the  entire 

nervous  svstem  on  a  uniform  base. 


174 


WILLIAM   HIRSCH. 


Only  if  we  succeed  in  explaining  all  psychopathic 
symptoms  by  a  strictly  physical  mechanism,  if  we  succeed 
in  freeing  ourselves  from  al  metaphysical  notions,  the 
bridge  between  neurology  and  psychiatry  will  be  complet- 
ed, and  the  study  of  mental  diseases  will  cease  to  stand 
apart  from  the  other  branches  of  clinical  medicine. 


Educational  Uses  of  Hypnotism. 

R.  Osgood  Mason,  M.D.,  (Pediatrics,  Feb.  ist,  1897)  reports  the 
following  cases.  A  girl  of  fifteen  was  intelligent,  but  had  no  aptitude 
for  routine  school  duties.  If  she  learned  a  lesson,  it  was  forgotten  in 
class  room.  Private  teachers  were  employed  to  prepare  her  for  aii 
examination,  but  after  months  of  efforts  they  reported  it  was  useless  for 
her  to  go  on.  At  this  time  she  was  treated  by  hypnotic  suggestion. 
Improvement  was  immediate,  both  in  ability  to  study  and  recite.  After 
six  treatments  she  greatly  surprised  her  teachers  by  passing  her  exam- 
ination with  a  percentage  of  79,  which  entitled  her  to  come  up  for  a 
college  examination,  and  later  on  passed  her  entrance  examination 
with  a  percentage  of  88.  An  intelligent  but  uneducated  woman,  al- 
though a  good  reader,  experienced  great  difficulty  in  spelling.  All 
her  life  she  had  been  a  sleep  walker.  She  was  an  excellent  hypnotic 
subject,  and  a  single  treatment  entirely  cured  her  somnambulism,  so 
that  she  has  not  left  her  bed  for  two  years.  Hypnotism  was  also  tried 
for  her  inability  to  spell.  The  effect  was  immediate,  and  after  two  or 
three  treatments  she  wrote  a  four-page  note  without  consulting  a 
dictionary — with  only  two  or  three  errors.  Her  language  was  that  of 
an  uneducated  person,  but  after  half  a  dozen  suggestions  it  became 
greatly  improved,  though  not  faultless.  A  little  boy  was  a  most  un- 
happy coward,  afraid  of  pain  and  a  cry-baby  among  his  playmates. 
Hypnotic  treatment  caused  a  marked  change  in  his  manner — all  cry- 
ing and  cowardice  disappeared  and  he  is  now  self-reliant  and  happy. 
A  little  girl  was  troubled  with  night  terror.  She  slept  soundly  when 
first  put  to  bed,  but  after  two  or  three  hours  awoke  screaming  on 
account  of  a  hideous  black  man  she  saw  in  her  dream.  Her  sleep, 
since  under  hypnotic  treatment,  has  been  perfect.  A  boy,  addicted  to 
self-abuse  and  cigarette  smoking,  had  a  poor  memory,  was  backward 
in  studies,  dejected  and  unmanly.  The  habit  of  self-abuse  was  cured 
in  one  month,  and  he  finally  only  smoked  one  cigarette  a  week.  There 
was  also  great  improvement  in  his  memory  and  interest  in  studies. 
A  young  man  suffered  from  morbid  sexual  ideas  and  practices  of  the 
homo-sexual  type.  A  week  after  treatment  he  reported  almost  entire 
freedom  from  his  troublesome  instincts  and  imaginings.  A  young  man 
whose  dominent  idea  had  reference  to  disease,  feared  and  expected  to 
be  attacked  by  every  ailment  which  he  heard  of.  He  was  unable  to 
attend  to  business,  and  had  frequent  suicidal  impulses.  He  was  a  good 
hypnotic  subject  and  the  cure  was  complete.  Dr.  Mason  remarks  that 
in  none  of  these  cases  has  the  patient's  will  been  weakened — in  no- 
case  has  he  been  made  dependent  upon  the  hypnotizer,  nor  has  any 
hypnotic  habit  been  formed;  the  power  of  self-control  has  not  been 
diminished,  but,  on  the  contrary,  he  has  been  helped  to  do  the  very 
thing  which  in  his  best  moments  he  desired  to  do  and  of  himself  was. 
not  able  to  accomplish.  Freeman. 


EQUILIBRATION  AND  ITS  RELATION  TO 

VERTIGO.^ 

By  frank  K.  HALLOCK, 
Cromwell,  Conn. 

The  following  physiological  considerations  may  be 
reg*aJ"ded  as  preliminary  to  a  future  discussion  of  the  or- 
igin and  mode  of  development  of  the  various  forms  of 
vertigo.  The  chief  point  of  this  article  is  an  attempt  to 
show  the  importance  of  the  relation  of  the  cortical  centres 
to  the  act  of  equilibration. 

X^ertigo  is  essentially  a  psychical  phenomenon  and 
may  be  defined  as  the  consciousness  of  a  disturbance  of 
the  body  equilibrium.  The  maintenance  of  equilibrium 
represents  the  action  of  those  forces  in  the  organsim  hav- 
ing- to  do  with  the  preservation  of  the  position  of  the  body 
in  space.  This  preservation  of  the  body  equipoise  is  only 
one  cf  the  acts  comprising  the  general  process  of  equi- 
li^^ration  which  consists  of  the  balancing  of  all  forces  oper- 
atingr  jn  the  organism.  These  forces  are  called  functions, 
a^<i     equilibration,   therefore,  in  its  broad   philosophical 

m 

^^firriificance  is  the  maintenance  of  the  physiological  bal- 
ance. Frequently,  however,  the  term  "equilibration'^  is  used 
m  a.  restricted  sense  as  meaning  simply  the  act  of  main- 
taining the  equilibrium.  Thus  limited  and  defined,  the 
^^pression  will  be  more  convenient,  and  for  the  present 
P^'^pose  will  be  so  employed. 

XJnder  normal  conditions  the  act  of  maintaining  the 

^^'^ilibrium  is  carried  on  automatically  and  independently 

o>  consciousness,  and  it  is  only  when  there  occurs  a  defect 

^^  ^he  mechanism  of  the  process  that  we  become  conscious 

^*  the  result  of  its  defective  operation.    This  result  is  that 

V^C'uliar  sensation  called  giddiness  or  dizziness,  or  when 

Presented  at  the  Annual  Meeting  of  the  American  Neurological 
Association.  May,  1897. 


176 


FRANK  K.  HALLOCK. 


the  sensation  is  more  intense,  it  is  termed  vertigo.  At  no 
time  are  we  conscious  of  the  process  of  equilibration  either 
in  its  defective  or  normal  action.  We  are  conscious  only 
of  the  results  of  this  action,  which  in  the  case  of  defective 
equilibration  is  the  sensation  of  vertigo,  and  in  the  case 
of  normal  equilibration  is  the  sensation  of  maintained 
equilibrium.  Ordinarily,  this  latter  sensation  is  not  per- 
ceived in  consciousness  unless  it  is  made  the  object  of 
special  attention.  When  this  is  done  the  act  of  equilibration 
ceases  to  be  automatic  and  becomes  in  part  voluntary, 
that  is,  it  is  associated  with  consciousness  and,  therefore, 
may  be  said  to  have  a  psychical  element.  The  simplest 
kind  of  action  which  will  illustrate  the  operation  of  this 
psychical  element  is  that  of  voluntary  body  balancing.  In 
such  effort  the  action  of  muscle  in  correspondence  to  sen- 
sory stimuli  does  apparently  yield  distinct  sensations  which 
can  best  be  described  as  those  of  lost  or  maintained  bal- 
ance. It  is  also  possible  to  conceive  of  these  acquired  re- 
flex sensations  as  of  frequent  occurrence  in  the  conscious- 
ness of  a  child  learning  to  walk.  As  the  motor  adjustment 
to  the  sensory  stimuli  becomes  more  perfect,  the  resulting 
sensation  grows  less  vivid  in  consciousness  until,  finally, 
by  constant  repetition,  the  act  of  equilibration,  like  the 
act  of  coordination,  with  which  it  is  closely  associated, 
becomes  purely  automatic.  The  term  automaticj  rather 
than  reflex,  is  used  to  denote  that  the  act  is  a  complex  of 
reflex  acts  and  may  be  subject  to  modification  by  inter- 
current cortical  influence. 

In  this  act  of  body  balancing,  which  represents  the 
mildest  form  of  equilibratory  disturbance,  there  is  no  true 
vertiginous  sensation.  Such  sensation  as  does  exist  is  the 
result  of  a  series  of  sensori-motor  processes,  each  short, 
complete  and  successful  in  its  alternating  loss  and  recovery 
of  the  body  equipoise.  If  we  were  to  imagine  a  rapid  suc- 
cession of  ineff'ectual  attempts  to  regain  the  body  balance, 
then  the  sensation  of  vertigo  would  arise  in  consciousness. 


EQUILIBRATION  AND    VERTIGO,  tJJ 

The  act  of  maintaining  the  body  equilibrium  t>r  equi- 
libration, using  the  term  in  its  restricted  sense,  as  an  or- 
ganic process  is  dependent  not  upon  the  operation  of  a 
special  equilibratory  apparatus  or  centre,  such  as  has  been 
suggested  to  exist  in  the  semi-circular  canals  and  cere- 
bellum, but  upon  the  operation  of  all  parts  of  the  general 
sensory-motor  system  which  in  any  way  subserve  the  prO:- 
cess  in  question.    The  action  of  these  parts  is  not  separate 
and  distinct,  it  is  combined,  and  yet  the  impairment  or  ab-? 
scence  of  one  or  more  parts  does  not  necessarily  destroy 
the  general  function,  it  simply  limits  its  extent  and  power.. 
Thus,  admitting  the  importance  of  the  part  played  by  the 
semi-circular  canals,  it  is  noted  that  their  destruction  does 
"ot  aparently  interfere  with  the  continuance  of  satisfact- 
ory equilibration.  < 
Likewise,  loss  of  vision  and  impairment  of  the  tactile 
sense    may  occur,  and  yet  the  body  equipoise  be  main- 
tained.    Indeed,  it  is  possible  to  conceive  that  all  sensory 
stimuli  may  be  diminished  to  the  point  of  barely  permit- 
ting the  simplest  motor  co-ordinations,  and  still  conscious- 
ness be  not  aware  of  disturbance  of  the  equilibrium.    Ex- 
periments with  animals  have  shown  that  the  function  of 
equilibration  may  still  persist  after  the  removal  of  the  cere- 
bral  hemispheres.      This  fact  clearly  demonstrates  that 
consciousness  is  not  an  essential  factor  in  the  act.     It  is 
also  certain  that  the  cutting  off  of  all  sensation  would 
render  the  phenomenon  of  vertigo  impossible.    The  sever- 
est attacks  of  vertigo  occur  only  when  the  sensory  paths 
are  in    a  condition  to  transmit  powerful,  but  perverted 
stimulations  to  encephalic  centres. 

^Vliile  there  need  not  be,  therefore,  and  commonly  is 

not,  a  psychical  element  in  equilibration,  it  is  nevertheless 

ttue  that  in  man  this  act  in  its  very  highest  development 

niay  be  considered  not  a  purely  physiological  but  a  psycho- 

p\^ysiological  affair.    And  viewed  as  automatic,  it  may  be 

saul  to  he  by  a  species  of  retrogressive  development  the 


K^ 


FR^^.SK   K 


HA. 


jIkK. 


result  in  part  ot  canicious  or  volun;ar\-  acts.  Thus,  in  the 
child  learning  to  walk,  or  in  feats  of  body  balancing,  the 
acts  l>ecome  automatic  by  practice,  i.  <•.,  by  repetition,  and 
what  are  largely  voluntary-  acts,  executed  at  first  with  the 
aid  of  consciousness,  gradually  lose  their  psychical  con- 
comitant and  become  automatic- 

In  the  act  of  locomotion,  which  is  an  allied  sensor- 
motor  mechanism  to  that  of  equilibration,  the  psychical 
element  is  present  to  a  greater  degree.  Yet  it  is  constant 
experience  that  the  act  of  locomotion  once  thoroughly 
inaugurated  is  frequently  carried  on  apparently  automatic- 
ally,tliat  is  independently  of  consciousness  for  short  periods 
at  least.  Equilibration  is  not  only  associated  with  loco- 
motion, it  also  underlies  it  as  a  primar>-  function.  Loco- 
motion cannot  occur  without  equilibration,  and  on  the 
other  hand  locomotion  is  not  essential  to  equilibration, 
as  it  is  conceivable  for  an  individual  to  maintain  the  bal- 
ance without  being  able  to  walk.  The  fitness  and  advant- 
age of  equilibration  becoming  automatic  is  obvious  from 
the  fact  that  no  act  of  such  constant  and  fundamental  im- 
portance could  have  a  psychical  concomitant  without  seri- 
ously embarrassing  the  efficiency  of  action.  In  other 
words,  conscious  effort  to  adjust  the  body  after  each 
change  of  position  would  subject  all  movements  to  delay 
and  imperfect  execution. 

Considering  now  the  purely  physiological  side  of  equil- 
ibration, we  find  that  the  act  consists  of  the  operation 
of  three  sets  of  factors. 

First,  peripheral  end  organs  with  their  afferent  nerves 
conducting  sensory  stimuli. 

Second,  co-ordinating  centres  receiving  these  stimuli. 

Third,  efferent  nerves  from  these  centres  conducting 
motor  impulses  to  the  skeletal  muscles. 

The  first  group  of  factors  represents  sensory  stimuli 
arising  from  all  sources  in  the  periphery  which  are  capable 
of  yielding  directly  or  indirectly  sensations  of  the  positions 


\ 


'  '  EQUILIBRATION  AND    VERTIGO,  IJi) 

of  the  body.    The  three  chief  sources  of  these  stimuli  are, 

first,  organs  and  nerves  in  the  skin  receiving  and  trans- 

niitting  tactile  impressions.    Also  grouped  with  this  class 

^t"e  the  sensory  nerves  of  the  muscles,  tendons,  ligaments 

^d  joints  which  transmit  impressions  indicating  the  posi- 

Uon  of  the  limbs  or  body  as  a  whole.    This  is  the  so-called 

muscular  sense. 

Second,  the  eyes  with  their  retinal  expansion  receiving 
and  transmitting  visual  impressions  through  the  optic 
nevxt. 

Third,  the  semicircular  canals  of  the  internal  ear  re- 
ceiving and  transmitting  through  the  vestibular  branch 
of  the  auditory  nerve  stimuli,  which  indicate  the  position 
and  balance  of  the  head,  and  less  directly  play  a  part  in 
the  precision  of  movement  and  general  state  of  equilibri- 
um throughout  the  body. 

The  coordinating  centres,  located  chiefly  in  the  mes- 
encephalon and  cerebellum,  are  the  second  factor  in  the 
act  of  equilibration.  Animal  experimentation  and  patholog- 
ical conditions  in  man  show  the  connection  of  those  centres 
both  with  the  cortex  above  and  the  lower  centres  in  the 
spinal  cord.  On  one  hand,  following  injury  or  absence  of  the 
hemispheres,  the  subcortical  centres  are  seen  to  function- 
ate satisfactorily  for  all  simple  peripherally  initiated  acts 
of  equilibration,  while  the  complex  or  originating  acts  fail 
of  execution.  On  the  other  hand,  injury  to  the  mesen- 
cephalic or  cerebellar  centres  causes  direct  and  more  or 
less  permanent  impairment  of  the  simple  as  well  as  com- 
phcated  acts  of  equilibration. 

The  third  factor  is  the  system  of  efferent  nerves  from 
these  centres  carrying  motor  impulses  which  excite  mus- 
cular action,  thereby  adjusting  the  position  of  the  body  in 
accordance  with  sensory  stimuli  previously  received. 

The  imperfect  operation  of  any  part  or  the  whole  of 
this  triple  mechanism  may  give  rise  to  a  vertiginous  sen- 
sation which  will  correspond  to  the  degree  and  extent  of 


i8o 


FRANK  K.  HALLOCK. 


the  disturbance  of  this  mechanism.  In  the  order  of  im- 
portance the  coordinating  centres  take  precedence  over 
the  other  factors,  and  it  mav  be  stated  that  unless  the 
disturbance  in  any  part  of  the  mechanism  also  involves 
these  centres  no  vertigo  will  result.  They  preside,  as  it 
were,  over  the  functions  of  equilibration,  and  on  their  in- 
tegrity depends  the  success  of  adjusting  the  efferent  motor 
impulses  to  the  afferent  stimulations.  These  centres  are 
subject  to  two  classes  of  impulses^  first,  the  peripheral 
afferent  stimuli,  and  secondly,  influences  from. the  higher 
cortical  centres,  which,  may  modify  or  interrupt  their 
action.  In  the  case  of  absence  or  perversion  of  stimuli 
from  any  point  in  the  periphery,  e.  g.,  the  eye,  we  note 
that  the  coordinating  centre  accommodates  itself  to  the 
deficiency  and  carries  on  the  mechanism  for  all  ordinary 
acts  of  equilibration  nearly  as  completely  as  before.  The 
cortical  or  psychical  influence  on  the  equilibrial  centres 
is  seen  under  emotional  conditions. 

The  efferent  nerves  are  the  least  important  factor  in 
the  general  mechanism  of  equilibration.  They,  and  the 
muscles  they  innervate,  may  be  subject  to  serious  disorder, 
and  yet  no  vertigo  result  unless  the  coordinating  centres 
from  which  the  impulses  are  derived  are  likewise  disturbed. 
This  is  seen  in  advanced  ataxia.  The  movements'  of  the 
legs  may  be  so  imperfect  and  uncertain  that  the  patient 
cannot  stand  or  walk,  and  yet  no  vertigo  results  because 
the  sensation  of  lost  balance  ceases  when  the  effort  stops. 
The  sensation  of  disturbed,  or  lost,  balance  must  persist 
in  consciousness  in  order  to  produce  vertigo. 

Pursuing  in  brief  detail  the  study  of  the  sensory  sti- 
muli on  which  the  integrity  of  the  equilibrial  centres  in 
the  main  depends,  the  truth  of  the  assertion  that  the  act 
of  equilibration  is  of  compound  and  not  simple  nature, 
is  soon  made  evident.  Considering  first  tjie  influence  of 
tactile  and  muscular  sense  impressions,  it  is  noted  that 
removal  of  the  skin  of  the  hind  limbs  of  the  frog,  or  Heyd's 


EQUILIBRATION  AND    VERTIGO,  l8l 

experiment  in  man  of  benumbing  the  cutaneous  nerve 
•endings  in  the  soles  of  the  feet  by  chloroform,  results  in 
difficulty  in  standing  and  keeping  the  body  balance.     In 
locomotor  ataxia  we  have  the  combined  effect  of  impaired 
tactile  sensibility  and  also  disturbed  joint-muscular  im- 
pressions resulting  from  the  ataxic  condition.     In  main- 
taining the  equilibrium  the  ataxia  is  relatively  of  less  im- 
portance than  the  loss  of  skin  sensibility.     That  is,  the 
ataxia,  may  be  pronounced  without  marked  equilibrial  dis 
turbance,  and  vice  versa,  the  equilibrium  may  be  greatly 
disturbed  without  ataxia.     With  the  loss  of  tactile  sensi- 
bility, say  of  the  soles  of  the  feet,  however,  there  always 
occurs  difficulty  in  balancing  the  body,  and  the  amount 
of  this  difficulty  seems  to  depend  more  upon  the  degree 
of  impaired  tactilie  sensibility  than  upon  the  degree  of 
^taxi3.. 

The  effect   of  visual   stimuli   upon   the  above   phen- 
omena is  very  distinct,  and  shows  the  intimate  relation 
existing  between  the  tactile  and  muscular  sense.   In  every 
instance  the  difficulty  of  maintaining  the  balance  is  im- 
mensely lessened  provided  the  eyes  remain  open.    Within 
certain  limitations  the  impairment  of  both  the  tactile  and 
muscvilar  sense  may  be  compensated  for  by  the  visual 
sens^.    The  simple  standing  erect  of  the  ataxic  individual 
with  eyes  alternately  open  and  shut  will  illustrate  the  close 
assooiation  of  the  two  kinds  of  stimuli  in  their  effect  upon 
the   equilibratory  centres.       In  the  blind  the  absence  of 
V1SU3.1  impressions  requires  the  higher  development  of  the 
tactile  and   muscular   senses,   with   a   consequent    much 
greater  dependence  upon  stimuli  of  this  character.     But 
^^    '^Xxe  normal  individual  the  two  sets  of  stimuli  are  de- 
veloped together,  the  eyes  noting  the  point  of  contact 
and.   following  the  movement  of  the  limbs  in  the  various 
positions  assumed  independently,  or  in  relation  to  cx- 
t^rnal  objects. 

Visual  stimuli  may  exert  a  disturbing  effect  upon  equi- 


>2  =i-5.VX  SL  HJJJSJI^ 

.ratu-jn  m  :-wi  laaj?.  Firit,  cj  the  unusual  movement 
A  z^^s^fL  rji  cc;ec:i5  in.  :-«  aei'i  of  vision,  soch  as  is 
:pene::cefL  on  cnj-^-zie  "-^j— -  or  m  regarding  those  pas- 
■^.  tn  vBatcr.irs:  }"»Tf:'_7  f-r-r-ne  water,  in  looking  over 
precipice,  etc  The  Tiscai  impressitjos  ariang  from  the 
itrarjTCirarv  reiaiioa  ot  external  objects  demand  new 
A  ancommoti  ccerenc  impclses  which  the  equilibria! 
Titres  are  not  caca-ole  oc  nimLicin^.     Hence,  a  {ailure 

the  motor  adJTXitnwin  to  the  a^erent  stimtilation  re- 
iti.  ar.d  conicqtient  cpoa  this  ailtire  there  arise  in 
msciocsnesa  feelings  oi  insecnrity.  of  abnormal  body 
miw/ti  and  space  relatiotLihip.  ot  tmperlect  balance  anfd 
zrinesa. 

Secondly,  these  same  sensatiofis  may  be  experienced 
ilowing  perverted  ^.-istia!  impressions  dependent  upon 
e  defective  operation  of  the  ocniomotor  mechanism. 
tie  condition  of  nyitagmui,  or  of  paralysis  of  the  external 
ctU5  muicie  of  the  eyeba!!.  vieids  disturbed  \-isual  im- 
essions  which  produce  the  feelings  in  consciousness  men- 
"jned  above- 
Pairing  now  to  the  consideration  of  the  semicircular 
nals  we  come  to  the  most  important  factor  in  the  main- 
nance  of  equihbrium.  \\  ithout  attempting  to  deline 
le  exact  nature  of  the  semicircular  canal  stimuli,  it  will 

'iifncient  to  say  i  hat  there  is  no  reasonable  d -iih^  among 
lysiologists  that  such  stimuli  exist,  and  that  they  play 
part  in  the  movements  of  the  head  and  body,  particularly 

regard  to  the  precision  and  equilibration  of  the  muscular 
ts.  The  evidence  of  this  function  is  derived  through 
:perimentation  upon  the  canals  in  aninials.an<l  thepatho- 
gical  and  functional  disturbances  of  the  ear  in  man. 
he  work  of  Flourens  and  subsequent  investigators  is  snf- 
Hently  convincing. and  the  disturbance  of  the  equilibrium 
sociated  with  affections  of  the  ear  in  the  symptom-com- 
ex,  called  Meniere's  disea.se.  is  unmistakable  proof  of 
sordcred  semicircular  canal  stimuli,     it  has  been  argued 


EQUILIBRATION   AND    VERTIGO,  185 

that  these  canals  can  not  be  such  an  important  factor  in 
equilibration  as  claimed,  because  we  are  so  unconscious 
of  their  operation.    It  is  true  that  the  stimuli  arising  in 
the  canals  and  carried  by  the  vestibular  nerve  do  not  excite 
sensations  such  as  result  correspondingly  to  the  visual 
or  tactile  stimuli,  but  this  very  fact  may  be  said  to  indicate 
the  deeper  and  vital  nerve  function  of  these  organs.    The 
acts  of  respiration,  circulation  and  digestion  under  normal 
conditions  yield  no  sensation.      Similarly  if  we  consider 
what  a  fundamental  and  vital  process  the  act  of  equilibra- 
tion is,  how  it  lies  at  the  very  bottom  of  organic  stability 
and  the  preservation  of  the  body  in  space,  then  it  is  easy 
to  see  how  the  function  should  be  independent  of  con- 
sciousness.   It  is  a  function,  too,  which  has  existed  from 
the  moment  of  birth,  and,  viewed  psychologically,  must 
have  been  present  in  an  incipient  degree  previous  to  the 
development  and  incorporation  of  its  visual  and  tactile 
'actors.     In  considering  the  cutaneous  sensations,  it  is 
possible  to  conceive  that  the  atmosphere  may  produce  by 
pressure  upon  the'tactile  endorgans  continuous  inflowing 
stimuli,  which  by  reason  of  their  constant  and  familiar 
existence  fail  to  develop  sensation.     If  a  change  in  this 
pressure  occurs  beyond  the  ordinary  limits,  then  the  stim- 
ulus yields  a  sensation.    In  a  similar  manner  one  can  con- 
ceive of  the  normal  unconscious  influx  of  stimuli  from  the 
semicircular  canals.     The  ordinary  atmospheric  pressure 
without  in  conjunction  with  a  given  state  of  the  endo- 
lymph  of  the  canals^-which  is  also  subject  to  internal 
variations  from  moment  to  momenf ,  owing  to  the  position 
and  movements  of  the  head — may  produce  stimuli  which 
affect  the  coordinating  centres  below  the  level  of  con- 
sciousness.  If  now  the  external  pressure  varies,  being  mark- 
tdVy  increased  or  decreased,  as  occurs  by  forcing  air  in 
X«e  ear,  or  in  a  caisson,  or  if  the  internal  condition  of  the 
canal  contents  departs  from  the  normal,  c.  g.,  by  sharp 
change  in  the  tension  due  to  circulatory  disorder,  then 


IS4 


FRANK  K.  HALLOCK. 


3,  variation  occurs  in  the  character  of  the  canal  stimuli. 
There  is  this  difference,  however,  between  the  change  of 
stimuli  of  the  skin  and  canals.  In  the  former  we  are  directly 
conscious  of  the  change,  as  interpreted  by  corresponding 
sensations.  I'l'r.,  touch  or  pressure.  In  the  latter  instance, 
by  virtue  of  the  change  in  stimuli,  we  are  conscious  of 
sensation  corresponding  to  the  stimuli,  but  of  a  totally 
different  sensation,  t-ir.,  dizziness  which  cannot  be  traced 
directly  to  the  canal  stimuli. 

This  dizziness  may  be  compared  in  character  to  the 
sensations  of  hunger,  thirst,  and  nausea,  which  cannot  be 
directly  connected  in  consciousness  with  the  stimuli  origi- 
nating them.  All  of  these  sensations  are  complex  in 
nature,  and  there  does  not  exist  the  simple  immediate 
relation  between  the  stimulus  and  sensation  as  in  the  case 
of  pressure  on  the  skin.  Although  of  such  a  general  and 
indefinite  character,  they  are  all  more  or  less  referrable  to 
that  region  of  the  body  from  which  the  stimuli  come. 
Thus,  thirst  is  referred  to  the  mouth  and  throat,  hunger 
and  nausea  to  the  stomach.  The  diminution  of  water  in 
the  cells  of  the  mucous  membrane  of  the  mouth,  tongue 
and  pharynx  may  generate  stimuli  which  are  the  chief 
factor  in  the  production  of  a  general  body  condition  which 
is  represented  in  consciousness  as  the  feeling  of  thirst.  In 
like  manner,  hunger  and  nausea  may  arise  from  the  alter- 
ations in  the  gastric  mucous  membrane.  In  dizziness, 
especially  of  pronounced  degree,  aural  symptoms  are  al- 
most always  present,  but  the  condition  is  so  general,  in- 
volving, as  it  does,  both  visual  and  tactile  factors,  that 
the  individual  fails  to  refer  it  to  the  ear. 

While  the  semicircular  canals  are  undoubtedly  a  factor 
of  most  unique  and  special  character  in  the  act  of  equil- 
ibration, it  is  still  true  that  their  absence  or  destruction 
•does  not  prevent  the  maintenance  of  the  equilibrium.  Ani- 
mals deprived  of  their  canals  show  marked  impairment  in 
Iheir  equilibrating  power  which  is  never  fully  recovered. 


EQUILIBRATION  AND    VERTIGO,  1 85 

In  deaf  mutes  and  persons  who  have  suffered  from  de- 
structive lesions  of  the  labyrinth,  vertigo  is  a  rare  symp- 
tom, and  cannot  be  induced  experimentally  with  anything 
like  the  frequency  that  it  can  in  normal  individuals.  The 
loss  of  the  semicircular  canal  stimuli  is  compensated  for  in 
great  part  by  the  visual  and  tactile  stimuli,  but  the  com- 
plex and  highly  developed  acts  of  equilibration  are  not  ^ 
possible^  and  the  capacity  of  the  individual  to  experience 
vertigo  is  correspondingly  decreased. 

As  stated  at  theoutset,underordinaryconditionsequili- j 
bration  is  an  automatic  process,  but  it  has  been  shown ' 
that  whenever  it  is  associated  with  con3cious  effort,  it 
necessarily  acquires  a  psychical  element.  That  it  is  pos- 
sible to  introduce  this  psychical  or  subjective  element  at 
all  times  becomes  apparent  when  we  consider  that  the 
afferent  sensory  stimuli  necessary  to  the  act  of  equilibra- 
tion are  the  same  as  those  which  yield  the  sensation  of 
position  in  consciousness,  that  is,  we  are  conscious  from 
moment  to  moment  of  our  position  in  space,  and  the 
relation  of  the  body  to  external  objects.  Indeed,  it  may 
be  said  that  equilibration  depends  for  its  existence  on  the 
combined  action  of  stimuli  which  occasion  sensations  of 
position  and  sensation  of  motion,  but  we  do  not  com- 
monly make  any  conscious  application  of  these  sensations 
in  the  execution  of  the  act.  These  afferent  stimuli,  there- 
fore, may  be  said  to  have  a  two-fold  effect,  one  is  the  pro- 
duction of  pure  sensations  of  position,  and  the  other  is 
the  concomitant  exciting  of  centres  below  consciousness, 
whereby  the  body  equilibrium  continues  to  be  preserved. 
I^  is  probably,  as  sugested  in  the  early  life  of  the  child, 
t^hat  the  sensations  of  position  were  made  use  of  as  a 
psychical  factor  in  the  act  of  equilibration,  but  g^radually, 
•^  the  act  became  more  perfect,  i.  e.,  more  automatic, 
these  sensations  ceased  to  be  necessary  as  being  con- 

<5fc^voiisly  related  to  the  act.      If  the  maintenance  of  the 
equilibrium  can  be  defined  as  the  action  of  those  forces  in 


S6  FRANK  K.  HALLOCK. 

he  organism  having  to  do  with  the  preservation  of  the 
losition  of  the  body  in  space,  then  the  consciousness  of 
disturbance  of  equilibrium,  or  vertigo,  may  be  inter- 
preted as  the  consciousness  of  a  disturbance  of  the  body 
losition.  This  definition  of  vertigo  is,  indeed,  correct 
^ith  the  qualification  that  the  disturbance  is  of  a  peculiar 
ind.  It  is  not  every  disturbance  or  change  of  the  body 
osition  which  is  temporary  and  due  to  inadequate  motor 
cts,  but  rather  a  permanent  disturbance  both  of  the  cor- 
ical  and  subcortical  nerve  centres,  due  to  the  continuous 
iflux  of  disordered  sensory  stimuli  from  the  periphery, 
'he  individual,  therefore,  becomes  doubly  conscious  of 
isturbed  spacial  relation,  primarily,  as  the  direct  result  of 
he  distorted  sensory  stimuli  on  the  cortex,  and  secon- 
arily.  as  the  result  of  the  disturbed  equilibrium  or  its 
quivalent  disturbed  body  position  which  is  occasioned 
Iso  by  these  same  stimuli  acting  through  the  medium 
f  the  subcortical  centres.  The  actively  disturbed  body 
quilibrium,  therefore,  may  be  considered  as  representing 
le  motor  side,  or  motor  expression,  of  the  disturbed 
Dndition  of  both  the  cortical  and  subcortical  centres. 

Stimulation  of  the  optic,  auditory,  and  nerves  of  gen- 
ral  sensibility  give  rise  constantly  to  sensations  of  posi- 
on  when  the  body  is  at  rest,  and  equilibrium  can  become 
:tively  associated  with  these  sensations  only  when  the 
ody  is  under  the  tension  of  the  act.  either  in  the  erect 
osition  or  motion.  Hence,  in  the  passive  condition  of 
le  body,  sensations  of  position  arc  developed  through 
urely  sensory  stimuli,  in  the  active  state  of  the  body,  the 
ime  stimuli  are  in  operation  plus  the  motor  adjustment 
fcessitated  by  them,  but  without  the  development  of 
insations  as  far  as  this  specific  adjustment  is  concerned. 
1  the  latter  instance  of  the  body  in  motion,  the  eguilibri- 
Ti  which  is  maintained  may  be  termed  dynanjic.  in  the 
■nse  of  Ijeing  dependent  largely  upon  motor  effort;  in 
le  former  instance,  when  the  body  is  at  rest,  the  equilibri- 


EQUIUBRATION  AND    VERTIGO,  187 

uni  is  almost  purely  psychical,  and  may  be  designated  as 
static,  being  dependent  upon  normal  sensory  stimuli  but 
without  motor  excitation. 

The  result  of  this  excitation  or  adjustment  is  present 
ill  consciousness  as  the  sensation  of  maintained  equilibri- 
um or  body  position,  and  if  this  adjustment  is  imperfect 
and  continuous,  then  sensations  of  disturbed  body  posi- 
tion are  the  chief  feature  of  consciousness.     Hence,  sum- 
ming  up  the  act  of  equiUbration  in  its  entirety,  it  would 
seem  justifiable  in  considering  it  a  psycho-physiological 
process,  to  define  its  psychical  element  as  the  conscious- 
ness of  body  position,  while  the  muscular  adjustment 
maintaining  this  position  represents  the  motor  element  of 
the  same  process.    Certainly,  in  vertigo  we  have,  on  the 
ont  side,  the  consciousness  of  disturbed  body  and  spacial 
relationship,  and  on  the  other,  the  consciousness  of  un- 
availing motor  efforts  to  rectify  this  relationship. 

Most  writers  on  the  subject  of  equilibration  and  vertigo 
W'e  emphasized  the  physiological  side  of  the  problem, 
^nd  it  has  seemed  to  the  author  that  the  failure  to  recog- 
nize the  importance  of  the  psychical  element  hasprevented 
the  full  understanding  of  the  nature  of  vertigo.    The  fact 
that  equilibration  can,  and  ordinarily  does  occur,  inde- 
pendent of  consciousness,  has  led  to  the  ignoring  of  the 
influence  and  connection  of  the  cortex  with  the  act.     It 
seems  to  have  escaped  notice  that  the  integrity  of  the  act 
depends  almost  as  much  upon  the  condition  of  the  cortical 
as  upon  the  mesencephalic  and  cerebellar  centres.    Thus, 
if  the  psychical  centre,  or  consciousness,  is  clear,  equili- 
bration is  perfect ;  if  consciousness  is  clouded  or  disturbed 
from  the  normal  condition,  then  equilibration  is,  or  may 
be  imperfect,  depending  upon  the  character  of  the  cortical 
disturbance.     As  far  as  equilibration  is  concerned,  con- 
sciousness may  become  clouded  in  two  ways:  directly,  by 
the  reception  of  disturbed  sensory  stimuli  yielding"  sensa- 
tions of  disturbed  body  position,  as  is  the  case  of  true 


i8  FRANK  K.  HALWCK. 

■imary  vertigo;  or  indirectly,  by  the  occupation  of  the 
hole  field  of  consciousness  by  other  sensations  to  the 
Lclusion  or  modification  of  its  normal  space  and  position 
tributes.  This  latter  condition  occii  s  iind  r  s.ronj  en-o- 
Dn,  shock,  pain,  or  the  effect  of  an  idea.  The  dizziness 
■  loss  of  the  sense  of  position  which  accompanies  this 
indition  of  consciousness  results,  primarily,  not  from  dis- 
irbed  sensory  stimuli,  but  from  the  more  or  less  complete 
(sorption  of  consciousness  in  some  powerful  impression 
ade  upon  it.  Consciousness  is  preoccupied,  and  the 
nsory  stimuli  fail  to  produce  their  natural  effect;  they 
e  negated,  and  consciousness,  therefore,  is  without  its 
ual  statical  attributes.  The  vertigo  associated  with 
istric  disorders,  cranial  nerve  crises,  emotional  states. 

whenever  present  and  not  originally  due  to  perverted 
isition  stimuli,  can  only  be  satisfactorily  explained  by 
cognizing  the  cortex  as  a  factor  in  the  function  of  equili- 
ation 

The  ground  or  basis  for  advocating  the  importance  of 
e  condition  of  the  cortex  in  the  act  of  equihbratton,  and 

related  to  the  production  of  vertigo,  is  the  principle  of 
ycho-physiologyso  ably  developed  among  English  medi- 
1  writers,  by  Hughlings-Jackson,  and  supported  by  the 
atomical  and  embryological  researches  of  Flechsig,  viz., 
at  all  parts  of  the  body  have  a  representation  in  the 
rtical  centres,  and  conversely,  that  these  centres  may 
ert  an  influence  on  all  these  parts.  Also,  in  connection 
th  this  principle  is  the  accepted  fact  that  all  ideas  or 
isations  tend  to  express  themselves,  so  that  whatever 
e  state  of  consciousness  may  be,  there  exists  a  constant 
idency  for  it  to  be  manifested  outwardly. 

The  understanding  of  this  principle  of  cortical  inflii- 
ce,  the  writer  believes,  is  the  key  to  the  explanation  of 

forms  of  vertigo  which  arise  outside  of  the  primary  in- 
Ivement  of  the  special  sensory  stimuli  which  yield  sen- 
tions  of  position. 


A  REPORT  OF  A  CASE  OF  UNUSUAL  EDEMA 

IN  HEMIPLEGIA.' 

By  H.  A.  HARE,  M.D., 
Prafoacr  ol  Tliet«penUcs  in  the  JeSeraon  Medical  CoUetce.  Philadelpliia,  F>. 

The  case  that  I  desire  to  present  this  evening  will  be  , 
described  in  detail  in  a  few  minutes.    I  report  it  because 
the  extraordinary  edema  of  the  hand,  forearm  and  the 
lower  and  middle  third  of  the  arm  is  certainly  an  unusual 
complication  in  cases  of  hemiplegia.    You  will  also  notice 
from  the  history  that  this  edema,  which  began  in  the  hand, 
gradually  spread  up  the  arm,  and  that  finally,  when  it 
ceased  to  spread,  it  was  separated  from  the  upper  arm  by 
a  distinct  linet3f  demarcation;  not  that  there  was  any  dis- 
coloration of  the  skin,  but    that  the    swelling   suddenly 
ceased  as  effectually  as  if  a  tight  band  were  placed  about 
\\vt  arm  at  that  place. 

The  swelling,  too,  is  far  in  excess  of  that  arising  from 
trophic  changes  in  the  arm,  which  is  sometimes  seen  in 
hemiplegias.  It  is  an  edema  quite  as  marked  as  that  which 
is  frequently  seen  in  cases  following  phlebitis  in  convales- 
cence from  typhoid  fever  or  parturition. 

The  picture  which  I  show  you  illustrates  the  condition 
fairly  well.  An  interesting  point  in  her  history  is  that, 
notwithstanding  the  fact  that  she  is  totally  hemiplegic 
and  that  this  symptom  came  on  suddenly,  there  was  no- 
loss  of  consciousness  with  its  onset. 

The  diagnosis  as  to  the  cause  of  the  hemiplegia  lies 
between  hemorrhage,  hysteria,  embolism  and  thrombosis. 
That  it  is  not  thrombosis,  I  think,  is  proved  by  the  manner 
of  onset  and  by  the  fact  that  Jhe  woman's  blood  vessels  are 
in  good  condition,  except,  perhaps,  in  the  area  of  the  brain 
in  which  the  rupture  may  have  taken  place.    Neither  does 


'Read  before   the    Philadelphia    Xeurological    Society,    February 
-'-^  1897. 


it  seem  to  me  likely,  from  a  study  of  her  case,  that  the  case 
is  one  of  embolism,  although  an  examination  of  her  heart 
shows  a  mitral  regurgitant  murmur.  It  is.  however,  much 
more  common  to  find  embolism  resulting  from  mitral 
stenosis  than  from  mitral  regurgitation. 

With  the  report  of  the  case  there  is  a  careful  report  in 
regard  to  her  eyes,  made  by  Dr.  de  Schweinitz.  this  report 
being  practically  negative.  I  am  inclined,  therefore,  to 
believe  that  tlie  case  is  one  of  hemorrhage,  and  I  am  quite 
confident  that  it  is  not  hysteria. 

A  careful  examination  of  her  arm,  with  particular  at- 
tention to  its  bloodvessels  and  nerves,  fails  to  throw  any 
light  upon  the  case.  There  is  no  evidence  of  interference 
with  either  the  venous  or  arterial  circulation,  nor  are  there 
any  signs  of  a  peripheral  neuritis. 

It  is  an  interesting  fact  that  tlie  paralyzed  leg  is  not  in 
the  slightest  degree  edematous.  It  may  also  be  important 
to  remark  that  this  edema  could  not  have  resulted  from 
pressure  as  the  result  of  lying  on  the  paralyzed  part,  as 


y 


UNUSUAL  EDEMA  IN  HEMIPLEGIA.  19 1 

she  has  been  carefully  nursed,  and  it  is  now  a  number  of 
weeks  since  the  edema  developed.  Because  of  the  un- 
usual character  of  the  case,  I  asked  Drs.  Dercum  and  Spil- 
ler  to  see  it  with  me,  and  they  both  agree  that  in  their 
experience  the  case  is  unique. 

Mrs.  Georgianna  Robertson;  widow;  aged,  46.  Resi- 
dence, Dearfield,  N.  J.    American-born. 

Admitted  to  Jefferson  Hospital,  Dec.  19th,  1897. 
Family  History. — Negative. 

Personal  History. — For  three  years  has  been  under 
treatment  for  valvular  disease  of  the  heart. 

Present  Trouble. — For  more  than  a  month  there  has. 
been  failure  of  compensation  as  evidenced  by  swelling 
(edema)  of  the  legs.  On  the  night  of  Dec.  17th  she  was 
seized  suddenly  with  paralysis  of  the  right  side  of  the  body 
and  aphasia.  She  was  conscious,  however,  and  has  been 
up  to  date,  Dec.  20th,  1896. 

Jan.  13th,  1897.     When  Dr.  Hare  came  on  duty  he 
noticed  that  there  was  no  ptosis,  no  forehead  paralysis — 
mouth  drawn  to  left,  typical  facial  palsy,  limited  to  lower 
P^rt  of  right  face.    Thyroid  gland  enlarged  and  somewhat 
pvriform.     No  other  signs  of  goitre.     Some  wasting  of 
^ght  arm  and  leg  of  right  side.    Aphasia  absolute.    Skin. 
'■eflex:es  normal  on  both  sides.  Hyperesthesia  of  left  handi. 
''Anesthesia  of  right  hand.     Analgesia  to  elbow  on  right 
wearni,  decreasing  to  arm.    No  marked  loss  of  temper-^ 
ature    sense  in  right  arm.     Apex  beat  well  marked  and 
somewhat  diffused;  no  thrill.    Moderately  well  developed 
mitra.1  systolic  murmur.    Faint  aortic  systolic. 

I**eb.  15th,  1897.  Tongue  is  protruded  all  right;  swel- 
Img  of  arm  decreased.  Great  restlessness  with  moaning 
and  groaning  and  holding  left  leg. 

^eb.  1 6th,  1897.    A^phasia  not  so  marked.    Rapid  re- 
spvt-ations,  48  per  minute;  pulse  rapid  and  feeble. 

^eb.  17th,  1897.    Speech  returned  to  fairly  clear  enun- 
c\at\on. 


192  H.  A.  HARE. 

Feb.  20th,  1897.  Drowsy  and  stupid. '  Tong"ie  foul 
from  lack  of  movement.  Can  protrude  it  very  well.  Urine 
loio,  acid,  albumin  1/6  layer.  No  sugar.  Hyaline  and 
granular  casts  and  renal  epithelium.  Eye — Movements 
of  the  eyes  good  in  all  directions  (Feb.  17th,  1897).  Right 
palpebral  fissure  wider  than  the  left,  12  and  10  rom.  re- 
spectively. Convergence  good  —  left  internal  rectus  is 
slightly  weaker  than  right.  As  left  eye  diverges,  right  still 
maintains  position  of  convergence.  Pupils  round  and 
equal — pupils  normal  in  reaction.  Eyes  very  unsteady. 
Field  examination  in  four  meridians;  intermediate  meridi- 
ans show  similar  contraction,  but  no  quadrant  loss.  Cen- 
tral field  apparently  normal — certainly  for  red  and  green. 
Oplitlialmoscopic. — R.  E.— Vertical  oval  disk,  grayish  in 
deeper  layers,  no  neuritis  or  atrophy — vessels  anemic, 
about  normal  in  size — slight  perivasculitis — no  hemor- 
rhages. L.  E. — Similar  disk,  grayer  than  on  other  side, 
and  slight  edema  of  fibre  layer  of  etina. 

Visual  field  measurements. — Outward,  O.  S.  40.  O.  D. 
50;  upward.  O.  S.  20,  O.  D.  30;  inward,  O.  S.  40,  O.  D.  35; 
downward,  O.  S.  45,  O.  D.  50.  Eye  negative  as  to  paral- 
ysis.    Examination  by  Dr.  de  Schweinitz. 

Jan.  i8th,  1897.  Patient  began  to  recover  speech, 
"yes,"  "no,"  "well." 

Jan.  22nd,  1897.  Recovery  of  speech  gradually  in- 
creasing. 

Jan.  30th.  Patient  can  speak  several  words,  "I  feel 
better,"  "No,"  "I  want  a  drink,"  and  such  short  phrases. 
Ecchymosis  under  right  eye  mostly  gone. 

Jan.  25111.  Fingers  of  right  hand  (the  paralyzed  one) 
slightly  edematous  and  swollen:  some  perception  of  pain 
in  moving  elbow;  no  recovery  of  motor  power. 

Jan.  27th,  1897.  Dorsum  of  hand  edematous;  skin 
smooth  and  shiny;  pits  slightly;  some  tension;  limited  at 
wrist. 

Jan.  30th.  Swelling  has  gradually  extended  to  the  el- 
bow of  same  character;  limit  sharply  marked. 


UNUSUAL  EDEMA  IS  HEMIPLEGIA.  193 

Jan.  31st.     Elbow  involved.     Some    sensory,  percep- 
tion on  handling  arm. 

Feb.  3rd.  Four  inches  above  elbow  line  of  demarca- 
tion marked.  Measurements,  4  inches  above  elbow,  9^ 
inches  circ;  3  inch  above  elbow,  12^  inches;  i  inch  below 
elbow,  12^  inches. 

Feb.  17th.  Swelling  diminished;  skin  brawny;  some 
sli jht  and  irregular  desquamation ;  area  of  bluish  color  on 
outer  anterior  aspect  of  arm  (right)  just  above  bend  of  el- 
bow and  directed  obliquely  up  and  out.  Hand  still  some- 
what edematous. 

Feb.  nth,  1897.  Abdomen  distended  with  gas;  Some 
pain;  swelling  of  hand  and  arm  better;  not  so  edematous; 
thyroid  much  enlarged. 

Feb.  22nd,  1897.  Abdominal  distention  not  so 
niarked;  thyroid  a  little  smaller. 

Note. — Before  the  pateint's  death  edema  was  also  no- 
ticed in  the  right  lower  extremity.     An  autopsy  was  ob- 
tained and  the  brain  was  found  to  be  very  edematous.    In 
a  horizontal  section  at  the  level  of  the  superior  part  of  the 
thalamus  and  striatum  of  the  left  side,  there  was  a  hem- 
orrhage occupying  the  external    capsule    and    lenticular 
nucleus.     It  appeared  to  be  about  the  size  of  a  hickory 
n"t,  and  the  brain  substance  around  it  was  softened,  more 
especially  on  the  inner  side  of  the   focus.     The   anterior 
part  of  the  posterior  limb  of  the  internal  capsule  was  evi- 
dently involvel  in  the  softening,  but  the  optic  radiation, 
except,  perhaps,  its  most  superior  part,  appeared  micro- 
scopically to  be  intact.     In  a  section  made  horizontally 
through  the  left  hemisphere,  one  inch  below  and  parallel 
to  the  first  section,  there  were  no  evidences  of  hemorr- 
^^g^.     All  the  basal  arteries  of  the  brain  were  athero- 
matous.   The  kidneys  were  greatly  contracted. 


i 


CLINICAL  CASES 

Reported  from  the  Clinic  of  Prof.   M.  Allen  Starr,  College  of  Phy- 
sicians and  Surgeons,  New  York. 

Friedreich's  ataxia. 


This  disease  is  sufficiently  rare  to  warrant  the  report 
of  cases. 

Case  I.  Susan  J.,  aged  thirteen  in  December,  1897,  is 
the  second  of  five  children.  Her  father  and  mother  are 
healthy,  and  no  one  of  her  grand  parents,  aunts  or  uncles 
are  known  to  have  had  any  form  of  paralysis.  An  older 
brother,  however,  suffered  from  this  disease  which  devel- 
oped at  the  age  of  eleven  and  rendered  him  a  cripple  until 
his  death  from  diphtheria  last  year.  The  patient  was  a 
healthy  child,  though  it  was  noticed  that  as  a  baby,  while 
learning  to  walk,  she  had  a  somewhat  waddling  gait  and 
was  clumsy  on  her  feet.  Her  present  illness,  however,  did 
not  begin  until  the  age  of  eight,  after  an  attack  of  measles. 
Since  that  time  difficulty  in  walking  has  gradually  and 
progressively  increased,  and  one  year  after  the  beginning 
of  the  trouble  in  the  legs  it  was  noticed  that  the  hands 
were  used  in  a  clumsy  manner.  During  the  past  five 
years  she  has  suffered  some  from  pains  which  were  sup- 
posed to  be  rheumatic,  and  has  occasional  retention  of 
urine  which  has  never,  however,  required  the  use  of  a 
catheter.  She  applied  at  the  clinic  on  account  of  the  un- 
steadiness of  her  gait  in  walking,  and  examination  showed 
her  gait  to  be  markedly  ataxic,  the  steps  being  irregular 
in  length,  the  feet  being  placed  too  widely  apart,  but  tend- 
ing to  overlap  in  walking  unless  corrected  by  voluntary' 
movements  to  preserve  her  equilibrium,  the  feet  dropping 
somewhat  with  the  toes  tumini::  inward  and,  hence,  being 
lifted  too  high  from  the  floor  in  the  act  of  walking.     It 


Attitude  of  patient  with  Friedreich's  disease.  The  feet  are  too 
Im  apart  and  the  body  is  bent  forward.  The  oscillation  of  the  head 
I"«v*med  a  clear  photograph  of  it. 


FRIEDREICH'S  ATAXIA.  195 

was  difficult  for  her  to  stand  still  without  swaying,  and 
this  swaying  was  increased  by  closure  of  the  eyes.  Her 
knee  jerks  were  lost.  There  was  considerable  ataxia  of  the 
hands  in  voluntary  movement,  and  in  all  the  automatic 
acts  of  dressing,  fixing  the  hair,  etc.,  the  ataxia  was  appar- 
ent. There  appears  to  be  no  disturbance  of  sensation  in 
any  part  of  the  body  to  touch,  temperature  or  pain  im- 
pressions. The  irregularity  in  the  action  of  the  bladder 
is  not  constant  but  occasional.  She  frequently  wets  the 
bed  at  night.  A  slight  scoliosis  is  present,  dorsal  with 
convexity  to  the  left,  but  there  is  no  evidence  of  Pott's 
disease.  There  is  some  unsteadiness  of  the  muscles  sup- 
porting the  head,  and  in  consequence  peculiar  nodding 
motions  of  the  head  are  seen,  both,  held  at  rest  and  while 
walking.  Her  pupils  react  normally,  both,  to  light  and 
accommodation,  and  her  optic  discs  are  clear.  Her  mental 
condition  appears  to  be  good. 

Case  II.  Paul  K.,  thirteen  years  of  age  in  January,  1898. 
He  is  the  third  of  nine  children,  only  three  of  whom  are 
living,  the  others  having  died  in  infancy  from  diseases  not 
of  a  nervous  character.  He  has  one  sister  older  and  one 
younger  than  himself,  neither  of  whom  is  affected  by 
the  disease.  He  is,  therefore,  the  only  member  of  the 
family  thus  far  affected.  His  father  died  of  paresis  one 
year  ago.  His  mother  has  had  several  miscarriages.  The 
probability  of  a  syphilitic  inheritance  is  therefore  great. 
The  boy  has  always  been  delicate,  has  had  numerous  chil- 
dren's diseases,  has  suffered  for  long  periods  from  gastro- 
intestinal derangement,  and  at  the  age  of  two  had  a  large 
abscess  of  the  neck.  He  has  always  been  considered  weak 
and  feeble,  and  was  never  bright  at  school,  it  being  re- 
marked that  he  laughed  at  everything  in  a  silly  manner, 
and  was  not  able  to  learn  quite  as  well  as  other  children; 
yet  he  appears  fairly  intelligent,  is  able  to  read  and  write, 
and,  though  having  a  dull  facial  expression,  is  not,  appar- 
ently, weak-minded.  His  present  illness  began  at  the  age 
of  ten,  very  gradually,  it  being  noticed  that  he  was  awk- 


196 


M:  ALLEN  STARR, 


ward  in  his  gait,  would  stumble  in  going  up  and  down 
stairs,  and  at  the  same  time  became  clumsy  in  the  move- 
ments of  his  hands.  About  the  same  time  his  mother 
noticed  peculiar  nodding  or  oscillating  movements  of  the 
head,  a  tendency  to  look  downward  a  good  deal  of  the 
time.  She  says  that  he  has  always  wet  the  bed  at  night, 
but  that  this  has  become  more  frequent  of  late. 

Examination  showed  a  very  marked  ataxia  of  gait,  it 
being  impossible  for  him  to  walk  a  straight  line.  His  body 
stoops  somewhat  forward,  as  shown  in  the  photograph, 
and  it  is  impossible  for  him  to  raise  the  toes  or  feet  from 
the  floor  while  standing  on  his  heels.  He  lifts  his  feet  too 
high  in  walking,  his  steps  are  of  irregular  length ;  there  is 
a  tendency  of  the  knees  to  overlap,  though  this  is  cor- 
rected by  voluntary  efforts  to  preserve  his  equilibrium, 
the  toes  fall  down  and  inward  as  the  foot  is  raised  from  the 
ground,  making  it  necessary  to  step  high  in  walking,  and 
any  attempt  to  stand  or  walk  with  the  eyes  closed  results 
in  a  fall.  The  feet  are  markedly  misshapen,  the  instep  be- 
ing too  high,  the  foot  somewhat  clubbed,  and  the  great 
toe  and  all  the  toes  to  a  less  degree  being  overextended 
so  that  all  the  tendons  stand  out  upon  the  back  of  the 
foot.  This  deformity  is  shown  in  the  photograph,  in  which 
a  normal  foot  of  about  the  same  size  is  shown  for  contrast. 
He  is  able  to  place  the  foot  flat  upon  the  floor  which  cor- 
rects to  some  extent  the  deformity,  but  does  not  aff^ect 
the  hyperextension  of  the  toes.  All  voluntary  movements 
of  the  feet  and  hands  are  extremely  ataxic.  There  appears 
to  be  a  tendency  to  hold  the  fingers  in  a  flexed  position, 
suggestive  of  a  beginning  claw-hand.  There  is  no  scoli- 
osis. There  is  constant  oscillation  of  the  head  of  sliglit 
degree  laterally  and  antero-posteriorly,  and  this  oscillati  n 
is  increased  on  efforts  of  walkinnf.  His  knee  jerks  are  very 
much  exaggerated,  but  there  is  no  clonus.  There  are  110 
sensory  disturbances  to  tests  of  touch,  temperature  or 
pain.  Muscular  sense  is  much  impaired:  there  are  no  elbow 


L*S- 


Appearance  o(  the  legs  and  feet  in  Friedreich's  disease.    The  slight 
ptosis  is  also  visible. 


FRIEDREICH'S  A  TAXI  A.  197 

or  wrist  jerks.  His  pupils  react  normally  to  light  and 
accommodation.  He  has  slight  lateral  nystagmus  in  both 
eyes  on  looking  far  to  either  'side.    Optic  discs  normal. 

Case  HI.  Female,  aged  eighteen  in  December,  1897. 
She  is  the  only  child  in  the  family,  and  both  parents  are 
perfectly  healthy,  and  there  is  no  history  of  any  similar 
affection  to  be  found  in  any  member  of  the  family.  Her 
disease  developed  about  the  age  of  six,  after  an  attack  of 
measles,  and  has  been  gradually  progressing  ever  since, 
but  its  progress  has  been  so  slow  that  it  is  difficult  to  fix 
a  date  for  the  onset  of  special  symptoms.  It  is  known, 
however,  that  by  the  time  she  was  thirteen,  her  walking 
was  very  difficult,  and  that  she  had  by  that  time  become 
awkward  in  her  hands  and  unsteady  in  her  head.  Examina- 
tion showed  a  rather  thin,  stupid-looking  girl,  with  her 
head  habitually  held  slightly  forward  and  downward  in 
a  slight  state  of  oscillation,  which  was  increased  by  the 
act  of  walking.  She  seemed  to  have  some  difficulty  in 
raising  the  eyes  or  in  looking  upward.  This  is  evident  in 
the  photograph.  There  is  po' strabismus,  but  she  has  a 
slight  lateral  nystagmus  on  turning  the  eyes  to  the  side, 
and  the  eyelids  cannot  be  fully  elevated,  and  the  eyeballs 
cannot  be  rolled  upward  as  far  as  normal.  The  pupils  react 
to  light  and  accommodation,  and  the  optic  discs  are  nor- 
mal. She  has  marked  ataxia  of  the  hands  on  all  move- 
ments, and  very  great  ataxia  of  the  legs  in  walking,  so 
that  the  act  is  an  irregular  stepping  one  with  characteristic 
deformity  of  the  feet,  tendency  to  drop  foot  with  incurva- 
tion of  the  foot  and  bending  forward  of  the  entire  body 
in  the  act  of  balance  to  a  slight  degree.  She  has  a  slight 
lateral  curvature  of  the  spine  toward  the  right  which  has 
required  the  use  of  braces  for  about  two  years.  She  has 
no  disturbance  of  the  bladder  or  rectum  and  no  sensory 
symptom  of  any  kind.  The  knee  jerks  are  lost.  The  awk- 
wardness of  her  hands  is  very  marked  in  the  act  of  dress- 
ing.    She  appears  to  be  dull  mentally,  takes  very  little 


A 


198  M.  ALLEN  STARR. 

interest  in  things  about  her,  and  is  rather  slow  in  her 
speech,  with  some  hesitation.  Her  mother,  however,  will 
not  admit  that  she  is  weak-minded  in  any  degree. 

These  cases  are  grouped  together  as  they  are  fairly 
typical  of  Frieflreich's  ataxia.  It  is  interesting  to  notice 
that  two  of  them  began  after  an  attack  of  measles.  Con- 
sidering the  frequency  of  this  disease  in  children  and  the 
fact  that  it  often  runs  through  a  family,  affecting  several 
members,  the  question  may  be  raised  whether  too  much 
attention  has  not  been  given  to  the  supposed  hereditary 
factor  in  this  disease.  I  have  records  of  three  other  cases 
of  Friedreich's  ataxia,  and  in  none  have  I  been  able  to 
ascertain  any  evidence  of  similar  disease  in  a  previous  gen- 
eration. As  the  disease  does  not  affect  the  duration  of 
life,  and  the  existence  of  a  chronic  cripple  in  a  family  can- 
not be  overlooked  or  forgotten,  it  seems  to  me  evident, 
that  many  cases  do  not  rest  upon  an  hereditary  basis.  Nor 
can  it  be  stated  with  precision  that  this  is  a  disease  of 
maldevelopment,  for  in  the  majority  of  cases  children  have 
grown  to  the  age  of  six  or  eiglit  without  any  manifestation 
of  the  disease,  and  have  learned  to  walk  well.  The  degen- 
erative changes,  therefore,  in  the  nervous  system  must 
supervene  upon  healthy  nervous  tissue,  and  while  it  may 
be  regarded  as  probable  that  from  some  unknown  reason 
the  life  period  of  some  neurons  may  be  unusually  short  in 
these  cases,  just  as  the  life  period  of  muscles  is  abnormally 
short  in  cases  of  dystrophy,  yet  it  is  manifestly  wrong  to 
speak  of  a  congenital  maldevelopment  in  these  cases.  That 
the  degenerative  process  is  not  exclusively  limited  to  the 
spinal  cord  is  manifest  from  the  existence  of  ocular  and 
mental  symptoms  in  all  the  cases.  Nystagmus  was  present 
in  all,  a  tendency  to  ptosis  and  manifest  weakness  of  the 
superior  rectus  muscle  was  present  in  two.  Marked  mental 
dullness  was  present  in  all  three.  It  is,  therefore,  probable 
that  the  influence  which  leads  to  the  disease  is  one  which 
affects  the  entire  nervous  system,  and  if,  as  seems  very 


r 


FRIEDREICH'S  A  TAXI  A.  1 99 

probable,  the  occurrence  of  acute  infectious  diseases,  not- 
ably measles,  is  the  exciting  cause,  this  disease  may  be  in 
future  classified  with  multiple  sclerosis,  as  a  nervous  sequel 
of  the  infectious  diseases  of  children. 

The  possibility  of  Marie's  disease,  in  the  second  case, 
is  admitted.  As  yet  it  seems  impossible  to  draw  a  sharp 
line  between  Marie's  disease  and  Friedreich's  disease  clin- 
ically. 


77.  Sputting  the  Kidney  Capsui^e  for  the  Relief  of  Nephral- 
gia. 

In  the  Medical  News,  Jan.  30th,  1897,  Dr.  George  B.  Johnson  re- 
ports two  cases  in  which  violent  pain,  resembling  attacks  of  renal  colic, 
led  to  the  operation  of  nephrotomy  for  supposed  calculus,  although 
the  urinary  symptoms  were  not  charateristic.  In  neither  case  was 
stone  found  to  be  present.  The  kidneys,  however,  appeared  to  be  too 
tightly  enclosed  in  a  tense  capsule.  In  each  case  a  free  slit  was  made 
18  the  whole  length  of  the  kidney  capsule.  The  pain  was  promptly 
abated  by  this  procedure  and  never  returned.    The  author  concludes: 

1.  Nephralgia  is  not  always  associated  with  a  demonstrable  lesion. 

2.  When  other  evidences  of  kidney  disease  are  wanting,  the  pain 
IS  perhaps  due  to  a  too-tight  capsule. 

3-  Nephralgia  may,  and  frequently  does,  simulate  symptoms  of 
gross  tissue  changes  or  presence  of  mechanical  irritants. 

4-  When  severe  and  persistent  pain  in  the  kidney  exists,  without 
other  evidences  of  renal  involvement,  exploratory  operation  is  indi- 
cated. 

5-  When  inspection,  palpation,  and  needle  punctures  fail  to  dis- 
close a  condition  sufficient  to  account  for  the  pain,  the  capsule  skould 
*>c  freely  opened.  Shively. 


jlocijetg  "H^epavtB. 


NEW  YORK   NEUROLOGICAL  SOCIETY. 

Stated  Meeting,  February  ist,  1898.  B.  Sachs,  M.D., 
President. 

Dr.  Mary  Putnam-Jacobi  presented  a  boy  of  three 
years,  who  had  begun  to  talk  well  when  two  years  old. 
About  September  2d,  1897,  the  mother  noticed  the  left 
arm  begin  to  tremble.  A  week  later  the  child  fell  down 
in  the  street,  and  a  wagon  ran  near,  but  not  over  him. 
A  policeman  insisted  that  the  child  had  been  injured,  and 
he  was  taken  to  a  hospital,  where  the  doctors  stated  that 
he  had  a  hemichorea  due  to  fright.  As  the  trembling  ^ 
the  arm  had  preceded  the  fall,  it  was  hardly  possible  to 
attribute  it  to  his  fright.  A  Httle  later,  the  child  had  had 
quite  a  severe  attack  of  measles,  with  pneumonia,  and 
during  that  time  the  tremor  ceased.  It  was  noted  shortly 
afterward  that  the  leg  also  trembled.  Iron  and  arsenic 
were  given  freely,  but  with  no  benefit.  On  November 
25th,  there  was  then  weakness  in  both  the  leg  and  arm, 
and -these  steadily  increased.  On  January  3d,  1898,  she 
had  first  seen  the  child.  There  was  then  a  condition  pres- 
ent which  the  mother  had  not  noticed — i.  e.,  a  deviation 
of  the  right  eye  outward  and  a  marked  dilatation  of  the 
pupil  and  very  slight  reaction  to  light.  Vision  was  good. 
At  present  there  is  a  noticeable  drooping  of  the  left  angle 
of  the  mouth.  Another  new  symptom  is  an  inclination  of 
the  head  to  the  left  side,  with  slight  resistance  on  attempt- 
ing to  straighten  it.  The  disposition  of  the  child  is  good. 
His  speech  is  indistinct,  but  this  may  be  because  he  is  so 
young.  The  spontaneous  tremor  in  the  leg  has  disap- 
peared, but  an  attempt  to  walk  sets  up  inco-ordinate 
movements  in  the  leg.  Sensation  and  electrical  reactions 
are  normal.  The  knee-jerk  on  the  affected  side  is  decidedly 
increased.  The  diagnosis  seems  to  rest  between  hemi- 
chorea, with  consecutive  paralysis,  post-hemiplegic  chorea 
and  multiple  sclerosis.    Two  or  three  physicians  had  made 


NEW  YORK  NEUROLOGICAL  SOCIETY.  20I 

a  diagnosis  of  tumor,  but  this  seemed  to  be  excluded  by 
the  "absence  of  vomiting,  convulsions,  headache  or  alter- 
ation of  character.  The  existence  of  ocular  symptoms  on 
the  opposite  side  would  seem  to  negative  the  diagnosis 
of  chorea.  A  lesion  in  the  inner  part  of  the  right  thalamus, 
or  under  the  aqueduct  of  Sylvius,  would  explain  the  symp- 
toms. The  extreme  youth  of  the  child  would  not  exclude 
such  a  diagnosis,  for  several  such  cases  were  on  record. 

DISCUSSION. 

Dr.  L.  Sti^litz  said  that  two  years  ago  he  had  exhibited 
to  this  society  the  brain  of  a  child  of  two  and  a  half  years, 
with  a  tubercle  in  the  right  crus.  In  this  case  a  very  similar 
symptom  complex  had  been  observed,  i.  e,,  left  hemplegia 
with  a  characteristic  crossed  third  nerve  paralysis.  There  was 
a  very  similar  tremor  for  months,  present  both  at  rest  and  on 
movement,  until  total  paralysis  occurred.  Gowers  states,  in 
his  book,  that  solitary  tubercle  produces  not  rarely  an  in- 
tuitional tremor.  He  had  found  recorded  as  many  as  35  cases 
of  disseminated  sclerosis  in  young  children.  One  should  be 
careful  not  to  base  the  diagnosis  upon  the  presence  of  inten- 
tion tremor  alone.  It  would  be  interesting  to  know  if  there 
had  been  choked  disk  in  the  case  just  presented.  .He  would 
venture  to  predict  that  the  case  would  progress  to  a  fatal  ter- 
mination, and  that  tubercle  would  be  found.  In  his  own 
case,  the  choked  disk  had  developed  only  very  shortly  before 
death. 

Dr.  C.  A.  Herter  said  that  he  had  seen  the  patient  about  a 
month  ago.  He  had  leaned  toward  the  diagnosis  just  made  by 
the  last  speaker.  iVo  years  ago  he  had  had  »  case  of  crossed 
paralysis  of  the  same  general  character.  In  view  of  the  fact 
that  tubercle  of  the  brain  is  a  much  more  common  condition 
than  multiple  sclerosis  in  children,  such  a  diagnosis  was  the 
more  probable  one.  He  was  under  the  impression  that  the 
child's  eyes  had  been  examined  with  negative  result. 

Dr.  Sachs  said  that  he  had  seen  this  child  about  three 
months  ago,  when  the  condition  had  been  quite  different.  On 
examination,  he  had  found  slight  rigidity  in  the  left  ex- 
tremities and  increased  reflexes  in  the  upper  extremity  and  in 
both  lower  extremities.  The  statement  was  made  at  the  time 
that  the  examination  of  the  fundus  of  the  eye  was  entirely 
negative.  At  the  time  he  had  made  a  tentative  diagnosis  of 
post-hemiplegic  tremor  or  a  post-hemiplegic  ataxic  tremor. 
He  thought  now  that  it  was  exceedingly  probable  that  there 
was  a  neoplasm  in  the  brain.  In  a  case  published  by  him 
some  time  ago  there  had  been  very  marked  ataxic  movements. 


202  NEW  YORK  NEUROLOGICAL   SOCIETY, 

and  the  autopsy  had  shown  a  lesion  in  the  cms.  In  all  the 
cases  of  this  kind  that  he  had  seen  the  ataxic  tremor  had  been 
observed  only  on  attempting  to  move  the  arm,  whereas  in  this 
case  the  tremor  is  continuous. 

Dr.  Putnam-Jacobi  said  that  the  occurrence  of  measles 
and  pneumonia  after  the  beginning  of  the  nervous  symptoms, 
without  the  development  of  pulmonary  tuberculosis,  seemed 
to  argue  against  the  diagnosis  of  tubercle.  If  a  tumor  were 
present,  as  had  been  suggested,  there  should  have  been  a  total 
paralysis  of  the  third  nerve,  whereas  there  was  only  an  as- 
sociated paralysis.  Another  point  was,  that  there  was  no 
hemiplegia  until  some  time  after  the  development  of  the 
tremor. 

LOCALIZED   SYRINGOMYELIA 

Dr.  L.  Stieglitz  presented  a  woman,  thirty-eight  years 
of  age,  who  two  years  ago  began  to  complain  of  pains  in 
the  left  shoulder,  arm  and  forearm.  Shortly  after  this,  she 
noticed  some  weakness  in  her  left  hand,  and  subsequently 
w^asting  of  the  muscles  of  the  hand.  The  fingers  then  be- 
came contracted  as  at  present.  Examination  in  August, 
1 897,  showed  complete  atrophy  of  the  thenar,  hypothenar, 
iiiterossei.and  other  intrinsic  muscles  of  the  left  hand,  and 
contractures  of  the  long  flexors  of  the  fingers,  especially 
of  the  three  ulnar  fingers.  Along  a  narrow  strip  of  the 
inner  surface  of  the  left  arm  sensation  was  disturbed.  The 
left  eye  is  markedly  sunken,  the  left  pupil  is  small  and  re- 
mains so  in  a  dark  room.  It  does  not  dilate  under  cocaine, 
but  is  dilated  b^  atropin  without  difficulty.  He  considered 
this  a  case  of  very  marked  localized  spinal  lesion  in  the 
anterior  part  of  the  left  side  of  the  spinal  cord.  He  thought 
an  inflammatory  condition,  such  as  myelitis,  could  be 
excluded.  There  was  also  no  history  or  evidence  of  syph- 
ilis, and  she  show^ed  no  change  under  specific  treatment. 
This  clinical  picture  might  be  produced  by  a  neoplasm 
at  the  level  of  the  anterior  horn,  or  by  gliosis.  She  had 
been  under  observation  for  six  months,  and  had  developed 
practically  no  new  symptoms.  He  was  inclined  to  regard 
the  condition  as  one  of  syringomyelia,  localized  for  the 
present  at  the  level  of  the  first  dorsal  root. 

In  connection  with  this  case  he  exhibited  a  classical 
example  of  syringomyelia,  in  which  there  was  the  same 
condition  of  the  eye.  This  patient,  twenty-one  years  of 
age,  is  a  porter  by  occupation.     Two  or  three  years  ago 


\ 


NEW  YORK  NEUROLOGICAL   SOCIETY.  203 

he  had  first  noticed  a  stiffness  of  the  left  hand,  and  this 
had  become  steadily  worse,  and  the  hand  always  felt  cold. 
Examination  showed  the  left  shoulder  to  be  considerably 
higher  than  the  right,  and  a  marked  scoliosis  to  the  left 
in  the  middle  and  upper  dorsal  region;  almost  complete 
atrophy  of  the  small  muscles  of  the  left  hand,  and  marked 
atrophy  of  the  muscles  of  the  left  forearm,  arm  and  shoul- 
der.   When  the  skin  of  the  left  hand  is  injured,  the  wound 
heals  very  slowly.    There  is  an  analgesia  of  the  entire  left 
arm,  and  of  a  large  part  of  the  left  chest  and  scapular 
region.    The  temperature  sense  is  less  affected  than  on  the 
right  side.    The  left  palpebral  fissure,  the  left  eyeball,  and 
the  left  pupil  are  smaller  than  on  the  opposite  side.    The 
left  pupil  does  not  dilsTte  under  cocain,  but  does  so  readily 
under  homatropin.    The  speaker  said  that  this  condition 
of  the  eye  was  not  uncommon,  but  was  sometimes  over- 
looked when  both  eyes  are  affected.     A  very  excellent 
point  in  the  differential  diagnosis  was  the  test  with  cocain. 

DISCUSSION. 

Dr.  C.  L.  Dana  said  that  some  years  ago  he  had  had  a 
patient  with  a  very  typical  kind  of  progressive  muscular 
atrophy.  It  ran  the  usual  course,  and  terminated  fatally.  In 
the  early  stage  there  were  precisely  the  same  conditions  of  the 
eye,  so  that  he  had  always  considered  this  part  of  the  usual 
symptomatology  of  the  disease.  For  that  reason,  it  seemed 
to  him  that  the  diagnosis  of  progressive  muscular  atrophy  was 
admissible  in  the  case  just  presented.  The  eye  symptoms 
could  hardly  be  of  any  particular  value,  except  in  localizing. 

Dr.  Stieglitz  said  that  he  could  not  positivdy  exclude  pro- 
gressive muscular  atrophy.  Before  the  clinical  picture  of 
syringomyelia  had  been  well  known  quite  a  number  of  cases 
were  diagnosed  as  progressive  muscular  atrophy;  moreover. 
S)77/igomyeIia  often  begins  without  sensory  symptoms,  be- 
C^y^e  the  gliosis  commences  in  the  anterior  part  of  the  cord. 


UNILATERAL  REFLEX   IRIDO-PLEGIA. 

Dr.  W.  M.  Leszynsky  said  that  the  term  "unilateral 
irido-plegia"  was  applied  to  an  ocular  condition  in  which 
onfe  pupil  does  not  react  directly  to  light,  while  its  reaction 
i^  convergence  is  preserved.    The  other  pupil  reacts  norm- 
ally.   The  pupil  may  be  either  dilated  or  contracted,  or 
I'oth  pupils  may  be  dilated.    It  is  usually  unaccompanied 


204  NE^  YORK  NEUROLOGICAL  SOCIETY. 

by  any  interference  with  vision,  or  changes  in  the  fundus. 
It  might  also  be  called  a  unilateral  Argyll-Robertson  pupi.. 
Absolute  iridoplegia  of  recent  origin  nad  been  knowii  lu 
a  few  instances  to  disappear  under  the  administration  of 
mercury  and  iodide  of  potassium.  It  had  been  erroneoulsy 
inferred  that  this  unilateral  form  of  iridoplegia  is  associ- 
ated with  tabes.  The  patient  presented,  a  woman  of  thirty- 
eight  years,  was  first  seen  by  him  in  December,  1896.  Her 
second  husband  had  had  syphilis,  some  years  before  mar- 
riage, and  had  since  then  given  abundant  evidence  of  the 
disease.  She  had  never  been  pregnant  after  this  marriage. 
The  patient  herself  had  been  somewhat  intemperate.  Her 
left  pupil  is  larger  than  the  right,  and  she  says  that  this 
has  been  so  for  at  least  three  year^.  All  of  the  external 
eye  muscles  act  normally.  There  is  none  of  the  usual  evi- 
dence of  syphilitc  infection,  but  the  other  signs  and  symp- 
toms seem  to  warrant  the  diagnosis  of  cerebrospinal  syph- 
iHs.  She  was  improved  somewhat  by  anti-syphilitic  treat- 
ment. At  the  second  examination  it  was  found  that  both 
patellar  reflexes  were  lost.  In  January,  1896,  the  pupils 
were  found  to  be  the  same.  This  case  could  be  considered 
as  a  typical  one  of  tabes,  or  one  of  cerebrospinal  syphilis. 

He  had  found  that  only  seventeen  other  cases  had  been 
reported  up  to  date.  From  a  study  of  these  it  would  be 
seen  that  in  nine  there  was  a  definite  history  of  previous 
syphilitic  infection,  and  in  four  the  nervous  manifestations 
justified  the  suspicion  of  antecedent  syphilis.  In  thirteen 
cases  the  left  pupil  was  affected;  in  eleven  the  iridoplegic 
pupil  was  dilated.  The  condition  of  vision  or  refraction 
seemed  to  have  no  bearing  on  the  condition  of  the  pupil. 
Apparently,  unilateral  iridoplegia  is  a  very  rare  condition, 
though  more  systematic  examination  would  probably 
show  that  it  is  more  frequent  than  is  now  supposed.  In 
three  unrecorded  cases  of  tabes  he  had  seen  unilateral 
iridoplegia  at  the  first  examination,  but  this  had  disap- 
peared in  a  few  weeks.  He  was  inclined  to  think  that  in 
his  patient  when  the  pupil  became  affected  there  was  a 
sudden  ophthalmoplegia  interna,  and  that  the  fibres  had 
only  partially  recovered, thus  leaving  the  pupil  in  its  recent 
permanent  condition. 

The  reader  believed  that  the  ciliary  and  sphincter 
nuclei  are  separate,  and  have  independent  muscular  fibres. 
His  conclusions  were:  (i)  That  unilateral  reflex  iridoplegia 


NEIV  YORK  NEUROLOGICAL   SOCIETY.  205 

is  a  condition  which  may  arise  in  tabes  or  paretic  dementia, 
being  confined  to  one  side  for  an  indefinite  time  before 
the  other  pupil  becomes  affected;  (2)  that  it  often  occurs 
in  cerebrospinal  syphilis,  and  as  a  remote  result  of  disease 
or  injury  of  the  third  nerve;  (3)  that  it  is  always  indicative 
of  degeneration  of  the  oculo-motor  nerve;  and  (4)  that 
the  lesion  is  situated  in  the  centrifugal  portion  of  the  reflex 
mechanism,  as  shown  by  its  occurrence  with,  or  as  a  con- 
sequence of,  oculo-motor  paralysis. 

Dr.  Carl  KoUer  said  that  unilateral  loss  of  light  reflex  is 
not  such  a  rare  condition  as  might  perhaps  appear  from  neu- 
rological literature.  Of  course,  the  loss  of  reflex  to  light  is 
brought  to  our  attention  in  two  ways— one  during  neurologi- 
cal examination,  and  the  other  when  the  patient  comes  to  the 
ophthalmologist  complaining  of  symptoms.  The  latter  are 
more  frequent.  He  called  to  mind  three  cases,  observed  in 
private  practice.  Two  of  them  had  been  followed  for  eight 
years.  These  patients  had  come  with  the  pupil  dilated  and 
complaining  of  loss  of  accoflmmodation.  In  the  beginning, 
with  the  loss  of  reflex  there  had  been  also  a  loss  of  the  power 
of  accommodation.  This  had  returned  in  part  after  a  time. 
In  two  cases  the  loss  of  reflex  appeared  in  the  other  eye,  and 
also  without  loss  of  accommodation.  From  his  own  experi- 
ence he  would  be  inclined  to  believe  that  it  was  a  nuclear  af- 
fection, (i)  because  the  accommodation  is  but  slightly  inter- 
fered with,  and  (2)  because  in  most  of  the  cases  the  nucleus 
on  the  other  side  becomes  subsequently  affected.  In  the  ma- 
jority of  cases  he  believed  syphilis  to  be  the  cause. 

Dr.  Herter  thought  the  conclusions  reached  by  the  reader 
of  the  paper  were  justified  by  the  facts.  In  one  or  two  in- 
stances he  had  noted  this  one-sided  irido-plegia,  and  had  been 
puzzled  by  it.  He  had  looked  upon  the  lesion  as  one  of 
syphilitic  origin. 

Dr.  Sachs  thought  a  difference  in  the  action  of  the  pupils 
not  uncommon,  and  that  for  this  reason  it  had  not  been  oftener 
recorded.  It  seemed  to  him  that  unilateral  reflex  irido- 
plegia  was  invariably  specific,  and,  indeed,  a  very  important 
diagnostic  symptom.  Its  presence  had  caused  him  often  to 
suspect  specific  disease.  Unilateral  immobility,  and  especially 
double  complete  immobility,  are  characteristic  sig^ns  of  syphilis. 
He  did  not  see  how  it  could  be  anything  else  than  nuclear  in 
its  nature. 

Dr.  Leszynsky,  in  closing,  said  that  the  experience  of  Dr. 
Sachs  was  opposed  to  that  of  a  number  of  observers,  who  had 
studied  a  large  number  of  cases  of  pupillary  phenomena  with- 
out finding  more  than  a  few  cases. 


PHILADELPHIA  NEUROLOGICAL  SOCIETY. 

December  20th,  1897. 
President,  Dr.  Charles  W.  Burr,  in  the  chair. 
Dr.  James  Hendrie  Lloyd  presented  a  case  of 

ASTASIA-ABASIA. 

The  patient,  a  female,  had  much  difficulty  in  standing 
and  walking.  Under  suggestive  therapeutics  her  condition 
had  improved. 

DISCUSSION. 

Dr.  Wharton  Sinkler  thought  that  the  gait  and  whole  atti- 
tude of  this  patient  were  very  characteristic  of  the  hysterical 
affections  of  gait.  He  stated  that  these  vary  greatly  in  degree 
and  character,  but  this  case  he  regarded  as  a  type  of  the  so- 
called  astasia-abasia.  In  hysterical  disturbances  of  gait  there 
is  usually  a  tendency  to  pitch  to  one  side  or  backward,  but 
the  patient  seldom  falls  or  completely  loses  her  balance,  unless 
there  is  some  one  near  to  catch  her. 

Dr.  David  Edsall,  by  invitation,  read  a  paper  on 


DISSOCIATION   OF   SENSATION,    OF   THE   SYRINGOMY- 
ELIC TYPE,  IN  POTTS  DISEASE. 

DISCUSSION. 

Dr.  Spiller  stated  that  a  few  years  ago  it  was  thought  that 
syringomyelia  could  be  positively  diagnosticated  by  dissocia- 
tion of  sensation;  but,  as  Dr.  Edsall's  case  and  many  others 
show,  the  difficulty  in  making  this  diagnosis  increases.  This 
dissociation  of  sensation  occurs  in  tumors  of  the  cord,  in  tabes, 
in  disseminated  sclerosis,  in  hysteria,  in  neuritis,  and  has 
been  observed  in  the  peculiar  disease  of  the  spinal  column  re- 
ported by  V.  Bechterew  and  Striimpell. 

He  did  not  think  that  the  diagnosis  of  a  tumor  in  this  case 
could  be  made  with  any  certainty.  A  spinal  growth  might  be 
present  and  cause  few  symptoms,  inasmuch  as  a  tumor  of  the 
oblongata  may  be  latent  for  some  time.  It  seemed  to  him 
that  all  the  symptoms  could  be  produced  by  a  lesion  of  the 
posterior  roots,  or  by  compression  of  the  cord.     This  sug- 


PHILADELPHIA  NEUROLOGICAL  SOCIETY.  20J 

gcsted  the  interesting  theory  of  Goldscheider  in  regard  to 
sensation,  according  to  which  pain  is  simply  a  summation  of 
tactile  impulses.  Where  pain  sense  is  lost,  and  tactile  sense  is 
present,  as  in  tabes,  the  posterior  roots,  though  degenerated, 
permit  the  transmission  of  certain  impulses,  but  not  of  a  suf- 
ticient  number  to  cause  the  perception  of  pain.  This  theory 
has,  by  no  means,  been  accepted  by  all  neurologists. 

Dr.  Hinsdale  remarked  that,  about  three  years  ago.  Dr. 
Lloyd  had  shown,  at  one  of  the  meetings  of  the  Society,  two 
cases  of  traumatic  lesions  of  the  spinal  cord  with  syringo- 
myelic symptoms.  He  thought  that  it  is  quite  possible  that  in 
such  cases  there  is  extravasation  of  blood — a  haematomyelia» 
which,  after  a  time,  is  absorbed,  but  gives  temporarily  the 
dissociation  symptom.  This  symptom  does  not  persist,  but 
causes  a  good  deal  of  difficulty  in  forming  a  diagnosis  while 
It  lasts. 

Dr.  Eshner  said  that  the  fact  that  the  sensory  symptoms 
receded  appeared  to  be  against  the  probability  of  the  ex- 
istence of  a  tumor  within  the  cord.  One  would  not  expect 
even  a  tuberculoma  to  diminish  in  size  or  to  disappear  within 
such  a  short  time. 

Dr.  Burr  spoke  of  the  frequency  of  new  growths,  as  shown 
h  the  necropsy,  which  have  not  been  diagnosticated  during 
life. 

Dr.  Edsall  thought  that  it  was  quite  possible  that  a  tumor 
"light  have  formed  since  the  caries  developed.    In  some  tuber- 
culous tumors  that  have  been  reported  the  growth  has  been, 
^^ry    rapid.     The  peculiar  distribution  of  the  hypalgesia  and 
jhermal  anaesthesia,  and  their  extension  to  lower  parts  of  the 
^^y>  had  led  him  to  suspect  the  presence  of  a  new  growth., 
^hese  could  be  better  explained  by  the  presence  of  a  tumor 
^•^a.n    by  any  other  means,  provided  the  tumor  originated,  in. 
tile  eentre  of  the  cord  and  grew-  outwards. 


I  >.  W.  E.  Hughes,  by  invitation,  reported 
I'VVO  CASES  OF  TUMOR  OF  THE  BASE  OF  THE  BRAIN, 

"^^  exhibited  one  of  the  specimens.    A  growth,  the  size 

^  a' hen's  egg,  was  situated  in  the  pituitary  body.      No 

symptoms  of  akromegaly  had  been  observed  during  life. 

DISCUSSION. 

Dr.  Hare  desired  to  know  how  much  of  the  pituitary  body 
was  left  intact.  If  it  is  true  that  akromegaly  often  arises  from 
disease  of  the  pituitary  body^  it  may  be  that  when  a  certain 


2o8  PHILADELPHIA  XHL'ROLOGICAL  SOCIETY. 

portion  of  this  body  is  left  intact  the  symptoms  do  not  develop. 
U\  the  same  way,  if  the  pancreas  is  destroyed  diabetes  may 
appear,  while  if  a  portion  is  left  pancreatic  diabetes  may  not 
develop. 

Dr.  Hughes  was  unable  to  say  how  much  of  the  pituitary 
bodv  was  involved. 


Dr.  A.  A.  Eshner  made 

A  FURTHER  CONTRIBUTION  UPON  A  CASE  OF  MEN- 
INGITIS. 

The  report  of  this  case  was  p\ibHshed  in  the  Journal 
of  Nervous  and  Mental  Disease  for  March,  1897,  p.  167. 
The  patient  died  in  convulsions,  and  a  necropsy  was 
made  by  Dr.  C'attell. 

On  removing  the  calvarium  the  dura  mater  was  not 
found  adherent  to  the  bone  in  this  situation.  The  vessels 
generally  were  greatly  injected,  and  the  capillaries  were 
somewhat  more  prominent  than  normal.  All  of  the  sulci 
in  the  Rolandic  area  on  both  sides  exhibited  a  grayish- 
white,  delicate,  fil)rous  reticulum,  which  was  slightly  ele- 
vated on  account  of  the  presence  of  subjacent  fluid.  There 
was  no  indication  of  any  process  suggestive  of  recent  bac- 
teriologic  involvement.  The  appearances  were  rather 
those  of  chronic  fibrous  thickening  of  the  pia-arachnoid, 
with  moderate  adhesion  to  the  brain  surface.  The  blood 
vessels  forming  the  circle  of  Willis  were  thickened,  and 
gaped  when  cut.  Many  of  them  contained  small  fibrous 
nodes.  The  fil)rous  thickening  of  the  meninges  previously 
referred  to  was  especially  pronounced  in  the  neighborhood 
of  the  basilar  artery  and  upon  the  pons  and  medulla,  the 
nerves  coming  off  from  which  passed  through  the  thick- 
ened membrane. 

The  under  surface  of  the  cerebrum,  the  olfactory,  and 
the  temporal  regions  were  remarkably  free  from  thick- 
ened membrane,  which  w^as,  however,  prominent  in  the 
fissure  of  Sylvius  along  the  course  of  the  middle  cerebral 
artery.  About  three-quarters  of  an  inch  from  the  point 
of  origin  of  the  left  middle  cerebral  artery  was  a  small, 
well-formed  sacculated  aneurism,  about  the  size  of  a 
small  pea.  The  island  of  Reil  and  the  retroinsular  convo- 
lutions displayed  no  abnormality,  other  than  atheroma 
of  the  blood  vessels,  and  a  small  clot  of  blood  on  the  right 


PHILADELPHIA  NEUROLOGICAL  SOCIETY.  209 

siue,  apparently  contained  within  a  miliary  aneurism. 
There  was  considerable  oedema  in  the  neigfhborhood  of 
the  optic  chiasm,  and  the  optic  nerve  appeared  flattened 
fmm  above  downward  and  diminished  in  size,  from  thick- 
ei  ing  of  the  overlying  adventitious  membrane. 

The  left  lobe  of  the  cerebellum  was  the  seat  of  an 

enormous  hemorrhage,  which  had  ploughed  its  way  into 

the  fourth  ventricle,  and  thence  through  the  iter  into  the 

third  and  also  into  the  left  lateral  ventricle.    So  enormous 

\vas  this  extravasation  that  a  considerable  clot  of  blood  was 

fnuiid  in  the  posterior  horn  of  the  left  ventricle.      The 

foramen  of  Munro  and  the  adjacent  nervous  tissues  were 

torn  apart  and  replaced  by  a  bloodclot.    Sections  through 

'^^W  parts  of  the  brain  failed  to  disclose  any  other  seat  of 

hemorrhage,   recent  or  remote.     The  injection  of  some 

portions  of  the  arbor  vit?e  of  the  cerebellum  was  especially 

pronounced. 

Concerning  the  other  organs,  it  seems  only  worth  saying 
fet  the  kidneys  exhibited  an  extremely  slight  degree  of 
parenchymatous  inflammation,  while  the  heart  was  some- 
what enlarged,  with  healthy  valves  and  orifices-,  and  the 
•'"rig's  were  oedema  tons  and  emphysematous. 

Owing  to  the  conditions  under  which  the  autopsy  was 
'i^W.  it  was  not  possible  to  obtain  even  the  smallest  por- 
tion of  tissue  for  more  careful  study.  It  could  not  be  de- 
cided from  the  macroscopic  appearances  whether  or  not 
the  upper  portion  of  the  spinal  cord  exhibited  any  changes, 
particularly  in  its  posterior  columns. 


I^r.  E.  Schreiner  presented 

^  CASE  OF  ARSENICAL  NEURITIS  FOLLOWING  THE 
TREATMENT  OF  CHOREA  WITH  FOWLER'S  SOLU- 
TION. 

The  patient,  a  female  of  ten  years  af  age,  was  seen 

April  T7th,  1896,  in  her  second  attack  of  chorea.    She  was 

\)\aceU  on   Fowler's  solution,  beginning  with  five  drops 

>^\ee  times  daily.  This  was  increavSed  to  twelve  drops, when 

,-w\^Aptoms  of  the  physioloi^ical  action  were  observed,  and 

^fie  quantity  was  reduced.  The  total  amount  taken  was  two 

ofthreeounces.  She  remained  under  occasional  observation 

ttntil  June  5th.  when  she  showed  loss  of  power  in  the  arms 


2IO  PHILADELPHIA  XEUROLOGICAL  SOCIETl  . 

and  in  the  legs,  more  marked  in  the  latter,  with  areas  of 
pigmentation  over  the  joints,  some  atrophy  of  the  leg 
muscles,  loss  of  patellar  and  plantar  reflexes,  diminution 
of  tactile  sensation,  and  marked  reaction  of  degeneration, 
viz.,  complete  loss  of  irritability  to  the  faradic,  and  very 
slight  response  to  strong  galvanic  currents. 

There  was  a  history  of  pain  in  the  calves  of  the  legs 
and  of  swelling  below  the  knees  two  weeks  before  the 
patient's  admission  to  the  hospital.  The  only  sensory 
symptom  present  on  admission  was  some  soreness  in  the 
course  of  the  radial  nerves. 

Motor  power  and  sensation  improved,  the  latter  more 
rapidly  than  the  former,  so  that  the  patient  finally  was 
able  to  walk,  though  she  presented  the  steppage  gait.  At 
present,  December,  nth,  1897,  the  electrical  reactions  in 
the  muscles  of  the  legs  and  forearms  are  absent,  and  the 
muscular  power,  especially  in  the  extensors  of  the  leg,  is 
imperfect,  causing  foot  drop  and  steppage  gait,  but  sensa- 
tion is  normal. 

DISCUSSION. 

Dr.  Charles  K.  Mills  said  that  this  case  interested  him. 
especially  in  connection  with  the  second  question  referred  to, 
that  is,  as  to  the  nature  of  the  pathological  changes  which  are 
probably  present,  and  as  to  the  names  which  should  be  used 
in  speaking  of  cases  of  this  kind.  He  thought  that  the  time 
had  come  for  us  to  revise  our  nomenclature  of  some  of  these 
toxic  and  infectious  diseases  of  the  nervous  system.  We  cer- 
tainly have  very  different  types  of  cases  which,  without  much 
thought,  we  class  under  the  same  names.  Formerly,  more 
than  at  present,  these  cases  were  spoken  of  as  instances  of 
myelitis;  now  we  are  more  inclined  to* speak  of  them  as  cases 
of  peripheral  neuritis.  It  is  to  this  point  that  he  wished  to 
ask  attention. 

He  referred  to  a  man  who  several  years  ago  presented 
signs  of  arsenical  poisoning.  He  got  well  after  a  time  and 
left  the  hospital.  Recently  he  came  back  with  conditions  simi- 
lar to  those  referred  to  to-night.  He  had  been  addicted  to 
the  use  of  alcohol,  and  had  been  working  as  a  painter,  largely 
in  white  lead,  for  six  or  seven  years.  He  had  double  foot 
drop,  lost  knee  jerks,  some  irregularly  disseminated  disturb- 
ances of  sensation,  particularly  dissociated  anaesthesia,  slight 
paresis  of  the  upper  extremities,  and  a  little  circumscribed  pain 
in  the  limbs.  Dr.  Mills  stated  that  a  short  time  ago  this  case 
would  have  been  looked  upon  by  some  as  one  of  multiple  neu- 
ritis; earlier,  as  one  of  myelitis;  or,  perhaps,  it  might  have  been 


9 


PHILADELPHIA  NEUROLOGICAL  SOCIETY.  211 

regarded  as  a  case  which  showed  a  concurrence  of  neuritis 
and  myelitis. 

The  point  which  he  wished  to  emphasize  is  that  we  need 
a  new  designation  for  these  cases.  We  need  to  reform  our 
nomenclature  and  classification  of  cases  in  which,  as  the  re- 
sult of  an  infection,  or  a  toxaemia,  or  the  direct  action  of  a 
metallic  poison,  we  have  symptoms  such  as  were  reported  to- 
nijjht.  The  only  sensory  evidences  of  true  neuritis  in  this 
case  were  the  pain  and  hyperaesthesia,  which,  how^ever,  were 
nut  marked  and  were  circumscribed;  although  the  paralysis 
and  loss  of  electrical  reaction  might  also  be  regarded  as  due 
to  neuritis. 

In  naming  these  diseases  the  idea  should  be  enforced  that 
ih  toxine,  infection,  or  poisonous  substance  has  set  up  a 
prcKress  which  has  led  to  the  destruction  of  the  peripheral 
"euron.    Something  ch-culating  in  the  blood  of  the  patient 
3ffacks  the  nerve  cells — ^both  cell  body  and  processes,  poison- 
}^f^  and  destroying  them,  but  not  necessarily  giving  rise  to 
wj/famniatioii.     It  is  difficult  to  have  clear  ideas  with  regard  to 
'J'yeiitis  and  neuritis  on  account  of  the  different  uses  of  terms. 
Dr.  Mills  said  that  if  he  were  asked  what  he  would  call 
cases  of  this  kind,  it  would  be  a  little  difficult  to  say.     We 
Icnow   that  the  chief  evidences  of  inflammation  are  found  in 
such   conditions  as  hyperaemia,  swelling  and  round  cell  infil- 
tration.    If  these  were  present,  we  could  properly  class  the 
disease    as    inflammatory.      In   their   absence    it   is   doubtful 
whether  they  should,  or  should  not,  be  regarded  as  inflamma- 
tory' affections.    In  reported  cases  both  the  peripheral  nerves 
and  the  j^^anglion  cells  in  the  anterior  horns  of  the  cord  have  - 
been  found  destroyed,  or  degenerated,  without  the  usually  ac- 
cepted  evidences  of  inflammation.     It  is,  therefore,  an  open 
question  wliether  these  cases  should  be  designated  as  neuritis, 
wiy^litis.  or  myleoneuritis:  or  whether,  indeed,  it  would  not  be 
better  to  invent  an  entirely  new  term  for  them.     Provisionally, 
he  suggested  that  they  should  be  called  cases  of  pcriphcro- 
nenrofial  degeneration,  with  the  prefix  of  acute,  or  chronic,  ac- 
cording to  tlie  intensity  and  rapidity  of  the  destructive  process. 
^r.  Wharton  Sinkler  thought  that  Dr.  Mills  was  going 
backward  if  he  advocated  the  theory  of  myelitis  in  cases  of 
toxic  |,r)isomng.     It  certainly  is  impossible  to  explain  many 
ot  the  curious  symptoms  present  by  regarding  the  lesion  as 
located  in  the  cord.     It  seemed  to  him  that  in  a  case  like  the 
one  reported  by  Dr.  Schreiner  the  view  of  peripheral  neuritis 
is  sufficient  to  account  for  the  symptoms.    In  myelitis  there  is 
not  apt  to  be  as  great  loss  of  electrical  irritability,  nor  is  there 
the  ^  er/^bt-ral  pain,  hypercesthesia  and  foot  drop. 

l^r.  A.  E.  Taylor  alluded  to  the  recent  address  of  Vifchow 
upon  inflammation,  and,  commenting  upon  our  ignorance  of 


212  PHILADELPHIA  NEUROLOGICAL  SOCIETY. 

many  aspects  of  that  process,  expressed  doubt  as  to  whether 
the  absence  of  round-celled  infiltration  could  be  relied  upon  as 
a  criterion  of  the  non-infianimatory  nature  of  a  pathological 
condition.  The  relations  of  infiammation  to  the  interstitial  ana 
parenchymatous  tissues  would  be  clear  if  we  knew  exactly 
what,  inflammation  always  is,  and  what  the  parenchyma  and 
interstitial  tissues  are. 

Dr.  Spiller  stated  that  in  many  cases  we  are  at  present 
utterly  unable  to  say  whether  a  poison  exerts  its  influence, 
primarily,  on  the  nerve  fibre  or  the  cell  from  which  this  arises. 
He  referred  to  the  selective  power  of  certain  poisons  for  cer- 
tain nerves,  as  seen  in  saturnine,  alcoholic,  diphtheritic  and 
other  forms  of  poisoning.  He  stated  that  probably  all  re- 
ported cases  of  recovery  from  tabes,  such  as  are  seen  after 
diphtheria,  are  examples  of  pseudo-tabes,  due  to  inflammation 
of  sensory  nerve  fibres,  and  that  certam  poisons  seem  thus  to 
pick  out  one  set  of  fibres,  even  within  a  nerve,  to  the  exclusion 
of  others.  He  referred  to  the  many  experiments  which  have 
shown  that,  when  a  motor  nerve  is  cut,  the  cell  with  which 
it  is  connected  degenerates  very  rapidly.  This  degeneration 
may  occur  within  a  few  hours  after  section  of  the  motor  nerve, 
and  there  is  no  reason  for  believing  that  these  cellular  changes 
are  of  an  inflammatory  character.  They  are  changes  in  the 
chromophilic  elements.  He  said  that  he  had  recently  studied 
a  case  of  compression  of  the  cord,  high  up  in  the  cervico- 
thoracic  region,  in  which  the  direct  cerebellar  tracts  were  de- 
generated below  the  lesion,  and  the  cells  of  the  columns  of 
Clarke  had  entirely  disappeared.  This,  however,  was  in  the 
nature  of  a  retrograde  degeneration  in  sensory  fibres.  lie 
spoke  of  a  case  of  acute  neuritis,  which  he  was  then  studying, 
and  stated  that  the  changes  in  the  nerves  were  very  great,  and 
that  the  cells  within  the  spinal  cord  presented  chromatolysis. 

Dr.  Hare  said  that  the  fact  that  different  poisons  attack 
different  parts  of  the  nervous  system  is  one  which  hardly  ad- 
mits of  debate,  and  also  that  we  h^ve  a  pretty  well-grounded 
idea  that  these  poisons  produce  a  primary  neuritis,  or  some 
similar  change.  Many  of  the  changes  which  occur  afterwa'd, 
and  appear  to  be  centred  in  the  higher  nerv^ous  system,  are, 
perhaps,  also  due  to  the  poison,  or.  perhaps,  due  to  what  may 
be  called  an  ascending  degeneration,  a  degeneration  secondary 
to  the  peripheral  degeneration. 

He  wished  to  know  from  Dr.  Schreiner  whether  he  noticed 
that  the  pigmentation  in  his  case  ^  id  any  relation  to  the  dis- 
tribution of  the  anaesthesia,  and  whether  these  areas  of  pig- 
mentation were  peculiar  in  localization.  It  was  taught  at  one 
time  that  the  areas  of  pigmentation  and  anaesthesia  are  in  re- 
lation to  the  joints.  In  arsenical  neuriti's,  for  example,  it  has 
been  said  that  the  anaesthesia  in  the  upper  extremity  has  a 


PHILADELPHIA  NEUROLOGICAL  SOCIErV.  213 

tendency  to  stop  at.  the  distal  joint;  if  it  goes  beyond  this,  it 
stops  at  the  elbow. 

Dr.  Mills  said  that  he  did  not  believe  that  the  podnts  which 
"C  had  made  had  been  met..   He,  of  course,  admitted  that  in 
•^any  cases  there  is  widespread  peripheral  involvement.    In  a 
^^e  such  as  Dr.  Spiller  mentioned,  where  we  find  the  peri- 
pheral nerves  degenerated,  and  the  cells  in  the  anterior  horns 
JUst  as  seriously  degenerated, to  his  mind  nothing  justified  us  in 
calling  these  cases  either  neuritis  or  myelitis.     If  the  law  is 
true  that  pathological  processes  tend  to  follow  in  the  line  of 
physiological  action,  it  is  more  probable  that  the  toxic  influ- 
ence would  be  exerted  from  the  centre  tow^ard  the  periphery 
^^  a  motor  nerve  than  the  reverse.     In  any  case,  it  must  be 
jl^knowledged  that  the  entire  neuron  is  usually     implicated. 
^^  desired  to  know  from   Dr.   Spiller  the  intensity  of  the 
^'Jges  in  the  case  he  had  referred  to. 
*^r.  Spiller  replied  that  he  had  examined  the  peripheral 
**tTves,  but  was  unable  to  say  from   ' 'teased"   preparations 
whether  the  fibres  were  inflamed  or  degenerated.    He  thought 
that  it  is  very  difficult  to  distinguish  between  the  two  con- 
ditions as  regards  the  changes  found  in  the  nerves.     He  had 
iKticed  that  the  axis  cylinders  were  destroyed,  that  some  of 
t/ie  sheaths  were  swollen  and  filled  with  an  increased  amount 
^^ protoplasm  and  degenerated  myelin,  or  else  contracted  and 
^pty\   and  that  the  medullary  substance  was  much  enlarged. 
^is  examination  had  not  yet  revealed  engorgement  of  vessels 
^fi    round-cell   infiltration.      He  said  that  the  chromophilic 
J^ienients  in  the  nerve  cells  from  which  these  fibres  arose  were 
"^ok:^rk    up,  and  that  the  nucleus  was  displaced.     He  was  un- 
able   to    decide  whether  the  cell  was  primarily  or  secondarily 
afreeto<l,  inasmuch  as  similar  lesions  have  been  noted  in  both 
pnma.i-y  and  secondary  degeneration. 

t^f-  Schreiner  stated  that  his  reason  for  describing  this  as 
\  case  of  neuritis  was  the  fact  that  in  recent  literature  cases  of 
arsenical  paralysis  are  described  as  neuritis,  and  because  in 
three  cases,  the  pathology  of  which  he  was  able  to  look  up, 
degenerative  changes  were  foimd  in  the  spinal  nerves. 

He   stated  in  reply  to  the  question  of  Dh  Hare  that  the 

pigrnentation  in  the  axilla  was  confined  by  the  anterior  and 

posterior  borders  of  the  axilla.   At  the  elbow  it  formed  a  rather 

\TtegvilarIy  oval-shaped  patch,  extending  above  and  below  the 

ciease  of  the  elbow  joint.  There  were  no  areas  of  pigmenta- 

uon  at  the  wrist  joint.    The  pigmentation  was    limited  by  the 

boundaries  of  the  popliteal  space,  and  extended  irregularly 

over  the  ankle. 


^exiscape. 


With  Ihe  Assislanct  of  the  FoUowmg  Coltaboralors: 

Chas-Lewis  ALLEN,M.D.,Wash.,D.C.R.  K.  Macalester,  M.D.,  N.Y. 
J.  S.  Chhistison,  M.D..  Chicago,  III.  J.  K.  Mitchell.  M.D.,  Phila.,  Pa 
A.  Fbeeuan,  M.D.,  New  York.  H.  Pathick,  M.D.,  Chicago,  111. 

S.  E.  Jelliffe,  M.D.,  New  York.  Joseph  Sailer,  M.D  .  Phila..  Pa. 
Wm.C,Krauss,M.D.,  Buffalo,  N.Y.  Hekbv  L.  Shivklv.  M.D..  N.  Y. 
W.  M.  Leszynsky,  M.D.,  New  York  A.  Sterne,  M.D.,  Indianapolis. 

.■=iN"  ATOMY. 

55-  On  the  Chrome  Silver  Imprkcnation  ok  Fobmaun-mardenbd 

Brain.     J.  S.  Bolt'on  I  Lancet,  i..  1898,  p.  ia8). 

The  author  has  obtained  e>:celleiil  Golgi  preparations  from  speci- 
mens fixed  in  formalin,  5  per  cent.,  tor  a  period  of  from  two  to  twelve 
lnon1h^.  His  results  were  les?  satisfactory  if  the  formalin  hardening 
was  less  than  two  weeks.  Specimens  should  be  cut  preferably  ontf- 
eighth  ot  an  inch  thick.  After  fixation  the  specimens  are  transferred 
to  a  bath  oi  I  per  cent,  ammonium  bichromate,  where  they  may  re- 
main for  from  a  lew  hours  to  five  days,  after  which  time  the  impreg- 
nation deteriorates  the  picture?  obtained.  Other  chromic  acid  prei>ar- 
ations  gave  less  protnisiog  results.  After  the  proper  time  of  im- 
mersion in  the  bichromate  the  pieces  are  transferred,  after  rinsing  in 
distilled  water,  into  i  per  cent,  silver  nitrate,  where  they  remain 
from  sixteen  to  twenty-four  hours.  A  longer  immersion  in  the  silver 
did  not  hurt  the  impregnation.  The  specimens  are  then  hardened  in 
60  per  cent  alcohol  for  a  few  hours,  dried  and  imbedded  in  melted 
paraffine  without  soaking  and  cut,  cleared  and  mounted  in  balsam 
without  cover  slip.  Jellikfe. 

56.    BKITKAECE  ZDR  STRl'tCTt'R  DER  NBRVENZELLEN    ITND    IHRB    PORT- 

SAKT/K(  Contributions  10  the  Structure  of  the  Nen*e  Cell).  Hans 
Held  (.\ri-h.  i.  .\nat,  u.  PhysioloRie.  Anatomische  Abtheilun^. 
No.  2.    iSg7.   pp.  J.  4), 

This  is  one  of  the  most  important  contributions  to  the  finer 
histology  of  the  nerve  cell  that  has  thus  far  appeared. 

The  auihor  tirst  takes  up  the  question  of  the  significance  of  what 
h;ive  been  termed  the  "  chromophylic  "  granules.  Held  has  alrody 
claimed  that  these  granules,  described  more  particularly  by  Nissl.  were 
arle-iacts  due  to  the  fi:tative  solutions  used,  and  in  his  previous  con- 
tribution in  the  same  journal.  1895.  gave  a  number  of  experimental 
■roofs  to  support  his  asserliun.  The  present  communication  is  an 
uswer  to  Lenhossek's  criticism  of  his  earlier  paper,  wherein  Len- 
ossek  sutes  that  the  granules  have  been  obsened  by  him  in  the  fresh 
pecimens.  The  author  adopts  the  idea  that  the  Nissl  granules  are 
rought  out  by  means  01  acid  fixatives,  and  shows  that  in  spinal  cord 
xed  with  weak  alkaline  solutions  i;  to  40  per  cent.  N'aOH  was 
sed)  the  large  cells  in  the  anterior  horns  were  completely  lacking  in 
lese  ciisraoieri^tit  bodies,  ami  that  when  he  fixed  with  alcohol  (which 


PERISCOPE.  215 

is  nearly  always  acid)  or  alcohol  plus  a  small  amount  of  acid,  acetic 
usualiy*^eing  used,  the  granules  were  very  conspicuous.  The  author 
further  considers  the  standpoint  of  physiological  chemistry,  which 
teaches  that  the  reaction  of  living  nervous  tissue  is  alkaline,  but  that 
almost  immediately  after  death  the  reaction  becomes  acid,  sometimes 
wjtiiin  a  few  minutes.  This  development  of  acid  is.  in  the  author's 
mind,  the  cause  of  the  formation  of  the  Nissl  chromophylic  bodies. 

The  paper  further  considers  the  erudite  questions  of  the  structure 
or  protoplasm,  the  nerve  cells  in  particular  being  the  ground  debated 
upon.  Held  is  inclined  to  adopt  the  reticulum  theory,  somewhat 
modified  from  the  original  Fromann  point  of  view,  and  rejects  the 
tiiiir  theory  of  Fleming.  The  article  is  one  that  cannot  be  omitted 
from  the  range  of  the  neurologist's  reading  if  he  is  interested  in  the 
problems  of  structure  and  the  interpretation  of  microscopical  pictures. 

Jelliffe. 

57  I'EBER  Variation  EN  im  Verlaufe  der  Pyramidenbahn  (On 
Variations  in  the  Course  of  the  Pyramidal  Tract).  A.  Hoche 
(Neurolog.  Centralblatt,  16,  1897,  No.  21). 

The  author  contributes  to  this  subject  the  anatomical  findings  in 
a  Case  of  glio-sarcoma.  situated  in  the  central  convolutions,  causing 
descenciing  degeneration,  in  the  pyramidal  tract;  the  course  of  the 
latter  wai^  found  to  vary  from  that  usually  observed.  Examination  by 
Marchi's  method  showed  that  in  the  peduncle,  pons  and  medulla  the 
regrion  of  the  left  pyramid  was  exclusively  degenerated. 

•  The  decussation  occurred  at  the  normal  level,  but  a  portion  of  the 
fibre*,  passed  down  into  the  opposite  anterior  tract. 

Thi>  decussated  anterior  tract  extended  throughout  the  entire 
cervical  region  of  the  cord,  and  disappeared  at  the  level  of  the  first 
dorsal  root. 

Another  unusual  occurrence  was  the  extension  forward  of  the 
area  of  degeneration  beyond  the  ordinary  region  of  the  lateral  pyra- 
midal tract,  wiiich  normally  does  not  reach  beyond  a  line  drawn 
through  the  lateral  horns. 

At  the  II.  cervical  in  Gower's  tract  a  bundle  was  observed,  which 
showed  itself  throughout  the  cervical  cord  as  an  irregular  figure. 

Throughout  the  dorsal  cord  the  crossed  pyramidal  tract  extended 
*-^*^  too  far  forward,  and  even  in  the  lumbar  region  the  pyramidal 
area  was  greater  than  usual.  . 

The  direct  pyramidal  tract  showed  a  hook-like  formation  as  low 
down  as  the  dorsal  region.  Meirowitz. 

5^-  On  thk  Endogenous  or  Intrinsic  Fibres  in  the  Limbo-sacral 
Region  of  the  Cord.     A.  Bruce  (Brain.  20.  1897.  p.  261). 

The  author  discusses  the  fibres  found  in  the  posterior  columns  of 
fik  ^^^^  "^  *^^  lumbo-sacral  region,  termed  by  Marie  the  endogenous 
nbres.  These  fibres  form  two  very  well-marked  tracts,  one  lying  in 
the  anterior  part  of  the  posterior  column,  in  close  opposition  to  the 
posterior  cornu.  commissure  and  septum:  the  second  in  immediate  re- 
lationship to  the  posterior  median  septum,  and  in  part  to  the  posterior 
surface  of  the  cord.  The  first  tract,  the  cormi-commissural  trad  (Hin- 
t^rstrangsfeld) :  the  second,  termed  by  the  author  the  septo-marginal 
tract.  "  Edinger's  medianisches   Hinterstrangsfeld." 

These  fibres  do  not  degenerate  upward  according  to  the  author, 
King  spared  in  locomotor  ataxia;  but  they  do  suffer  degeneration  in 
eruditions  which   induce  degeneration   in   the  cells  of  the  posterior 
h«»rns. 

I.)  The  comu-catnmissural  tract  extends  through  the  whole  of  the 
Umibo-sacral  region,  being  traceable  from  the  lowest  dorsal  segments 


2 1 6  PERISCOPE. 

to  the  extreme  tip  of  the  conns  medullaris.  At  the  level  of  the  lower 
lumbar  region  it  attains  its  greatest  size,  and  diminishes  above  and 
below  this  level.  It  lies  throughout  in  close  relation  to  the  posterior 
commissure  and,  in  the  main,  to  the  anterior  part  of  the  inner  margin 
of  the  posterior  horns.  Posteriorly  the  tract  has  no  definite  margin. 
Its  outer  portion  merges  gradually  into  the  part  of  the  column  behind 
it,  Flechsig's  middle  root  zone.  The  fibres  which  compose  it  can  be 
seen  entering  it  from  the  gray  matter  of  the  posterior  cornu,  and  al- 
most exclusively  from  that  of  the  same  side. 

2.)  The  septo-marginal  tract  forms  a  racquet-shaped  area  or  tri- 
angle, two  of  its  sides  being  applied  to  the  posterior  median  septum 
and  to  the  periphery,  respectively,  and  the  third  forming  a  somewhat 
indefinite  margin  between  the  degenerated  and  undegenerated  parts 
of  the  cord,  the  anterior  angle  seemingly  extending  anteriorly  to  the 
cornu-commissural  tract. 

With  reference  to  its  origin,  the  evidence  is  still  insufficient:  the 
tract  originates  in  part  in  the  higher  segments  of  the  cord,  gains 
greatly  in  bulk  about  the  level  of  the  first  sacral  segment,  and  ter- 
minates in  the  lower  sacral  and  the  coccygeal  region,  by  sending  fibres 
along  the  posterior  median  septum  into  the  gray  matter  near  the 
central  canal,  where  they  are  lost  among  the  other  fibres  in  this  part. 

The  author  believes  that  in  some  parts  of  its  path  this  i**  the  same 
as  Flechsig's  "oval  field."  The  tract  is  mainly  descending,  but 
Spiller  and  Dejerine  have  shown  it  to  contain  some  ascending  fibres. 

Their  function  is  undecided,  but  the  evidence  seems  to  point  to 
their  being  connected  with  the  lower  organic  reflexes.  The  paper  is 
well  illustrated  and  contains  a  partial  bibliography.  Vo(;kl. 

59.    ZUR    L/EHRKVON  DKN  SECUNDARKN  DEG  EN  K  RATION  EN  IM  RUCKKS 

MARKE      (Secondary   Degenerations   in   the   Spinal   Cord).        By 
Dr.  B.  Worotynski    ( Neurol og.  Central blatt,  lO.  1897,  No.  2Ti). 

Experiments  were  made  upon  dogs,  in  which  total  and  hemi- 
lateral  sections  01*  the  cord  at  different  levels  were  practiced.  In  all. 
18  experiments  were  performed,  the  animals  surviving  from  i  to  127 
days.    The  author's  results  are  summarized  as  follows: 

1.  Secondary  degeneration  of  the  individual  systems  in  the  spinal 
cord  of  dogs  docs  not  develop  synchronously:  the  fibres  of  the  pos- 
terior columns  of  L^wenthal's  bundle  degenerate  first;  then  those  of 
the  direct  cerebellar  and  of  the  antero-lateral  tracts;  finally,  the  fibres 
of  the  pyramidal  tracts.  In  the  human  brain  the  same  order  seems 
to  be  followed. 

2.  Degenerative  processes,  once  begun,  develop  rapidly,  almost 
simultaneously  throughout  the  entire  extent  of  the  tract. 

3.  In  the  columns  of  Goll  and  Lowenthal  the  degenerative 
process  att<iins  its  maximum  severity,  which  may  be  observed  by  the 
methods  of  Marchi,  in  the  course  of  the  second  week  following  sec- 
tion of  the  cord;  in  the  direct  cerebellar  and  antero-lateral  bundles,  in 
the  course  of  the  third  week:  in  the  lateral  pyramidal  tracts  it  is  still 
possible  at  the  end  of  the  fourth  week  to  observe  a  general  intensifica- 
tion of  the  degenerative  process. 

4.  With  Weigcrt's  method  the  secondary  degentrations,  even 
three  weeks  after  section  of  dog's  cord,  are  hardly  to  be  seen. 

5.  The  order  in  which  the  secondary  degenerations  of  the  dif- 
ferent columns  show  themselves  corresponds  approximately  to  that 
in  which  the  systems  receive  their  sheaths  during  development. 

6.  Kahler's  law  on  the  arrangement  of  the  root  fibres  in  the 
posterior  columns  can  be  accepted  absolutely.  The  same  law  holds 
good  with  reference  to  the  human  brain. 


PERISCOPE,  2 1 7 

7.  Throughout  the  entire  cord  up  to  the  cervical  region  the  col- 
amns  of  Goll  receive  their  fibres  from  the  posterior  roots.  In  the 
cervical  cord  the  posterior  root  fibres  enter  the  columns  of  Burdach. 

8.  The  descending  system  of  the  posterior  columns  consists 
principally  of  myelogenic  fibres.  The  bundles  of  descending  fibres  in 
tbe  posterior  columns,  described  by  different  authors  under  various 
Mines,  belong  to  one  and  the  same  system,  which  at  different  levels 
of  the  cord  changes  its  position  and  form. 

g.  In  hemi-sections  of  the  cord  degenerations  of  the  columns  of 
Goll,  Burdach,  Flechsig,  Gowers  and  L()wenthal  are  observed  on  both 
sides.  The  decussation  of  the  columns  of  Goll  and  Burdach.  and 
partly  of  Flechsig,  takes  place  on  the  posterior  commissure.  The 
fibres  of  Gowers*  and  Lowenthal's  bundles  cross  over  principally  in 
the  anterior  commissure. 

10.  The  antero-lateral  (Gowers')  columns  in  dogs  extend  for- 
ward as  far  as  the  anterior  fissure  of  the  cord,  and  partly  enter  the 
anterior  columns. 

11.  Gowers*  and  Flechsig's  columns  must  be  considered  as  be- 
longing, anatomically,  to  one  and  the  same  system.  A  portion  of  both 
tracts  terminates  unquestionably  in  the  cerebellum  in  the  region  of  the 
nucleus  dentatus  and  nucleus  tecti.  Decussion  of  part  of  these  fibres 
occurs,  in  all  likelihood,  in  the  upper  cerebellar  vermiform  process. 

12.  Descending  degeneration  of  Gowers'  and  Flechsig's  columns 
appears  questionable.  Such  described  degenerations  must  be  at- 
tributed to  the  fibres  of  Lowenthal's  bundle. 

13.  The  existence  in  man  of  a  separate  descending  system  in  the 
antero-lateral  tract  may  be  considered  as  proved. 

14.  The  descending  degeneration  of  the  intra-spinal  anterior 
roots  from  the  point  of  section  may  be  best  explained  by  the  passage 
into  the  former  of  fibres  from  Lowenthal's  bundle. 

15.  The  ascending  degeneration  of  the  intra-spinal  anteri^ir  roots 
is  occasioned  by  the  passage  into  them  of  the  direct  cerebellar  and 
antero-lateral  fibres. 

16.  The  traumatic  degeneration,  in  the  sense  of  Schiefferdecker, 
is  only  observed  for  a  space  of  J^-i  cm.  above  and  below  the  section. 

17.  In  the  anterior  pyramidal  tracts  of  the  human  brain  are  fibres 
which  degenerate  upward,  and  which  may  be  separated  to  form  a 
distinct  system   (Marie).  Meirowitz. 

PHYSIOLOGY. 

60.  ATkntative  Kxpi^anation  of  Some  ok  the  Phenomena  op 
Inhibition  on  a  Histo-Physiological  Basis,  Inci^uding  a 
Hypothesis  Concerning  '  the  Function  of  the  Pyramidal 
Tracts.     B.  Onuf  (State  Hospitals'  Bulletin,  2,   1897,  p.  45). 

The  author  offers  the  following  theory  to  account  for  the  phe- 
nomena of  inhibition  of  the  patellar  reflexes:  "For  the  excitation  of  a 
nerve  cell  the  movement  has  to  pass  in  the  direction  from  the  cell 
body  or  its  protoplasmic  processes  toward  the  nervous  process;  for  the 
inhibition  of  the  cell  the  nerve  current  has  to  pass  in  the  opposite 
direction,  that  "is,  from  the  nerve  process,  or  its  collaterals. 'back  to 
the  cell  body.  In  .other  words,  to  pfoduce  excitation  of  a  given  cell 
the  nerve  current  must  enter  this  cell  from  the  surface  of  its  cell 
body  or  of  its  dendrites;  but  in  order  to  inhibit  or  moderate  the  ac- 
tion of  the  cell  the  nerve  current  has  to  enter  the  cell  from  its  nerve 
process  or  collaterals  thereof." 

Interpreted  in  anatomical  terms,  the  author  suggests  that  in  the 
test  of  the  knee  jerk  the  peripheral  motor  neuron  is  acted  upon  in 
three  ways: 


2l8  PERISCOPE. 

1.  From  the  peripheral  sensory  nerve  fibres,  probably  through  a 
collateral  thereof.     (The  direct  reflex  arc.) 

2.  From  the  cerebellum,  which  maintains  a  constant  stimulation 
of  the  peripheral  motor  neuron,  producing  the  necessary  excitation. 

3.  From  the  cortico-spinal  fibres,  which  have  an  inhibitory  ac- 
tion, and  thus  counteract  the  other  two  exciting  impulses.  "Assum- 
ing all  this  to  be  the  case,  interruption  of  the  cortico-spinal  pyramidal 
fibres  will  give  rise  10  exaggeration  of  the  knee  jerk  by  loss  of  the  in- 
hibitory inHuence.  Interruption  of  the  cerebello-spinal  motor  tract 
will  cause  absolute  loss  of  the  reflex,  as  the  sensory  stimulus  coming 
from  the  tendon  will  be  counteracted  by  the  inhibitory  action  of  the 
pyramidal  fibres."  Jelliffe. 

61.  Le  Mkchani.smk  dEvS  mouvemknts  rkfi^exes  (Mechanism  of 
Reflex  Movements).  Van  Gehuchten  (Neurolog.  Central blatt, 
16,  1897,  p.  919;  abst). 

The  author  presented  this  paper  at  the  International  Medical  Con- 
gress of  Moscow,  an  abstract  of  it  appearing  in  the  above  mentioned 
journal. 

A  number  of  observers  have  shown  that  after  complete  transverse 
lesion  of  the  cervical  or  dorsal  region  there  is  a  complete  loss  of  the 
tendon,  skin  and  visceral  reflexes,  save  perhaps  the  persistence  of  tlie 
plantar  reflex  upon  deep  needle  puncture.  According  to  our  present 
physiological  knowledge  these  facts  are  diflicult  of  explanation. 

The  normal  muscular  tonus,  according  to  Van  Gehuchten,  de- 
pends upon  the  condition  of  excitation  which  at  any  moment  may  be 
present  in  the  cells  of  the  anterior  horns.  This  excitability  depends 
upon  the  connecting  fibres  going  to  these  cells:  fibres  from  the  pos- 
terior horns  and  from  the  cortex  and  cerebellum  through  the  pos- 
terior longitudinal  fasciculus. 

Such  fibres  convey  either  excitation  (posterior  root  fibres,  intes- 
tinal and  cerebellar  fibres)  or  impulses  (cortico-spinal  fibres). 

The  normal  muscular  tone  is  thus  dependent  upon  the  nervous 
tone  of  the  anterior  horn  cells,  which  is  imparted  to  them  by  these  two 
forms  of  stinmlation,  and  any  change  in  the  nervous  tone  of  these  cells 
aiTects  the  muscle  tonus.  For  the  consummation  of  a  voluntary  move- 
ment it  is  not  enough  that  the  fibres  from  the  motor  zone  to  the 
muscles  be  intact,  the  cells  in  the  anterior  horns  must  have  their  nor- 
mal nervous  tone. 

Thus  a  reflex  motor  act  can  occur  only  when: — 

1.  The  reflex  arc  is  both  anatomically  and  physiologically  intact. 

2.  When  the  motor  cells  have  a  normal  nervous  tone.  Upon  this 
second  postulate  depends  the  relationship  of  the  intensity  of  the  reflex 
act  to  the  peripheral  stimulation.  Thus  it  is  possible  to  understand 
why  after  the  lesions  of  the  pyramidal  tracts  exaggerated  reflexes 
may  be  present,  without  the  necessary  theoretical  assumptions  of  sec- 
ondary degeneration  or  sclerosis  of  these  fibre  tracts. 

.Also  it  may  be  explained  along  some  such  hypothesis  why  re- 
flexes may  be  lost  after  complete  lesion  of  the  cora  without  calling 
into  account  the  nervous  shock  and  inhibition  fibres,,  according  to 
Kahler  and  Pick,  or  to  speak  of  a  functional  disturbance  of  the  gray 
matter  of  the  lumbo-sacral  cord.  Vogel. 

62.  Ueber  die  Lkitungsbahnen  der  Reflex b  im  Ruckenmark 
UND  den  Ort  der  RKFLKxiJBERTRAOi'NG  (On  the  Conduction 
Paths  of  the  Reflexes  in  the  Spinal  Cord  and  the  Locality  of  the 
Reflex-Tranter).  J.  Rosenthal  and  .M.  Mendelssohn  (Neurolog. 
Centralblatt,  16.  1897.  p.  21) 

In  contradiction   of  the  accepted   view   that   the   short  paths  be- 


PERISCOPE..  219 

tween  the  ingoing  sensory  fibres  and  the  outgoing  motor  fibres  arc 
involved  in  the  production  of  the  phenomenon  called  the  reHex,  the 
authors  have  experimentally  shown  that  in  frogs  and  mammals  the 
reflex -transfer  takes  place  in  the  cervical  portions  of  the  spinal  cord, 
and  perhaps  also  partly  in  the  medulla  oblongata. 

After  having  determined  the  minimum  amount  of  the  irritation 
just  suf^cient  to  produce  a  definite  reflex,  sections  were  made  at  dif- 
ferent levels  of  the  cord  and  the  alterations  noted.  It  was  found 
that  the  integrity  of  the  connection  of  the  upper  cervical  cord,  im- 
mediately beneath  the  calamus  scriptorius,  with  the  sensory  and  motor 
paths  was  indispensable  for  the  production  of  the  reflex.  If  thi.<^ 
region  of  the  cord  be  destroyed  the  former  effective  minimal  stimuli 
no  longer  produce  the  reflex.  If  their  strength  be  increased  the  stim- 
uli find  other 'paths  to  the  origins  of  the  motor  nerves 

It  therefore  appeared  probable  to  the  authors  that  in  cases  pre- 
senting lesions  of  the  bulbo-ccrvical  region  the  reflexes  below  wouM 
be  either  abolished  or  very  much  diminished.  In  diametrical  oppo- 
sition to  this  view  was  the  teaching  that  separation  of  the  cord  from 
the  medulla  occasioned  an  exaggeration  of  the  reflex. 

At  that  time  (1875)  the  only  reported  cases  were  those  of  Kadner. 
Weiss,  Kahler  and  Pick,  in  which  transverse  ihjury  in  the  upper  cord 
caused  abolition  of  the  reflexes  below  the  lesion.  Since  1882,  when 
the  authors  renewed  their  investigations,  other  cases  were  put  on 
record  in  which  complete  transverse  lesion  of  the  cord  was  followed 
by  flaccid  paralysis  of  the  lower  extremities  with  abolition  of  the 
tendon,  skin  and  visceral  reflexes  (Bastian,  Bowlby,  Thorburn,  Bab- 
inski,  Bruns,  Gerhadt,  Hitzig,  Egger,  Hoche,  Habel,  Van  Gehuch- 
tcn),  in  spite  of  absolute  integrity,  microscopically  determined,  of  the 
lumbo-sacral  regions  of  the  cord. 

Another  significant  fact  is  that  in  no  case  recorded  of  complete 
transverse  division  of  the  cord  did  the  tendon,  visceral  and  skin  re- 
flexes persist. 

It  appears  therefore  that  the  clinical  observations  are  in  accord 
with  the  experimental  in  placing  the  reflex  centre  in  the  bulbo-cervical 
portion  of  the  cord.  Meirowitz. 

63.    EXPHRIMRNTAI,  OBSERVATIONS  ON  THE  CROSSED  ADDUCTOR  JKRK. 

P.  Stewart  (Journal  of  Physiology,  22,  1897,  p.  61). 

As  the  result  of  the  author's  observations  on  a  case  in  which  the 
phenomenon  of  crossed  knee  jerks  was  obtained  the  following  con- 
clusions were  offered : — 

1.  That  the  crossed  adductor  jerk  is  not  due  to  direct  stretching 
of  the  adductor  muscles  by  a  shock  communicated  to  the  pelvis. 

2.  That  the  crossed  adductor  jerk  is  not  due  to  a  shock  me- 
chanically transmitted  to  the  spinal  cord. 

3.  That  the  crossed  adductor  jerk  is  a  true  reflex,  occurring  at  a 
period  distinctly  later  than  the  ordinary  knee  jerk. 

4.  That  the  average  time  required  for  the  appearance  of  the 
crossed  adductor  jerk  is  about  .126  of  a  second  from  the  time  wheii 
the  opposite  tendon  is  tapped.  Jelliffe. 

PATHOLOGY. 

64.  Note  on  Mhsci^e-spindi^bs  in  Psrudo-Hypertrophic  Parai^ysis. 
A.  S.  Grunbaum  (Brain,  20,  1897,  p.  365). 

The  author  gives  a  short  note  of  his  findings  in  a  case  of  pseudo- 
hypertrophic paralysis.  He  says  the  muscle-spindles  were  for  the 
most  part  unaffected,  but  in  a  few  there  was  a  diminution  in  size  of  an. 


2  20  PERISCOPE. 

intra-liusal  tibre  with  a  ^loposit  of  hyaline  material  around.     The  or- 
dinary muscular,  nervous  and  vascular  changes  were  also  present. 

65.    NOT£  SUR    LEX   REKl^KXiSS    FEMOKAUX   CROISBS  CUBZ   LES    EPXi:#EP- 

TiQUES      (On  Crossed  Femoral  Reflexes  in  Epileptics.)  Ch.  Fete 
(Comptes  rend.  Soc.  de  Biologie,  5,  1898,  p.  7). 

An  examination  by  the  author  of  some  143  non-paralytic  epilep- 
tics, examined  in  a  period  when  but  few  were  deeply  under  the  in- 
fluence of  bromides,  revealed  the  presence  of  this  phenomenon  in 
twenty-four  instances.     The  author  presents  the  following  table: — 

Crossed 
Patellar  Reflex.  Femoral  Reflcs. 

Feeble  35  — 

Medium    64 8 

Strong 44 16 

Total   143  24 

The  variety  of  the  crossed  reflex  varied;  in  16  cases  the  r.  ad- 
ductor, m  3  the  r.  extensor  and  in  3  both  muscles  showed  the  phe- 
nomena. In  general,  the  crossed  femoral  reflex  was  equal  on  both 
sides,  save  in  one  case,  where  the  right  side  predominated. 

Bromides  &eemed  to  have  no  influence  upon  either  the  patellar 
reflex  or  crossed  femoral  reflex.  Vogel. 

CLINICAL  NEUROLOGY. 

66.  hSL  SCOMPARSA   DEL   RIFUESSO   DEL  TKNDINE   ACHILLBO   NELL  SCI- 
ATICA   (Tendon    Reflexes   in  Sciatica)     J.  Babinski  (Gazz.  d.  Os- 

pedali,   18,   1897,  p.  2g). 

In  a  note  the  author  shows  that,  whereas  in  healthy  individuals 
the  tendon -reflex  is  normal,  in  sciatica  there  is  usually  a  diminudcw 
or  a  loss  of  such  tendon-reflex.  This  phenomenon  was  found  not 
only  in  severe  cases  of  the  disease,  but  also  in  much  lighter  forms,  as 
ischialgia.  In  some  cases  there  were  marked  differences  in  the  re- 
flexes on  opposite  sides  of  the  body. 

The  author  considers  this  a  valuable  diagnostic  sign,  especially 
to  diflferentiate  simulation  from  hysterical  sciatica.  It  is  not  clear, 
however,  that  incipient  tabes  is  ruled  out  in  this  report.       Jellifpe. 

67.  Le  reflexe  rotulien  dans  la  syphilis  (The  Knee-jerk  ia 
Syphilis.)  Valentine  Zaroubine  (Jour,  de  Conn.  Med..  Mardi 
II,  1897). 

The  author  found  the  knee-jerk  exaggerated  in  all  syphilitic  pa- 
tients during  the  secondary  stage.  Following  this  increase,  the  ex- 
citability often  fell  and  then  regained  its  normal  state. 

Mac  A  LESTER. 

68.  Cases  op  Pseudo-Hypertrophic  Paralysis  and  other  Forms 

OF  Progressive  Muscular  Dystrophy.  Bryom  Bramwell  (Atlas of 
Clinical  Medicine,  iii.,  1897,  p.  95). 

In  an  elaborate  report  the  author  presents  the  clinical  histories 
of  fifteen  cases  of  pseudo-hypcrtrophic  paralysis  and  one  case  of  my- 
opathic muscular  atrophy  affecting  the  face,  tongue,  ocular  muscles, 
muscles  of  the  head,  neck,  shoulder  girdle  and  upper  extremities. 

In  about  five  cases  detailed  microscopical  examinations  were 
made  of  the  muscles,  the  peripheral  nerves  and  the  spinal  cord. 


PERISCOPE.  221 

While  there  is  little  new  in  the  communication,  the  detailed  clini- 
cal examinations,  large  number  of  post-mortems  made  and  the  nu- 
merous illustrations  render  this  contribution  an  important  one. 

Jelliffe. 

69.  Atrophia  muscolarb  progressiva  spinai^b  ( Progressive  Spinal 
Muscular  Atrophy).  Morasca  (Resoconto  degli  Ospedali  di 
Genova,   i8g6). 

The  author  describes  a  case  of  progressive  muscular  atrophy  of 
the  Aran-Duchenne  type,  and  comes  to  the  general  conclusion  that  if 
the  patient  does  not  come  to  autopsy,  a  clinical  diagnosis  of  this 
disease  is  alone  possible:  but  that  from  a  pathological  point  of  view 
the  findings  may  be  syringomyelia,  or  an  amyotrophic  lateral  sclero- 
sis, or  an  anterior  poliomyelitis,  a  chronic  myelitis  or  a  progressive 
muscular  atrophy  (Erb).  The  clinical  diagnosis  without  anatomical 
confirmation  is  of  relative  value  only.  Vogel. 

70.    Un    CAS     D'ATROPHIE    MUSCl'LMRE     PROGRESSIVE     W     TYPE    Du- 

chenne-Aran.  (A  Case  of  Progressive  Muscular  Atrophy  of  the 
Duchenne-Aran  Type).  Villers  (Journ.  Med.  de  Bruxelles,  Jan. 
M.   1897)- 

The  case  reported  here  occurred  in  a  man  52  years  of  age,  who 

^ve  years   previously   suddenly   became   paralyzed   in   the   right   arm, 

^vhich  recovered  in  about  three  months.    After  this  there  set  in  a  weak- 

"'^ss  and  gradual  atrophy  of  the  muscles  of  the  hand,  of  the  thumb 

^^d  fingers,  which  gradually  progressed  to  the  arm.      One  year  after 

.''5  first  i^udden  attack  of  paralysis  he  had  a  peculiar  attack  of  twitch- 

?^  in  the  left  hand,  and  was  taken  to  a  hospital.     His  condition  then 

j^/-^^'ed   marked    atrophy    of   the   upper   extremities,    main    en    griffe, 

j^.*''llary  twitchings   in   the   opponens   pollicis   and    interossei    of   the 

s^.    '"^and.    The  muscles  of  the  neck  and  face  were  less  involved.     Sen- 

*^    and  reflexes  'ntact.     No  reactions  of  degeneration. 
■jiYi^i   he  patient  died  two  years  after  entering  the  hospital,  having  suf- 
V  ^  ^rom  a  number  of  epileptiform  attacks,  after  each  one  of  which 
uVe  atrophy  bci-anic  more  profound,  although  his  condition  had  bet- 
^^et'^d  by  electrical  and  massage  measures. 

Autopsy  showed  a  universal  atrophy  of  the  muscles,  more  pro- 
found on  the  right  side.  The  spinal  cord  showed  a  decrease  in  the 
-ize  of  the  anterior  horns,  the  cells  being  decreased  in  size.  Sections 
at  the  level  of  the  anterior  end  of  the  optic  thalamus  showed  the 
position  of  an  old  hemorrhage. 

Microscopical  examination  showed  general  arterio-sclerosis,  also 
involving  the  brain:  degeneration  of  the  muscular  substance 
throughout:  in  the  spinal  cord  absence  of  any  fibre  degenerations, 
marked  atrophy  of  the  ganglion  cells  of  the  anterior  horns  at  the  level 
oi  the  cervical  and  upper  dorsal  regions.  There  were  no  marked 
changes  found  in  the  peripheral  nerves,  though  some  showed  de- 
generative lesions.  Jelliffe. 

71.    EXISTE-T-TL  UNB  ATROPHIE  MUSCULAIRE   PROGRESSIVR  ARAN-Du- 

CHENNE    ( Is  there  a  Progressive  Muscular  Atrophy  of  the  Aran- 
Duchenne  Type?)     P.  Marie  (Revue  Neurologique.  5,  1897,  p.  686. 

In  a  short  note  the  author  discusses  the  type  of  progressive  muscu- 
lar atrophy' of  Duchenne.  He  states  that  this  was  described  at  a  time 
when  our  knowledge  of  the  nervous  system  was  quite  incomplete,  and 
that  subsequent  investigations  have  shown  ^hat  Duchenne's  symp- 
tom complex  includes  a  rmmber  of  diseases,  which  later  writers  have 
heen  able  to  diflferentiate  and  render  classic  descriptions  of  the  same. 


222  PERISCOPE. 

Some   oi    thc-^e   have    been    amyotrophic    lateral    sclerosis,    my(»paihie 
progressive  primitive,  syringomyelia  and  multiple  neuritis. 

These  considerations  lead  the  author  to  conclude  that  there  re- 
mains no  well-defined  type  to  accord  with  Duchenne's  original  de- 
scription, and  that  the  disease,  as  such,  has  ceased  to  exist. 

Jklliffe. 

72.  Weitkrkr  Beitrag  zuk  Lhhre  von  der  hhkeditaeren  pro- 
gressive n  SPINALEN  MrSKELATROPHIE  IM  KlNDESAl,TER,  NKBST 
BEMERKUNGEN  UEBER  den  FnRTSCHRElTENDEN  MUSKEWCHWUND 

IM  Allgemeinen  (A  further  Contribution  to  the  Study  of  the 
Hereditary.  Progressive.  .Spinal.  Muscular  Atrophy  in  Childhood; 
with  Remarks  on  Progressive  Muscular  Atrophy  in  General). 
J.  Hoffmann  (Deutsche  Zeitschr.  f.  Xervenheilk.,  x.,  1897,  p.  29J. 

Hoffmann  publishes  a  very  important  addition  to  his  paper  on 
the  spinal  form  of  hereditary  muscular  atrophy,  which  appeared  in 
1893.  He  reports  the  case  of  a  child,  who  was  born  of  sound  parents, 
and  in  normal  labor,  and  seemed  to  be  healthy  until  the  seventh  or 
eighth  month  of  life.  At  this  time,  without  known  cause  and  without 
the  signs  of  an  acute  or  chronic  general  affection,*  bilateral,  flacci»i 
paresis  of  the  muscles  of  the  hip,  buttock  and  thigh  was  observed, 
which  gradually  extended  and  involved  symmetrically  the  muscles  oi 
the  back,  neck,  shoulder,  upper  limbs  and  legs,  and  caused  more  or 
less  paralysis  of  these  parts.  The  muscles  first  affected  were  most 
atrophied.  The  tendon  reflexes  were  absent.  Secondary  changes  in 
the  joints  and  vertebral  column  were  noted.  Fibrillary  tremor  was 
absent.  Sensation  and  the  action  of  the  sphincters  were  normal.  The 
electrical  reactions  could  not  be  obtained,  though  reaction  of  degen- 
eration had  been  observed  in  other  children  of  the  family  who  had 
died  with  similar  symptoms.  The  mental  condition  was  normal.  The 
facial,  lingual  and  throat  muscles  were  not  paralyzed.  Death  occurred 
from  secondary  pulmonary  disease  when  the  child  was  about  two  and 
a  half  years  old.  The  microscopical  examination  showed  symmetrical 
and  marked  degeneration  of  all  the  peripheral  motor  neurons  below 
the  twelfth  nerve,  including  the  eleventh  nerve;  disappearance  or 
degeneration  of  the  cells  of  the  anterior  horns  of  the  cord;  great 
degeneration  of  the  anterior  spinal  roots:  less  noticeable  changes  in 
the  peripheral  nerves  and  the  intramuscular  nerve  branches;  distinct 
degeneration  of  the  crossed  and  direct  pyramidal  tracts  and  of  a  por- 
tion of  the  lateral  columns,  which  was  most  evident  in  the  upper 
thoracic  and  cervical  regions,  but  not  traceable  above  the  motor  decus- 
sation. Simple  atrophy  in  all  stages  was  noted  *in  the  muscles.  The 
spinal  affection  was  believed  to  be  primary. 

Hoffmann  describes  a  third  family  in  which  this  hereditary  spinal 
form  of  atrophy  was  observed.  The  diagnostic  features  of  the  maladv 
are:  the  heredity;  the  commencement  in  the  first  year  of  life:  the  first 
signs  of  atrophic,  flaccid  paralysis  in  the  muscles  of  the  pelvic  girdle 
and  thighs;  the  extension  of  the  atrophy  to  the  muscles  of  the  trunk 
and  limbs;  the  absence  of  tendon  reflexes:  the  presence  of  reaction  of 
degeneration,  and  the  early  death. 

Twenty-two  cases  in  all  of  this  disease  and  four  necropsies  have 
been  reported.  In  all  four  the  peripheral  neurons  were  found  much 
degenerated  and  the  muscles  in  a  simple  state  of  atrophy,  and  in  three 
the  anterolateral  columns  were  affected. 

At  one  time  only  the  different  forms  of  muscular  atrophy,  known 
as  dystrophy,  were  supposed  to  be  hereditary.  Hoffmann  speaks  of 
the  following  four  forms  of  hereditary  muscular  atrophy: 

I.   A  forni  which  begins  in  childhood  in  the  muscles  of  the  pelvic 


PERISCOPE.  223 

girdle  and  extends  from  the  trunks  to  the  muscles  of  the  extremities 
(Werdnig,  Hoffmann). 

2.  An  infantile,  bulbar,  paralvfic,  facial  type  (Fazio,  Londe). 

3.  A  Duchenne-Aran  type  (Striimpell,  Gowers). 

4.  A  transitional  form. 

It  seems  at  present  that  the  influence  of  heredity  is  more  clearly 
shown  in  the  myopathic  and  neurotic  forms  than  in  the  myelopathic 
form  of  muscular  atrophy.  Fibrillary  tremor  is  the  rule  in  the  spinal 
form  and  the  exception  in  the  purely  muscular  form  of  atcophy,  and 
yet  it  may  be  absent  in  the  spinal  form.  Reaction  of  degeneration  may 
occasionally  be  absent  in  spinal  muscular  atrophy  and,  in  exceptional 
cases,  be  present  in  the  purely  muscular  form.  Neither  simple  nor 
degenerative  atrophy  of  the  muscular  fibres  is  a  fair  criterion  of  the 
nature  of  the  atrophy.  Spiller. 

73.  Bbitrag  zur  Lbhrb  vox  dbr  progrbsstvbn  nburai«bn  Muskel- 
ATROPHiB  (A  Contribution  to  the  Study  of  Progressive,  Neural, 
Muscular  Atrophy).  By  F.  Egger  (Archiv  fiir  Psychiatric,  29,  1897, 
p  400). 

Egger  reports  two  cases  of  progressive,  neural  muscular  atrophy 
which  occurred  in  brothers  in  a  healthy  family.  The  disease  began 
in  the  younger  patient  when  he  was  thirty-eight.  It  was  first  observed 
in  the  lower  extremities  in  the  peroneal  muscles  and  on  the  right  side 
of  the  body.  Sensory  disturbances  were  present  in  both  cases.  Mus- 
cular atrophy  and  paresis  were  soon  visible  in  the  upper  limbs.  Re- 
action of  degeneration  was  also  observed.  The  cases  are  reported  on 
account  of  certain  peculiar  features.  In  both  there  was  a  possibility 
of  poisoning  from  lead,  and  it  may  be  that  the  effects  of  lead  aided 
in  the  development  of  the  disease.  Vesical  disturbance  (frequent  mic- 
turition and  dribbling  after  urination)  and  swaying  of  the  body  on 
closure  of  the  eyes  were  unusual  symptoms  in  one  patient.  One  of 
these  cases  shows  that  tabes  must  sometimes  be  considered  in  making 
a  diagnosis  of  progressive,  neural,  muscular  atrophy,  for  pain,  loss  of 
reflexes,  Romberg's  sign,  girdle  sensation  and  vesical  disturbances 
arc  certainly  very  suggestive  of  tabes.  Absence  of  pupillary  rigidity 
does  not  necessarily  exclude  tabes,  for  an  examination  of  over  four 
hundred  cases  of  tabes  in  Erb's  clinic  by  Leimbach  showed  that 
changes  in  pupillary  reaction  were  present  only  in  70.25  per  cent,  and 
in  cases  of  one  or  two  years'  duration  only  in  63  per  cent.  The 
presence  of  the  disease  in  two  brothers  and  the  early  development  of 
the  muscular  atrophy  were  contrary  to  the  manifestation  of  tabes. 
Egger  shares  Oppenheim's  opinion,  viz.,  that  progressive,  neural, 
muscular  atrophy  is  a  chronic  hereditary  form  of  multiple  neurosis; 
and  in  this  aspect  the  possibility  of  lead  poisoning  in  these  two  cases 
becomes  of  unusual  interest.  Egger  thinks  with  Hoffmann  that  it  is 
not  probable  that  neuritis  may  be  hereditary,  but  a  slight  power  of 
resistance  to  disease  may  be  transmitted,  and  it  is  well  in  treating  a 
case  of  progressive  neural,  muscular  atrophy  to  remove  all  injurious 
substances,  lead,  alcohol,  etc.,  which  are  so  deleterious  in  neuritis. 

Spiller. 

74.  BB'Trao  zur  nburtttschkk  Form  dkr  p^?ogrksstven  Mt^skbl- 
ATROPHIB  (Contributions  to  tHe  Neural  Form  of  Prosjressive  Mus- 
cular Atrophy).     Siemerling  (Neurologisches  Centralblatt,  16.  1897, 

p.  568,  Abst). 

The  case  described  occurred  in  a  young  man  of  20.  whose  mother 
died  of  tuberculosis.  Up  to  his  5-7th  year  he  developed  normally,  and 
then  his  hands  and  lower  thighs  began  to  atrophy.     From  his  thir- 


224  PERISCOPE, 

teenth  year  he  was  unable  to  walk.     At  first  his  psyche  was  normal, 
but  later  he  became  sullen  and  taciturn. 

There  was  loss  of  pupillary  light  reaction,  spasmodic  twitchings 
in  the  left  zygomatici,  nasal  speech  with  tremor  of  the  tongue,  marked 
atrophy  of  the  hands  and  arms,  main  en  griflfe,  the  deltoid,  pectoralis 
and  biceps  being  the  best  preserved;  no  tendon  phenomena,  left  leg 
extended,  right  contracted  at  the  knee;  marked  atrophy  of  both  sides, 
loss  of  active  motion  in  both  lower  extremities;  loss  of  pain  sensa- 
tions throughout  the  entire  body,  more  markedly  in  the  legs;  fibrillary 
contractions  in  the  intercostal  muscles;  marked  diminution  in  the  fara- 
dic  and  galvanic  currents;  hypochondria. 

Autopsy  showed  a  normal  brain,  macroscopic  patches  in  the 
lateral  and  posterior  columns;  fatty  degeneration  of  the  lower  thigh 
muscles.  Microscopic  examination  of  the  cord  showed  degeneration 
of  the  posterior  and  lateral  columns,  particularly  in  the  dorsal  and 
lumbar  region;  atrophy  of  the  anterior  horn  cells  and  of  Clark's  col- 
umns; posterior  roots  intact,  anterior  degenerated;  degeneration  of 
spinal  ganglia,  sympathetics  intact;  a  widely  spread  degeneration  of 
the  sensory  and  mixed  nerves;  degeneration  of  the  muscles  in  various 
places.  The  author  believes  the  peripheral  changes  to  have  been  the 
primary  ones,  the  changes  in  the  spinal  cord  being  secondary. 

Jelliffe. 

75.  Beitrag  zur  hemiatrophia  facialis  progrhssiva  (Contributions 
to  Progressive  Facial  Hemiatrophy).  J.  Donath  (Wien.  klin. 
Woch.,  X.,  1897). 

The  patient  described  was  a  man  26  years  of  age,  who  ten  years 
previously  had  received  a  wound  on  the  right  side  of  the  face,  which 
left  a  scar  upon  his  chin.  Three  years  later  the  patient  had  a  tooth 
pulled,  and  in  the  operation  a  portion  of  the  lower  jaw  was  also 
taken  with  the  tooth.  The  clinical  picture  began  at  that  time;  the 
skin  was  thinned,  pale,  furrowed;  there  was  an  atrophy  of  the  muscles 
and  of  the  bones,  suppression  of  the  perspiration  and  diminution  or 
suppression  of  the  growth  of  hair.  The  sensibility  of  the  right  half 
of  the  face  was  diminished  and  the  electrical  reactions  of  the  right 
facialis  increased.  There  also  was  some  atrophy  of  the  right  half  of 
the  tongue.  There  was  no  sensation  of  pain  in  the  wound,  but  there 
was  slight  pain  produced  by  movements  of  the  lower  jaw.  The  author 
was  of  the  opinion  that  the  pathological  process  was  due  to  the  infection 
of  the  wound  at  the  time  when  the  tooth  was  pulled,  and  that  a  dif- 
fuse nerve  and  vessel  inflammation  was  produced,  resulting  in  the 
clinical  picture  described.  Vogel. 

THERAPY. 

76.  Myopathie  progressive  ameuoree  par  la  medication  thyrot- 
DiENNE.  (Progressive  Muscular  Atrophy  Improved  by  Thyroid 
Therapy).    Lepine  (Lyon.  Medical,  82,  1896,  p.  35). 

In  a  case  of  juvenile  muscular  atrophy,  where  the  patient  was  un- 
able to  walk  or  even  to  stand  erect  for  any  length  of  time,  the  author 
gave  weekly  doses  of  thyroid  gland — 120  gms. — with  the  result  that 
the  patient  was  enabled  to  stand  erect,  and  finally  to  go  to  work. 
There  were  no  objective  changes  in  the  muscles.  The  author's  ex- 
planation was  that  the  thyroid  secretions  might  have  some  influence 
over  the  energy  of  muscle  contractility.  Suggestion,  he  believes, 
was  ruled  out.  Jelliffe. 


Sooli  gljetiijeitrs. 


A  TsxT-BooK  ON  Mental  Diseases.  For  the  use  of  students  and 
practitioners  of  medicine.  By  Theodore  H.  Kellogg,  A.M.,  M.D. 
William  Wood  &  Company,  New  York,  1897. 

The  work  before  us  is  a  large  volume  of  seven  hundred  and  fifty- 
nine  pages.  The  object  of  the  book,  as  stated  in  the  preface,  is  "to 
set  forth  in  a  condensed  but  comprehensive  manner  the  present  state 
of  the  science  of  mental  disease.  The  book  is  made  to  embrace  the 
wide  range  of  the  history,  statistics,  nosology,  etiology,  clinical  course, 
symptomatology,  pathology,  diagnosis,  prognosis  and  treatment 
of  mental  disorders.  An  attempt  has  been  made  to  introduce 
such  clear  and  systematic  sub-divisions  as  would  best  tend  to  facili- 
tate the  comprehension  of  the  whole  subject  and  render  the  book 
available  for  students  and  practitioners  of  medicine.  The  book  aims 
to  be  a  practical  guide  to  the  diagnosis  and  treatment  •of  all  the  vari- 
ous types  of  insanity  with  which  the  physicians  have  to  deal  in  public 
hospitals  or  private  practice,  and  also  to  act  as  a  work  of  ready  refer- 
ence to  psychiatrists  in  the  emergencies  of  their  specialty." 

The  subject  is  divided  into  two  parts,  the  first  of  which  deals 
with  "general  mental  pathology''  and  the  second  with  "the  special 
groups  and  typical  forms  of  insanity."  Part  first  embraces  a  series 
of  interesting  and  well-written  chapters.  Among  them  are  to  be 
specially  mentioned  one  on  the  nosology  of  insanity  and  those  of 
psychical  and  somatic  symptomatology.  In  that  on  nosology  the  sub- 
ject of  classification  is  considered  in  a  very  systematic  manner. 

However,  general  statements,  generalizations  and  time-worn  plati- 
tudes are  of  little  value  when  compared  with  the  specific  statements 
which  should  be  made  regarding  the  etiology,  symptomatology,  diag- 
nosis and  treatment  of  each  specific  mental  affection.  In  the  experi- 
ence of  the  writer  these  general  sections  in  treatises  of  mental  diseases 
are  rarely,  if  ever,  read  by  the  student  or  by  the  practitioner.  What  the 
student  and  physician  need  are  systematic  statements  and  elaborate 
clinical  descriptions  of  the  actual  diseases  with  which  he  meets  in 
daily  life.  It  is  therefore  disappointing  to  find  that,  while  516  pages 
are  given  up  to  the  consideration  of  merely  general  matters,  only 
241  are  given  to  the  actual  discussion  of  the  various  forms  of  in- 
sanity. The  conviction  forces  itself  upon  the  reader  that  the  special 
and  clinical  part  of  the  book  must  have  been  condensed  and  much 
abbreviated  in  order  to  admit  of  the  expansion  of  the  almost  useless 
;<eneral  section.  The  writer  does  not  desire  to  imply  that  the  general 
section  is  badly  written,  but  merely  that  it  is  disproportionately  large, 
and  contains  much  matter  that  has  no  practical  application. 

Chapter  first,  on  the  history  of  insanity,  is  sufficiently  condensed; 
tliat  on  statistics  of  insanity  had  best  have  been  entirely  omitted,  while 
that  on  the  nosology  of  insanity  is  an  admirable  review  of  the  various 
forms  of  classification  at  present  adopted,  but  the  author  errs,  in  the 
opinion  of  the  writer,  in  not  contenting  himself  in  the  present  unfor- 
tunate state  of  our  knowledge  by  simply  enumerating  the  various  forms 
in  which  insanity  manifests  itself.  The  chapter  on  the  etiology  of 
insanity  could  have  been  much  condensed,  while  that  on  the  evolution 
stadia,  clinical  progression  and  termination  of  mental  disorders  could 


226  BOOK  REVIEWS. 

with  advantage  have  been  entirely  omitted.  The  chapters  on  psychk 
and  somatic  symptomatology  are  excellent,  and  deserve  unstinted 
praise,  and  yet  it  is  an  open  question  whether  the  student  will  not  gain 
a  clearer  conception  of  the  symptomatology  of  insanity  in  general  by 
a  study  of  symptomatology  of  the  specific  forms.  In  the  opinion  of  the 
writer  this  is  the  only  way  in  which  a  knowledge  of  the  symptoms  is 
really  acquired,  especially  as  insanity  is  a  disorder  a  knowledge  of 
which  can  only  be  acquired  by  the  actual  study  of  living  cases.  The 
generalizations  present  in  the  general  sections  of  works  on  insanity 
are  abstractions  of  clinical  experience,  and  are  not  materials  fit  for 
presentation  to  the  student  or  practitioner,  save  to  an  exceedingly 
limited  degree.  The  practical  value  of  chapters  on  the  pathology, 
diagnosis,  prognosis  and  treatment  of  insanity  are  also,  in  the  opinion 
of  the  writer,  equally  open  to  question.  Certainly,  in  the  considera- 
tion of  each  specific  form  of  mental  disease  every  factor  considered 
in  Part  First,  from  a  general  standpoint,  must  be  considered  a  second 
time  in  the  special  section,  and  it  is  specific  statements  of  facts  in 
relation  to  specific  affections  that  are  of  importance.  Considered  in 
this  light  it  is  certainly  an  anomaly  that  more  than  two-thirds  of  the 
book  sliould  be  devoted  to  general  considerations  and  less  than  one- 
third  to  detailed  descriptions  of  the  various  mental  diseases.  It  is 
difficult  to  avoid  the  inference  that  as  a  result  of  this  arrangement 
the  special  section  has  suffered,  and  an  examination  of  its  pages  shows 
this  to  be  the  case.  The  descriptions  are  for  the  most  part  exceedingly 
condensed.  For  instance,  melancholia  is  considered  in  less  than  six 
pages;  mania  in  less  than  eight,  while  paresis,  which  is  a  very  world 
within  itself,  is  disposed  of  in  twenty-two  pages,  including  history,  eti- 
ology, symptomatology,  diagnosis,  prognosis  and  treatment.  The 
other  forms  of  insanity  are  considered  in  a  like  condensed  manner. 

The  author  classifies  the  various  forms  of  insanity  into  two 
groups. 

Group  A  "is  made  in  accordance  with  the  etiological  and  patholog- 
ical principles,  and  is  hence  briefly  defined  as  an  etio-pathological  and 
as  having  assignable  etiological  and  pathological  relations."  It  con- 
sists of  seven  parts:  First,  insanity  from  general  arrested  development; 
second,  insanity  emerging  from  constitutional  neuropathic  states, 
usually  hereditary,  though  occasionally  acquired;  third,  insanity  with 
established  neuroses;  fourth,  insanity  in  connection  with  the  physi- 
ological crises;  fifth,  insanity  with  general  systemic  states;  sixth,  in- 
sanity with  definite  pathological  conditions  of  the  encephalo-spinal, 
vaso-motor  or  peripheral  nervous  system,  and  seventh,  insanity  from 
pathological  psychic  influences. 

The  second  group  "consists  of  the  simple  psychoses  without 
definitely  assignable  etiological  and  pathological  relations,  and  hence 
the  group  is  briefly  named  psycho-symptomatological."  It  consists 
of  the  emotional  (Class  VIIL),  the  intellectual  (Class  IX.)  and  vo- 
litional (Class  X.)  insanities.  In  the  present  unsatisfactory  state  of 
our  knowledge  of.  insanity,  almost  any  classification  can  be  adopted, 
and  a  reviewer  could  reasonably  be  charged  with  being  captious  if  he 
found  fault  with  the  classification  adopted  by  any  one  author.  As 
a  matter  of  fact,  the  classification,  that  is  to  say,  the  order  in  which 
the  subjects  are  considered,  is  of  a  relatively  slight  importance,  the 
real  point  of  importance  being  the  accuracy,  the  fullness  and  complete- 
ness of  the  clinical  descriptions.  A  standard  work  upon  insanity  should 
consist  of  elaborate  and  comprehensive  word-pictures  of  the  things 
actually  met  with  in  the  daily  life  of  the  physicians  in  or  out  of  the 
asylum,  and  should  be  interspersed  with  appropriate  records  of  cases 
actually  studied.  This  is  assuredly  not  the  case  in  the  special  section 
of  the  work  before  us.  Dercum. 


BOOK  REVIEWS,  227 

SULtA  OPPORTUNITA  ED  EFFICACIA  DEI,LA  CURA   CHIRURGICO-GINECOI,- 

OGico  NEi,i*A  NEUROSi  isTERiCA.  (E  nelle  alienazioni  mentali.) 
Risulta  di  una  inchiesta  internazionale.  Dottori  G.  Angelucci 
e  A.  Pieraccini,  Naples,  1897. 

As  a  result  of  an  international  inquiry  into  the  relations  of  gyn- 
ecology to  nervous  and  mental  disorders,  and  the  hopes  of  operative 
cure  in  such  cases  where  such  a  relationship  is  stated  to  be  estab- 
lished, the  authors  present  a  careful  and  extended  statistical  study. 
In  all,  they  received  from*  alienists,  neurologists  and  gyjiecologists 
some  117  replies  in  full  for  all  the  points  asked  about.  As  a  result 
of  their  analysis  of  these  117  cases,  they  eliminate  at  first  six  cases 
in  which  the  history  would  indicate  that  the  results  were  obtained 
by  suggestion;  in  the  remaining  11 1  cases  it  could  be  shown  that  in  17 
only  was  there  any  improvement,  the  remaining  94  being  left  in  prac- 
tically the  same  condition  as  before.  Further,  it  was  to  be  noted 
that  in  the  17  cases  12  would  fall  under  the  general  head  of  hysterical 
disturbance,  in  9  of  which  diseased  organs  were  found,  and  in  only 
three  were  these  sound.  The  remaining  cases,  which  resulted  favor- 
ably, in  which  the  gynecological  operations  could  be  said  to  be  re- 
sponsible, were  but  five  in  number;  in  these  two  were  improved, 
while  three  were  called  cured. 

This  scarcity  and  uncertainty  of  favorable  results  inclines  the 
authors  to  believe  that  in  the  many  reported  favorable  cases  of  nervous 
disturbance  cured  by  means  of  operations  on  the  pelvic  organs  an- 
other factor  is  responsible;  that,  they  believe,  is  suggestion,  the  oper- 
ations serving  to  make  the  impression  more  permanent.  A  brief 
series  of  conclusions  closes  this  interesting  brochure.    These  are: — 

1.  The  extirpation  of  the  normal  uterus  or  its  adnexa  as  a  means 
of  cure  for  hysterical  neuroses  or  insanity  is  distinctly  contraindicated. 

2.  This  same  condition,  "hysteria,"  even  constitutes  a  contra- 
indication to  surgical  operations  which  aim  to  cure  gynecological 
ailments. 

3.  Unless  there  is  grave  disease  of  the  sexual  organs  there  is  no 
indication  for  their  removal,  and  any  operation  for  such  removal 
should  be  considered  apart  from  its  remote  effect  upon  the  neuro- 
pathic state. 

4.  In  certain  cases  in  which  there  are  grave  pathological  changes 
in  the  pelvic  organs  the  operative  suggestion  effects  may  legitimately 
be  exercised  when  there  are  co-existing  neuropathic  conditions. 

Finally,  in  conditions  of  hysteria  or  allied  disorders,  in  which 
reputable  methods  of  suggestion  have  proven  ineffectual,  one  may  be 
justified  in  resorting  to  a  simulated  laparotomy.  Jelliffe. 

Dyskinesias    arsenicaeS     (Arsenical    Dyskinesia.)     By  Dr.   Juliano 

Moreira,  Bahia,  1896.    Also  abstract  in  Revue  Neurologique,  1896, 

p.  S13 

This  work  was  a  competitive  thesis,  presented  before  the  Faculty 
of  Medicine  and  Pharmacy  in  Bahia. 

The  first  part  of  the  monograph  contains  eight  personal  observa- 
tions of  accidental  and  therapeutical  arsenic  poisoning  by  the  author. 
The  second  part  treats  of  the  etiology  and  toxic  symptoms  arising 
from  the  use  of  arsenic,  studying  and  dwelling  in  particular  upon  im- 
pairment of  voluntary  motility,  *.  e.y  dyskinesia.  After  considering 
and  describing  in  detail  the  functional  disturbances  of  sensory  organs 
(disturbance  of  tactile  insensibility,  vision,  taste,  sense  of  heat  and 
pain  and  muscular  sense),  the  author  proceeds  to  discuss  the  impair- 
ment of  the  motor  apparatus  (mechanical  and  electrical  irritability 
of  the  affected  nerves  and  muscles).    Following  these  observations  a 


22^  BOOK  REVIEWS. 

chapter  is  devoted  to  the  exhaustive  consideration  of  the  pathological 
anatomy,  diagnosis,  prognosis  and  treatment  of  the  conditions,  respec- 
tively, and  an  elaborate  bibliography  is  appended. 

The  treatise  shows  proof  of  painstaking,  precise  and  scholarly  in- 
vestigation, and  our  South  American  colleague  is  to  be  congratulated 
for  having  contributed  such  a  valuable  addition  to  our  knowledge  of 
arsenical  poisoning.  Macalester. 

DiB  Darstei,i,ung  krankhafter  Geisteszustaende  in  Shakes- 
peare's Dramen.  Von  Dr.  Hans  Laehr.  Stuttgart,  Paul  Neff 
Verlag,   1898. 

There  is  hardly  any  subject  in  literature  which  has  given  rise  to 
more  discussion  and  interpretations  than  the  various  cases  of  insanity 
m  Shakespeare's  dramas.  It  would  therefore  seem  impossible  to  say 
anything  new  on  this  subject.  The  little  work  by  Dr.  Laehr  is  never- 
theless interesting  in  various  directions,  especially  as  the  author  en- 
deavors to  submit  all  the  different  views  and  theories  to  a  careful  in- 
vestigation. Special  chapters  are  devoted  to  King  Lear,  Ophelia, 
Hamlet  and  Lady  Macbeth,  in  which  the  author  tries  to  reach  a  defi- 
nite diagnosis  in  each  case.  I  must  confess,  however,  that  any  attempt 
of  this  kind  has  always  seemed  to  me  of  doubtful  value,  if  not  quite 
fruitless.  We  must  not  forget  that  Shakespeare,  after  all,  was  not  a 
physician  who  relates  to  us  the  dry  history  of  a  case  for  diagnosis,  but 
that  he  was  the  great  phenomenal  poet,  who,  true  enough,  possessed 
an  unusual  gift  for  observation,  but  who  combined  this  talent  with 
the  necessary  physical  elements  of  an  ingenious  artist;  ».  e.,  poetical 
fancy  and  imagination.  To  approach  his  heroes  to-da^  for  the  pur- 
pose of  discussing  the  diagnosis  and  prognosis  of  their  mental  con- 
dition from  the  purely  medical  standpoint,  as  we  would  do  at  the  bed- 
side of  our  patients,  seems  to  me  just  as  unreasonable  as  to  study  the 
topography  of  the  moon  on  an  oil  painting.  Whether  King  Lear 
suffered  from  senile  dementia,  or  from  paranoia,  or,  as  Dr.  Laehr 
says,  from  acute  confusional  insanity,  seems  to  me  just  as  useless  to 
discuss  as  to  criticise  the  treatment  of  Lear  by  his  physician,  who 
awakes  his  patient  from  sleep  with  the  melodious  sounds  of  music. 

Of  much  greater  interest  and  scientific  value  to  the  historical  de- 
velopment of  psychiatry  as  well  as  to  the  psychological  analysis  of  the 
ingenious  poet  are  the  other  questions  discussed  in  Dr.  Laehr's  work, 
i.  e.,  "Wherefrom  did  Shakespeare  take  the  conception  of  mental 
diseases?"  and  "What  induced  Shakespeare  to  describe  cases  of  in- 
sanity in  his  dramas?"  The  chapter  devoted  to  the  first  question 
contains  a  number  of  interesting  data  concerning  the  medical  views  of 
insanity  at  the  Elizabethan  period,  Shakespeare's  own  observations 
of  psychopathic  cases,  and  the  descriptions  of  mental  diseases  by  poets 
before  Shakespeare.  As  to  the  latter  question,  the  motives  which  in- 
duced Shakespeare  to  picture  mental  diseases  in  a  dramatic  form.  I 
must  disagree  with  Dr.  Laehr  on  several  points.  His  view,  for  in- 
stance that  Shakespeare  described  Hamlet  as  a  psychopathic  in- 
dividual in  order  to  be  able  to  introduce  the  apparition  of  the  ghost 
in  the  tragedy,  seems  to  me  to  do  injustice  to  the  poet.  A  genius  like 
Shakespeare  would  never  adapt  his  characters  to  the  surrounding  cir- 
cumstances. The  latter  would  only  form  the  means  for  expressing 
and  describing  the  poet's  ideas,  but  could  never  form  the  primary 
motive  for  a  tragedy. 

The  aims  in  Shakespeare's  dramas  are  the  picturing  of  the  mani- 
fold traits  of  the  human  character,  the  conflicts  which  must  necessarily 
arise  from  their  mutual  contact,  and  the  superhuman,  divine  provi- 
dence which  determines  the  fate  of  men,  which  exercises  vengeance 


BOOK  REVIEWS.  229 

and  retaliation.  The  characters,  therefore,  were  the  starting  point,  to 
which  all  other  considerations  were  subordinated.  Mental  diseases 
were  at  that  time  much  more  apt  to  create  serious  conflicts  in  public 
life  and  the  mutual  contact  of  men  than  nowadays  on  account  of  their 
being  recognized  less  readily,  and  of  the  different  conception  of  their 
origin  and  nature.  The  religious  doctrine  of  the  independence  of  the 
soul  from  the  body  and  the  belief  in  individual  eternal  life  after  death 
caused,  of  course,  mental  aberrations  to  appear  in  an  entirely  different 
light  from  bodily  diseases.  Insanity  was  the  divine  vengeance,  the 
tragic  punishment  for  sin  arid  wickedness.  That  even  a  genius  like 
Shakespeare  stood  under  such  impression  seems  the  more  pardonable 
if  we  consider  that  even  in  comparatively  recent  times  one  of  the 
greatest  psychiatrists,  whose  studies  of  mental  diseases  became  funda- 
mental for  modern  psychiatry,  i.  e.,  Heinroth,  maintained  that  sins 
formed  the  principal  cause  for  insanity.  From  this  point  of  view  men- 
tal diseases  must  necessarily  form  one  of  the  most  powerful  dramatic 
elements  in  the  tragedy  of  vengeance.  Whether  Lear  suffered  from 
the  one  or  the  other  disease  is  therefore  entirely  irrelevant.  It  was 
neither  Shakespeare's  intention  to  describe  mental  diseases  accurately 
in  the  medical  sense,  nor  was  it  possible  to  do  so  in  the  poetical  form 
of  the  drama. 

However  much  we  may  differ  from  Dr.  Laehr's  views  in  some 
respects,  his  book  will  be  read  with  pleasure  by  all  who  are  interested 
in  this  subject.  William  Hirsch. 

Die  Akromegalie.     By  Dr.   Maximilian  Sternberg.     With   16  illus- 
trations.    Published  by  Alfred  Holder,  Vienna,  1897. 

This  monograph  forms  part  'of  the  large  work  on  special  pa- 
thology and  therapy  edited  by  Nothnagel.  The  author  has  carefully 
searched  the  literary  field  of  acromegaly,  and  has  put  together  his  find- 
ings in  a  book  of  116  pages.  The  introductory  chapter  is  devoted  to 
the  history  of  the  disease.  Although  the  latter  was  first  introduced  to 
the  medical  world  tinder  its  present  nomenclature  by  Marie,  in  1886. 
Sternberg  tries  to  show  that  the  affection  was  known  to  former  in- 
vestigators under  different  titles,  who,  however,  never  recognized  the 
true  position  of  the  malady.  Thus  as  far  back  as  1772  Saucerotte  de- 
scribes a  case  with  "considerable  enlargement  of  the  bones  in  an 
adult,"  which  doubtless  was  an  example  of  acromegaly. 

Chapters  II.  and  III.  are  devoted  to  the  general  consideration  of 
the  clinical  picture  presented  by  acromegaly  and  to  its  pathological 
anatomy.  A  number  of  excellent  photographs  are  reproduced,  show- 
ing the  abnormal  changes  in  the  features,  hands,  feet  and  skull.  The 
hypertrophies  in  the  skeleton  appear  to  be  one  of  the  most  striking 
features  of  the  pathological  anatomy  of  acromegaly.  Hardly  any  of 
the  organs  have  escaped  being  affected.  For  the  neiirologist  the  most 
interesting  changes  are,  of  course,  those  in  the  brain,  cord  and  nerves, 
and  these  are  discussed  at  length.  Owing  to  the  important  role  played 
by  the  hypophysis  in  acromegaly  an  appendix  on  the  morphology  and 
physiology  of  the  hypophysis  has  been  added  to  the  chapter  on  pa- 
thological anatomy. 

In  Chapter  IV.  the  symptoms  of  acromegaly  are  discussed  in  great 
detail.  This  chapter  is  also  illustrated  by  a  number  of  photographs 
and  by  several  skiagraphs  of  the  skull  and  hand. 

The  chapters  following  are  concerned  with  the  development, 
course  and  relation  of  acromegaly  to  other  diseases.  The  latter  are 
cranium  progeneum,  myxoedema  and  cretinism,  Basedow's  disease, 
gigantism,  diffuse  hyperostoses  and  diabetes.  These  conditions,  as 
well  as  a  number  of  others  to  be  presently  mentioned,  present  symp- 
toms which  may  occur  in  the  course  of  acromegaly,  and  hence  the 


230  BOOK  REVIEWS. 

latter  affection  may  easily  be  overlooked  and  an  erroneous  diagnosis 
made.  To  prevent  such  a  blunder  it  is  always  well  to  bear  in  mind 
the  affections  for  which  acromegaly  may  be  mistaken.  The  author 
lias  therefore  tabulated  them  as  follows: 

A.  Diseases    whose    symptoms    participate    in    acromegaly,    and 
which  may  be  mistaken  for  the  latter:  —  i.   Brain  tumors.     2.  Base- 
dow's disease.    3.  Diabetes.    4.  Myopathies.    5.  Genital  affection.    6. 
Acroparesthesia.    7.  Rheumatism.    8.  Traumatic  neurosis  and  its  simu- 
lation. 

B.  Diseases  and  conditions  with  acromegaly-like  alterations  in 
the  external  appearances: — 

I.  Anomalies  of  growth: — i.  Gigantism.  2.  Congenital  partial 
niacrosomia.    3.  Congenital  and  progressive  partial  macrosomia. 

II.  General  vegetative  ' disturbances  (dystrophies):  —  i.  Myxo- 
cdema.  2.  Cretinism.  3.  Basedow's  disease.  4.  Lymphatic  constitu- 
tion with  rachitis. 

III.  Diseases  of  the  nervous  system: — i.  Syringomyelia.  2.Erythro- 
melalgia.  3.  Various  "neurotic  hypertrophies."  4.  Acquired  hemi- 
macrosomia. 

IV.  Diseases  of  the  bones  and  joints: — i.  Diffuse  hyperostosis 
(megalocephaly).  2.  Multiple  timior-like  hyperostosis  (Leontiasis 
ossea).  3.  Osteitis  deformans  Paget.  4.  Arthritis  deformans.  5. 
Cranium  Progeneum.  6.  Secondary  hyperplastic  osteitis  (osteoar- 
thropathie  hypertrophiante).  7.  Multiple  symmetrical  enchondro- 
mata. 

V.  Diseases  of  the  tendon-sheaths: — i.  ** Progressive  enlarge- 
ment of  hands,"  Hersmann.  2.  Chronic  inflammation  of  the  palmar 
sheaths. 

VI.  Diseases  of  the  skin: — i.  Peculiar  pachydermy  following  pro- 
longed diminution  of  vessel-tone.  2.  Adiposis  dolorosa,  Dercum.  3. 
Elephantiasis  neuromatodes.     4.  Elephantiasis  arabum.    5.  Oedema. 

The  treatment  of  acr(imegaly  is  summed  up  by  the  author  in  com- 
paratively few  words.  As  the  pathogenesis  of  acromegaly  is  unknown, 
neither  prophylactic  nor  etiological  treatment  can  be  instituted. 

In  addition  to  dietetic  and  hygienic  measures  are  mentioned  iodide 
of  potash,  mercury,  fhyroid  and  hypophysis  preparations,  arsenic  and 
operative  procedures.  As  none  of  them  has  been  found  to  be  a  specific, 
the  therapeutic  chapter  of  the  disease  is  far  from  being  closed. 

The  bibliography  which  forms  the  completing  chapter  of  the  work 
is  quite  lengthy,  containing  about  450  references.  This  is  certainly  a 
most  valuable  feature  of  the  book  and  will  interest  those  contemplat- 
ing further  studies  of  the  subject. 

The  book  impresses  one  as  being  the  result  of  much  painstaking 
labor,  and  is  highly  recommended  to  such  as  desire  to  be  au  tourant 
with  what  has  thus  far  been  published  on  the  subject. 

Ph.  Meirowitz. 

An  Epitome  of  the   History  of    Medicine      By  Roswell  Park 
a.m.,  m.d.,    Professor    of    Surgery    in    the    Medical    Department 
of  the  University  of  Buffalo.     F.  A.  Davis  Company,  1897. 

This  epitome  of  the  history  of  medicine  is  based  upon  a  series  of 
lectures  given  by  the  author  at  the  University  of  Buffalo.  In  the 
preface  Dr.  Park  states  what  is,  we  believe,  only  too  true,  that  "the 
history  of  medicine  has  been  sadly  neglected  in  our  medical  schools. 
The  valuable  and  fruitful  lessons  which  it  tells  of  what  not  to  do  have 
been  completely  disregarded." 

While  the  present  volume  is  a  little  too  statistical  in  its  biographic 
details,  it  nevertheless  is  a  work  that  cannot  fail  to  be  of  value  to  all 


BOOK  REVIEWS,  23 1 

genuinely  interested  in  medicine,  past  and  future.     We  hope  to  see  it 
receive  a  generous  recognition.  Jelliffe. 

CBNTRALBLATT   fur   die    GRENZGEBItTE   DER  MKDTZIN   UND  ChIRUR- 

GiE.     Edited  by  Dr.  Hermann  Schlesinger.    Gustav  Fischer,  Jena, 

Germany. 

This  new  journal  has  a  very  important  work  to  accomplish.  In 
England  and  in  this  country  specialism  has  not  been  carried  to  the 
extreme  that  it  has  in  Germany  and  Austria,  where  a  physician  an- 
nounces his  specialty  upon  his  sign.  Even  here  specialism  is  rapidly 
gaining  ground.  The  object  of  this  new  journal  is  to  bridge  over  the 
gap  between  the  various  specialties  and  to  give  to  the  reader  a  stronger 
grasp  on  general  medicine.  Only  abstracts  and  critical  digests  on  im- 
portant  subjects  of  the  border-line  character  will  be  published,  and 
original  papers  will  be  left  to  the  recently  established  journal,  Mitt- 
heilungen  aus  den  Grenzgebieten  der  Medizin  und  Chirurgie.  The 
editor  is  especially  well  known  from  his  publications  on  neurological 
subjects.  Spiller. 

Systems  Nerveux  Centrai^  Coupes  Histoi^ogiques  Photograph- 
litES  (The  Central  Nervous  System.  Histological  Sections  Photo- 
graphed).    By  J.  Dagonet.    J.  B.  Bailliere  et  Fils,  Paris,  1897. 

This  photographic  atlas  is  the  complement  of  a  paper  on  general 
paralysis,  published  by  the  writer  in  the  "Traite  des  Maladies  Men- 
tales,"  by  H.  Dagonet.  The  pictures  have  been  made  from  sections  of 
the  central  nervous  system  .of  a  patient  who  was  afHicted  with  the 
disease  under  consideration. 

Dagonet  follows  the  teaching  of  Tuczek.  and  believes  that  the 
primary  lesions  of  paralytic  dementia  are  parenchymatous.  He  dis- 
putes the  statement  made  by  Weigert  in  regard  to  the  independence 
of  the  neurogliar  cells  and  fibres^  He  believes  also  that  the  pericellu- 
lar spaces  are  not  artifacts.  The  atrophy  of  nerve  cells  and  their 
fibres,  as  well  as  the  hypertrophy  of  the  neurogliar  cells  and  their 
fibres,  is  well  shown,  and  the  hyaloid  bodies,  which  the  writer  says 
have  received  little  attention,  are  described.  The  latter  have  been  re- 
cently studied  by  Edsall  and  Sailer,  and  the  reviewer  has  found  them 
in  large  quantities  in  a  case  of  basal  tumor  of  the  brain. 

Dagonet  does  not  believe  that  the  ependymal  granulations,  so  com- 
monly' seen  in  cases  of  general  paralysis,  are  caused  by  primary  de- 
struction of  the  ependymal  epithelium  (Weigert)  and  proliferation  of 
the  unrestrained  neuroglia.  .When  the  ependymal  cells  proliferate  in 
paralytic  dementia  their  fibres^  which  are,  very  visible  in  the  em- 
bryo, but  not  in  the  adult,  become  thickened  and  are,  easily  perceived. 
There  is,  therefore,  a  return  to  embryonic  conditiqns,  and  the  greater 
part  of  these  granulations  is  formed  by  the  ependymal  aiid  neurogliar 
fibres.  Dagonet  has  not  been  .^iXt  to  observe  the  mitosis  in  the 
ependymal  cells  which  has  b^en  seen  in  the  embryo.  He  describes 
changes  in  the  motor  cells  of  the  cord,  but  not  of  so  intense  a  de- 
gree as  those  of  which  Berger  has  recently  spoken. 

The  book  is  short,  and  only  contains  twelve  plates,  but  it  is 
written  in  an  interesting  style.  Spiller. 

A  year-book,  with  the  title  "Jahresbericht  iibcr  die  Leistungen 
und  Fortschritte  auf  dem  Gebiete  der  Neurologic  und  Psychiatric," 
will  be  published  under  the  direction  of  Mendel,  Flatau  and  Jacob- 
sohn.  The  first  number  will  appear  in  1898.  As  the  various  depart- 
ments will  be  under  the  charge  of  well-known  specialists,  the  book 
will  doubtless  prove  of  great  value.  The  publisher  will  be  S.  Karger, 
in  Berlin. 


232 


BOOK  REVIEWS. 


BOOKS  RECEIVED. 

"A  Manual  of  Legal  Medicine,"  by  Justin  Herold,  M.  D.  J.  B. 
Lippincott  Co.,  Philadelphia. 

"The  American  Year  Book  of  Medicine  ajid  Surgery,"  edited  by 
Gca  M.  Gould,  M.  D.    W.  B.  Sanders,  Philadelphia 

"Orthopedic  Surgery."  by  Jas.  E.  Moore,  M.  D.  W.  B.  Sanders, 
Philadelphia. 

The  Report  of  the  Board  of  Health  of  the  City  of  New  York  to 
Hon.  Wm.  L.  Strong,  entitled  "Pulmonary  Tuberculosis." 

"Preventive  Medicine  in  the  City  of  New  York,"  address  in  pub- 
lic medicine,  Hermann  M.  Biggs,  M.D.j  Health  Dept.,  New  York  City. 

"The  American  System  of  Practical  Medicine,"  Vol.  iii.  Edited 
by  Alfred  L.  Loomis,  M.  D.,  and  Wm.  Oilman  Thompson,  M.  D. 
Liea  Bros.  &  Co.,  Philadelphia. 


A  letter  from  Dr.  Bechterew: — 

It  is  proposed  to  establish  two  museums,  a  psychiatric  and  a  neu- 
rological, in  commemoration  of  the  thirtieth  anniversary  of  the 
founding  of  the  psychiatric  clinic  in  St.  Petersburg. 

In  the  psychiatric  museum  there  will  be  collected: 

1.  Plans,  photographs,  models,  etc.,  of  psychiatric  institutions, 
etc. 

2.  Models  of  rooms,  dress,  etc.,  of  the  insane. 

3.  Work  done  by  the  insane. 

4.  Photographs  of  the  insane  at  different  periods  of  their  disease, 
etc. 

5. 
6. 

tions. 

7.     Documents  relating  to  the  care  of  the  insane. 

In  the  neurological  museum  there  will  be  collected: 

K    Brains  of  animals  and  men  and  microscopical  preparations. 

Preparations  of  pathological  brains. 

instruments   for   weighing   and    methods    of   preserving    the 


The  apparatus  used  in  examining  the  insane. 

Skulls  and  brains  of  the  insane  and  microscopical  prepara- 


a. 

brain. 
4. 

5- 
6. 


Photographs  and  representations  of  pathological  processes. 

The  different  forms  of  apparatus  employed  in  treatment. 

Plan$  and  photographs  of  neurological  institutions. 
The  mnseums  are  intended  for  the  use  of  students  of  all  countries. 
and  assistance  is  asked  in  carrying  out  the  above  plans.  Plans  of 
iMiildtngs,  samples  of  the  work  of  patients,  statistics  relating  to  instt- 
tittions,  signed  photographs  of  physicians  connected  with  institutions, 
anatomico-pathological  preparations,  etc.,  are  desired. 

The  expenses  of  transportation  wi'1  be  lessened  if  the  articles  arc 
addressed:  Russie,  St.  Petersbourg,  Clinique  des  Maladies  Mentales 
ct  Nerveuses,  Rue  Samarskaya,  No.  9. 


DR.  EDWARD   CONSTANT    SEQUIN. 


VOL.    XXV.  April,  1898.  No.  4. 

THE 

Journl 

OF 

Nervous  and  Men 


EDWARD  CONSTANT  SEGUIN,  M.  D., 

New  York. 

Dr.  Edward  C.  Seguin,  the  distinguished  neurologist 
of  this  city,  died  on  Saturday  evening,  February  19th.  His 
health  began  to  fail  in  the  winter  of  i894-'9S;  but,  in  spite 
of  progressive  loss  of  strength,  he  did  not  give  up  pro- 
fessional work  until  July,  1896.  Soon  after  this  time  the 
real  nature  of  his  illness  became  apparent,  and  from  this 
time  he  was  confined  to  his  home,  growing  gradually 
weaker,  but  retaining  his  great  mental  powers  almost  to 
the  last. 

Dr.  Edward  Constant  Seguin  was  bom  in  Paris  ^ 
France,  in  1843.  He  was  the  only  child  of  Dr.  Edward  O. 
Seguin,  whose  brother,  father  and  several  relatives  of  the 
same  name  were  physicians,  chemists,  engineers  and  archi- 
tects. Dr.  Edward  O.  Seguin  devoted  nearly  all  his  life 
to  the  training  and  education  of  idiotic  and  backward  chil- 
dren, in  France  and  in  this  country.  He  was  the  origin- 
ator of  the  "physiological  method"  of  education,  which 
method  was  based  (as  far  back  as  i873-'78)  upon  the  prin- 
ciple of  training  the  special  senses  and  the  two  hands 
(muscular  sense)  as  the  means  of  developing  the  cerebral 
functions.  It  included  in  its  practical  details  most  of  the 
work  now  known  as  "object-lessons"  and  "kindergarten" 
drill.  In  1850  Dr.  Seguin,  foreseeing  the  inevitable  suc- 
cess of  the  policy  which  culminated  in  the  bloody  coup- 
d'etat  of  December  2d,  185 1,  emigrated  to  this  country 
with  his  family,  and  finally  settled  in  Cleveland,  Ohio. 


f 


234  OBITUARY, 

There,  atid  in  Portsmouth.  Ohio,  the  subject  of  our  sketch 
received  a  good  public  and  high  school  education.  One 
year  of  this  time  was  given  to  an  apprenticeship  at  the 
wheelwright  trade  in  Portsmouth.  Circumstances  made 
it  impossible  for  him  10  go  to  college.  In  1861,  then  re- 
siding at  Mt.  Vernon,  New  York,  he  began  the  study  of 
medicine  with  his  father,  attended  three  courses  of  lectures 
at  the  College  of  Physicians  and  Surgeons,  New  York 
(the  Medical  Department  of  Columbia  University),  and 
was  graduated  therefrom  in  the  autumn  of  1864.  Mean- 
while, from  May,  1862,  Dr.  Seguin  had  entered  the  medical 
department  of  the  army,  serving  for  the  fihst  two  months 
(when  less  than  nineteen  years  old)  as  "dresser"  in  the 
hospital  steamships  of  the  U.  S.  Sanitary  Commission,  in 
the  Pamunkey  and  James  Rivers.  In  July  he  was  ap- 
pointed  a  Medical  Cadet  in  the  regular  army,  and  served 
two  terms,  till  August,  1864.  During  much  of  this  time 
he  had,  practically,  the  charge  of  the  patients  in  the  wards 
to  which  he  was  attached,  performing  all  the  duties  of 
surgeon,  except  the  doing  of  major  operations.  In  this 
service,  living  in  the  hospitals,  he  developed  non-tuber- 
cular phthisis  in  the  spring  of  1864,  from  the  effects  of 
which  he  did  not  recover  for  several  years.  From  Septem- 
ber, 1864,  to  June,  1865,  he  served  at  Little  Rock,  Ark., 
as  Acting  Assistant  Surgeon,  and  during  the  last  two 
months  as  Assistant  Surgeon,  U.  S.  Volunteers.  From 
1865  to  1867  he  passed  through  the  grades  of  interne  and 
house  physician  in  the  New  York  Hospital,  then  at  Broad- 
way and  Duane  street.  Early  in  1868  symptoms  of  phthi- 
sis reappeared,  and  he  applied  for  a  position  in  the  medi- 
cal department  of  the  army.  By  special  courtesy  of  the 
Surgeon-General  he  was  assigned  to  duty  in  New  Mexico, 
and  there  served  as  post  surgeon  at  Forts  Craig  and  Sel- 
den.  In  the  summer  of  1869  he  returned  to  New  York 
entirely  cured  (as  the  result  showed)  of  his  pulmonary 
trouble. 

The  winter  of  1 869-' 70  was  spent  by  Dr.  Seguin  in 


OBITUARY.  235 

Paris,  studying  privately  under  Brown-Sequard,  Charcot, 
Ranvier  and  Cornil,  masters  whose  friendship  he  always 
retained.  This  course  of  study  led  him  to  look  forward 
to  making  nervous  diseases  a  specialty;  but  after  his  re- 
turn to  New  York  he  entered  upon  general  practice  in 
association  with  Dr.  William  H.  Draper.  In  1876  this 
friendly  association  was  severed,  in  order  that  he  might 
devote  himself  exclusively  to  the  study  and  treatment  of 
nervous  diseases.  From  1871  to  1885  Dr.  Seguin  was 
connected  with  the  Faculty  of  the  College  of  Physicians 
and  Surgeons,  lecturing  upon  diseases  of  the  spinal  cord 
and  upon  insanity.  In  1873,  with  the  permission  of  the 
Faculty,  he  founded  the  Clinic  for  Nervous  Diseases, 
which,  though  unavoidably  placed  upon  an  unfavorable 
day  (viz.,  Saturday  afternoon),  prospered  satisfactorily. 
From  1882  to  1893  Dr.  Seguin  was  in  Europe  several 
times,  but  resumed  the  practice  of  his  specialty  whenever 
he  was  in  New  York. 

Dr.  Seguin  has  written  many  monographs  relating  to 
nervous  diseases,  more  especially  to  their  treatment  by 
hygienic  as  well  as  by  medicinal  means,  and  a  number  of 
these  were  edited  in  book  form,  entitled  "Opera  Minora.'* 
Various  circumstances,  and  the  belief  that  there  were  al- 
ready too  many  books  upon  the  subject,  prevented  him 
from  carrying  out  a  long-cherished  plan  of  writing  a  for- 
mal treatise  upon  nervous  diseases. 

He  was  one  of  the  founders  of  the  American  Neuro- 
logical Association  and  of  the  New  York  Neurological 
Society,  and  these,  with  the  New  York  Pathological  So- 
ciety, received  most  of  his  attention.  He  was  also  a  mem- 
ber of  the  New  York  County  Medical  Society,  Academy 
of  Medicine,  besides  several  European  medical  societies. 

Although  naturally  disposed  to  the  scientific  study  of 
medicine,  it  was  always  his  guiding  principle  to  make, 
everything  subservient  to  the  welfare  of  each  patient  who 
intrusted  himself  to  his  care.  The  chief  objects  of  medi- 
cine he  believed  to  be  the  cure,  alleviation  and  prevention 
of  disease. 


236  OBITUARY. 

The  Neurological  Society  records  with  profound  sor- 
row the  death  of  Dr.  Edward  Cqnstant  Seguin,  who  died 
of  cirrhosis  of  the  liver  on  Saturday,  February  19th,  1898^ 
aged  54  years. 

Dr.  Seguin  was  one  of  the  founders  of  this  society,  and 
its  president  during  i877-'78,  and  was  for  many  years  a 
constant  attendant  at  its  meetings,  taking  a  leading  part 
in  its  scientific  discussions;  his  opinions  being  always  lis- 
tened to  with  that  respect  to  which  his  vast  clinical  ex- 
perience and  his  sound  judgment  entitled  them. 

For  many  years  Dr.  Seguin  ranked  with  the  foremost 
neurologists  of  the  world,  and  his  contributions  to  science 
were  valued  highly. 

Whereas,  This  society  has  lost  by  the  death  of  Dr. 
Seguin  one  of  its  original  incorporators  and  an  earnest 
supporter;  therefore  be  it 

Resolved,  That  in  his  death  this  society  has  lost  a  valu- 
able and  honored  member.  In  his  professional  attainments 
he  was  most  eminent;  enthusiastic  in  his  devotion  to  his 
special  field  of  work,  in  which  he  was  justly  esteemed  an 
authority.  As  an  author  he  was  remarkable  for  his  acute 
observation  and  logical  reasoning,  while  the  clearness  of 
his  style  gave  evidence  of  the  directness  of  his  thought. 
By  his  death  scientific  neurology  has  lost  a  zealous  and 
successful  disciple,  while  the  community  has  been  de- 
prived of  the  services  of  a  skillful  counsellor  and  prac- 
titioner. The  members  of  the  Neurological  Society  de- 
sire thus  to  give  expression  to  their  feelings  of  respect 
for  his  memory  and,  sympathizing  sincerely  with  his  fam- 
ily in  their  loss,  ofTer  them  respectful  condolence; 

Resolved,  That  this  minute  be  entered  upon  the  records 
of  the  society  and  that  a  copy  be  sent  to  the  family  of  Dr. 
Seguin  and  to  the  medical  journals. 

J.  ARTHUR    BOOTH.  M.D., 
M.  ALLEN   STARR,  M.D., 
GEORGE  W.  JACOBY,  M.D., 

Committee. 


^viQltml  ^vticlts. 


SEXUAL  PERVERSION   OR  VICE?     A  PATHO- 
LOGICAL AND  THERAPEUTIC  INQUIRY.* 

Bv  MORTON  PRINCE,  M.D., 

Instructor  in  Diseases  of  the  Nervous  System,  Harvard  Medical  School. 

■ 

It  is  not  necessary  for  me  before  a  society  of  experts 
in  psychiatry  to  dwell  upon  the  medical,  social  and  foren- 
sic importance  of  sexual  perversion.  Nor  need  I,  for  the 
purposes  of  this  paper,  more  than  mention  the  different 
ways  in  which  the  sexual  instinct  may  be  perverted.  It 
may  be  excited  by,  and  therefore  lead  to  acts  of  cruelty 
or  violence  inflicted  upon,  the  opposite  sex  (Sadism), 
or  by  the  opposite  state,  the  passive  suffering  of  pain 
which  has  been  inflicted  by  the  opposite  sex  (Masochism), 
or  it  may  be  excited  by  certain  objects,  whether  a  part  of 
the  female  body  or  dress,  or  other  objects  (Fetichism). 

Perversion  may  further  take  the  form  of  homo-sexu- 
ality, that  is,  the  substitution  or  co-existence  of  sexual 
feeling  for  the  same  sex  in  place  of,  or  by  the  side  of,  that 
for  the  opposite  sex.  This  is  also  known  as  contrary  sexual 
instincty  or  sexual  inversion.  These  different  forms  of  per- 
version have  also  been  classed  as  varieties  of  sexual  paraes- 
thesia. 

The  object  of  this  paper  is  not  to  present  any  new 
facts  or  new  theories  of  these  aberrations,  but  rather  to 
re-examine  the  grounds  on  which  the  later  and  dominat- 
ing views  of  the  nature  of  these  so-called  perversions  are 
based,  with  a  view  of  ascertaining  whether  these  views 
are  really  well  founded,  and  whether,  after  all,  the  facts 


*  Read  before  the  Medico-Psychological  Society,  Jan.  27th,  1898. 
This  paper  is  largely  based  on  the  article  on  "Sexual* Psychoses"  by 
the  writer  in  vol.  iv.  of  the  Amer.  Syst.  of  Practical  Medicine,  now 
in  press. 


238  MORTON  PRINCE, 

upon  which  they  are  supposed  to  rest  have  been  so  well 
proven  that  we  are  justified  in  accepting  the  prevailing 
doctrine.  Further,  it  may  be  inquired  whether  the  com- 
mon acceptance  of  those  views  which  marks  most  of  the 
contemporary  literature  is  not  due  to  the  influence  of  per- 
sonal authority  rather  than  a  careful  consideration  of  the 
facts.  We  may  also  inquire  whether,  by  taking  a  broader 
view  of  these  anomalies,  we  may  not  class  them  with  many 
well-recognized  non-sexual  manifestations  of  hysteria, 
neurasthenia,  or  other  forms  of  nervous  degeneration,  and 
find  a  common  method  of  treatment. 

As  the  time  limit  of  such  a  paper  does  not  admit  of  a 
separate  study  of  each  of  the  perversities,  I  shall  limit 
myself,  for  the  most  part,  to  an  examination  of  the  one 
which  is  most  frequent  and  has  received  the  widest  dis- 
cussion, namely,  contrary  sexuality,  prefacing  this  special 
inquiry  by  a  few  general  remarks  on  the  perversities  as 
a  whole. 

The  first  important  question  is:  How  far  are  these  per- 
versions the  necessary  expression  of  a  disordered  nervous 
system,  and  how  far  do  they  represent  merely  indulgences 
in  vice  and  cultivated  habits?  So  far  as  they  are  simply 
vicious  habits,  they  can  only  be  regarded  as  penfersity.  not 
perversion;  that  is,  as  vice,  not  disease.  This  view  is  not 
altered  even  in  the  case  of  individuals  who  have  degen- 
erate or  in  other  ways  diseased  nervous  systems,  provided 
that  they  have  cultivated  the  habits,  and  that  the  habits 
are  the  direct  result  of  such  cultivation.  A  paranoiac  or  an 
imbecile  may  cultivate  vice  as  well  as  sound-minded  peo- 
ple. Degenerate  people  may  not  be  morally  or  legally  re- 
sponsible; but  this  inquiry  is  not  one  of  responsibility,  but 
of  genesis.  What  is  the  origin  of  and  what  influences  have 
developed  the  sexual  aberrations?  If  these  are  the  mani- 
festation of  a  diseased  nervous  svstem,  in  the  same  sense  as 
hysteria  is  the  manifestation  of  a  neuropathic  condition, 
then  these  sexual  phenomena  are  true  perversions  and 
pathological. 


i 


SEXUAL  PERVERSION  OR   VICE.  239 

On  the  other  hand — this  point  may  further  be  insisted 
l^KXl,  in  addition  to  what  has  just  been  said — the  presence 
of  a  psychopathy  does  not  necessarily  indicate  that  the 
sexaal  habits  are  not  vice.  A  person  who,  let  us  say,  has 
by  inheritance  received  a  neuropathic  constitution,  or  even 
exhibits  weakmindedne^s  or  some  form  of  insanity,  is  no 
less  subject  to  the  same  influences  as  are  normal  individu- 
als. His  nervous  system  is  equally  open  to  education;  so 
that  feelings,  tastes  and  habits  can  be  cultivated  in  the  one 
as  in  the  other.  But  it  cannot  necessarily  be  inferred 
from  the  co-existence  of  such  habits  and  a  psychopathy 
that  the  former  is  the  symptomatic  manifestation  of  the 
latter.  Hysterics,  degenerates  and  imbeciles  have  less  in- 
tellectual power  for  resisting  feelings  and  external  influ- 
ences than  healthy  people.  Their  judgments  are  warped, 
and  they  do  not  normally  foresee  the  consequences  of 
their  actions,  or,  if  they  do,  they  are  not  influenced  there- 
by in  their  conduct.  They  may  not  have  a  normal  power 
of  self-control,  of  restraining  impulses.  From  this  lack 
of  resisting  power  they  are  more  likely  to  submit  to  ex- 
ternal influences  and  cultivate  the  gratification  of  their 
senses;  that  is,  they  are  more  likely  to  be  the  victims  of 
vice  than  normal  persons.  But  a  diminished  resisting 
power  does  not  make  the  thing  to  be  resisted  pathological; 
for  this  other  conditions  are  necessary. 

The  power  of  resistance  is  a  force  of  varying  quantity 
in  different  individuals,  and  the  difference  between  the 
resisting  power  of  a  normal  individual  and  a  diseased  one 
is  only  one  of  degree,  and  may  be  small.^  Nevertheless, 
though  such  diseased  persons  are  more  likely  to  exhibit 
vice  than  healthy  people,  it  is,  a  priori,  possible  that  what 
would  be  vice  in  others  may  be  only  a  pathological  phe- 
nomenon in  them.     Feelings  aTid  actions  may  be  only 


■  What  degree  of  lack  of  resisting  power  constitutes  irresponsibility 
is  still  another  question,  and  a  distinct  one,  of  an  entirely  different 
nature,  which  does  not  change  the  nature  of  an  act,  otherwise  vicious, 
but  may  affect  the  culpability. 


240  MORTON  PRinrCE. 

pathological  and  necessary  reactions  of  a  diseased  nervous 
system  to  external  influences.  A  careful  inquiry  is,  there- 
fore, essential  to  determine  which  of  these  conditions  ob- 
tains. 

These  observations  are  here  made,  because  there  is 
considerable  and  important  difference  of  opinion  regard- 
ing the  pathology  and  nature  of  these  sexual  aberrations, 
and,  as  it  seems  to  the  writer,  much  confusion  of  thought 
regarding  their  relation  to  disease  and  vice. 

There  are  two  views  regarding  the  nature  of  perver- 
sion which  are  radically  opposed,  and  which,  from  a  social 
and  therapeutic  point  of  view,  have  respectively  important 
consequences.  The  one  leads  to  therapeutic  nihilism  and 
social  hopelessness;  the  other  offers  hope  and  possibilities. 

The  theory  that  has  been  most  widdy  accepted  by 
writers  on  the  subject  is  that  sexual  perversion  has  its 
basis  in  a  diseased  nervous  system,  which,  in  most  cases,  is 
the  result  of  inheritance.  A  psychopathic  or  neuropathic 
groundwork  is  in  almost  all  cases  essential,  but  the  per- 
verse phenomenon  arises  spontaneously,  without  external 
cause.  Its  origin  is,  therefore,  entirely  independent  of 
cultivation  by  vicious  habits,  education  or  seduction.  In 
some  instances  it  is  equally  rhaintained  that  these  perver- 
sions are  acquired  as  the  result  of  cultivation,  with  or  with- 
out the  co-operation  of  an  inherited  neuropathic  condi- 
tion. But  it  would  seem  that,  with  the  exception  of 
fetichism,  which  is  always  acquired,  according  to  this 
school,  the  acquired  cases  are  a  distinct  minority.  In  most 
cases  nascitur,  non  fit. 

"This  perverse  sexuality,''  says  von  Krafft-Ebing, 
speaking  of  the  contrary  sexual  instinct,  "appears  spon- 
taneously, without  external  cause,  with  the  development 
of  sexual  life,  as  an  individual  manifestation  of  an  abnormal 
form  of  the  vita  sexualis,  and  then  has  the  form  of  a  con- 
genital phenomenon;  or  it  develops  upon  a  sexuality,  the 
beginning  of  which  was  normal,  as  a  result  of  any  definite 
injurious   influences,   and    then   appears   as   an   acquired 


SEXUAL  PERVERSION   OR    VICE.  24 1 

anomaly.  .  .  .  Careful  examination  of  the  so-called 
acquired  cases  makes  it  probable  that  the  predisposition 
also  present  here  consists  of  a  latent  homo-sexuality,  or, 
at  least,  bi-sexuality,  which,  for  its  manifestation,  requires 
the  influence  of  accidental  causes  to  rouse  it  from  its  slum- 
ber."^  While  objections  may  be  made  to  this  theory  when 
applied  to  homo-sexuality,  as  has  been  don.e  with  great 
force  by  von  Schrenck-Notzing,*  the  theory  has  consider- 
able strength  when  we  seek  for  an  explanation  of  Sadism 
and  Masochism.  Between  the  homo-sexual  influences  and 
the  sadistic  influences,  which  lead  to  murder  and  mutila- 
tion of  the  victim's  body,  there  is  a  wide  gulf,  and  we 
should  not  necessarily  expect  a  similar  pathological  con- 
dition as  a  basis  of  both.  As  to  Sadism,  von  Krafft-Ebing 
expresses  the  opinion  that,  **as  a  rule,  it  may  be  safely  as- 
sumed  that  the  psychopathic  state  (perverse  instinct)  ex- 
ists ab  origine." 

"Sadism  is,  then,  nothing  else  than  an  excessive  and 
monstrous  pathological  intensification  of  phenomena — 
possible,  too,  in  normal  conditions  in  rudimentary  forms — 
which  accompany  the  psychical  vita  sexualis,  particularly 
in  males."^  The  same  writer  lavs  stress  on  the  weakness  or 
absence  of  all  restraining  ideas  in  the  psycho- 
path Y^ho  gives  free  hand  to  the  development  and 
expression  of  the  congenital  perversion.  But  he  neglects 
the  influence  which  a  deliberate  cultivation  may  have  upon 
a  mild  impulse  or  sensory  association  at  the  beginning. 
If  Sadism  is  an  "excessive  and  monstrous  intensification 
of  phenomena"  existing  "in  a  rudimentary  form"  in  normal 
individuals,  then  the  perversion  is  the  intensification,  and 


•  "Psychopathia  Sexualis"  (p.  187),  translated  by  Charles  Gilbert 
Chaddock,  M.  D.,  1893.  See  also  "Zur  Erklarung  der  contraren  Sexual- 
empfindung/'  Jahrbiicher  fiir  Psychiatric  und  Neurologic,  1895,  by  the 
same  writer. 

•  "Suggestive  Therapeutics  in  Psychopathia  Sexualis."  Translated 
by  Charles  Gilbert  Chaddock.     1895. 


ft  • 


■  Psychopathia  Sexualis,"  p.  60. 


242  MORTON  PRINCE. 

the  question  is,  To  what  is  this  intensification  due?  Does 
it  exists,  ab  origine,  in  its  intense  form  as  a  result  of  patho- 
logical development,  or  is  it  a  later  disease  symptom,  or  is 
the  intensification  due  to  cultivation  by  a  morally  de- 
praved and  mentally  weakened  individual?  Or,  may  it 
be  due  to  two  or  more  of  these  factors?  The  auto- 
biographies and  histories  of  cases  found  in  the  literature 
do  not  allow  of  the  first  interpretation.  It  is  possible  that 
certain  anomalous  sensory  associations  may  be  the  starting 
point  of  such  perversion,  and  cultivation  does  the  rest. 
For  example,  the  case  was  brought  to  my  attention  of  a 
perfectly  healthy,  mentally  and  physically,  medical  man 
who  was  sexually  excited  by  the  sight  of  a  syrgical  op- 
eration. This  person  is  a  typically  strong  and  healthy- 
minded  man.  Suppose  him  to  have  been  a  mental  de- 
generate;  how  easy  it  would  have  been  for  him  to  culti- 
vate sadistic  impulses.  The  origin  of  sadistic  impulses  is 
of  less  practical  importance  than  is  that  of  contrary  sexu- 
ality, as  most  of  the  individuals  who  exhibit  them  are 
otherwise  psychopathic  (e.  g.,  imbeciles,  degenerates  or 
insane),  though  the  question  is  of  some  importance 
forensically  as  bearing  on  the  question  of  responsibility. 

Von  Krafft-Ebing's®  work  being  almost  the  first  to 
treat  systematically  the  subject  of  sexual  perversion,  and 
presenting  the  matter  with  great  erudition,  has  been  very 
widely  drawn  upon  by  subsequent  writers.  The  iliterpre- 
tation  of  these  aberrations  g^ven  by  the  author  has  very 
profoundly  influenced  medical  opinion,  and  has  been  quite 
extensively  accepted.  This  work  was  soon  followed  by 
a  publication  on  the  contrary  sexual  instinct  by  A.  Moll/ 
who  also  adopted  the  congenital  theory,  origiucjly  pro- 
posed, it  is  true,  by  Casper,®  in  1852.  Quite  a  larg^  num- 
. _  ^- 

•According  to  von  KraffuEbing,  the  most  important  pnVious 
writings  were  those  of  Mbreau  ("Des  aberrations  du  sens  g6ileritiw") 
and  Tarnowski  ("Die  krankhaften  Erscheinungen  des  Geschle-^ts* 
sinnes."). 

Die  contrare  Sexualempfindung."     Berlin,  1891. 

Westphall  adopted  the  congenital  theory  for  contrary  sexuaiy. 


7  *i 


I 


SEXUAL  PERVERSION  OR   VICE.  243. 

ber  of  ccmtributions  to  the  subject,  with  reports  of  nu- 
merous cases  of  diflFerent  kinds  of  perversion,  have  ap- 
peared since  von  Krafft-Ebing's  work.  In  America,  Kier- 
ifiin,  Cfaaddock  and  Lydston  have  advocated  the  congeni- 
tal theory.  More  lately,  a  strong  protest  against  these 
views  has  appeared  in  the  work  of  von  Schrenck-Notzing.* 
This  author,  in  opposition  to  the  opinion  of  the  writers 
just  cited  and  of  others,  has  urged  with  great  force  that 
sexual  perversion,  instead  of  being  an  original  psychopathy,, 
is  a  cultivated  instinct.  Heredity  and  a  neuropathic  con- 
stitution play  an  important  part,  but  this  part  is  only  that 
of  weakened  power  of  resistance  to  external  influences. 
The  contrary  sexual  instinct  is,  as  such,  not  inherited,  nor 
is  it  congenital  any  more  than  are  the  majority  of  psy- 
choses, but  only  that  tainted  or  degenerated  nervous  sys- 
tem, in  consequence  of  which  the  individual  offers  a  men- 
tal weakness,  a  lack  of  resistive  power  to  external  infhi- 
ences  and  a  lack  of  control  over  desires,  however  excited. 
By  a  process  of  cultivation  the  neuropath  develops  feelings 
and  gives  them  expression  in  outward  acts,  over  which  he 
sooner  or  later  may  lose  all  control.  The  first  awakening 
of  the  perverse  instinct  may  be  entirely  fortuitous,  or  by 
auto-suggestion,  or  it  may  be  seduction,  or  other  acciden- 
tal external  circumstances;  from  this  time  on  it  is  a  process 
of  education.  Von  Schrenck-Notzing  would  explain  in 
this  way  the  origin  of  all  forms  of  sexual  perversion,  al- 
though in  the  exposition  of  his  theory  his  argument  is  de- 
voted almost  entirely  to  the  contrary  sexual  instinct. 

The  influence  of  von  Krafft-Ebing's  able  exposition  of 
the  subject,  as  just  said,  has  colored  much  of  the  writings 
of  others.  But  I  think  the  conviction  must  be  forced 
upon  fhe  careful  student  of  these  writings  that  the  attempt 
to  make  vicious  habits  the  result  of  congenital  anomalies 
has  been  based  upon  evidence  that,  from  its  very  nature, 
must  be  incomplete  and  unreliable. 


•  it 


tive  Therapeutics  in  Psychopathia  Sexualis."   Translated 
by  Charles  Gilbert  Chaddock,  M.  D.,  1895. 


244  MORTON  PRINCE. 

In  support  of  this  statement  let  us  consider  briefly,  but 
with  more  particularity,  the  pathogenesis  of  contrary  sex- 
uality, in  accordance  with  the  design  mentioned  at  the 
outset. 

This  aberration,  as  has  been  said,  consists. in  the  ex- 
istence of  sexual  feeling  for  the  same  sex,  co-existing  in 
its  fully  develoi>ed  form,  with  entire  absence  of  sexual 
feeling  for  the  opposite  sex.  In  the  more  moderate  form 
there  may  still  be  inclination  toward  the  opposite  sex, 
but  in  the  higher  degrees  of  the  perversion  there  may  be 
a  feeling  of  actual  repulsion  for  the.  opposite  sex,  while  the 
whole  psychical  personality,  the  tastes,  feelings  and  modes 
of  thought  of  the  individual  may  become  changed  to  corre- 
spond with  the  sexual  perversion;  that  is,  the  character 
of  the  male  becomes  feminine,  and  vice  versa.  Now,  the 
thesis  is  that  all  this  change  of  character,  psychical  as  well 
as  sexual,  is  not  only  congenital,  but  a  partial  manifesta- 
tion of  a  neuropsychopathic  state,  in  most  cases  hered- 
itary. Hence  it  is  in  no  sense  a  perversity  or  vice,  but  a 
true  anomaly  or  perversion  of  instinct,  in  the  sense  that  it 
is  the  product  of  mal-development,  in  the  same  way  that 
any  of  the  normal  instincts,  tastes  or  sensory  functions 
are  the  product  of  normal  development.  In  other  words, 
with  **a  normal  anatomical  and  physiological  state  of  the 
(genital)  organs  a  sexual  instinct  may  be  developed  which 
is  the  exact  opposite  of  that  characteristic  of  the  sex  to 
which  the  individual  belongs."  It  appears  spontaneously, 
without  external  cause,  with  the  development  of  sexual 
life. 

Various  theories  have  been  proposed,  many  of  them 
fanciful,  to  account  for  the  development  of  this  (according 
to  this  view)  anomalous  condition.  But,  as  all  these 
theories  presuppose  the  congenital  character  of  the 
anomaly,  a  serious  consideration  of  them  is  hardly  in  order 
until  the  phenomenon  has  been  proved  to  be  congenital. 

Nevertheless,  a  brief  statement  of  some  of  their  the- 
ories  makes   the   point   of  view  of   these   writers   more 


SEXUAL  PERVERSION  OR   VICE.  245 

definite.  Ulrichs.  himself  a  pervert,  thought  that  a  female 
mind  was  inclosed  in  a  male  body;  that  is,  that  there  were 
people,  to  whom  he  gave  the  name  of  **Urnings,'*  whose 
bodily  structure  was  that  of  a  man,  whose  sexual  instincts 
were  those  of  a  woman.  He  also  considered  this  condition 
due  to  atavism. 

This  same  idea  has  been  put  in  a  more  taking  form  by 
Kieman/®  who  rests  it  upon  the  biological  facts  that  bi- 
sexuality,  or  hermaphroditism,  is  found  in  the  lowest 
orders  of  life,  and  that  in  the  human  embryo  this  same  bi- 
sexuality  exists  up  to  a  certain  age.  In  degenerates  there 
is  a  "throwing  back,"  to  use  the  language  of  the  kennel, 
to  this  primitive  embryological  form,  to  the  extent  that, 
while  in  the  adult  male  there  is  a  differentiation  of  anatom- 
ical form  (sexual  organs),  the  nervous  system  is  developed 
on  the  female  type.  To  quote  his  language,  "The  original 
bi-sexuality  of  the  ancestors  of  the  race,  shown  in  the  rudi- 
mentary female  organs  of  the  males,  could  not  fail  to  oc- 
casion functional,  if  not  organic,  reversion,  when  mental  or 
physical  manifestations  were  interfered  with  by  disease  or 
congenital  defect."  Again,  ....  "It  seems  certain 
that  a  femininely  fimctionating  brain  can  occupy  a  male 
body,  and  vice  versa." 

The  lowest  animals  are  bi-sexual,  and  the  various  types 
of  hermaphroditism  are  more  or  less  complete  reversions 
to  the  ancestral  type.  Lydston^^  advocates  the  same  hy- 
pothesis, which  is  meant  to  be  the  principle  of  atavism. 
I  say,  meant  to  be,  for  it  seems,  oddly  enough,  to  have  been 
overlooked  that  there  is  very  little  atavism  about  it.  If 
there  was  a  development  of  a  female  anatomical  structure 
we  might  talk  of  "throwing  back,"  but  when  the  anomaly 
consists,  as  it  does,  of  psychical  phenomena  and  nervous 
reflexes,  it  is  difficult  to  see  how  there  can  be  a  reversion 
to  or  inheritance  of  a  nervous  system  which  never  had  any 

■•Med.  Standard.     Nov.,  1888. 

"Med.  and  Surg.  Reporter.     Sept.,  1889. 


246  MORTON  PRINCE. 

existence  in  the  lower  order  of  life,  and  never  came  into 
existence  until  the  present  mono-sexual  being  was 
evolved.  It  is  only  fair  to  state  that  credit  may  be  given, 
if  credit  is  desired.to  one  of  v.KraflFt-Ebing's  patients,  by 
whom  this  theory  was  proposed. 

Chevalier  has  proposed  a  modification  of  this  theory 
in  this  wise:  Originally,  in  the  embryo,  man  is  bi- 
sexual; in  the  future  development  there  is  a  sort  of  con- 
test, in  which  one  or  the  other  factor,  male  or  female,  de- 
velops at  the  expense  of  the  other,  with  the  result  of  a 
mono-sexual  individual.  But  traces  of  the  other  sexuality 
remain.  Under  certain  conditions  these  latent  sexual 
characteristics  successfully  succeed  in  developing  them- 
selves, and  contrary  sexuality  results. 

Magnan  and  Gley  also  imagine  a  female  brain  in  a  male 
body. 

In  all  these  expositions  there  is  a  naive  assumption  that 
in  the  brain  of  either  sex  there  is  a  sort  of  nervous  mechan- 
ism, peculiar  to  either  sex,  and  corresponding  to  the  dif- 
ference in  anatomical  form — 3,  hazy  sort  of  cerebral  lo- 
calization involving  a  different  cerebral  architecture  for 
each  sex.  This  seems  to  me  nothing  more  nor  less  than 
the  old-fashioned  phrenology,  and  difficult  to  reconcile 
with  the  first  principles  of  psychology. 

Westphal,  who  first  gave  the  name  contrary  sexuality, 
thought  the  condition  was  congenital,  but  refrained  from 
hypothesis,  excepting  that  in  one  case,  in  which  there 
were  olfactory  hallucinations,  he  thought  this  particular 
phenomenon  was  atavistic  from  the  lower  animals.  West- 
phal, who  also  regarded  the  condition  as  a  psychosis,  gave 
the  impetus  to  the  publication  of  a  long  list  of  cases  by 
other  writers. 

The  best  congenital  hypothesis  is  undoubtedly  that  of 
von  Krafft-Ebing,  who  thinks  that  an  explanation  "may 
perhaps  be  found  in  the  fact  that  it  represents  a  peculiarity 
bred  in  descendents,  but  arising  in  ancestry.  The  hered- 
itary factor  might  be  an  acquired  abnormal  inclination  for 


SEXUAL  PERVERSION  OR   VICE.  247 

the  same  sex  in  the  ancestors,  which,  being  transmitted, 
becomes  fixed  as  a  congenital,  abnormal  manifestation  in 
the  descendents/* 

Kieman  had  also  suggested  this  possibility  for  certain 
cases. 

On  the  other  hand,  Binet  considers  that  the  whole 
perversion  is  acquired  through  the  force  of  the  law  of  as- 
sociation of  ideas. 

Among  the  names  of  those  contributing  to  the  sub- 
ject are  to  be  found  many  of  well-known  writers  in  neurol- 
ogy and  psychiatry.  But  the  most  important  contribu- 
tions are  those  already  mentioned,  and  particularly  the 
works  of  Moll,^^  von  Krafft-Ebing*®  and  von  Schrenck- 
Notzing.^*  The  difference  in  the  views  of  these  writers 
has  alreaidy  been  pointed  out.  Besides  the  fact  that  the 
manifestations  of  contrary  sexuality  are  acquired,  von 
Schrenck-Notzing  holds  that  nevertheless  these  manifes- 
tations become  in  time  imperative  sensations  and  impera- 
tive ideas,  and  thus  from  this  point  of  view  may  be  looked 
upon  as  psychoses — artificially  created  in  a  neuropathic 
soil  in  most  instances.  This  opens  a  very  wide  field  for 
discussion,  as  it  is  no  easy  matter  to  settle  what  decisive 
element  constitutes  an  imperative  idea.  The  familiar  lan- 
guage of  the  pervert,  which  is  stereotyped  in  "irresistible 
impulse,"  too  often  should  be  written,  "I  don't  want  to."^* 
Still,  we  must  allow,  as  we  see  in  the  alcoholic  and  opium 
habit,  that  for  weakened  resisting  powers  sensations  may 
be  well  educated  to  such  an  extent  as  to  become  im- 
perative. 


U  i<1 


'Contrare  Sexualempfindung.*' 

Tsychopathie  Sexualis"  and  "Zur  Erklarung  der  contraren 
Sexualempfindung/' 

'Suggestive  Therapeutics  in  Psychopathia  Sexualis." 

'I  wish  to  state  expressly  that,  though  I  am  conscious  of  the  ab- 
normality of  my  inclinations,  I  have  no  desire  to  change  them;  I 
long  only  for  a  time  when  more  easily,  and  with  less  danger  of  dis- 
covery, I  can  give  rein  to  my  desires  and  experience  a  delight  that 
will  harm  no  one." — Autobiography;  case  149,  v.  K.-E. 


14  4i4 

15  4<1 


248  MORTON  PRINCE. 

Now,  putting  aside  hypotheses  of  the  ''how/'  an  ex- 
amination of  the  congenital  perversion  theory  shows  that 
it  rests  entirely  upon  the  autobiographies  of  perverts,  and 
certain  assumptions  (to  be  presently  mentioned)  regarding 
the  normal  development  of  the  vita  sexualis,  and  of  the 
tastes,  habits  and  modes  of  thought  peculiar  to  each  sex. 
It  is  believed  that  a  person  is  capable  of  remembering 
all  the  circumstances  attending  the  gradual  growth  of  the 
sexual  functions  in  early  childhood,  has  a  distinct  recollec- 
tion .of  the  causes  which  first  called  it  forth,  and  that  a  fail- 
ure to  remember  possible  excitants  is  equivalent  to  their 
non-existence.  A  reliance  upon  evidence  of  this  kind  in  any 
other  department  of  human  knowledge,  whether  medical 
or  non-medical,  I  am  sure,  would  only  excite  surprise. 
Even  in  taking  an  ordinary  medical  history,  we  should 
hesitate  to  accept  such  testimony  as  final,  and  I  think  we 
should  be  even  more  cautious  in  our  examination  of  auto- 
biographies which  attempt  to  give  an  analysis,  founded  on 
introspection,  of  the  feelings,  passions  and  tastes  of  de- 
generate individuals  who  attempt  to  explain  their  first 
beginnings  in  early  childhood,  and  attribute  each  to  its- 
proper  excitant.     As  von  Schrenck-Notzing  has  pointed 
out,  in  his  very  careful  study  of  the  published  cases,  very 
few  of  these  autobiographies  will  stand  analysis.     Prob- 
ably there  is  no  class  of  people  whose  statements  will  less 
stand  the  test  of  a  searching  cross-examination  than  the 
moral  pervert.    One  cannot  help  feeling  that  if  the  pervert 
was  thus  examined  by  an  independent  observer,  instead  of 
being  allowed  to  tell  his  own  story  without  interruption, 
a  different  tale  would  be  told,  or  great  gaps  would  be 
found,  which  are  now  nicely  bridged,  or  many  asserted 
facts  would  be  resolved  into  pure  inferences. 

Taking  one  point  alone,  it  is  extremely  doubtful 
whether  any  one  can  remember  the  first  beginnings  of  the 
vita  sexualis.  He  may  remember  certain  occasions,  which,, 
from  the  special  intensity  of  the  excitation,  or  from  pe~ 
culiar  associations,  persist  as  vivid  mental  pictures;  just 


SEXUAL  PERVERSION   OR   VICE.  249 

as  we  remember  certain  pleasurable  experiences  of  boy- 
hood connected  with  sports,  but  not  all  nor  the  first. 

The  second  error  of  those  who  maintain  the  congenital 
theory  is  that  they  overlook  the  influence  which  casual 
external  circumstances  have  in  suggesting  feelings  and 
ideas  to  the  mind,  and  in  directing  thoughts  which  ap- 
pear to  be  spontaneous.^®  These  external  circumstances 
may  be  trivial  or  not,  and  may  be  forgotten.  Even  when 
very  prominent  for  the  moment  in  consciousnes,  they  may 
be  forgotten,  while  the  effects  may  persist.  The  enlarge- 
ment of  our  knowledge  of  the  substrata  of  consciousness, 
and  the  after-influence  of  such  subconscious  states  upon 
the  personality  of  the  individual,  has  made  it  possible  for 
us  to  understand  the  genesis  of  certain  neuroses  which  be- 
fore were  inexplicable,  Janet  has  demonstrated  this  in- 
fluence in  the  production  of  some  of  the  manifestations  of 
hysteria.  With  this  knowledge  it  is  next  to  impossible  to 
say  that  sexual  aberrations  were  not  originally  suggested 
by  external  conditions  in  individual  'cases,  or  the  product 
of  auto-suggestion.^''^  A  very  suggestive  example  of  the 
influence  of  this  kind  upon  the  lower  strata  of  conscious- 
ness in  producing  psychoses  is  the  following,  from  the 
writer's  own  experience:  A  young  girl,  about  16  years  old, 
was  pursued  with  an  uncontrollable  fear  of  vomiting.  As 
a  matter  of  fact,  she  never  did  vomit,  but  the  fear  was  scv 
intense  that  she  was  unwilling  to  leave  the  house  alone,  or, 

"Whether  or  not  a  neuropathic  taint  is  necessary,  as  has  been 
maintained,  is  a  secondary  matter.  The  existence  of  an  hereditary 
taint  has,  however,  been  sometimes  accepted  on  insufficient  evidence. . 

"  A  capital  illustration  of  the  influence  of  forgotten  causes  in  pro- 
ducing physical  phenomena  is  the  following:  A  lady  told  me  of  a 
dream,  in  which  she  saw  distinctly  the  face  of  a  person 
whom  she.  had  never  seen.  Her  description  of  the  person  being 
very  accurate,  I  insisted,  to  test  the  matter,  that  she  must  have  seen 
or  heard  of  the  person  before.  On  assuring  me  of  the  impossibility 
of  this,  I  told  her,  as  was  the  fact,  that  a  few  days  previously  I  had 
described  this  person  to  her,  using  the  same  language  that  she  now 
used  for  the  same  description.  She  had  no  recollection  of  it.  Sexual 
suggestions  and  excitants  might  be  similarly  forgotten. 


250  MORTON  PRINCE. 

for  that  matter,  even  when  accompanied,  go  in  places 
of  amusement,  or  to  such  distances  from  home  that  she 
could  not  quickly  reach  her  house.  The  fear,  although 
always  present,  was  subject  to  exacerbations.  In 
such  attacks  her  suflfering  was  very  great  and  the  mental 
state  uncontrollable.  She  would  take  off  her  clothes,  and 
run  up  and  down  the  room,  crying  and  begging  her  mother 
not  to  let  her  vomit.  This  fear  had  apparently  developed 
spontaneously  during  early  girlhood,  and  might  easily 
have  been  considered  congenital  if  the  original  history,  as 
given  by  the  patient  herself  and  mother,  had  been  be- 
lieved. But  from  the  mother,  after  persistent  inquiry,  T 
obtained  the  following  history,  till  that  moment  forgotten: 
When  the  patient  was  a  child,  say,  5  years  old,  her  sister 
was  taken  ill  with  scarlet  fever,  the  first  symptom  of  which 
was  violent  vomiting.  That  the  other  child  (my  patient) 
might  be  prevented  from  catching  the  disease,  she  was  told 
that  if  she  went  near  her  sister  she  would  be  taken  with 
vomiting  in  the  same  way.  This  had  the  desired  effect, 
but  when  the  sister  recovered  it  was  with  some  difficulty 
that  my  patient  could  be  induced  to  come  into  her  pres- 
ence. She  ran  away  and  hid  in  a  closet,  exhibiting  con- 
siderable fear.  It  is  reasonable  to  suppose  that  the  im- 
pression made  upon  »the  mind  at  that  time  had  left  a  sub- 
conscious idea,  which  was  the  Cause  of  the  apparently  mo- 
tiveless fear  later  exhibited.  The  patient  had  no  memory 
of  all  this.  The  excitation  of  abnormal  sexual  feelings  may 
well  have  similar  external  causes  long  since  forgotten. 

The  third  error  of  this  school  is  that  it  assumes  that 
normally  there  is  a  hard  and  sharp  line  drawn  by  nature 
between  the  normal  personalities  of  the  sexes.  As  a  mat- 
ter of  fact,  sharp  lines  of  demarcation  do  not  occur  any 
more  than  in  the  length  of  the  nose  or  size  of  the  hand. 
Taking  a  large  number  of  people,  the  male  personality 
normally  shades  into  the  female,  and  vice  versa.  What 
I  mean  to  say  is  that,  taking  a  large  number  of  normal 
males  and  an  equal  number  of  normal  females,  we  might 


SEXUAL   PERVERSION   OR    VICE.  25 1 

place  them  in  a  row,  so  that  at  one  end  would  come  the 
males  with  strong,  vigorous,  masculine  characters;  in  the 
middle,  but  at  the  extreme  end  of  the  male  line,  the  men 
with  female  personaHties;  adjoining  these  the  masculine 
females,  differing  but  slightly  except  in  anatomical 
form  from  the  males;  while  at  the  extreme  end  of 
the  female  line  would  come  those  with  strongly  marked 
feminine  personalities. 

Fourthly,  the  effect  of  education,  meaning  by  this  the 
total  environment,  intentional  education,  unconscious 
mimicry,  external  suggestion,  example,  etc.,  etc. — the  ef- 
fect of  this,  I  repeat,  in  moulding  the  tastes  and  habits  of 
thought  and  manners  of  the  child,  and  thus  differentiating 
those  of  one  sex  from  those  of  the  other,  has  been  over- 
looked. 

I  think  it  is  extremely  probable  that  if  a  boy  were 
l)rought  up  as  a  girl  and  a  girl  as  a  boy,  and  absolutely 
freed  from  all  counter  influences,  such  as  the  unconscious 
influence  of  public  criticism,  etc.,  each"  would  have  the 
non-sexual  tastes  and  manners  of  the  other  sex. 

Fifthly,  it  is  questionable  whether  only  abnormally  the 
vita  sexualis  of  the  male  is  excited  by  the  female,  and  con- 
versely. There  is  every  reason  to  believe  that  in  some 
perfectly  healthy  individuals  some  degree  of  erotic  feel- 
ing or  ideas  may  be  excited  by  the  sight  or  touch  of  the 
form  of  a  person  of  the  same  sex,  and,  at  any  rate,  thoughts 
(pertaining  to  anatomy)  so  excited  may  very  naturally 
awaken  secondarily  associated  sexual  feelings.  For  in- 
stance, the  vita  sexualis  in  a  boy  is  first  associated  with 
his  own  sexual  organs.  Later,  the  sight  of  those  of  an- 
other boy  awakens  the  association  of  ideas  by  the  well- 
known  law,  and  then,  in  a  degenerate,  cultivation  does 
the  rest.  Von  Krafft-Ebing's  first  case  (106)  of  a  girl 
with  hyperesthesia  sexualis  and  homo-sexuality  is  readily 
explainable  in  this  way.  As  von  Krafft-Ebing  points  out, 
in  the  beginning  of  sexual  development  in  the  child  '*the 
psychical  relation  to  persons  of  the  opposite  sex  is  still 


252  f  MORTON  PRINCE. 

absolutely  wanting,  and  the  sexual  acts  during  this  period 
partake  more  or  less  of  a  reflex  spinal  nature/'     **VVith 
the  inception  of  anatomical  and  functional  development 
of  the  generative  organs,  and  the  differentiation  of  form 
belonging  to  each  sex,  which^goes  hand  in  hand  with  it 
in  the  boy  or  girl,  rudiments  of  a  mental  feeling  corre- 
sponding with  the  sex  are  developed,  and  in  this,  of  course, 
education  and  external  influences  in  general  have  a  power- 
ful eff^ect  upon  the  individual,  who  is  now  all  attention/' 
Now,  in  a  person  of  perfectly  healthy  mind  and  body,  all 
social  customs,  habits  of  thought,  unwritten  laws,  and 
moral    precepts    tend   to   suppress    any    existing    homo- 
sexual feeling  and  its  gratification,  and  to  encourage  het- 
ero-sexual   feeling.     On  the  other  hand,  the  person  of 
tainted  constitution  does  everything  in  his  power  to  foster^ 
indulge  and  cultivate  the  perverse  instinct,  while  in  such 
a  soil  the  feelings  themselves  acquire  monstrous  force. 
That  the  future  development  of  this  perversity  is  due  to 
cultivation  there  is  no  question.    We  have  only  to  read  the 
autobiographies  to  be  convinced  of  it.    Thus  may  arise  a 
perversity  that  had  its  origin  in  a  normal  reflex,  but  the 
accidental  cause  of  which  is  forgotten  with  much  else  of 
the  psychical  life  of  childhood,  or,  if  not  forgotten,  con- 
sidered  abhormal   because   of  its   future   monstrous   de- 
velopment.   Such  a  reflex,  it  may  be  said,  if  normal,  is  con- 
genital.    This  much  is  in  strictness  true,  but  an  entirely 
different  aspect  is  given  to  the  congenital  theory.    What 
is  really  pathological  in  this  aberration  is  the  extraordinary 
intensification  of  the  sexual  feelings  and  the  unbridled 
lack  of  restraint  with  which  the  subject  indulges  his  senses 
and   seeks  every  opportunity  for  gratification.       These, 
without  doubt,  depend  upon  the  neuropathic  constitution. 
The  contrast  in  this  respect   with  normal  hetero-sexual 
petsons  brings  the  difference  into  strong  reli'ef. 

Finally,  the  fact  must  not  be  lost  sight  of — it  is  not 
questioned — that  cultivation  is  capable  of  generating  this 
aberration  and  developing  it  to  its  most  intense  degree. 


SEXUAL  PERVERSION   OR    VICE.  353 

€ven  to  the  feeling  of  repulsion  for  the  opposite  sex  and 
to  the  acquisition  of  contrary  tastes  and  habits.  Acquired 
cases  of  this  kind  are  recognized  and  illustrated  by  cases 
94,  95,  96,  99,  etc.,  of  von  KraflFt-Ebing.  It  is  not,  then, 
a  question  of  the  sufficiency  of  this  influence.  The  only 
question  is,  "Are  all  cases  due  to  this  influence,  or  are  those 
cases  in  which  there  is  no  evidence  in  the  histories,  so  far 
as  obtained,  of  cultivation,  and  in  which  there  is  an  apparent 
spontaneous  origin,  properly  to  be  regarded  as  congenital? 

One  logical  consequence  of  the  cultivation  theory  has 
been  overlooked,  as  it  seems  to  me,  by  von  Schrenck- 
Notzing.  It  follows  as  a  necessary  corollary  that  this  so- 
called  perversion  is  not  really  a  perversion,  but  a  perversity 
— a  vice  rather  than  a  disease. 

From  one  standpoint  the  view  may  be  modified.  It 
has  already  be^n  said  that  a  habit  may  be  so  intensely  cul- 
tivated as  to  become  in  time  almost  automatic  and  inde- 
pendent of  volitional  control.  The  nervous  processes  in- 
volved may  thus  become  shunted  oflf  from  the  rest  of  the 
psychical  life  as  true  psychoses.  It  is  tenable  that  in  some 
persons  these  aberrations  may  become  by  cultivation  real 
imperative  sensations  and  ideas.  Though  vice  may  be  the 
road  traversed,  the  final  stage  may  be  disease. 

Analogy  with  what  takes  place  in  other  fields  of  the 
nervous  system  would  make  it  intelligible  that  sexual  feel- 
ings and  actions  may  by  constant  repetition  (cultivation) 
become  associated  together  and  developed  into  a  sort  of 
quasi-independent  neural  activities,  which  may  then  be- 
come practically  independent  of  tJie  will — or,  in  other 
words,  a  psychosis. 

Sexual  perversion,  then,  may,  from  the  point  of  view 
of  pathogenesis,  be  put  in  the  same  class  with  many  of  the 
manifestations  of  hysteria  and  other  psycho-neuropathic 
states.  The  constant  excitation  of  various  bodily  symp- 
toms by  the  neurasthenic  tends  to  cultivate  them  into 
imperative  habits,  which  control  his  organism.  The  hys- 
teric dwelling  on  certain  ideas,  whether  they  relate  to 


254  MORTON  PRINCE, 

herself  or  her  environment,  tends  to  nurture  and  cultivate 
them,  till  they  may  acquire  such  monstrous  intensification 
that  they  control  her  psychical  life. 
,  From  small  beginnings  it  is  possible  that  even  most 
intense  doubts  and  fears  may  be  evolved  by  this  cultiva- 
tion, culminating,  perhaps,  in  imperative  ideas  (insanity 
of  doubt,  folic  de  toucher,  etc.).  By  constant  indulgence 
of  her  feelings — revelling  in  morbid  introspection — ^giving 
herself  up  to  egotistical  debauches,  self-pity  and  wrong 
inferences,  the  hysteric  or  neurasthenic  cultivates  her 
body  and  mind  into  becoming  such  a  sensitive  ma- 
chine that  she  can  no  longer  adapt  herself  to  her  en- 
vironment, but  must  be  removed  to  an  institution,  where 
her  environment  can  be  adapted  to  her;  of  course,  I  am 
drawing  an  extreme  picture,  but  such  extreme  pictures 
exist. 

Therapeutically,  the  point  of  view  which  we  take  of 
the  genesis  of  these  psychoses,  sexual  and  non-sexual,  is  of 
extreme  importance.  If  they  are  not  the  manifestations 
of  a  diseased  nervous  system,  in  the  sense  that  they  are 
the  necessary  expression  of  a  diseased  body,  whether  con- 
genital or  not,  then  there  is  no  escape  from  therapeutic 
hopelessness  so  long  as  the  psychopathic  state  continues. 
But  if  psychoses  of  this  kind  are  the  result  of  cultivation^ 
whether  by  the  influence  of  external  surroundings  or  by 
the  subject's  own  conduct — cultivated  into  psychoses  be- 
cause the  soil  is  a  psychopathic  one — then  we  may  fairly 
hope  by  cown^^r-education  to  replace  the  morbid  processes 
by  healthy  ones.  For  myself,  I  believe  that  cultivation 
is  the  road  by  which  many  neurasthenics  and  hysterics 
reach  the  final  goal  of  confirmed  invalidism — cultivated 
sometimes  by  the  patient  herself,  too  often  by  the  timid 
physician,  who  dares  not  speak  the  truth,  or  who  fears 
to  do  harm.  I  do  not  believe  in,  cmd  I  am  afraid  I  have  no 
patience  with  the  laissez-faire  system  which  contents  itself 
with  removing  every  source  of  external  irritation  and  then 
— doing  nothing.     The  neurasthenic  will  be  more  easily 


I 


SEXUAL   PERI' ERS JON   OR    VICE.  255 

cured  if  she  is  isolated,  but  after  this  her  treatment  must 
be  a  process  of  education.  The  hysteric  will  do  better  if 
her  environment  is  adapted  to  her  weakness,  but  her  edu- 
cation must  then  begin.  I  am  aware  that  when  the  dam- 
age is  too  great  nothing  will  avail — 1)ut  we  can  always 
try.  The  physician  is  capable  of  doing  the  greatest  good — 
but  he  is  also  capable  of  doing  the  greatest  harm — -and 
no  influence  for  harm  is  greater  than  that  of  the  phy- 
sician who  unwittingly  encourages  corporeal  symptoms 
by  intimation  of  possible  disease,  danger  and  caution,  or  of 
psychical  symptoms  by  a  failure  to  combat  fixed  ideas,  and 
to  develop  a  sense  of  duty,  self-control  and  right-minded- 
ness. A  harmful  influence  of  this  kind  is  multiplied  a 
hundred  fold  by  the  unremitting  kindness  and  attention 
and  devotion  of  the  physician  himself. 

Coming  now  to  hard  facts,  the  treatment  of  the  sexual 
psychoses — if  we  can  accept  the  statistics  of  von  Schrenck- 
Notzing — has  given  results  which  contradict  the  congeni- 
tal theory.  Far  from  being  hopeless,  as  the  congenital 
theory  would  imply,  the  treatment  of  sexual  paraesthesia 
is  attended  in  a  large  proportion  of  cases  with  encouraging 
results.  When  the  sexual  aberration  is  only  a  part  of 
great  mental  degeneration,  such  as  imbecility,  dementia 
or  paranoia,  of  course,  any  attempt  must  be  hopeless.  But 
where  the  psychopathic  basis  is  of  a  minor  degree,  and  the 
intellect  is  not  materially  affected,  it  must  appear,  if  we 
are  to  judge  by  reports  of  published  cases,  that  improve- 
ment or  cure  may  be  accomplished.  This,  of  course,  pre- 
supposes that  a  person  desires  to  b^  cured.  It  is  highly 
improbable  that  a  person  can  be  cured  -against  his  wilK 
and  it  is  evident  that  many  do  not  want  to  be  cured.  The 
chief  and  most  effective  therapeutic  remedy  has  been 
hypnotic  suggestion.  In  the  hands  of  von  Schrenck-  Not- 
zing  and  others  this  remedy  has  given  decidedly  favorable 
results.  The  total  number  of  cases  collected  by  von 
Schrenck-Notzing  is  32.  The  results  of  treatment  Were 
as  follows: 


256  MORTON  PRINCE. 

Failures 5 — 15.623  per  c 

Slightly  improved 4 — 12.5      per  c 

Essentially  improved,  with  later  report 11 — 34. 375  per  c 

Cured,  10;  without  later  report,  3 12 — 37.5      per  c 


Thus,  about  70  per  cent,  were  essentially  improved  or 
cured.  The  fact  that  of  the  12  cures  later  reports  were 
obtained,  sometimes  after  considerable  periods  (four  or 
five  years)  in  10  makes  these  statistics  of  considerable 
value.  Of  the  32  patients,  5  were  not  amenable 
to  hypnosis,  7  were  cases  of  psycho-sexual  hermaphrodit- 
ism, 20  of  contrary  sexual  instinct,  2  of  sadism,  3  of  maso- 
chism. 

But,  besides  direct  suggestion,  other  forms  of  mental 
therapeutics  should  be  employed  for  the  purpose  of 
strengthening  the  will  power  and  developing  the  charac- 
ter of  the  patient. 

To  be  brief,  the  methods  of  treatment  and  the  results 
are  the  same  as  when  dealing  with  other  manifestations 
of  neurasthenia,  hysteria  or  degeneracy,  when  these  are 
cultivated,  as  is  more  than  frequently  the  case.  For 
these,  also,  isolation  is  not  enough,  nor  is  the  so-called 
rest  cure  or  forced  feeding,  but  education  is  essential — 
education  in  a  broad  sense — which  includes  the  develop- 
ment of  the  common  sense,  the  intelligence,  the  will,  the 
moral  sense  and  the  building  of  the  character  of  the  indi- 
vidual. 

Dr.  William  Hirsch  submitted  a  paper  entitled: 
NOTES    ON    A    CASE   OF   TRAUMATIC    INJURY    OF    THE 
PNEUMOGASTRIC.  HYPOGLOSSAL,  AND  SYMPATHET- 
IC   NERVES, 

fidate's  paper.    It  is  published  elsewhere. 


i.  M.  Thomas  submitted  a  paper  entitled: 

SSIVE  CENTRAL  MUSCULAR  ATROPHY;  R 

OF  A  CASE  WITH  AUTOPSY, 

lidate's  paper.     It  is  published  elsewhere. 


DISSOCIATION  OF  SENSATION  OF  THE  SYRIN- 
GOMYELIC  TYPE:  OCCURRING  IN  POTT'S 
DISEASE. 

By  DAVID  LINN  EDSALL,  M.D., 

Associate  of  the  William  Pepper  I^bratorv  of  Clinical  Medicine;  Physician  to  St. 

Christopher's  Hospital  for  Children. 

I  present  this  report  solely  because  of  the  peculiar 
character  and  distribution  of  the  sensory  changes. 

The  observations  which  I  record  were  made  upon  a 
boy,  14  years  of  age.  whose  family  history  has  no  relation 
with  the  origin  of  his  disease,  there  being  no  tuberculosis 
in  the  family.  The  boy's  personal  history  is,  excepting  an 
attack  of  mumps  in  early  childhood,  entirely  free  from 
disease  up  to  last  February,  when,  while  carrying  a  heavy 
basket,  he  felt  sudden,  sharp  pain  in  the  right  shoulder 
and  around  both  sides  of  the  chest,  which  continued. 
The  diagnosis  of  pleurisy  and  also  of  spinal  injury  had 
been  made,  but  the  pain  was  undoubtedly  due  solely  to  the 
spinal  caries,  as  he  had  no  other  subjective  symptoms  of 
pleurisy,  and  has  now  no  physical  signs  of  such  disease 
remaining.  His  pain  gradually  ceased  after  resting,  and 
disappeared  after  six  weeks  or  two  months.  It  has  only 
returned  as  twinges  about  either  side  of  the  chest,  and 
no  pain  has  been  felt  for  several  months.  In  the  early 
summer  he  rode  a  bicycle  excessively,  but  discontinued 
this  in  August,  as  he  felt  weak  in  his  legs.  This  weakness 
was  succeeded  by  stiffness,  which  increased  rapidly,  until  \ 

he  walked  only  with  the  aid  of  two  canes  and  partly  sup-  j 

ported  by  a  companion,  moving  the  right  leg  with  some 
freedom,  but  with  an  extremely  spastic  gait,  while  the  left 
leg  was  very  spastic  and  almost  powerless.  He  was 
emaciated  and  emotional.    When  sitting  or  lying  he  could 


258  DAI 'ID    LINN    EDS  ALL. 

I 

raise  the  right  leg  a  Httle  and  had  some  power  of  ex- 
tension and  flexion  at  the  joints.  The  left  leg  was  almost 
entirely  helpless.  The  right  patellar  reflex  was  violent. 
On  the  left  it  was  much  excited,  but  less  excessive  than 
on  the  right.  The  abdominal,  cremasteric  and  plantar 
reflexes  were  absent.  Ankle-clonus  was  present  on  both 
sides,  and  was  very  forcible.  There  was  no  evident  atrophy 
of  the  muscles.  The  skin  was  dry,  rough  and  ill-nourished 
below  the  knees.  He  had  then  no  difficulty  with  bladder 
or  rectum. 

Examination  of  his  spine  showed  quite  pronounced 
posterior  projection  of  the  spines  of  the  second,  third  and 
fourth  lumbar  processes,  with  some  tenderness  on  pressure 
upon  them. 

The  sensory  condition  was  the  most  interesting  fea- 
ture. Tactile  sense  was  entirely  preserved  everyw^here, 
while  pain  sense,  though  still  present  upon  energetic  stim- 
ulation, was  much  lessened  in  a  peculiar  area,  and  it  re- 
quired quite  severe  procedures  to  cause  him  pain  in  this 
region.  Anteriorly,  the  analgesia  began  on  a  horizontal 
line,  which  was  on  a  level,  in  the  centre  of  the  body,  with 
the  fifth  intercostal  space,  and  extended  from  here  down 
to  the  level  of  the  knee  joint,  including  all  the  skin  space 
between  these  points.  Posteriorly,  the  upper  level  was 
at  a  lower  point  by  about  two  inches,  and  extended  only 
one-third  the  way  down  the  buttocks.  Below  this  the 
posterior  skin  surface  showed  no  loss  of  sensation  of  any 
form.  The  same  area  that  exhibited  a  lessened  pain  sense 
showed  an  absolute  loss  of  discriminative  temperature 
sense,  even  to  objects  which  were  very  hot  or  almost  ice- 
cold.  Whatever  the  temperature,  he  inclined  to  call  things 
**a  little  warm,"  though  this  feeling  of  slight  warmth  was 
not  constantly  produced. 

This  examination  was  confirmed  on  several  occasions 
by  Dr.  Willard,  who  took  charge  of  him  in  the  University 
Hospital.  Just  before  his  admission  he  had  developed 
some  incontinence  of  urine  and  of  feces.     By  October  7th,. 


DISSOCIATION    OF    SENSATION  259 

after  he  had  been  entirely  at  rest,  with  head  extension,  for 
two  months,  he  had  regained  control  of  his  sphincters,  and 
still  retains  normal  control.  Muscular  power  in  his  legs 
seemed  rather  better,  especially  in  the  right  leg.  The 
knee-jerks  were  not  noticeably  changed,  and  ankle-clonus 
was  still  energetic  on  either  side.  Reactions  of  degenera- 
tion were  not  present.  The  muscles  responded  to  the 
faradic  current.  His  sensation  was  nearly  normal,  though 
over  the  areas  that  have  been  described  pain  sense  still 
seemed  lessened,  and  he  had  a  good  deal  of  hesitancy  in 


The  Area  of  Sensory  Disturbances. 

discriminating  between  hot  and  cold,  and  often  gave  im- 
proper answers  when  the  difference  in  temperature  was 
very  marked,  and  was  readily  appreciated  on  any  other 
s»^ln  surface  than  the  one  indicated. 

This  improvement  did  not  continue,  however,  and  two 

'N^eVs  later  his  motor  symptoms  bad  increased,  and  the 

'^M  dissociation  of  sensation  had  returned.     By  November 

^S^hhe  was  entirely  paraplegic;  the  original  condition  of 

*lie  knee-jerks  and  ankle-clonus  persisted,  but  the  hypal- 

gfsia  and  thermoane.sthesia  had  extended  down  over  the 


26o  DAyiD    LINN    EDSALL. 

legs  and  feet  and,  below  the  upper  limit  of  the  sensory  dis- 
turbance, the  only  portion  of  the  surface  that  showed  no 
change  was  a  posterior  area  on  each  side,  extending  from 
the  upper  third  of  the  buttocks  down  nearly  to  the  knees. 
At  the  present  time  this  surface  is  partly  anesthetic  to 
pain  and  does  not  discriminate  between  various  tempera- 
tures, and  he  remains  entirely  paraplegic,  though  in  much 
improved  general  health. 

The  appearance  of  this  form  of  dissociation  of  sensa- 
tion, or  the  existence  of  thermo-anesthesia  alone  in  Pott's 
disease,  is  of  some  interest,  as  very  Httle  attention  seems 
to  have  been  given  to  it.    Almost  all  of  the  studies  of  sen- 
sory changes  in  Pott's  disease  have  been  confined  to  the 
determination  of  disturbance  of  the  tactile  or  pain  senses. 
Kocher  included   several   cases   of   this   affection   in   his 
studies  on  spinal  anesthesia,  and   Chipault   carefully   re- 
corded the  areas  of  anesthesia  in  22  cases  of  spondylitis, 
but  they  did  not  investigate  the  condition  of  the  thermal 
sense.    Several  of  the  text  books  on  nervous  diseases  make 
no  allusion  to  the  occurrence  of  dissociation  of  sensation 
in  Pott's  disease,  other  than  to  mention  that  it  may  be 
found  in  compression  myelitis  from  various  causes.   Gowers 
and  Striimpell  say  that  all  the  forms  of  sensation  may  be 
destroyed  together,  or,  more  frequently,  tactile  or  pain 
sense  alone.     Schlesinger  states  that   he  has  frequently 
met  with  thermo-anesthesia  in  spinal  caries,  and  refers  to 
Gowers  and  Bruns  as  making  the  same  assertion.     The 
individual  case  which  Schlesinger  casually  mentions  and 
one  recorded  by  Daxenberger  are  the  only  cases  found  by 
nie  in  detail.    In  the  latter  there  was  loss  of  pain  and  tem- 
rature  sense  in  the  right  hand.     In  this  case  in  the  left 
r  there  was  at  first  loss  of  all  sensation;  later  the  tem- 
rature  sense  alone  was  absent.    Thi§  difficulty  in  finding 
:ords  like  my  own  seems,  however,  due  purely  to  the 
:k  of  investigation  into  the  thermal  sense.    Isolated  dis- 
rbance  of  this  sense,  or  its  loss  with  loss  of  pain  sense, 
curs  in  myelitis  as  in  Biernacki's  cases,  in  spinal  tumor, 


DISSOCIATION    OF    SENSATION  26 1 

in  tabes,  in  disseminated  sclerosis  and  in  lesions  of  the  ner\  e 
roots  and  of  the  peripheral  nerves,  besides  being  more  fre- 
quently met  with  in  syringomyelia  and  hysteria.  So  that 
we  cannot  be  surprised  at  its  occurrence  in  a  disease  where 
organic  changes  are  so  common  as  in  Pott's  disease.  It 
is,  however,  rather  curious  that  so  little  attention  has  been 
given  to  it  by  authors. 

More  difficult  to  understand  than  the  occurrence  of 
this  dissociation  of  sensation  is  its  distribution  in  this 
case.  It  does  not  correspond  to  spinal  segments,  nor  is 
it  a  typical  example  of  the  peculiar  regional  form  so  com- 
monly found  in  syringomyelia,  and  which  has  been  the 
recent  subject  of  discussion  by  Chipault  and  Knapp,  since 
it  did  not  encircle  the  leg  below,  but  was  more  extensive 
over  the  front  than  posteriorly.  Beyond  the  fact  that  it 
does  not  correspond  to  the  usual  limitations  in  lesions  of 
spinal  segments,  as  Thorburn,  Starr,  Kocher  and  others 
have  determined  these  limits,  it  would  seem  that  com- 
pression must  have  acted  with  a  peculiar  nicety  to  have 
so  pressed  upon  the  posterior  nerve  roots  throughout  this 
extent,  and  in  each  case  have  destroyed  only  pain  and 
temperature  sense.  So  that  we  are  practically  forced  to 
accept  some  change  in  the  cord  itself  as  the  cause  of  this. 
It  accords  fairly  well  with  Chipault's  division  of  a  com- 
bined nerve  root  and  medullary  lesion,  in  which  division 
he  adopts  the  hypothesis  of  Brissaud  that  a  certain  circular 
level  of  the  cord  supplies  a  corresponding  circular  area  of 
the  limbs  or  body.  This  is,  of  course,  purely  hypothesis, 
but  is  made  somewhat  more  forcible  by  his  discovery  in 
five  of  the  22  cases  he  examined  that  when  the  caries  was 
not  situated  over  the  cord,  but  over  the  cauda,  he  got 
only  the  root  type.  When  the  caries  was  situated  over  the 
cord  itself  the  medullary  type  was  found  alone  or  com- 
bined with  the  root  type,  or  in  certain  cases  neither  type 
occurred.  The  root  type  occurred  alone  with  such  situa- 
lion  of  the  lesion  in  but  two  cases,  and  these  two  cases 
showed  fair  evidence  of  involvement  of  the  roots  alone 


262  DAVID    LINN    EDS  ALL. 

without  damaging  the  cord.  I  have  examined  quite  a 
large  number  of  records  of  distribution  of  anesthesia,  and, 
while  that  variety  which  Chipault  and  Brissaud  term  the 
root  type  may  occur  alone  when  the  disease  is  seemingly 
limited  to  the  cord,  I  have  not,  on  the  other  hand,  seen 
any  records  which  showed  the  medullary  type  either  alone 
or  combined  in  which  there  was  probably  no  lesion  of 
the  cord.  This  is  not  positive  evidence,  but  points  to  the 
cord  as  the  probable  situation  of  at  least  a  portion  of  the 
disease. 

If  the  cord  be  diseased  in  this  case — beyond  the  prob- 
able implication  of  the  roots — it  is  an  interesting  question 
whether  we  have  here  simply  a  compression  myelitis,  an 
extension  of  the  tuberculous  disease  into  the  cord,  or  a 
central  conglomerate  tubercle  of  the  cord.  • 

This  is  a  question  which  cannot  be  finally  answered 
in  life.  Compression  myelitis  alone  might,  of  course,  in- 
volve areas  of  the  cord,  the  disease  of  which  would  give 
rise  to  the  symptoms,  as  could  extension  of  tubercular 
disease  into  the  cord.  A  good  explanation  of  the  progress 
of  the  sensory  disturbance  downward  would  seem  to  be 
the  existence  of  some  originally  central  lesion,  which  gave 
rise  to  the  early  peculiar  distribution  of  hypalgesia  and 
thermo-anesthesia,  which  lesion  subsequently  extended 
outward,  so  that  the  fibres  conducting  temperature  and 
pain  sensations  from  the  portions  below  the  area  first  af- 
fected have  since  beien  cut  oflf,  and  a  complete  loss  of  these 
senses  has  resulted  in  the  corresponding  parts.  This  could 
be  most  easily  accomplished  by  a  central,  isolated  tu- 
])ercle,  as  either  simple  compression  myelitis  or  tubercular 
myelitis  could  do  this  only  with  difficulty  and  with  peculiar 
progress.  Very  possibly,  if  such  is  the  case,  the  motor 
symptoms  may  be  largely  caused  by  compression  from  the 
nerves  and  exudate. 

Such  cases  of  isolated  conglomerate  tubercle  have  been 
described  by  Chvostek,  Gerhardt,  Sachs,  Herter,  Schles- 
inger  and  others,  and  are  well  established  as  occasional. 


DISSOCIATION    OF    SENSATION  263 

though  rare,  occurrences,  and  have  been  diagnosed  during 
life. 

Beyond  the  conditions  mentioned,  the  only  other  pos- 
sibility of  much  interest  in  diagnosis  is  that  of  the  ex- 
istence of  hysteria  with  the  spondylitis,  and  that  the  pe- 
culiar distribution  of  the  sensory  changes  is  explained  by 
coincidence.  As  the  fields  of  vision  are  of  normal  extent 
and  the  color  fields  are  normal,  and  all  other  hysterical 
stigmata,  except  this  peculiar  symptom,  are  absent,  I 
think  the  claim  that  the  sensory  changes  are  hysterical 
would  be,  as  Knapp  says  of  such  cases,  **begging  the  qi;es- 
tion." 

REFERENCES. 

Schlesinger:  Deutsche  Zeitschr.  f.  Nervenheilk.,  vol.  viii. 
Chipault:  Presse  Medicale,  Sept.  23d  and  30th,  1896. 
Brissaud:  **Lec.  sur  les  Mai.  Nerv.,*'  p.  219. 

Kocher:  Mittheilungen  aus  den  Grenzgebieten  der  Medizin  u. 
Chir,  i..  4. 

Starr:  American  Jour,  of  the  Med.  Sciences,  July.  1892.  ' 

Knapp:  Journal  of  Nerv.  and  Mental  Disease,  Sept.,  1897. 

Daxenberger:  Deutsche  Zeitschr.  f.  Nervenheilk..  vol.  iv. 

Bicmacki:  The  same,  vol.  x.,  3  and  4. 

Burgess:     Lancet,  Nov.  13th,  1897,  p.  1,253. 

Chvostek:  Abstracted  by  Schlesinger,  loc.  cit. 

Gerhardt:     Abstracted  by  Schlesinger,  loc.  cit. 

Sachs:     Abstracted  by  Schlesinger,   loc.   cit. 

Herter:     Abstracted  by  Schlesinger,  loc.  cit. 

Gowers:  **  Diseases  of  the  Nervous  System." 

Striimpell:  "Spec.  Path.  u.  Ther." 


^octjetg  "^tpovts. 


NEW  YORK  NEUROLOGICAL  SOCIETY. 

Stated  Meeting,  March  8th,  1898. 

B.  Sachs,  M.  D.,  President. 

Dr.  William  Hirsch  presented  a  baby  of  fifteen  months, 
who  had  been  referred  to  hini  about  one  week  ag-o  be- 
cause of  certain  movements  of  the  head.  The  child  had 
been  perfectly  healthy  up  to  about  two  months  ago,  when 
it  had  fallen  from  a  chair,  and  struck  the  back  of  the  head. 
Vomiting  set  in  immediately  afterward,  and  lasted  for 
about  a  week.  The  mother  then  noticed  the  peculiar 
shaking  of  the  head,  which  has  kept  up  ever  since.  Ex- 
amination of  the  nervous  system  is  absolutely  negative. 
On  examining  the  eyes,  one  observes  that  there  is  a  nearly 
absolute  unilateral  nystagmus.  There  is  a  horizontal  nys- 
tagmus of  the  left  eye,  while  the  right  eye  shows  the  same 
condition,  though  very  much  less  marked.  T^e  speaker 
said  that  it  had  been  claimed  by  some  that  these  move- 
ments in  children  were  brought  about  by  an  effort  at  com- 
pensation for  the  nystagmus.  A  point  in  favor  of  this 
theory  was  that  the  movements  cease  during  sleep. 
Others  had  claimed  that  the  movements  of  the  head  and 
the  nystagmus  had  a  common  cause — e.  g.,  cerebellar 
lesion.  None  of  the  reported  cases  shows  the  difference 
existing  in  the  two  eyes  as  in  this  case. 

Dr.  W.  M.  Leszynsky  said  that  he  had  seen  quite  a  num- 
ber of  these  cases.  A  great  many  of  them  had  been  found  to 
have  ocular  defects.  In  this  case,  the  injury  was  prob^ 
ably  only  a  coincidence.  When  the  child  gets  old 
enough  to  fix  the  eyes  on  objects,  these  movements  are  prone 
to  occur.  Some  years  ago  he  had  seen  such  a  case  at  the 
Manhattan  Eye  and  Ear  Hospital.  It  was  thought  that  the 
child  was  blind  and  had  optic  atrophy.  He  had  kept  the 
child  under  his  observation  for  seven  or  eight  months.  It 
improved   rncier  tonic   treatment,   and   ultimately   recovered 


NEW  YORK  NEUROLOGICAL   SOCIETY.  26^; 

completely.  He  did  not  believe,  therefore,  that  there  was 
any  actual  morbid  change  in  these  cases. 

Dr.  George  W.  Jacoby  said  that  h-e  had  not  found  these 
cases  uncommon,  and  he  believed  that  they  occur  directly 
as  a  consequence  of  traumatism.  There  were  two  distinct 
classes  of  cases,  i.  e.,  those  with  nystagmus,  and  those  without 
it.  In  the  majority  of  cases,  by  excluding  vision,,  it  would  be 
found  that  the  movements  of  the  eye  cease.  In  this  child  there 
seemed  to  him  to  be  some  up  and  down  movement  inter- 
spersed with  the  other  movements.  Some  years  ago  he  had 
seen  an  interesting  medico-legal  case,  occurring  in  an  adult — 
a  man  who  had  been  struck  in  the  eye  by  an  electric  light  wire. 
The  eye  had  been  perforated.  After  losing  the  eyeball  he 
presented  certain  psychic  symptoms,  together  with  some  head 
nodding,  which  he  had  continued  ever  since.  He  was  now 
rather  feeble-minded.  Inasmuch  as  in  this  man  there  was 
nothing  pointing  to  injury  of  any  other  part  of  the  brain  ex- 
cept the  frontal  lobe,  the  question  arose  as  to  whether  there 
was  any  possible  connection  between  the  injury  to  this  lobe 
and  these  movements. 

Dr.  Frederick  Peterson  said  he  believed  Henoch  first  de- 
scribed these  movements,  many  years  ago.  He  had  himself 
described  ten  cases,  some  years  ago,  as  gyrospasms,  repre- 
senting all  the  different  varieties.  -Most  of  the  cases  have  a 
lateral  movement,  but  some  have  the  head  nodding.  Henoch 
thought  the  condition  was  a  reflex  from  dentition,  as  the 
majority  of  the  cases  developed  at  about  the  age  of  eight  or 
ten  months.  The  theory  that  he  had  adopted  was  that  these 
cases  were  almost  always  the  result  of  a  trauma  or  concussion. 
A  point  worthy  of  note  was  that  there  could  not  be  any  marked 
pathological  lesion,  as  all  of  them  recovered.  The  lateral 
movement  of  the  head  and  the  movement  of  the  eyes  seemed 
to  him  to  be  due  to  functional  troubles  in  different  parts  of 
the  brain.  Many  of  these  cases  would  temporarily  stop  the 
movement  if  the  eyes,  were  fixed  on  an  object.  If  the  lateral 
movement  were  due  to  nystagmus,  it  was  curious  that  the 
nystagmus  should  be  present  in  the  head-nodding  move- 
ment. 

Dr.  Mary  Putnam- Jacobi  said  that  many  years  ago  she 
had  seen  a  case  coming  on  spontaneously  in  a  child  of  two 
years.  It  was  peculiar  in  that  a  rotary  movement  came  on 
every  nig-ht  at  bedtime. 

Dr.  Fraenkel  said  that  he  had  recently  seen  a  child  of 
nine  months,  who,  according  to  the  mother,  had  exhibited 
a  rotary  movement  of  the  head  and  a  vertical  nystagmus  since 
it  was  three  months  old.  This  nystagmus  occurred  when  the 
nodding  movements  ceased.  This  would  seem  to  support  the 
view  oit  Dr.  Leszynsky,  that  it  is  dependent  upon  some  re- 
fractive condition  of  the  eye. 


266  NEIV  YORK  NEUROLOGICAL  SOCIETY. 

Dr.  Hirsch  said  that  th<;  objective  examination  by  Dr. 
Koller  showed  the  eyes  to  be  entirely  normal.  All  the  theories 
offered  would  not  hold  good  in  a  case  of  unilateral  nystagmus. 
That  the  condition  in  the  present  instance  was  caused  by  trau- 
matism alone  seemed  almost  certain  from  the  history.  The 
movements  of  the  head  are  entirely  separate  from  those  of 
the  eyeball.  The  fact  that  most  of  the  children  recover  was 
sufficient  to  exclude  an  organic  lesion,  but  a  slight  pachy- 
meningitis in  the  region  of  the  cerebellum  might  recover. 

Dr.  Fraenkel  presented  a  child,  two  and  a  half  years 
old,  born  of  healthy  parents.  The  family  history  is  nega- 
tive. The  child  was  bom  at  full  term,  by  the  breech,  after 
a  rather  difficult  labor.  Immediately  after  its  birth  the  ab- 
normal condition  of  the  lower  extremities  was  noted.  The 
mother  insists  that  the  child  has  improved.  Examination 
shows  a  moderate  lateral  curvature,  and  the  child  is  un- 
able to  sit,  walk  or  stiind.  Electrical  examination  shows 
extensive  degeneration  of  all  the  muscles  except  the 
calves.  The  knee-jerks  are  absent,  but  there  is  an  ankle 
clonus  on  both  sides.  At  first  sight,  the  case  seemed  to 
he  one  of  poliomyelitis,  but  it  was  conceivable  that  the 
condition  was  the  result  of  a  dropsy,  or  of  a  hemorrhage 
from  rupture  of  the  anterior  spinal  artery.  As  this  vessel 
supplies  the  anterior  horn  almost  exclusively,  it  was  pos- 
sible that  a  traumatic  poliomyelitis  had  developed,  ex- 
tending from  the  mid-dorsal  to  about  the  third  lumbar 
segment.  Or,  there  might  be  a  localized  cavity  formation. 
He  would  explain  the  existence  of  the  ankle  clonus  by 
the  theorv  that,  as  the  calf  muscles  were  in  a  state  of  in- 
creased  tonus,  due  to  the  fact  that  the  antagonists  were 
gone,  the  moment  a  sensory  stimulus  was  applied,  and 
entered  the  cord,  the  latter  being  in  a  state  of  increased 
receptivity:  the  evidence  of  its  having  received  this  stimu- 
lus was  shown  by  an  additional  motor  discharge.  The 
spinal  curvature  was  to  be  explained  by  the  unilateral 
involvement  of  the  spinal  muscles.  The  posterior  muscles 
below  the  knee  gave  an  exaggerated  response  with  both 
electric  currents,  while  there  was  no  reaction  in  the 
muscles  above  the  knee. 

Dr.  Peterson  asked  why  this  explanation  of  the  ankle 
clonus  would  not  apply  to  all  other  cases  of  poliomyelitis,  in 
which,  it  was  well  known,  there  was  no  ankle  clonus. 

Dr.  Fraenkel  replied  that  the  presence  or  absence  of  ankle 
clonus  was  dependent  upon  quantitative  changes  in  the  tonus 


NEIV  YORK  NEUROLOGICAL  SOCIETY.  267 

of  the  muscles.  The  increased  tonus  of  the  calf  muscles  only 
he  did  not  think  existed  ordinarily  in  cases  of  poliomyelitis. 

Dr.  Terriberry  said  that  the  marked  extension  of  the  foot 
was  seen  quite  frequently  in  ordinary  poliomyelitis,  owing 
to  one  set  of  muscles  being  left  without  any  antagonizing  ones. 
But  the  other  features  of  this  case  were  certainly  unusual. 

Dr.  Joseph  Collins  accepted  the  pathological  explanation 
given  by  Dr.  Fraenkel.  The  fact  that  ankle  clonus  does  not 
occur  in  ordinary  cases  of  anterior  poliomyelitis  did  not  nega- 
tive the  explanation  given.  The  case  was,  in  reality,  a  unique 
substantiation  of  the  theory  proposed  by  Dr.  Fraenkel  last 
winter,  and  adopted  by  Hughlings  Jackson  in  his  lecture  this 
year.  In  no  case  of  complete  anterior  poliomyelitis  that  he 
l]ad  seen  had  there  been  any  hypertonus  of  the  calf  muscles. 

Dr.  B.  Sachs  thought  there  was  at  least  one  other  view 
that  could  be  put  forward.  He  did  not  think  that  there  was 
this  amount  of  spasticity  in  a  very  large  number  of  cases  of 
ordinary  poliomyelitis.  He  had  not  seen  a  single  instance  of 
ankle  clonus  in  an  ordinary  case  of  poliomyelitis;  the  unusual 
spastic  condition  in  the  present  case  must  be  due  to  some 
special  lesion.  It  was  fair  to  assume  that  in  this  case  there 
was  some  developmental  defect.  The  entire  appearance  of  the 
leg  reminded  him  very  much  of  cases  in  which  children  had 
been  born  with  defective  limbs.  On  the  supposition  that  the 
spinal  cord  was  defective,  chiefly  in  the  gray  matter  in  the 
region  of  the  lumbar  segments  and  in  the  lateral  columns,  one 
could  understand  how  the  knee-jerks  might  be  absent  and 
the  ankle  clonus  present. 

Dr.  Fraenkel  said  that  in  estimating  the  comparative  fre- 
quency of  ankle  clonus  and  of  absence  of  the  knee-jerks  in 
ordinary  cases  of  polomyelitis,  it  should  be  remembered  that 
it  was  exceptional  to  examine  such  cases  on  these  points. 

Dr.  Joseph  Collins  presented  a  boy  of  thirtcjen  years 
with  lateral  curvature  of  the  spine,  atrophy  of  the  muscles 
of  the  right  upper  extremity  and  the  condition  of  the 
face  known  as  the  Schultze  eye.  The  only  history  was 
that  he  had  begun  to  have  diarrhoea  three  or  four  years 
ago.  and  that  this  had  persisted  pretty  constantly  for  a 
year  or  two.  He  looked  upon  the  case  as  one  of  syringo- 
myelia affecting  the  anterior  horns,  and  he  bas.ed  this 
diagnosis  chiefly  on  the  ocular  symptoms  on  one  side,  the 
atrophy  of  the  hand  and  the  spinal  curvature.  The 
atrophy  of  the  hand  had  begun  about  two  years  ago. 

Dr.  G.  W.  Jacoby  said  that  to  base  the  diagnosis  on  these 
three  symptoms  alone  required  considerable  assurance.  In  his 
opinion,such  a  diagnosis  was  not  warranted,  unless  there  were 
marked  sensory  disturbance  Vvith  the  atrophy. 


268  NEW  YORK  NEUROLOGICAL  SOCIETY. 

Dr.  William  Hirsch  said  that  he  had  recently  shown  two 
cases  of  syringomyelia  in  another  society,  which  showed  the 
same  condition  of  the  muscles  and  of  the  eye — ^the  narrowing: 
of  the  fissure  of  the  eyeHd  and  the  contraction  of  one  pupil. 
There  were  also  present  the  typical  sensory  symptoms,  but 
the  atrophy  of  the  ulnar  group  and  the  condition  of  the  eye 
had  led  him  to  believe  that  it  was  a  typical  form  of  syringo- 
myelia located  between  the  last  cervical  and  first  dorsal  seg- 
ment. He  had  also  recently  seen  in  private  practice  a  lady 
with  the  same  condition  of  the  eye,  and  with  a  herpes  zoster 
in  the  trigeminal  region,  and  who  also  showed  instead  of  an 
atrophy  a  tremor  of  the  left  arm  and  a  slight  analgesia.  The 
diagnosis  made  by  Dr.  Collins  seemed  to  him  perfectly  justi- 
fied. The  other  more  characteristic  symptoms  would  probably, 
develop  later. 

Dr.  L.  Stieglitz  agreed  with  the  diagnosis  of  syringo- 
myelia, and  remarked  that  at  the  last  meeting  he  had  pre- 
sented a  counterpart  of  this  case,  in  which  no  sensory  symp- 
toms-were present,  and  also  a  typical  case  of  syringomyelia. 
He  thought  it  was  not  uncommon  to  find  these  cases  without 
sensory  symptoms. 

Dr.  Terriberry  remarked  that  an  injury  of  an  anterior  root 
might  produce  the  atrophy  and  the  ocular  symptoms. 

Dr.  Collins  asked  at  what  level  this  must  be  to  cause  sym- 
pathetic involvement  of  the  right  side  of  the  face  with  de- 
struction of  the  sixth,  seventh  and  eighth  cervical  segments. 

Dr.  Terriberry  replied  that  he  did  not  think  there  was  any 
reason  why  the  cord  need  be  considered  to  be  involved. 

Dr.  Onuf  said  that  in  a  joint  investigation,  made  by  Dr. 
Collins  and  himself,  they  had  found  that  the  zone  situated 
between  the  central  ganglia  on  one  side  and  the  end  of  the 
lateral  horn  on  the  other,  and  between  the  base  of  the  pos- 
terior and  anterior  horns,  was  intimately  connected  with  sym- 
pathetic fCmcticms.  They  had  found  that  atrophy  of  the  cells 
of  the  lateral  horn  took  place  in  a  certain  group  (the  lateral, 
the  central  ganglia,  and  in  the  whole  zone  in  between),  and 
that  this  atrophy  was  partly  in  the  sensory  and  partly  in 
motor  fibres.  The  motor  fibres  originate  from  the  smaller 
cells  of  the  zone  mentioned.  This  being  the  case,  it  was  evi- 
dent that  syringomyelia  could  present  very  different  pictures 
depending  upon  the  particular  locality  aflPected.  In  the  case 
under  discussion  the  sympathetic  symptoms  were  very  marked 
in  connection  with  the  eye,  and  the  diarrhoea  and  the  lateral 
curvature  might  also  be  considered  as  belonging  to  the  same 
class.  In  three  cases  they  had  extirpated  the  stellate  ganglion 
in  cats.  This  was  usually  followed  after  some  weeks  by  a 
diarrhoea,  which  was  most  persistent  and  exhausting.  This 
ganglion  is  supplied  chiefly  by  the  upper  dorsal  nerves. 


NEW  YORK  NEUROLOGICAL  SOCIETY,  269 

Dr.  M.  Allen  Starr  said  that  the  combination  of  the  sym- 
pathetic paralysis  with  ulnar  nerve  paralysis  he  had  known  to 
occur  in  one  case  of  undoubted  gumma  on  the  anterior  sur- 
face of  the  cord.  The  gumma  was  absorbed  after  a  time.  The 
condition  had  been  undoubtedly  produced  by  the  pressure 
on  the  anterior  nerve  roots. 

Dr.  Pearce  Bailey  said,  regarding  the  first  dorsal  root,  and 
its  relation  to  the  sympathetic,  that  over  ten  years  ago 
Klumpke  had  made  her  experiments  on  animals.  She  had 
found  that  the  nutritive  fibres  for  the  eyeball  were  affected  by 
the  injury  of  the  first  dorsal  root,  but  that  there  were  no  ac- 
companying vascular  disturbances.  This  had  been  substan- 
tiated by  other  observers.  The  vascular  supply  of  the  face  goes 
along  the  spinal  canal  externally,  and  is  joined  by  the  first 
dorsal  root  at  its  exit. 

Dr.  Collins  said  that  he  had  been  largely  led  to  make  the 
diagnosis  of  syringomyelia  in  this  case  by  the  experiments 
that  he  had  conducted  in  conjunction  with  Dr.  Onuf.  There 
was  nothing  else  which  would  produce  the  four  prominent 
symptoms,  viz.,  the  diarrhoea,  curvature  of  the  spine,  atrophy 
.  of  the  hand  muscles  and  the  Schultze  eye. 

Dr.  Hirsch  presented  a  young  woman  vvho  was  an 
example  of  total  unilateral  congenital  sweating  of  the 
face.  She  complained  that  half  of  the  face  would  become 
red  and  moist,  while  the  left  half  remained  dry  and  of 
normal  color.  She  never  sweats  on  the  left  side  of  the 
face.  He  had  experimented  with  hypodermic  injections 
of  different  drugs.  Physostigmin  had  had  no  effect  at 
all.  Pilocarpin,  injected  hypodermically,  caused  perspira- 
tion all  over  her  face,  for  the  first  time  in  her  life;  but,  of 
course,  this  was  only  transient.  The  fact  that  in  this  case 
absence  of  perspiration  is  associated  with  absence  of  vaso- 
motor symptoms  seemed  to  be  in  favor  of  the  view  that 
the  vasomotor  centres  and  the  sweat  centres  are  at  least 
intimately  connected.  The  condition  is  confined  to  the 
face. 

Dr.  Starr  remarked  that  a  case  of  this  kind,  occurring  in  a 
man  of  twenty-three  years,  had  been  entirely  cured  in  his 
clinic  by  boring  out  his  turbinated  bones. 

Dr.  Fraenkel  presented  a  young  boy,  who  had  come 
under  his  observation  al)out  three  months  ago  with  a 
diagnosis  of  pulmonary  tuberculosis,  because  of  an  attack 
of  haemoptysis.  He  had  been  well  up  to  two  years  ago; 
then  he  had  begun  to  suffer  from  shortness  of  breath.  On 
admission  to  the  Montefiore  Home  the  head  was  turned 


270  NEW  YORK  NEUROLOGICAL  SOCIETY. 

to  one  side,  there  was  inspiratory  stridor,  a  moderate 
amount  of  exophthalmos,  swelling  of  the  neck  and  tachy- 
cardia. The  physical  examination  of  the  chest  was  prac- 
tically negative.  The  tumefaction  in  the  neck  was  lobu- 
lated,  and  moved  up  and  down  during  deglutition.  Under 
treatment  with  thyroid  extract  he  had  decidedly  im- 
proved subjectively,  and  had  gained  fourteen  pounds  in 
body  weight.  The  tachycardia  had  disappeared.  The 
case  was  interesting  as  showing  the  difference  between 
genuine  Basedow's  disease  and  the  secondary  or  symp- 
tomatic form. 

Dr.  C.  E.  Nammack  asked  if  Hodgkin's  disease  had  been 
excluded. 

Dr.  Fraenkel  replied  that  a  brother  of  this  patient  had 
twice  had  tuberculous  glands  removed,  and  there  had  been 
good  reason  to  believe  that  this  might  be  a  case  of  Hodgkin's 
disease,  but  it  had  been  excluded  (i)  by  the  absence  of  other 
evidence  of  lymphatic  involvement;  (2)  by  its  long  duration; 
(3)  by  examination  of  the  blood,  and  (4)  by  the  mobility  of 
the  swelling  in  the  neck  on  deglutition,  showing  its  connec- 
tion with  the  thyroid  gland. 

Dr.  B.  Sachs  presented  a  man,  fifty-one  years  of  age, 
whom  he  had  first  seen  about  one  week  ago.  He  had 
been  married  twenty-seven  years.  Six  years  ago  his  wife 
had  been  afflicted  with  the  same  affection  as  the  one  he 
now  suffers  from.  The  patient  himself  had  been  in  good 
health  in  former  years,  and  he  still  weighs  230  pounds. 
He  has  been  an  extremely  heavy  drinker,  chiefly  of  beer, 
taking,  at  times,  as  much  as  fifty  or  sixty  glasses  a  day. 
Syphilitic  infection  could  not  be  established.  He  had  been 
in  good  health  up  to  January  12th,  1898,  when,  while  at- 
tending the  funeral  of  a  friend,  he  says  he  saw  a  flash  of 
light,  and  this  was  immediately  followed  by  double  vision 
and  intense  photophobia.  At  first  glance  there  would 
appear  to  be  a  double  ptosis,  but  the  eyelids  can  be  moved 
upward.  Ordinarily  they  droop  in  an  effort  to  protect 
the  eyes.  There  is  slight  nystagmus  and  a  decided  pa- 
resis of  the  left  rectus  externus.  The  pupils  are  irregular; 
they  do  not  react  to  light,  and  but  slightly  to  accommoda- 
tion. The  case  had  been  referred  to  him  by  Dr.  Marple, 
who  had  found  nothing,  on  cvcular  examination,  to  ex- 
plain the  photophobia.  Further  examination  showed  a 
very  widespread  and  marked  hemi-analgesia,  but  no  im- 
pairment of  tactile  sensibility.  He  had  arrived  at  the  con- 
clusion that  there  was  a  large  hysterical  element  in  the 


r 


NEIV  YORK   NEUROLOGICAL   SOCIETY.  271 

case.  The  visual  fields  are  normal;  the  reflexes  are  nor- 
mal, and  there  is  no  evidence  of  loss  of  power  in  the  ex- 
tremities.    His  diagnosis  was  hysterical  ophthalmoplegia. 

Dr.  J.  Arthur  Booth  referred  to  a  girl  of  twenty  years,  who 
had  had  double  ptosis,  but  no  ocular  paresis,  who  had  been 
cured  by  hypnosis. 

Dr.  Fraenkel  said  that  in  a  recent  monograph  hysterical 
ophthalmoplegias  of  this  character  had  been  described.  Aside 
from  the  clinical  development  of  the  case,  its  development 
after  emotional  disturbance  was  particularly  significant.  About 
six  months  ago  a  man,  in  a  very  similar  condition,  had  ap- 
plied for  admission  to  the  Home.  He  presented  ataxia,  loss 
of  knee-jerks,  ptosis  and  ophthalmoplegia.  After  admission 
his  ptosis  and  ophthalmoplegia  disappeared,  and  the  case 
proved  to  be  clearly  one  of  locomotor  ataxia,  the  other  symp- 
toms having  been  hysterical,  and  added  to  the  others  with  a 
view  to  securing  his  admission. 

Dr.  Leszynsky  said  it  was  important  to  distinguish  be- 
tween ptosis  and  blepharospasm.  In  the  case  under  discussion 
there  seemed  to  be  a  certain  amount  of  blepharospasm.  With 
photophobia  tonic  blepharospasm  was  much  more  likely  to 
occur  than  ptosis.  He  had  seen  a  number  of  such  cases  in 
hysterical  individuals,  and  quite  recently  one  in  a  young  girl 
who  responded  promptly  to  hypnosis. 

Dr.  Peterson  referred  to  a  case  of  bilateral  ptosis,  or, 
rather,  of  tonic  blepharospasm,  which  had  presented  very 
much  the  picture  shown  in  this  patient.  A  cure  had  been  ef- 
fected by  two  or  three  appHcations  of  the  faradic  current. 

Dr.  Sachs  said  he  proposed  to  treat  this  case  bv  suggestion. 

Dr.  Sachs  then  presented  another  case  of  ophthalmo- 
plegia, in  a  boy  of  seventeen  years.  In  October,  1894,  at 
9  A.  M.,  he  had  found  himself  unable  to  utter  words. 
This  had  passed  away,  but  had  been  repeated  at  noon  and 
at  4  P.  M.  He  had  then  a  convulsion  lasting  ten  minutes, 
after  which  the  left  eyelid  had  been  noticed  to  droop. 
There  had  been  no  convulsions  since  then.  He  had  been 
perfectly  well  previously.  Examination  showed  ptosis  of 
the  left  eye  and  slight  ptosis  of  the  right  eye.  The  out- 
ward and  inward  movements  were  limited  in  single  and 
conjugate  action;  both  pupils  reacted  well  to  light  and 
accommodation;  the  sensation  of  the  face  was  normal. 
There  had  been  comparatively  little  change  in  the  past 
three  years.  There  is  diplopia,  chiefly  when  looking  to 
the  left.  The  diagnosis  lay  between  thrombosis  or  em- 
bolism in  the  basilar  artery.  The  heart  action  is  irregular 
and  rather  rapid,  but  no  murmur  is  audible.    Six  years  ago 


/ 


272  NEIV  YORK  NEUROLOGICAL   SOCIETY. 

he  was  under  treatment  for  a  time  for  cardiac  palpitation. 
Dr.  Sachs  also  presented  a  man,  thirty-nine  years  of 
age,  who  had  been  admitted  to  the  Montefiore  Home 
some  time  ago.  There  was  no  evidence  of  syphilis.  At 
the  age  of  twenty  he  was  weak  in  the  knees  and  frequently 
made  missteps.  In  1887  he  had  sought  medical  advice 
because  of  difficulty  of  locomotion,  noticed  especially  in 
cHmbing  stairs.  When  examined  in  March,  1895,  ^^  com- 
plained chiefly  of  difficulty  in  walking,  weakness  in  the 
extremities  and  sHght  difficulty  in  speech.  At  first  the 
case  was  supposed  to  be  one  of  locomotor  ataxia.  He  now 
has  an  ataxic  spastic  gait,  and  also  has  static  ataxia;  the 
pupils  react  to  light  and  during  accommodation;  the  pa- 
tellar reflexes  are  absent.  There  is  no  Argyll-Robertson 
pupil.  There  is  distinct  ataxia  of  the  right  upper  extremity. 
He  has  a  form  of  speech  which  is  midway  between  a  slow 
speech  and  a  bulbar  speech.  The  diagnosis  lies  between 
a  bulbar  form  of  multiple  sclerosis  and  the  possibility  of 
Friedreich's  ataxia  instead  of  an  ordinary  tabes.  The  great 
point  against  Friedreich's  ataxia  was  its  occurrence 
rather  late  in  life;  while  the  absence  of  the  knee-jerks  mili- 
tated against  multiple  sclerosis.  There  was  no  disturbance 
of  sensation.    The  jaw-jerk  is  absent. 

Dr.  Fraenkel  said  that,  although  the  lack  of  co-ordination 
was  first  noticed  at  the  age  of  nineteen,  when  his  attention 
was  naturally  directed  to  it  by  entering  the  army,  it  was  not 
improbable  that  it  had  been  present  long  before.  There  was 
also  slight  atrophy  of  the  optic  nerves.  The  absence  of  sexual 
and  sphincteric  disturbance  and  the  peculiar  thick  and  scan- 
ning speech  seemed  to  point  rather  to  the  diagnosis  of  mul- 
tiple sclerosis. 

Dr.  Collins  said  that  when  he  had  first  seen  the  man,  three 
years  ago,  the  intention  tremor  and  the  optic  atrophy  had 
not  been  present,  and  it  was  then  thought  that  the  man  had 
Friedreich's  disease.  In  the  last  two  years  the  speech  had  be- 
come very  much  more  bulbar  in  quality.  He  was  inclined  to 
believe  that  there  was  a  diffuse  insular  sclerosis,  bulbar  and 
spinal. 

Dr.  Hirsch  said  that  even  at  the  present  time  there  was 
not  a  perfect  agreement  as  to  what  constitutes  the  pathological 
basis  of  Friedreich's  disease.  The  case  seemed  to  him  like 
the  cerebellar  form  of  Friedreich's  disease. 

Dr.  Sachs  said  that  the  term  ** Friedreich's  disease"  is  at  the 
present  time  applied  usually  to  the  ordinary  hereditary  ataxia, 
the  disease  being  located  partly  in  the  posterior,  and  partly  in 
the  lateral  columns  of  the  cord. 


t 


PHILADELPHIA    NEUROLOGICAL    SOCIETY. 

January  24th.  1898. 
The  President.  Dr.  Charles  W.  Burr,  m  the  chair. 
Dr.  F.  X.  Dercum  exhibited 

A  CASE  OF  HEMIALGIA. 

The  patient  was  a  well-developed  man  of  thirty-seven 
years,  a  native  of  Poland  and  a  laborer  by  occupation. 
He  had  been  in  this  country  seven  years,  and  had  al- 
ways worked  in  iron  works.  During  this  period  he  had 
been  exposed  to  very  high  temperatures.  His  family  his- 
tory was  negative.  He  had  had  none  of  the  diseases  of 
childhood,  and  had  always  been  in  good  health  until  a 
little  more  than  a  year  ago,  when  the  present  trouble  be- 
gan. He  denied  venereal  disease  and  alcoholism.  He 
first  noticed  pain  in  his  right  knee,  which,  after  six  months, 
l)ecame  so  severe  that  he  was  obliged  to  give  up  work. 
Shortly  afterward  the  whole  of  the  right  thigh  began  to 
ache,  and  later  on  this  aching  involved  the  right  half  of 
the  trunk,  especially  the  chest,  the  right  upper  limb,  and 
the  right  side  of  the  face.  The  knee  presented  no  objec- 
tive features  worthy  of  note.  The  physical  examination 
of  the  chest  revealed  nothing  abnormal.  The  knee-jerks 
on  both  sides  were  much  exaggerated.  The  right  pupil 
was  slightly  larger  than  the  left,  but  the  eyes  reacted  nor- 
mally to  light.  Later  it  was  noted  that  the  patient  had 
less  muscular  force  in  the  arm  and  leg  of  the  right  side 
than  in  those  of  the  left. 

Dr.  Tyson,  who  had  had  charge  of  the  patient,  being 
unable  to  arrive  at  a  definite  conclusion  with  regard  to 
the  case,  termed  it  one  of  hemialgia,  the  pain  being  the 
most  conspicuous  symptom  presented. 

After  the  patient  had  been  in  the  hospital  five  months, 
he  was  transferred  to  the  service  of  Dr.  Dercum.  Ex- 
amination now  showed  that  Romberg's  sign  was  absent. 
The  man  stood  readily  upon  the  left  leg  alone,  but  was 


274  PHILADELPHIA  NEUROLOGICAL  SOCIETY. 

unable  to  stand  alone  upon  the  right.  The  gait  revealed 
decided  weakness  of  the  right  leg.  which  was  especially 
marked  when  the  patient  was  asked  to  walk  backward. 
Both  knee-jerks  were  exaggerated,  but  especially  the 
right,  and  a  distinct  ankle  clonus  was  also  elicited  upon 
the  right  side.  There  was  no  ataxia  of  the  legs  or  hands. 
There  was  no  loss  of  the  tactile  sense  or  the  thermal  sense, 
and  no  analgesia.  Fibrillary  tremors  were  noticed  in  the 
quadriceps  extensor  muscles  of  both  sides,  and  in  the 
gastrocnemius  of  the  right  leg  only,  but  they  were  not 
present  in  the  arms.  There  were  also  signs  of  marked 
vasomotor  relaxation.  The  thighs,  legs  and  feet  of  the 
patient  were  mottled  and  livid,  and  pin  pricks  produced 
bright  pinkish  areas.  The  arms  showed,  to  a  slight  degree, 
the  mottled  and  flushed  condition  seen  in  the  legs.  This 
was  slightly  more  pronounced  in  the  right  arm,  and  rather 
more  noticeable  in  the  forearms  and  hands.  The  muscles 
and  tendon  reflexes  in  the  arms  were  also  exaggerated 
upon  the  right  side. 

The  trunk  anteriorly  and  posteriorly  presented  a  similar 
condition  of  vasomotor  relaxation.  Marked  tache  cere- 
brale  was  also  noted  in  the  back.  The  patient  wore  a 
flannel  binder  and  gave  as  a  reason  the  pain  and  stiffness 
in  the  back.  Girdle  pains  were  absent.  Exaggerated 
irritability  was  also  observed  in  both  pectoral  muscles, 
and  in  both  scapular  groups.  The  tongue  was  protruded 
in  the  median  line  but  with  slight  tremor.  There  was 
slight  tremor  of  the  lips  upon  pouting.  At  this  examina- 
tion the  pupils  were  equal  and  responsive  to  tight.  An 
ophthalmic  examination  by  Dr.  de  Schweinitz  was  nega- 
tive.   The  skin  reflexes  revealed  no  change. 

At  present,  Jan.  24th.  1898,  the  patient  still  complains 
of  severe  pains  in  the  entire  right  half  of  the  body,  but 
the  signs  of  motor  weakness,  quite  distinct  and  notable 
some  months  ago,  have  now  almost  entirely  disappeared. 
Peripheral  causes  of  pain  can  readily  be  excluded.  No 
pain  is  caused  by  pressure  on  the  nerve  trunks  or  by  move- 
ment. There  are  no  signs  of  hysteria.  The  symptoms  sug- 
gest an  organic  hemiplegia  with  a  lesion  in  such  a  situation 
as  to  give  rise  to  the  symptom  of  pain.  Dr.  Dercum  stated 
that  his  case  was  unique  in  his  experience,  because  the 
hemiplegia  was  relatively  slight  while  the  pain  was  ex- 
cessive. He  thought  it  harclly  safe  to  speculate  regard- 
ing the  nature  of  the  le.sion.     Headache  and  other  symp- 


FHILADELPHIA  NEUROLOGICAL  SOCIETY.  275 

toms  of  brain  tumor  were  absent,  and  for  the  present  he 
could  but  coincide  with  Dr.  Tyson  in  terming  this  case, 
in  accordance  with  the  principal  symptom  present,  one 
of  liemialgia. 

Dr.  Charles  K.  Mills  said  that  this  case  was  interesting  in 
connection  with  the  recorded  cases  of  pain  associated  with 
hemiplegia,  which,  as  is  well  known,  are  of  at  least  two  classes. 
In  one  set  of  cases  the  pain  is  undoubtedly  due  to  f>eripheral 
conditions  like  neuritis.  Again,  as  has  been  recorded  by  Weir 
Mitchell  and  others,  we  have  cases  in  which,  preceding,  ac- 
companying or  following  the  hemiplegic  attack,  pain  on  the 
paralyzed  side  is  a  marked  feature.  He  had  seen  a  few  cases 
of  this  description  in  which  there  were  no  evidences  of  local 
conditions  to  account  for  the  pain.  He  referred  to  a  case  re- 
ported by  Edinger,  in  which  pain  was  found  to  have  been  due 
to  a  cerebral  lesion,  and  he  thought  that  Dr.  Dercum*s  case 
might  be  one  in  which  the  hemialgia  was  caused  by  an  irrita- 
tive lesion  in  some  portion  of  the  cerebrum,  possibly  in  the 
cerebral  sensory  pathway,  or  in  the  thalamus. 

Dr.  A.  A.  Eshner  spoke  of  the  possibility  of  there  having 
been  some  acute  infective  or  inflammatory  process  at  the  be- 
ginning of  the  trouble.  The  distribution  of  the  symptoms,  the 
presence  of  pain,  the  primary  loss  of  motility,  and  the  increase 
of  the  knee-jerk,  suggested  cerebro-spinal  meningitis  to  him. 
He  acknowledged  that  this  diagnosis  might  seem  far-fetched, 
but  it  would  explain  the  symptoms,  as  well  as  any  other,  and 
would  not  be  in  discord  with  the  ocular  manifestations. 


Dr.  Wm.  Pepper,  Jr.,  presented  for  Dr.  Mills 

THE  BRAIN  FROM  A  CASE  OF  BILATERAL  SYMMETRIC/L 
SOFTENING   OF   THE   INTERNAL   CAPSULE, 

AND 

THE  BRAIN  FROM  A  CASE  OF  CEREBELLAR  TUMOR. 

The  first  patient  had  had  bilateral  hemiplegia,  and  the 
second  had  complained  of  occipital  headache,  staggering 
gait  and  stupor.  At  the  necropsy  of  the  second  case  several 
masses,  probably  tubercles,  were  found  in  the  right  lobe 
of  the  cerebellum. 

Dr.  Charles  K.  Mills  said  that  instances  of  bilateral  soften- 
ing are  rare.  There  were  three  apoplectic  attacks  in  this  first 
case:  one  seven  or  eight  years  ago,  a  second  two  or  three  years 
later,  and  a  third  ten  or  twelve  days  ago. 


276  PHILADELPHIA  NEUROLOGICAL  SOCIETY. 

,riie  second  patient  was  supposed  to  have  been  syphilitic, 
and  probably  the  diagnosis  was  correct,  but  he  was  also  the 
victim  of  wide-spread  tuberculosis.  He  had  been  salivated 
without  the  slightest  improvement.  Dr.  Mills  spoke  of  the 
importance  of  bearing  in  mind  the  possibility  of  tuberctilosis 
in  cases  of  this  kind. 


Dr.  Wm.  Pepper,  Jr.,  exhibited  for  Dr.  Dercum 

THE  BRAIN  FROM  A  CASE  OF  CEREBRAL  ABSCESS. 

Convulsions,  progressive  weakness  of  the  right  side 
of  the  body,  stupor,  some  hyperpyrexia,  though  usually 
a  normal  temperature,  and  negative  ophthalmoscopical 
findings,  had  been  noted  in  this  case.  Two  communicating 
abscesses  were  found  in  the  upper  part  of  the  left  parietal 
lobe  at  the  necropsy. 

Dr.  Dercum  said  that  abscesses,  especially  large  ones,  are 
infrequent  in  this  situation,  and  that  when  they  do  occur  they 
are  generally  multiple.  In  his  case  there  was  one  large  ab- 
scess, together  with  another  smaller  one.  Had  abscess  in  this 
case  been  diagnosticated,  it  is  probable  that  the  larger  one 
could  have  been  successfully  treated  by  surgical  means;  but 
even  then  it  is  extremely  probable  that  the  smaller  one  would 
not  have  been  found.  He  had  been  led  astray  by  the  history 
of  specific  infection.  The  rise  of  temperature  was  regarded 
as  due  to  purulent  cystitis  and  pyelitis.  The  subnormal  tem- 
perature, so  frequently  present  in  abscess  of  the  brain,  was 
not  present  here.  Just  what  the  source  of  infection  was,  it  is 
diffiiTiilt  to  say.  There  was  no  lesion  in  the  lungs  or  pleural 
cavity:  no  endocarditis,  and  there  were  none  of  the  ordinary 
sources  of  ififection  which  give  rise  to  cerebral  abscess.  We 
must  remember,  however,  that  not  infrequently  cerebral  ab- 
scess follows  a  wound  of  the  external  tegument,  and  may  not 
produce  svniptoms  until  long  after  the  wound  has  healed 
and  been  forgotten.  This  woman  had  been  operated  upon  for 
pelvic  disease,  which  was  probably  some  purulent  affection. 

Dr.  Dercum  recalled  the  case  of  a  young  man  who  was 
admitted  to  the  University  Hospital  with  a  stab  wound  of  the 
left  side.  The  wound  healed,  and  months  afterward  the  tnan 
was  readmitted  to  the  hospital,  presenting  symptoms  of  or- 
ganic cerebral  disease.  Tn  this  instance,  as  in  the  previous 
ono.  cerebral  syphilis  was  diagnosticated,  the  diagnosis  being 
based  largely  upon  the  obscure  character  of  the  symptoms 
and  the  history  of  the  specific  infection.     At  the  autopsy  a 


PHILADELPHIA  NEUROLOGICAL  SOCIETY.  277 

large  abscess,  involving  one  hemisphere,  was  discovered.  No 
source  of  infection  could  be  detected,  but  Dr.  Dercum  could 
not  ddssociate  the  stab  wound  of  the  side  and  the  affection 
from  which  the  man  died. 

Dr.  Spiller  said  that  the  temporal  lobe  is  the  most  common 
location  of  cerebral  abscess,  and  that  Korner,  in  a  critical 
digest  on  the  recent  literature  of  this  subject,  had  stated  that 
Oppenheim,  Pick  and  Manasse  had  observed  optic  aphasia 
in  abscess  of  this  portion  of  the  bfain.  It  seems  to  be  caused 
by  the  location  of  the  abscess  in  the  posterior  part  of  the 
second  and  third  temporal  gyri. 

Oppenheim,  in  his  Lehrbuch,  says  that  pure  cases  of  optic 
aphasia  have  not  been  studied  post-mortem,  but  they  seem 
to  be  due  to  lesions  at  the  junction  of  the  left  occipital  lobe 
with  the  temporal,  when  they  are  sufficiently  extensive  to  in- 
terrupt the  fibres  passing  from  both  occipitsd  lobes  to  the  left 
first  temporal  convolution.  Oppenheim  observed  three  cases 
of  optic  aphasia.  In  the  first,  an  instrument  penetrated  the 
skull  during  an  operation  on  the  ear,  and  probably  injured  the 
anterior  part  of  the  occipital  lobe.  The  optic  aphasia  was  only 
transitory.  In  the  second  case,  optic  aphasia,  with  right  hemi- 
anopsia, was  the  first  sig^  of  a  tumor  in  the  left  parietal  lobe, 
which  almost  entirely  separated  the  temporal  from  the  occipital 
lobe.  In  the  third  case,  a  tumor  was  situated  in  the  basal  part 
of  the  occipito-temporai  convolutions. 

Dr.  Spiller  said  that  the  case  reported  some  time  ago  by 
Dr.  Mills  and  Dr.  McConnell,  as  a  proof  of  the  existence  of  a 
"naming  centre,"  was  one  of  optic  aphasia  associated  with 
tactile  aphasia,  and  that  in  this  the  lesion — a  tumor — -Had  also 
been  found  in  the  lower  posterior  part  of  the  left  temporal 
lobe.  We  have,  therefore,  considerable  evidence  regarding 
the  location  of  a  lesion  producing  optic  aphasia. 


Dr.  J.  W.  McConnell  reported 

A    CASE    OF   NEURITIS    OF   THE    FIFTH    NERVE    WITH 

HERPES  AND  ECZEMA. 

The  patient  was  a  white  female,  aged  about  sixty  years. 
married,  a  native  of  America,  and  had  always  been  in  good 
health  until  the  present  illness.  A  shampooing  of  the  scalp 
and  exposure  to  night  air  were  followed  by  pain  in  the 
distribution  of  the  first  division  of  the  left  fifth  nerve, 
and  later  by  a  herpetic  eruption  over  the  area  of  the  pain. 
There  was  no  pain  elsewhere  in  the  body,  except  in  the 
preauricular  and  cervical  glands  of  the  left  side,  which 


278  PHILADELPHIA  NEUROLOGICAL  SOCIETY. 

were  enlarged  and  tender.  A  few  days  later  an  eruption 
of  fine  vesicles  appeared  over  the  skin  of  the  affected  area, 
which  was  previously  healthy.  These  were  moist,  inclined 
to  crust,  and  attended  with  burning  and  itching.  Anaes- 
thesia of  the  diseased  locality  was  found,  but  there  was  no 
motor  paralysis.  The  patient  at  this  time  complained  of 
general  pains,  and  a  slight  rise  in  temperature  was  de- 
monstrable. The  acute  symptoms  lasted  three  weeks, 
leaving,  on  their  disappearance,  discoloration  of  the  skin, 
anesthesia,  dull  pain  and  soreness;  the  latter  continuing^ 
for  nearly  a  year. 

Several  interesting  features  were  presented  by  the  case. 
Tlie  patient  bad  years  before  suffered  an  attack  of  "shin- 
gles," recovery  from  which,  however,  was  good.  The 
writer  could  not  find  any  account  of  an  eruption  of  eczema 
occurring  simultaneously  with  an  attack  of  herpes.  He 
considered  the  limitation  of  the  eczematous  eruption  to 
the  distribution  of  one  nerve  a  rather  unusual  circum- 
stance. The  occurrence  of  adenopathies,  either  local  or 
general,  he  argued,  might  support,  in  a  degree,  the  theory 
of  the  infectious  nature  or  origin  of  herpes;  and,  in  view 
of  the  prevalence  of  influenza  at  the  time  of  the  patient's 
illness,  and  the  fact  that  she  presented  some  symptoms 
of  that  disease,  he  was  led  to  believe  that  the  skin  con- 
ditions were  dependent  upon  a  neuritis,  which  probably 
liad  as  its  exciting  cause  an  attack  of  influenza. 


Dr.  J.  H.  \\'.  Rhein  reported 

A    CASE   OF    UNILATERAL   SWEATING    AND    FLUSHING 
OF  THE  FACE. 

The  patient  had  periodic  attacks  of  pain  in  the  right 
arm  and  hand,  with  perspiration  and  flushing  of  the  right 
side  of  the  face. 


Dr.  Charles  \V,  Burr  reported 

A  CASE  OF  DISTURBANCE  OF  GAIT  DUE  TO  A  DELUSION. 

This  man  would  take  a  few  short  steps  and  be  un- 
able to  advance  further  until  nfter  waiting  a  minute  or  two. 


PHILADELPHIA  NEUROLOGICAL  SOCIETY.  279 

or  after  some  words  of  encouragement,  he  was  able  to 
make  another  attempt.  He  said  that  he  feared  that  there 
might  be  an  opening  in  the  floor  into  which  he  would  fall. 
Dr.  Burr  thought  that  the  abasia  was  due  to  the  man's 
mental  condition. 


Dr.  Burr  also  presented 

A  CASE  OF  ASTASIA-ABASIA. 

This  woman  was  able  to  walk  when  in  the  open  air, 
but  could  not  do  so  when  she  was  within  the  house.  He 
regarded  the  case  as  one  of  hysteria. 

Dr.  Dercum  said  he  had  repeatedly  examined  the  first  case 

described  by  Dr.  Burr.    He  believed  it  to  be  due  to  a  mental 

*    condition.    The  man  seemed  to  be  very  much  afraid.     When 

urged,  he  would  walk  a  short  distance,  stop,  and  then  tremble 

with  fear.    The  gait  he  presented  suggested  similar  gaits  which 

we  sometimes  observe  in  the  wards  of  insane  asylums. 

Dr.  A.  F.  Packard  and  Dr.  Alfred  Hand,  Jr.,  showed 

A    SPECIMEN   OF   MULTIPLE   TUMORS   OF  THE   BRAIN 

/"roiii  a  mulatto  child,  aged  three  and  a  half  years,  who 

hsid    died  of  tuberculous  peritonitis.     During  life  there 

ivas  absolute  paralysis  with  rigid  contracture  of  the  left  arm 

a,ncl  leg.    The  palsy  and  contracture  followed  immediately 

aft  ^ra  severe  convulsion,  which  had  involved  the  left  face, 

a-rrn  and  leg,  two  and  a  half  months  before  the  death  of 

tH^    child;  no  change  was  ever  detected  in  the  eye-grounds. 

-At  the  autopsy,  in  addition  to  the  tuberculous  peri- 

t<^i"iitis, three  brain  tumors  were  found;  one  in  the  posterior 

P^-i^ietal  region  of  the  right  cerebellum,  a  second  in  the 

^Q»"^esponding  portion  of  the  left  cerebellum,  and  a  third 

1^^    t:he  basal  ganglia  of  the  right  side  of  the  brain,  which 

^*  l>sd  replaced  or  destroyed. 

Dr.  Alfred  Hand,  Jr.,  said  that  the  intense  round-cell  in- 

*^^tT-ation  suggested  either  gumma  or  tubercle.     The  absence 

^^  tlie  tubercle  bacilli  would  be  merely  negative  evidence.  The 

^^sence  of  endarteritis  would  point  more  toward  the  exclusion 

^^    gumma  than  the  absence  of  tubercle  bacilli  would  to  the 

^^clusion  of  tuberculosis. 


28o  PHILADELPHIA  NEUROLOGICAL  SOCIETY. 

He  had  been  asked  as  to  fiie  method  of  preservation  of  the 
specimens,  and  stated  that  it  was  the  one  elaborated  by  Kaiser- 
ling,  for  which  three  solutions  are  necessary. 

Solution  No.  i  consists  of  formalin  250  parts,  potassium 
acetate  30  parts,  potassium  nitrate  10  parts,  water  1,000  parts. 

Solution  No.  2  is  alcohol,  85  per  cent. 

Solution  No.  3  is  made  of  potassium  acetate  lOO  parts, 
glycerine  200  parts,  water  1,000  parts. 

The  specimen  is  left  in  No.  i  for  from  one  to  five  days;  in 
No.  2  until  the  color  returns,  in  from  one  to  six  hours,  and 
then  preserved  finally  in  No.  3. 

Dr.  Spiller  spoke  of  the  great  value  of  formalin  in  the 
preservation  of  nervous  tissue.  Muller's  fluid  is  not  thcwough- 
ly  reliable,  especially  in  warm  weather,  and  when  the  brain 
is  not  cut  into  pieces;  it  also  stains  the  tissues,  and  renders 
gross  lesions  much  less  distinct;  it  prevents  the  employment 
of  Nissl's  stain,  which  often  is  a  most  serious  objection.  For- 
malin (ten  parts  to  ninety  parts  water),  on  the  other  hand,  har- 
dens much  more  quickly,  preserves  the  tissues  better,  does 
not  stain  the  material,  and,  most  important  of  all,  permits  the 
use  of  Nissl's  method.  If  the  sections  are  placed  for  twenty- 
four  to  forty-eight  hours  in  Muller's  fluid,  they  may  be  stained 
as  well  by  Weigert's  hsematoxylin  method  as  if  they  had  been 
originally  hardened  in  the  bichromate  solution.  Every  student 
of  the  pathology  of  the  nervous  system  knows  the  great  need 
o*  staining  sections  from  the  same  region,  so  as  to  show  the 
cells  as  well  as  the  fibres. 


Dr.  Joseph  Sailer  reported 

A  CASE  OF  SECONDARY  SUPPURATION  IN  THE  SELLA 
TURCICA    IN  TYPHOID    FEVER. 

Exophthalmos,  among  other  symptoms,  4iad  been 
noted.  At  the  necropsy  purulent  phlebitis  of  the  right 
Sylvian  vein,  of  both  cavernous  sinuses,  and  of  the  left 
anterior  cerebellar  vein,  as  well  as  suppuration  within  the 
sella  turcica  and  retrobulbar  abscesses,  were  found. 


"^cxiscopz. 


With  the  Assistance  of  the  Following  Collaborators: 

ChasXewis  ALLEN,M.D.,Wash.,D.C.R.  K.  Macalester,  M,D.,  N.Y. 
J.  S.  Christison,  M.D.,  Chicago,  111.  J.  K.  Mitchell.  M.D.,  Phila.,  Pa 
A.  Freeman,  M.D.,  New  York.  H.  Patrick,  M.D.,  Chicago,  HI. 

S.  E.  Jelliffe,  M.D.,  New  York.  Joseph  Sailer,  M.D.,  Phila.,  Pa. 
Wm.C.Krauss,M.D.,  Buffalo,  N.Y.  Henry  L.  Shively,  M.D.,  N.  Y. 
W.  M.  Leszvnsky,  M.D.,  New  York,  A.  Sterne,  M.D.,  Indianapolis. 


ANATOMY. 

78.  EiNE  GoldfXrbung  des  Nervenmarkes  (Staining  the  Axis 
Cylinders  of  Nerves  by  Gold).  M.  v.  Frey  (Archiv  f.  Anatomic 
u,  Entwicklungsgeschichte,  1897,  Supplementband,  Dec,  p.   108). 

The  author  describes  a  method  which  has  proven  of  service  to  him 
in  the  tracing  of  nerve  fibres  in  the  skin,  mucous  membrane  and  vis- 
cera. 

Small  pieces  of  tissue  are  allowed  to  lie  for  two  weeks  in  a  2  per 
cent,  aqueous  solution  of  ammonium  bichromate,  at  a  temperature 
of  from  I — 5  deg.  C.  They  are  then  carefully  washed  in  running 
water  for  ten  or  fifteen  minutes  and  placed  in  a  i  per  cent,  solution 
of  chloride  of  gold  to  which  i  per  cent,  hydrochloric  acid  has  been 
added.  The  length  of  time  required  in  this  solution  is  determined  in 
large  part  by  individual  experiment.  The  specimens  are  then  washed 
slightly  and  the  reduction  of  the  gold  effected  by  a  one-fiftieth  per  cent, 
aqueous  solution  of  chromic  acid.  Specimens  can  be  cut  after  twenty- 
four  hours  of  reduction.  The  superfluous  gold  may  be  removed  by 
sodium  hyposulphite  solution. 

The  nerve  fibres  are  stained  a  bluish  green  to  a  bluish  black  if 
properly  impregnated.  Jelliffe. 

79.  Zur  Kenntniss  der  peripheren  Gehorleitxjng  (On  the  Peri- 
pheral Acoustic  Conducting  Paths).  H.  Held  (Archiv  f.  Anatomic 
u.  Entwicklungsgeschichte,  10,  1897,  p.  350). 

The  author  holds  that  the  fibres  of  the  ring  plexus  of  the  spiral 
ganglia  are  collaterals  of  the  peripheral  branches  of  the  cochlearis 
cells;  they  end  in  the  hair  cells  of  Corti's  organ,  and  again  j?ive  off 
from  each,  collaterals  which  run  forward  to  other  hair  cells.  Thus  hair 
cells  from  different  parts  of  Corti's  organ  are  brought  into  communi- 
cation with  one  ganglion  cell. 

80.  Die  Nervenendiouncen  an  den  Tasthaaren  von  Saugk- 
Thieren  (The  Nerve  Endings  of  the  Tactile  Hairs  in  Mammals). 
E.  Botezat  (Archiv  f.  mik.  Anat.,  50,  1897,  p.  142). 

The  nervous  fibres  going  to  the  taste  follicles  are  described  by 
the  author  as  being  disposed  in  two  sets — a  deep  and  a  superficial. 
The  first  forms  a  complicated  plexus,  by  frequent  and  irregular  ana*?- 
tomoses,  of  varicose  fibres  pursuing  an  undulating  path  and  surround- 


282  PERISCOPE. 

itig  the  base  of  the  root  sheath,  and  the  basal  thickening  of  the  pa- 
pillae. The  superficial  layer  consists  of  ascending  longitudinal  fibres, 
which  cover  the  preceding.  The  fine  axis  cylinders  which  come 
from  these  two  series  of  fibres  traverse  the  vitreous  membrane,  and 
form  thick  plaques  about  the  tactile  cells  of  Merkel,  These  plaques 
are  somewhat  meniscus  shaped;  they  are  not  the  true  nerve  termina- 
tions, however:  these  are  found  as  very  minute  and  delicate  axis  cyl- 
inder prolongations,  which  end  between  the  cells.  Vocel. 

Si.    Observations    on    Sknsorv    Nerve-endings   in    Voluntary 

Muscles.    A.  Ruffini  (Brain.  20,  1897,  p.  368). 

A  series  of  notes  is  here  presented  dealing  with  muscle  spindles, 
tendon  organs  and  Pacinian  corpuscles  found  in  muscles.  The  general 
conclusions  to   be  derived  from  the  author's  paper  are: 

1.  There  are  in  the  voluntary  muscles  nerve  fibres  of  three  kinds — 
motor,   sensory   and   vasomotor, 

2.  The  motor  nerve  fibres  end,  as  is  well  known,  in  the  end  plates 
of  Rouget  and  Kiihne. 

3.  The  sensorial  nerve  fibres  possess  three  quite  distinct  end 
organs  in  man  and  in  all  the  higher  vertebrata.  These  sensorial  end 
organs  of  muscle  are;  (a)  The  muscle  spindles,  (b)  the  tendon  or- 
gans (or  Golgi  organs)  and  (c)  Pacinian  corpuscles. 

4.  The  vaso-motorial  nerve  fibres  form  reticular  plexuses  or  true 
terminal  plates  (Mazzoni),  or  terminate  simply  on  the  capillary  walls 
with  a  fine  apical  enlargement  (Ruflini). 

5.  The  functions  of  the  motor  plates  and  vaso-motorial  endings 
has  been  known  for  years.  Further,  physiological  experimentaiion  is 
now  wanted  to  investigate  the  functional  activities  of  the  three  sensor- 
ial organs,  the  spindles,  the  tendon  organs,  and  the  Pacinian  corpus- 
cles. In  the  author's  opinion  it  is  to  these  three  kinds  of  sense 
organs  that  physiology  must  turn  its  attention  if  it  will  resolve  the  prob- 
lem of  the  muscular  sense.  Jelliffk. 

PATHOLOGY. 

8i.    The  Muscix  Spindle  i;nder  Pathological  Conditions.    Fred 

E.  Batten  (Brain,  zo,  1897,  p.  138). 

The  author  treats  of  the  following  subjects  in  this  paper;  The  his- 
tory of  the  researches  made  upon  the  muscle  spindle,  the  various  views 
held  with  regard  to  its  origin  and  function,  the  technical  methods  em- 
ployed in  the  research,  the  histology  of  the  spindle  as  found  in  man. 
and  its  modifications  in  the  following  diseases:  Infantile  paralysis, 
tabes,  myopathy,  progressive  muscular  atrojihy,  peripheral  neuritis, 
trauma  of  brachial  plexus  and  following  sciatic  nerve  section. 

In  these  various  diseases,  serialim.  the  author  states; 

In  infanlile  paralysis  it  would  seem  probable  that  the  muscle  spin- 
dle remains  absolutely  intact,  both  in  regard  to  the  intra-fusal  muscle 
fibres  and  in  regard  to  the  contained  nerves. 

In  tabes,  in  two  cases  of  three  examined,  the  spindles  were  normal: 
in  a  third  there  was  a  mild  grade  of  degeneration. 

In  myopathy  (Leyden  form)  the  spindles  seemed  increased  in 
number,  but  there  were  no  traces  of  deceneration.  or  other  change. 

In  progressive  muscular  atrophy  the  author's  observations  are  in 
accord  with  those  of  other  writers  who  find  no  changes  in  the  muscle 

In  peripheral  neuritis,  in  one  case  only  examined,  there  were  no 
changes  in  the  muscle  spindles. 

'  try  to  the  brachial  plexus,  with  loss  of  motion  and  sensation 
:  standing  there  was  an  atrophy  of  the  muscle  spindle. 


"el'J's"' 


PERISCOPE.  283 

In  experimental  sciatic  sections  in  cats  atrophy  of  the  spindles  was 
found. 

The   paper    is    richly    illustrated    and  a    careful    bibliography  is 

appended.                                                    ^  Jelliffe. 

83.     LE  PH^NOMENE  DE  CHROMATOLYSE.  CONSECUTIF  a  hA   I^ESION   PA- 

THOW)GiQUE  ou  experimentale  DE  i^'axone  (The  Phenomena  of 
Chromatolysis,  etc.)  M.  Van  Gehuchten  (Bulletin  de  I'Academie 
Royale  de  Medicine  de  Belgique  11,  1897,  p.  805). 

The  phenomena  of  chromatolysis,  or  the  changes  taking  place  in 
the  ganglion  cells  following  pathological  or  experimental  lesions  of  the 
axon,  disappearance  of  the  chromophilic  granules,  swelling  of  the  cell 
body,  displacement  of  the  nucleus,  etc.,  have  occupied  such  a  promi- 
nent place  in  the  pathological  field  within  the  past  few  years,  that  the 
conclusions  of  Van  Gehuchten  upon  these  changes  are  of  especial  in- 
terest.    These  are  as  follows: 

1.  All  pathological  and  experimental  lesions  of  the  axis  cylinder 
of  a  motor  neuron  result  in  the  process  of  chromatolysis  in  the  orig- 
inating cell  body  of  this  neuron,  the  duration  and  intensity  of  which 
being  in  direct  proportion  to  the  duration  and  intensity  of  the  lesion. 

2.  Lesion  of  a  peripheral  nerve  is  not  the  only  cause  capable  of 
producing  chromatolysis.  Such  a  phenomenon  can  follow  in  a  variety 
of  conditions,  which  fact  must  be  borne  in  mind  in  the  explanation  of 
clinical  conditions. 

3.  The  section  of  the  cellulipetal  prolongation  of  a  peripheral 
sensory  neuron  also  results  in  chromatolysis  of  the  cell  of  origin.  This 
chromatolysis  is  more  marked  than  that  which  is  seen  in  a  motor  neu- 
ron. It  is  followed  by  the  disorganization  and  disappearance  of  the 
corresponding  cell. 

4.  The  disappearance  of  the  cells  of  the  spinal  ganglia,  following 
section  of  their  peripheral  prolongations,  is  due  not  only  to  the  lesion 
of  these  prolongations,  but,  of  more  import,  it  is  due  to  the  lack  of 
trophic  action  which  stimulation  from  without  produces  upon  these 
nerve  cells. 

5.  The  ganglion  cells  in  a  nervous  chain  exercise  the  one  upon 
the  other  a  trophic  action,  the  suspension  of  which  produces  a  chro- 
matolysis and  disappearance  of  the  corresponding  cells. 

6.  The  section  or  the  lesion  of  a  cellulifugal  prolongation  of  the 
cells  of  the  cerebro-spinal  ganglia  is  not  followed  by  profound  chro- 
matolysis, contrary  to  what  is  seen  for  the  motor  cells.  In  the  present 
state  of  our  knowledge  this  fact  remains  inexplicable.  Jelliffe. 

84.  The  effect  of  Inanition  on  the  Structure  of  Nerve  Cells. 
F.  W.  Barrows  (Am.  Journal  of  Physiology  i,  1898,  p.  14,  Pro- 
ceedings, part  2). 

The  author  studied  the  cells  of  the  occipital  cortex,  spinal  ganglia 
and  cord  in  rats,  comparing  the  cells  of  those  which  were  well  nour- 
ished with  those  that  had  been  starved  to  death.  Observations  of  the 
movements  of  the  animals  were  also  taken  so  as  to  compare  the  fatigue 
effects.    The  study  shows: 

(i)  A  decided  shrinkage  in  the  size  of  the  cells  and  nuclei  in  the 
famished  animals,  averaging  about  20  per  cent.,  and  a  still  greater 
shrinkage  in  the  nucleoli. 

(2)  An  evident  exhaustion  of  the  substance  of  famished  cells,  as 
!>hown  by  their  faint  staining  with  osmic  acid  and  the  notable  absence 
of  nuclei  and  nucleoli.  The  protoplasm  of  these  cells  shows  a  very 
fine  vacuolation,  not  so  marked  as  that  described  by  Rosenbach  for 
starving  animals,  and  by  Hodge  for  extreme  fatigue.  In  the  brains  of 
famished  rats  the  pericellular  lymph  spaces  are  considerably  enlarged. 

VOGKL. 


2S4  PERISCOi'E. 

85.     Sul,t,E  Al.TKRAZIONE  DEGLl   ELEMKNTI 

(Alterations  in  the  Nervous  System  due  to  Starvation).  Lugaro  c 
Chiozzi  (Rivista  di  Patologia  nervosa  e  mentale,  2,  189?,  No.  9). 
The  authors  starved  animals  for  some  time  and  then  examined  the 
nervous  tissues  by  the  newer  methods.  They  conclude  that  in  starva- 
tion the  changes,  occurring  in  the  nervous  tissues,  arc  of  slow  develop- 
ment, that  the  lo^s  of  chromophilic  substance  is  not  marked, and  i.s  cap- 
able of  prompt  restitution  until  late. stages  of  actual  death  are  immi- 

In  the  animals  studied  great  variatioi',,;  were  observed.  The  pos- 
terior cells  of  the  cord,  of  the  spinal  ganglia,  the  cortex  and  Purkinjc 
cells  were  those  most  subject  to  change,  while  the  large  ganglion  cells 
of  the  anterior  horns  suffered  but  slight  alteration. 

The  chromophilic  substances  were  affected  in  greatest  measure,  tlie 
achromatic  substances  suffering  but  little  change. 

The  character  of  the  changes  is  comparable  in  many  ways  to  those 
induced  by  subacute  or  chronic  poisoning  by  the  metals,  and  the  au- 
thors take  tlie  position,  which  appears  to  us  rather  fanciful,  that  the 
changes  found  in  the  nervous  system  may  be  induced  by  auto-toxic 
agents,  which  rapidly  increase     before  death.  Jelliffe, 

f)6.    Anatomical  Findings  in  a  Cask  oi-'  I'aciai.  Pakalysis  of  Tkn 
Days'  Dur.^tion  in  a  Ghnkkai.  l'An.M.\Tit:,  with  Rkmarks  on 
THE  Termination  of  the  "Auditory"  Nerves.       A.     Meyer 
(Jour,  of  Experiment.     Med.,  vol.  2,  l8g7,  p.  607), 
The  case  of  a  paralytic,  who,  ten  days  before  death  developed  a 
facial  (complete)  paralysis  on  the  left  side,  is  reported  by  Meyer,  and 
the  results  oi  the  autopsy  given.     Death  ensued  in  a  convulsion;  post- 
mortem nineteen  hours  later.     The  facial  nucleus  was  fixed  in  alcohol. 
94  per  cent,  in  part;  the  rest  and  the  middle  ear  in  formalin  io!>.     Clin- 
ically no  evidence  of  ear  trouble  had  been  shown,  but  neither  hearing 
nor  taste  could  be  examined  owing  to  the  dementia  ot  the  patient.     A 
^ulnmary  of  the  findings  is  as  follows: 

Medulla,  right  side,  normal.  Left  side — nucleus  of  facial  nerve 
showed  the  typical  changes  of  reaction  to  a  peripheral  lesion  as  de- 
scribed by  NissI  and  others  in  experiments  on  animals. 

There  was  no  evidence  of  decussation  of  elements  of  the  seventh 
nerve,  the  cells  of  the  right  nucleus  being  everywhere  intact.  The  ter- 
n^inal  nuclei  of  the  eighth,  both  the  dorsal  and  the  ventral,  showed 
well -circumscribed  neuroglia-cell  infiltration,  whereas  Deiter's  nucleus 
was  almost  completely  free.  The  central  auditory  cells  were  also 
slightly  affected  within  the  region  of  infiltration. 

The  case  contradicts  any  decussation  of  the  roots  of  the  facial 
nerve,  and  speaks  for  a  relative  independence  of  the  nucleus  of  Deit- 
er's from  the  auditory  nerve  endings  (contrary  to  the  views  of  Bech- 
terew).  The  facial  palsy  was  caused  by  the  condition  within  the  in- 
ternal auditory  canal,  i.  e.  a  peripheral  lesion,  showing  that  the  cells 
of  one  fibre  system  (the  facial)  can  be  involved  by  affection  of  another 
system  (the  auditory)  with  which  it  comes  in  contact.  Two  plates  il- 
lustrate the  article.  Sternk. 
I 

87.    SUR   LA    HISTOLOGIE  PATHOLOtllQl'E  UE  LA  POI.VNfeURITE  dans  SES 

rapports  avec  les    lesion.s  de  la    cellule    nervei'se    (On 
the  Pathological   Histology  of  Polyneuritis,  etc.)     S.  Soiikhanoff 
(Nouvelles  Iconographie  de  la  Salpetriere,  10.  1897,  p.  347)- 
The  author  presents  the  clinical  history  and  a  complete  cytologicat 

study  of  a  case  of  multiple  neuritis  of  probable  alcoholic  origin. 

The  methods  of  Nissi  and  of  Marchi  were  used  in  the  study  of  the 

nervous  system.     In  the  anterior  horn  cells  there  was  marked  ce::tral 


PERISCOPE.  285 

I 

chromatolysis;  the  nucleus  occupied  an  eccentric  position.  In  a  few 
cases  the  nucleus  was  centric  with  some  perinuclear  chromophilic  sub- 
stance, but  about  this  the  chromatolysis  was  marked. 

Following  Marinesco's  studies,  the  author  shows  that  the  lesions 
in  the  greater  number  of  affected  cells  were  similar  to  those  seen  after 
lesions  of  the  peripheral  nerves,  and  therefore  secondary  and  not  like 
those  found  when  the  lesion  is  a  primary  one,  such  as  is  seen  in  the 
case  of  the  acute  intoxications.  The  author  interprets  the  lesion  as 
primary  in  those  cells,  fewer  in  number,  in  which  the  nucleus  remained 
central  with  perinuclear  chromatolysis.  Jelliffe. 

88.     SUR  I,' ABSENCE    I) 'ALTERATION   DKS  CEI.I,UI.KS    NERVKUSES   DE   LA 
MOELLE    ^PINlfeRE   DANS  UN  CAS    DE    PARALYSIE    ALCOOUQUE   EN 

voiE  D' AMELIORATION  (Absence  of  Alteration  of  the  Nerve  Cells 
of  the  Spinal  Cord  in  a  Case  of  Alcoholic  Paralysis  in  Process  of 
Amelioration).  Dejerine  et  Thomas  (Comptes  Rendus  Hebdo- 
niaires  des  Seances  de  la  Societe  de  Biologic,  4,  May  ist,  1897). 

Dejerine  and  Thomas  report  a  case  of  alcoholic  paralysis  of  the 
inferior  limbs  with  muscular  atrophy;  hyperaesthesia  of  the  skin  and 
muscles;  talipes  equinus;  loss  of  patellar  reflex;  lesions  of  the  cutan- 
eous and  muscular  nerves  of  the  lower  limbs,  consisting  of  empty 
nerve  sheaths,  and  diminution  in  the  number  of  large  medullated  fibres, 
without  evidences  of  Wallerian  degeneration.  The  anterior  and  pos- 
terior roots,  the  white  matter  and  cells  of  the  cord,  appeared  to  be 
normal. 

The  writers  think  that  the  absence  of  the  cellular  lesions  may  have 
been  due  to  the  fact  that  the  reaction  of  the  cell  body  had  ceased,  the 
condition  of  the  peripheral  nerves  being  one  of  amelioration,  although 
the  j)ower  of  motion  was  still  much  affected.  The  findings  show,  how- 
ever, that  in  peripheral  neuritis  the  nerves  may  be  much  altered 
without  the  presence  of  appreciable  changes  in  their  cell  bodies.  It 
is  wise  to  maintain  a  certain  reserve  in  judging  of  the  importance  of 
chromatolysis  in  the  nerve  cells,  for,  while  it  occurs  after  infectious 
processes  or  intoxications,  it  does  not  seem  to  have  great  significance. 
Goldscheider  and  Flatau  have  recently  shown  experimentally  that 
pronounced  cellular  alterations  may  be  found  in  animals  which  have 
presented  no  symptoms  during  life.  These  lesions  are  temporary,  and 
the  restoration  of  the  nerve  cell  to  a  normal  condition  is  very  rapid. 
According  to  Goldscheider  and  Flatau,  the  corpuscles  of  Nissl  are 
not  of  vital  importance,  and  their  physiological  significance  is  unknown. 
Jacottet  has  noticed  an  absence  of  paralytic  phenomena  in  animals 
intoxicated  by  different  substances  in  which  chromatolysis  was  found 
at  the  autopsy.  Chromatolysis  is,  therefore,  of  interest  cytologically, 
but   is   not   of  physiological   importance.  Spiller. 

CLINICAL  NEUROLOGY. 

89.    A  Case  of  **  Landry's"  Paralysis  with  Autopsy.  T.  Diller  and 
A  Meyer  (American  Journal  of  the  Medical  Sciences,  11 1,  p.  104). 

This  case  occurred  in  a  female,  fifty-three  years  of  age,  who  was 
suddenly  taken  ill  with  paralysis  of  the  legs,  which  was  followed  after 
three  days  by  weakness  of  the  arms,  the  bladder  and  intestinal  canal. 
Three  months  later  the  patient  died  with  bulbar  .symptoms,  a  gradual 
paralysis  of  the  extremities  having  developed  in  the  meanwhile.  The 
patellar  reflex  was  lost,  but  the  sensations  remained  normal.  Death 
was  due  to  respiratory  paralysis. 

The  microscopical  investigation  showed  a  slight  sclerosis  in  the 


286  PERISCOPE. 

crossed  pyramidal  tracts.  The  spinal  roots  were  intact,  and  the  author 
describes  a  pigmentation  of  the  gangUon  cells  of  the  anterior  horns. 
He  concludes  that  the  symptoms  suggest  a  classification  into  two 
groups. 

(i)  In  children,  where  the  disease  is  termed  acute  anterior  poiio- 
myelitis. 

(a)  In  older  patients,  when  polyneuritis  is  accompanied  by  a  spe- 
cial disease  of  the  peripheral  nerves,  and  Landry's  paralysis  with 
marked  spinal  symptoms.  Jei 


90.   iNFKCTious  Caitkation  OF  Landkv's  SYMPTOM.     RemliHger  (Med. 

Week.  5,  1897,  Nov.  s>- 

At  the  Biological  Society  oi  Paris,  the  author  recalled  a  case 
previously  reported  by  him  of  an  acute  ascending  paralysis  in  which 
the  streptococcus  was  detected  in  the  spinal  substance  by  cultivation, 
and  was  also  found  in  stained  sections. 

In  experimenting  on  the  subject  Dr.  Remlinger  has  succeeded  in 
producing  acute  ascending  paralysis  in  a  rabbit  in  which  cultivation 
tests  furnished  evidence  of  the  presence  of  the  inoculated  microbe  in 
the  cord.  The  microbe  was  a  micrococcus  derived  from  septic  absces- 
ses in  a  human  patient.  Dr.  Remlinger  thinks  his  successful  produc- 
tion of  ascending  paralysis  in  this  case  is  an  additional  argument  in 
favor  of  the  infective  nature  of  ■■'  •■ —  n..-^.,^.  . 


91.  Paralysie  asckndante  aigue  (Acute  Ascending  Paralysis^ 
Hirix  el  Lesne  (La  Pres^e  Medicale,  S.  '897,  P-  269). 
The  case  described  occurred  in  a  woman  of  22.  beginning  suddenly 
while  she  was  in  the  third  month  of  a  so, far  normal  pregnancy.  The 
■symptoms  were  first  acute  and  then  chronic.  The  disease  lasted  about 
four  months,  being  then  terminated  by  the  death  of  the  patient  from 
broncho-pneumonia.  Two  weeks  before  death,  there  was  premature 
delivery,  the  child  living  but  a  few  minutes.  From  this,  however,  the 
patient  rallied  quite  well.  There  was  complete  paralysis  of  both  lower 
extremities,  and  of  the  right  upper  extremity,  with  paresis  of  the  left 
arm  and  of  the  back  muscles.  The  respiratory  muscles,  and  those  of 
the  face,  tongue,  palate,  pharynx,  ancl  larynx  remained  intact.  The 
paralyzed  muscles  showed  no  reaction  of  degeneration,  but  the  tendon 
reflexes  were  lo.st.  Sensibility  was  present,  and  the  muscles  of  the 
lower  extremities  were  very  tender,  and  the  seat  of  severe  pains,  in- 

A  clear  liquid,  withdrawn  by  lumbar  puncture  two  hours  after 
death,  proved  sterile.  The  brain  and  the  peripheral  nerves  showed 
nothing  abnormal.  The  vessels  of  both  spinal  pia  mater,  and  cord 
proper,  were  greatly  dilated,  and  their  walls  infiltrated  with  leucoeytes. 
This  was  speciallj  marked  in  the  anterior  horns  about  the  ganglion 
cells.  These  latter  were  much  altered,  especially  in  the  lumbar. region, 
some  having  disappeared,  others  being  shrunken  and  their  nuclei  dis- 
placed; others,  again.  Iiypertrophied.  Above  the  cervical  enlargement 
the  cells  were  normal,  and  the  vascular  lesions  disappeared  in  the 
bulb.  There  was  no  degeneration  in  the  columns  of  the  white  matter. 
C.  L.  Allen. 


7.VR    PATHOIA>GIStHKN    A.\, 
AUFSTKIGENDRN  Si"is. 
Anatomy   and   the   Etiology   of   Landry's 
(Zeits.  I.  Klin.  Med,.  ,v.  iSg?.  p.  115). 
Since  1893  the  author  has  observed  four  case 
,  in  three  of  which  he  was  enabled  to  perforn 


PERISCOPE.  287 

three  fatal  cases  there  was  a  preceding  history  of  alcoholism,  one  tu- 
bercular, and  in  all  three  the  nervous  svmptoms  were  preceded  by  an 
attack  of  influenza.  The  pathological  findings  were  those  of  an  acute 
or  subacute  multiple  neuritis  and  those  of  an  acute  myelitis. 

The  author  concludes  that  Landry's  paralysis  should  not  be  con- 
sidered a  disease  sui  generis,  but  should  be  regarded  as  an  exceptionally 
severe  form  of  polyneuritis,  which  involves  not  only  the  peripheral 
neuron,  but  also  the  spinal  and  the  bulbar  neurons,  and  that  its  chief 
etiological  factor  is  some  acute  infectious  disease,  notably  influenza. 

Jelliffe. 

93    MuivTiPi^E  Neuritis  FoLi^owiNG  INFI.UKNZA.  H.B.  Allyn  (Journal 
American  Medical  Association,  29,  1897,  p.  152). 

The  author  reports  six  original  cases  of  mutiple  neuritis  following 
epidemic  influenza.  From  a  study  of  his  own  and  thirty  cases  collected 
from  other  sources  his  conclusions  are  as  follows: 

1.  Influenza,  like  other  infectious  diseases,  may  be  followed  by 
neuritis  and  multiple  neuritis. 

2.  One  sex  does  not  seem  to  be  more  liable  to  multiple  neuritis 
than  the  other. 

3.  It  occurs  most  frequently  between  the  twenty-fifth  and  forty- 
fifth  years;  and  appears  during  convalescence  in  a  few  days  or  two  or 
three  weeks  after  the  influenza  has  subsided. 

4.  It  may  present  sensory,  motor,  vasomotor  or  trophic  symptoms, 
or  all  combined,  but  sensory  and  vasomotor  symptoms  are  more 
prominent  than  in  diphtheritic  and  some  other  cases  of  multiple  neu- 
ritis 

5.  The  great  majority  of  the  cases  recover,  both  as  regards  res- 
toration of  function  and  power  as  well  as  regards  life.  Five  of  the 
thirty-six  cases  collected  in  this  paper  died.  In  one  of  Bruns'  cases  the 
symptoms  resembled  Landry's  paralysis,  in  the  other  there  was  paraly- 
sis of  the  tongue  and  throat.  In  Eisenlohr's  fatal  cases  there  was  gen- 
eral motor  paralysis  with  intense  hyperaesthesia  of  the  skin.  In  Fer- 
guson's case  the  neuritis  was  visceral,  and  in  Leyden's  fatal  case  there 
was  coincident  disease  of  the  cord. 

6.  Recovery  does  not  usually  take  place  under  four  weeks  and 
may  be  delayed  for  months. 

7.  Treatment  should  consist  first  of  absolute  rest  in  bed.  Ano- 
dynes must  be  given  in  sufficient  doses  to  relieve  pain,  when  that  is  a 
prominent  symptom.  Morphine  hypodermically  mayj>e  necessary,  but 
may  be  often  substituted  for  with  advantage  by  cocame.  The  antipy- 
retic anodynes  are  insufficient  in  any  safe  Jose  if  the  patient  has  pains 
for  many  days.  The  salicylate  of  cinchonidin  js  distinctly  valuable,  es- 
pecially when  the  pain  is  not  of  the  greatest  intensity.  At  a  later  stage 
potassium  iodide  and  the  bichloride  of  mercury  in  small  doses  are  help- 
ful. When  the  pain  is  in  an  extremity,  firm  pressure  with  a  flannel 
bandage  gives  great  comfort.  Blisters  over  the  painful  nerve  trunks 
when  they  are  superficial  are  also  valuable  in  relieving  pain. 

Close  watch  must  be  kept  on  the  action  of  the  heart  and  the  char- 
acter of  the  breathing.  Most  of  the  fatal  cases  die  through  paralysis 
of  the  diaphragm.  The  closest  attention  must  be  given  throughout  the 
course  of  the  case  to  the  nutrition  of  the  pat'ent  and  to  the  condition 
of  the  skin,  especially  over  portions  of  the  body  where  pressure 
occurs. 

As  far  as  possible  the  stomach  should  be  reserved  for  food.  Medi- 
cine in  these  cases  acts  better  when  given  hypodermically,  and  the 
stomach  is  not  so  likely  to  be  deranged.  This  caution  applies  espec- 
ially to  the  giving  of  anodynes. 

8.  Finally,  while  he  thinks  diphtheria  as  a  cause  can  be  excluded  in 


288  PERISCOPE. 

the  cases  which  he  has  seen,  both  from  the  absence  of  any  clinical  evi- 
dence of  it  in  the  patient  or  his  surroundings  and  from  the  fact  that 
diphtheritic  neuritis  is  almost  purely  motor,  yet  he  cannot  exclude  the 
poison  concerned  in  the  production  of  follicular  tonsilitis — infectious 
tonsillitis,  for  sometimes  this  is  "ssoctated  w.th  inOuenza.  and  it  may 
produce  as  much  headache,  backache  and  prostration  as  usually  char- 
acterize the  onset  of  influenza  itself.  Shivelv. 

i  MEASLES.    S  W.  Morton  (Uni- 

The  author  reports  what  in  all  likelihood  was  a  severe  multiple 
neuritis  Following  measles,  in  a  child  of  two  years  and  eight  months. 
The  possibilitv  of  mixed  infection  is  not  to  be  excluded,  as  deglutition 
was  unusually  painful  and  the  entire  course  of  the  disease  somewhat 
anomalous.  The  paralysis  involved  not  onlv  the  extremities  but  also 
the  muscles  of  the  neck  and  those  of  phonation,  articulation  and  de- 
glutition. Four  months  aiter  the  beginning  o(  the  sickness  the  child 
had  not  yet  fully  recovered,  although  he  looked  well,  and  the  knee 
jerks  and  faradic  contractility  of  the  muscles  had  returned. 

Patrick. 

95.  GoN-ouKEfliEA,  HIT  POLYNEURITIS  CoMPijciRT  (Gonorrhcea  com- 
plicated with  Polyneuritis.  E.  Welander  (Nord.  Med.  Ar- 
chiv.  N.  F,  8,  1897.  p.  36). 

The  clinical  history  is  here  given  of  a  case  of  acute  gonorrhcea 
with  prostatitis  and  epididymitis  occurring  in  a  young  man  of  twenty- 
one  years  of  age.  One  month  later  symptoms  of  acute  general  infec- 
tion appeared  which  soon  disappeared,  but  superimposed  upon  these 
general  symptoms  there  was  a  marked  motor  affection  which  persisted 
until  the  patient  died  of  paralysis  of  the  respiratory  muscles  and  a  pu- 
rulent bronchitis.  The  nerves  which  were  affected  to  the  greatest  ex- 
tent were  those  of  the  face  and  the  muscles  of  the  limbs  and  trunks. 
The  muscles  of  the  bladder  and  intestine  were  paretic.  There  was  no 
atrophy,  the  reHexes  were  abolished,  and  there  was  no  reaction  of 
degeneration.  A  microscopical  examination  (methods?)  showed  there 
were  no  changes  in  the  spinal  cord,  nor  of  the  nucleus  of  the  seventh 
nerve.   The  peripheral  nerves  were  in  a  profound  state  of  degeneration. 

H. 

The  author  reports  several  cases  of  injury  to  the  brachial  plexus 
and  external  popliteal  nerve  caused  by  carelessness  in  the  position  of 
limbs  during  long-continued  operations.  In  summing  up,  he  says; 
"The  patient's  arms  should  not  be  allowed  to  hang  down,  and  care 
should  be  taken  that  during  operation  the  weight  of  the  body  is  as 
evenly  distributed  as  possible.  Keeping  the  patient  in  any  constrained 
position  should  be  avoided  when  not  absolutely  necessary,  and  the  use 
of  any  mechanical  contrivance  for  maintaining  a  desired  position 
should  be  with  due  care  to  prevent  nerves  from  being  stretched  or 
pressed  upon.  If  neuritis  does  occur,  the  first  indication  is  to  secure 
absolute  rest  of  the  affected  part  during  the  early  stage.  At  this  time 
voluntary  motion,  massage,  electricity,  or  any  other  excitant  of  muscle 
and  nerve  will  do  harm.  When  the  pain  and  tenderness  have  subsided, 
counter-irritation,  gentle  nibbing  and  the  galvanic  current  may  be 
used  to  advantage.  The  faradic  current  often  is  harmfid,  and  is  useless  ' 
except  as  a  means  of  diagnosis  or  as  a  counter-irritant  applied  to  the 
skin.  Shivelv. 


PERISCOPE,  289 

97.     ZUR    KUNIK    DER     FAMIUARKN    OPTICUSAFFECTIONEN       (Clinical 

Communication  concerning  Family  Diseases  of  the  Optic 
Xerve).  H.  Higier  (Deutsche  Zeitschrift  fiir  Nervenheilkunde, 
10,  1897.  p.  489). 

Higier  describes  two  cases  of  optic  neuritis  occurring  in  brothers. 
An  uncle  of  the  patients  was  said  to  have  had  a  similar  affection.  In 
one  of  Higier's  cases  *the  failure  of  sight  began  at  the  age  of  twenty; 
in  the  other  at  the  age  of  twenty-seven.  Central  scotoma  was  found  in 
both  cases.  This  affection  was  described  by  Leber  in  1871.  The  optic 
neuritis  begins  between  the  ages  of  thirteen  and  twenty-eight  without 
demonstrable  cause;  there  are  central  and  paracentral  scotomata  for 
colors;  the  visual  fields  are  not  limited  peripherally  as  in  ordinary 
atrophy:  nyctalopia  is  not  rare;  and  the  ophthalmoscope  presents 
quite  a  characteristic  picture.  Although  about  twenty-five  cases  are 
reported,  nothing  is  known  of  the  nature  and  location  of  the  inflam- 
matory process.  A  neuropathic  disposition  is  often  noted.  The  pe- 
culiar fact  that  in  the  family  form  of  neuritis  only  the  macular  fibres 
in  the  optic  nerve  are  affected  seems  to  be  best  explained  by  the 
greater  functional  activity  of  these  fibres.  This  affection  is  not  only 
a  family  one,  but  also  hereditary,  and  is  transmitted  especially  by  fe- 
males to  their  sons. 

Higier  speaks  also  of  the  syphilitic  family  optic  neuritis,  which 
should  be  distinguished  from  Leber's  form,  and  is  similar  to  the  syphil- 
itic retinitis.  He  describes  also  two  cases  of  family  optic  atrophy  which 
are  unlike  Leber's  form.  In  the  latter  there  is  subacute  neuritis  axialis, 
in  which,  chiefly  or  exclusively,  the  macular  bundle  in  the  centre  of 
the  optic  nerve  is  altered,  and  the  temporal  half  of  the  papilla  is  atro- 
phied; whereas  in  Higier's  form  the  atrophy  of  the  opticus  is  complete 
and  chronic,  and  has  an  early  development:  the  papilla  is  uniformly 
gray  without  any  signs  of  neuritis,  and  the  visual  fields  are  concentric- 
ally limited  without  the  presence  of  central  scotomata.  In  addition  to 
the  cases  of  disease  of  the  optic  nerve  dependent  on  malformation  of 
the  cranium,  there  is  a  family,  possibly  congenital,  variety  of  optic 
atrophy  entirely  independent  of  such  visible  malformation. 

Higier  reports  three  cases  of  amaurotic  family  idiocy  (Sachs)  in 
one  family,  and  compares  this  disease  with  the  cerebellar  hereditary 
ataxia.  He  refers  to  the  presence  of  optic  atrophy  in  hereditary  and 
family  cerebral  and  spinal  diseases — a  subject  which  he  has  treated  at 
length  in  a  previous  paper.  Spiller. 

98.    A  New  Symptom  in  Peripheral  Facial  Paralysis.     Bordier 
and  Frenkel  (Medical  Week,  5,  October  ist,  1897). 

The  authors  relate  their  observations  of  a  phenomenon  which 
they  believe  they  are  the  first  to  mention,  and  which  they  think  im- 
portant for  its  prognostic  value. 

When  a  patient  affected  with  severe  peripheral  facial  paralysis  is 
asked  to  shut  his  eyes,  it  will  be  found  that  the  eye  on  the  healthy  side 
closes  energetically,  whereas,  on  the  diseased  side,  there  is  but  a  very 
slight  decrease  in  the  width  of  the  palpebral  fissure,  the  globe  of  the  eye, 
which  remains  visible  to  the  observer,  moving  first  upward,  then 
slightly  outward,  the  eyelid  meanwhile  finishing  its  movement  of  de- 
scent, the  range  of  which  varies  in  different  cases  with  the  degree  of 
paralysis  of  the  orbicular  muscle. 

The  patient,  in  other  words,  cannot  close  his  lids  on  the  paralyzed 
side  without  at  the  same  time  deviating  the  globe  of  his  eye  upwards, 
and  slightly  outwards.  If  he  is  fixing  some  object  before  him,  he  is 
compelled  to  look  away  before  he  can  contract  his  orbicularis  palpe- 
brarum. 


290  PERISCOPE. 

In  treating  such  cases  with  electricity,  it  was  observed  that  im- 
provement in  reaction  coincided  with  improvement  in  tlie  closure  of 
the  eye.  The  symptom,  therefore,  gives  us  a  means  ol  following  the 
progress  of  the  improvement  in  these  paralyses;  recovery  is  near  when 
the  patient,  who,  at  first,  was  oljliped  to  turn  one  eyeball  upward  be- 
fore he  could  bring  its  upper  lid  to  its  lowest  possible  point,  begins  to 
be  able  to  shut  bis  eye  without  deviating  from  l(ie  line  of  sight. 

The  phenomenon  is  then  of  help  in  three  ways;  first,  as  an  aid  in 
diagnosis;  second,  as  a  prognostic  indication;  third,  as  a  measure  of 
the  progress  of  improvement. 

First,  it  throws  light  on  the  diagnosis,  seeing  that  it  is  not  met 
with  in  cases  of  central  paralysis.  It  Is  not  necessary,  however,  to  in- 
sist on  this  point,  as  there  are  other  and  simpler  means  of  ascertaining 
the  special  form  of  a  given  case  of  facial  paralysis. 

Second,  it  establishes  tlie  prognosis,  the  presence  of  this  symptom 
coinciding,  as  has  been  seen,  with  that  of  complete  reaction  of  degen- 
eration, it  being  totally  absent  when  the  reaction  is  only  partial. 
When  therefore  contraction  of  the  orbicularis  Is  attended  with  deviation 
upwards  of  the  eye,  the  paralysis  may  be  consiuered  as  serious;  but 
when  contraction  of  the  orbicularis  can  be  effected  without  this  devia- 
tion of  the  eye,  the  paralysis  is  not  srave  and  will  yield  easily  to  treat- 
Third,  it  permits  of  following  the  progress  of  improvement,  for 
the  deviation  of  the  eyeball  also  becomes  less  and  less  marked,  in  pro- 
portion as  the  reaction  of  degeneration  tends  to  become  partial;  more- 
over, the  patient  is  still  liable  to  lower  his  upper  lid  without  any  devia- 
tion of  the  globe,  when  the  reaction  of  degeneration  consists  simply 
II  of  the  faradic  stimul ability.  MiTriii-M.. 

LAtGiK  (Epicondylalgia).     E.   Riviere   (Gaz.   Heb- 
domadaire,  2,  1897,  p.  683). 

In  iHgb.  Dr.  Riviere  in  his  thesis  reviewed  the  history  and  status 
of  the  disease  described  by  Benliard  as  professional  neuralgia  of  the 
epicondyle,  upon  which  Remak  had  already  written.  This  neuralgia 
follows  fatigue  or  over-use  of  the  forearm,  and  is  met  ordinarily  in 
violinists,  or  those  who  write  a  great  deal.  It  is  also  located  at  the  epi- 
condyle. often  in  the  muscular  mass  in  the  neighborhood  of  the  epi- 
condyle, and  sometimes  at  the  head  of  the  radius. 

The  characteristic  pains  radiate  from  the  epicondyle  towards  the 
external  surface  of  the  forearm,  and  extend  even  into  the  hand,  of 
which  they  somewhat  hinder  the  movements.  The  pains  are  lessened 
and  disappear  when  the  arm.  and  esnecially  the  hand,  is  in  repose.  Cer- 
tain movements  are  especially  painful,  (or  example,  those  which  in- 
clude prehension  with  the  extended  arm.  Pressure  upon  the  epicon- 
dyle gives  a  lively  pain  well  localized,  although  this  Is  not  the  piiiiii  at 
which  the  patients  complain  of  spontaneous  pain. 

Like  other  professional  neuroses,  the  affected  muscles  are  ^ome- 
what  impaired  In  Iheir  strength,  and  there  Is  a  special  degree  of  feeble- 
ness in  the  movements  of  extension  with  prehension. 

Riviere  has  not  found  that  any  special  work  predisposes  to  this 
affection.  All  occupations  which  necessitate  the  play  of  the  epicon- 
dylar  muscular  mass  may  bring  on  this  form  of  neuralgia,  which  he  has 
observed  In  fencing  masters,  violinists,  laboring  men,  coachmen, 
leather  dressers  and  others.  Like  other  professional  neuroses,  the 
treatment  consists  in  rest  and  massage,  and  the  earlier  that  these  are 
applied,  the  better  is  the  result.  Mitchell. 


PERISCOPE.  291 

100.  NSURITIS  ISCHIADICA,  NEURAI/JIA  ISCHIADICA  UND  HYSTERIE  (Sci- 

atic     Neuritis,     Sciatic     Neuralgia    and     Hysteria).      Max    Biro 
(Deutsche  Zeitschrift  fur  Nervenheilkunde,  11.  i8g8,  p.  207). 

Biro  presents  some  diagnostic  points  between  intlammation,  neu- 
ralgia, and  hysterical  disease  of  the  sciatic  nerve.  In  neuritis  the  Ach- 
illes tendon  reflex  is  absent,  and  altered  electric  reaction  and  muscular 
atrophy  arc  noticed;  these  signs  are  not  present  in  neuralgia.  Painful 
points  (points  douloureux)  are  present  in  neuralgia,  and  are  rare  in  neu- 
ritis. When  no  symptoms  of  inflammation,  no  disturbance  of  sensa- 
tion, other  than  the  points  douloureux,  are  noticed,  the  case  may  more 
properly  be  considered  one  of  neuralgia  than  one  of  neuritis,  but  from  the 
perusal  of  the  paper  it  is  evident  that  Biro  does  not  regard  the  distinc- 
tion between  neuritis  and  neuralgia  as  very  sharp.  The  Achilles  ten- 
don reflex  has  not  received  the  attention  it  deserves;  often  it  disappears 
in  disesase  before  the  patellar  reflex  (tabes,  diabetes).  When  the  sci- 
atic nerve  is  only  slightly  affected,  the  Achilles  tendon  reflex  may  not 
be  altered,  and  every  doubtful  case  in  which  this  reflex  is  present  is  not 
one  of  neuralgia,  but  its  absence  always  indicates  neuritis.  Hysteria 
not  infrequently  simulates  true  sciatica,  but  in  hysteria  the  painful 
points  are  absent,  or  are  not  limited  to  the  course  of  the  nerve,  passive 
movements  are  not  painful,  Laseque*s  sign  (flexion  of  the  extended 
lower  limb  on  the  trunk  causing  pain)  is  not  present,  the  pain  is  sel- 
dom confined  to  one  extremity,  the  muscles  do  not  atrophy,  no  change 
is  noted  in  the  electric  reactions,  and  the  tendon  reflexes  are  not  ab- 
sent. Hysterical  sciatica  occurs  at  a  period  when  true  sciatica  is  un- 
common (before  the  twentieth  year),  is  more  frequently  observed  in 
females,  and  may  be  associated  with  other  signs  of  hysteria.  No  the- 
ory satisfactorily  explains  the  scoliosis  of  sciatica,  and  many  of  the  so- 
called  causes  are  doubtful.  Spillek. 

PSYCHOLOGY. 

101.  After-sensations  ok  Touch         F.  N.  Spindler  (Psychological 
Review,  4,  1897,  Nov.  6). 

■ 

Frank  N.  Spindler  experimented  on  five  subjects,  applying  weights 
ranging  from  25  grms.  to  1,000  grms.  to  the  back  of  the  hand.  He 
found  it  absolutely  impossible  to  have  the  results  absolutely  accurate, 
as  the  after-sensations  fade  always  gradually.  He  sums  up  the  results 
as  follows: 

(i)  The  minimal  time  of  stimulation  which  will  yield  an  after- 
sensation  of  the  kind  under  investigation  is  about  5  seconds,  with  a 
pressure  of  150  grms. 

(2)  The  relation  between  the  duration  of  stimulation  and  the 
length  of  the  interval  which  elapses  before  the  appearance  of  the  after- 
sensation  is  very  irregular.  The  intervals  increase  up  to  stimulations 
of  about  3  minutes  and  then  again  decrease. 

(3)  The  duration  of  the  after-sensation  increases  with  the  dura- 
tion of  stimulation,  though  without  any  discoverable  regularity. 

(4)  The  longest  duration  of  after-sensations  is  given  by  pressures 
of  from  150  to  500  grams.  Above  and  below  these  limits  of  pressure 
the  duration  decreases. 

(5)  In  quality  the  after-sensations  arc  very  variable.  The  writer 
could  discover  no  waves  in  his  own  after-sensations,  but  only  a  steady, 
persistent  feeling  of  contraction.  Other  subjects  experienced  waves 
of  heat,  of  pain,  etc.,  but  they  also  in  most  cases  felt  a  steady,  persist- 
ent underlying  touch  on  contraction  sensation,  lasting  through  tiie  dull 
aches,  the  smarts,  and  the  heat  or  cold.  Christison. 


The  authors  received  reports  from  nearly  3.000  persons  in  response 
to  a  syllabus  sent  out.  The  analysis  shows  that  in  exceptional  cases 
the  first  symptom  or  source  of  laughter  may  take  place  in  almost  any 
part  of  the  body,  but  it  is  most  frequent  in  the  eyes  and  next  in  fre- 
quency at  the  mouth.  The  eyes  become  brighter,  smaller  and  c 
late,  and  the  mouth  opens,  stretches  and  curves  upward,  but  somet 
downward.  In  some  lew  cases  the  laugh  begins  with  dimples  in  the 
cheeks:  in  others  a  movement  of  the  muscles  just  below  the  ears;  in 
others  a  throwing  back  of  the  head. 

Subjectively,  too,  the  "funny  teelinp-"  may  begin  in  the  stomach, 
throat,  head,  diaphragm,  face  etc.  Sometimes  beauty  is  evoked  or  in- 
creased, or  ugliness  is  produced.  The  eyes  are  sometimes  open,  some- 
times shut,  sometimes  grow  dull,  both  lids  may  tremble  and  balls 
twitch.  They  may  grow  rigidly  fixed  or  roll  wildly,  may  be  turned  up- 
ward and  inward  and  arc  often  sultused  with  tears.  The  mouth,  too, 
may  take  almost  every  variety  of  oosition.  as  does  the  eyes,  and  almost 
any  setfuence  may  be  inverted. 

In  the  height  of  laughter  individual  peculiarities  become  multiplied 
and  emphasized.  Two  returns  described  laughter  so  intense  that  death 
from  ruptured  blood-vessels  ensued. 

The  unset  may  be  very  gradual  or  instantaneous  and  explosive; 
and  the  omilled  sounds  may  be  almost  any  kind  of  noise,  although  hr 
hf,  passing  over  to  ha  ha,  are  the  usual.    Some  sob. 

The  alter  effects  of  a  hearty  laugh  were  described  as  exhaustion, 
heavy  breathing,  fatigue,  shame,  weakness,  depression,  soberness,  sad- 
ness, relief,  weakness  localized  in  various  parts  of  the  body,  the  deep 
sighs,  giddiness,  perspiration,  headache,  stitch  in  the  side,  soreness, 
thirst,  sweating,  chills,  sleepiness,  uncontrollable  movements,  nausea. 
(ears,  fear  of  impending  disaster,  breathlessness,  etc.  On  the  whole, 
Dr.  Hall  remarks,  the  laugh  is  not  unlike  an  epilepsy  from  the  aura,  at 
which  stage  it  may  be  checked,  to  the  subsequent  exhaustion.  In  ■ 
number  of  cases  laughter  was  evoked  by  news  or  sights  really  sad. 

Dr.  Hall  refers  to  Brucke's  experiments,  showing  that  when  the 
head  is  thrown  back,  shoulders  up.  and  the  body  generally  is  bent 
backward,  the  blood  tends  to  flow  from  the  arteries,  where  pressure 
is  high,  into  the  veins,  where  pressure  is  low,  and  thus,  he  concludes, 
that  "if  laughter  is  more  often  associated  with  the  later  position,  and 
crying  with  the  former,  this  would  go  far  to  account  for  the  subjective 
difference  between  the  two  and  would  connect  the  relief  of  a  laugh 
with  the  remission  of  arterial  tension.  In  the  majority  of  adults  it  be- 
gins with  the  highest  level  in  consciousness  and  the  finer  muscles,  and 
passes  down  to  lower  levels  and  earlier  developed  musculature,  al- 
though sometimes  in  children  this  order  is  exactly  inverted." 

From  the  returns  children  were  found  to  be  the  most  ticklish,  as 
follows:  Soles  of  feel,  uj:  under  the  arms.  104;  neck,  86;  under  the 
chin.  76:  waist  and  ribs,  60;  cheeks,  58;  knee.  25:  down  the  back.  19; 
behind  the  ears,  rj:  palms.  14;  corners  of  mouth.  8:  breast,  8;  nose,  7; 
legs,  5;  elbows,  3:  lips.  3.  etc.  Some  of  these  children  mentioned  sev- 
eral places  and  so  appear  several  times.  Two  small  children  are  so  tick- 
lish they  scream  with  laughter  if  touched.  Mention  of  the  word  "soles" 
would,  in  some  cases,  cause  slight  tickling,  and  the  mere  pointing  the 
finger  in  107  cases.  When  near  the  cry-point,  some  children,  otherwise 
very  ticklish,  are  like  stone  to  every  stimulus.  Some  are  ticklish  only 
near  bed  time  or  when  very  tired.  Sixty  clearly  marked  cases  were 
ticklish  when  "hanny"  or  "unwell."  or  "after  a  good  meal,"  "when 
perfectly  well,"  etc.,  and  their  susceptibility,  through  the  different 
senses,  varied  greatly.  Crristison. 


PERISCOPE.  29s 

THERAPY. 

103.  A  CuNiCAi^   Lecture    on    Some   Cases   of    Injury   to   the 
Ui^NAR  Nerve.    Bennett  (Clinical  Journal,  Nov.  loth,  1897). 

In  this  lecture  there  are  four  points  worthy  of  mention. 

1.  In  nerve  suture  it  is  not  necessary  to  remove  all  of  the  bulb 
which  may  have  formed  on  the  proximal  end.  Indeed,  it  is  better  to 
leave  part  of  it  as  the  stitches  will  hold  better  than  in  normal  nerve 
tissue. 

2.  Sensation  may  improve  within  twenty-four  hours,  to  be  again 
lost  after  two  or  three  days,  without  at  all  affecting  the  prognosis  for 
ultimate  recovery. 

3.  When,  after  an  injury  to  a  nerve  the  pain  spontaneously,  or 
on  pressure,  shoots  upward  toward  the  origin  of  the  nerve  the  prog- 
nosis is  much  more  serious  than  when  it  shoots  toward  tb*  periphery. 

4.  Many  months  may  elapse  after  suture  before  the  first  sign  of 
improvement,  and  yet  ultimate  recovery  be  almost  perfect. 

Patrick. 

104.  Treatment  of  Sciatica.  A.  Marty  (Medical  Week,  5,  1897, 
July  ;30th). 

The  author  in  his  thesis  relates  that  two  cases  of  sciatica  which  had 
resisted  every  variety  of  medical  treatment,  were  cured  by  Dr.  Gerard- 
Marchaipt  by  means  of  an  operation  which  consisted  in  tearing  apart 
the  fibres  of  the  nerve  with  a  blunt  instrument.  This  treatment  had  pre- 
viously been  employed  by  Dr.  Delageniere,  who  denuded  the  nerve  and 
teased  the  nerve  fibres  with  a  pair  of  haemostatic  forceps,  his  object  be- 
ing to  destroy  any  small  veins  which  might  exist  in  the  interior  of  the 
nerve  and  thus  prevent  any  stasis  in  them.  It  seems  possible  enough 
that  the  successful  results  were  as  much  due  to  the  rest  in  bed  and  the 
immobility  of  the  limb  which  the  operation  made  necessary,  as  to  the 
operation.  Mitchell. 

105.  De  i*a  cure  radicals  i)U  MAI,  perforant  par  l' elongation 
DES  NERFS  PLANTAIRES.  (Nerve  Stretching  for  Perforative  Ulcer). 
Chipault   (La  Medecine  Moderne,  April  7th,  1897). 

The  author  reports  on  a  radical  cure  lOr  perforatinjr  ulcer  of  the 
foot  by  elongation  of  the  plantar  nerves. 

After  discussing  various  other  surgical  means  of  treatment  of  nervous 
diseases — lumbar  punctures  and  reduction  by  operation  of  the  deform- 
ity of  Pott's  disease,  M.  Chipault  considers  further  the  question  of 
perforating  ulcer  and  the  success  attending  this  treatment.  Amputa- 
tion is  not  always  successful,  as  the  ulcer  is  apt  to  return  upon  the 
stump.  In  such  case  a  second  amputation  becomes  necessary.  In  fact, 
a  perforating  ulcer  is  only  a  manifestation  of  a  number  of  different 
affections  of  the  nervous  system. 

The  author  states  that  he  has  performed  the  operation  on  the 
plantar  nerves  for  this  disease  seven  times;  five  of  the  operations  were 
done  more  than  two  years  ago.  He  advises  that  the  operation  be  per- 
formed at  some  distance  from  the  seat  of  the  disease,  selecting,  accord- 
ing to  the  case,  the  plantar  nerve  below  the  internal  malleolus;  the 
muscular  cutaneous  above  the  external  malleolus;  or  the  external 
saphenus  at  the  margin  of  the  tendo-achillis. 

Of  the  seven  cases  operated  upon,  but  one  was  not  cured.  The 
causes  were  various — locomotor  ataxia,  frost  bite,  trautfiatic  neuritis. 
All  the  cases  remained  healed. 

The  same  operatjion  was  proposed  by  Dr.  Weir  Mitchell,  two  or 
three  years  ago,  for/ erythromelalgia,  and  successfully  performed  in 
several*  instances  by  Prof.  W.  W.  Keen  and  Dr.  T.  G.  Morton. 

Mitchell. 


^ooh  ^euieuis. 


Thb  Nervous  Svstkm  and  Its  Diseases.  A  Practical  Treatise 
on  Neurology  for  the  Use  of  Physicians  and  students.  By 
Charles  K.  Slills,  iVl.  D„  Professor  of  Mental  Diseases  and  of 
Medical  Jurisprudence  in  the  University  of  Pennsylvania,  etc. 

Diseases   of  the   Brain   and  Cranial  Nkbvks        With  a   General 

Introduction  on  the  Study  and  Treatment  of  Nervous   Diseases. 

With  459  illustrations,     J,   B.   Lippincott  Co.     Philadelphia,   iSgB. 

The  author  has  been  known,  here  and  abroad,  as  one  of  the 
ablest  among  American  neurologists.  His  scientific  work  has  always 
been  characterized  by  exceeding  thoroughness  and  sound  judgment. 
It  was.  therefore,  a  foregone  conclusion  that  a  book  from'  Dr.  Mills' 
pen  would  be  distinguished  by  these  same  high  qualities;  but,  even 
so,  it  came  as  a  surprise  to  us  to  find  that  it  is  altogether  the  most 
ambitious  effort  in  the  line  of  neurological  book-makiniif.  It  exceeds 
in  size  the  corresponding  volume  of  Gowers  and  the  monograph  of 
Von  Monakow,  and  in  excellence  of  its  contents,  we  hasten  to  add, 
it  is  surely  the  equal  of  either  of  them. 

Of  its  1.056  pages,  256  are  devoted  to  a  general  Introduction  to 
diseases  of  the  nervous  system,  and  the  remaining  (nearly  800  pages) 
to  diseases  of  the  brain  and  of  the  cranial  nerves.  We  do  not  see 
why  the  author  and  publishers  have  not  called  this  "  Volume  t," 
since  it  is  to  be  followed  by  another,  "which  shall  include  the  re- 
maining diseases  of  the  nervous  system,  insanity,  and  the  medical 
jurisprudence    of    both    nervous    and    mental    diseases." 

The  first  chapter  is  called  (modestly)  a  sketch  of  the  nervous  sys- 
tem; it  contains,  in  fact,  a  sufficient  account  of  the  development  and  of 
the  architecture  of  the  nervous  system.  The  embryological  data  will 
be  particularly  welcome  to  English-speaking  readers,  for  they  have 
been  omitted  loo  often  from  English  text-books.  The  statements 
made  are  accurate,  and,  as  far  as  it  is  at  all  oossible,  illustrations  have 
been  utilised  to  make  the  subject  matter  clear  to  the  student.  But 
it  is  to  be  feared  that  the  student  will  not  be  grateful  to  Dr.  Mills  for 
the  introduction  of  the  new  cerebral  terminology  of  Wilder  and  Gage, 
While  recogniiing.the  full  merits  of  this  new  nomenclature,  and  ap- 
preciating the  benefits  conferred  upon  the  comparative  anatomist  and 
the  comparative  embryologist.  the  truth  is,  (be  student  of  neurology 
does  not  need  it.  He  can  get  along  well  enough  with  the  old  terms. 
The  proKocoele.  the  mesocoele,  the  epicoele,  the  metacoele,  and  all 
the  other  "'coeles."  are  not  a  great  advance  upon  the  good,  old- 
fashioned  designations  for  the  ventricles;  nor  does  one  take  kindly  to 
the  various  "mononyms"  (the  translation  of  this  term  is  found  in 
the  toot-note  on  page  47*.  '"  Postoblongata"  is  not  particularly  eu- 
phonious, nor  in  keeping  with  the  spirit  of  the  language,  and  it  will 
be  a  long  while  before  "Metapore"  eclipses  the  foramen  of  Ma- 
gendie."  Life  is  proverbially  short,  and  neurologists  care  less,  at 
present,  about  the  cavities  and  holes  of  the  brain  (the  "coeles"  and 
the  "pores")  than  they  do  about  tracts  and  cells;  and  since  Van  Ge- 


BOOK  REVIEWS. 


295 


\ 


hiichten  has  recently  blessed  us  with  "tautomeral,"  "heteromeral"  and 
"hecatomerar'  cells,  we  shall  be  kept  busy  enough  with  these.  Mills 
has  evidently  felt  some  hesitation  in  introducing  a  section  on  nomen- 
clature, and  we  find  that  in  the  middle  of  the  book  he  himself  pre- 
fers to  speak  of  "lesions  of  the  ventricles,"  and  not  of  the  "coeles." 
We  have  no  doubt  that  in  the  course  of  time  some  of  these  names  will 
be  adopted  by  general  consent;  but  it  will  be  well  along  in  the  next 
century  before  the  system,  as  a  whole,  will  come  into .  use.  It  has 
been  suggested  that  children  should  begin  the  study  of  brain  anatomy. 
The  plan  is  a  good  one  with  reference  to  this  nomenclature;  the  only 
way  to  acquire  it  is  to  acquire  it  early  in  life,  when  the  cortical  cells 
are  ready  for  the  reception  of  any  and  all  auditory  impressions. 

In  the  section  on  general  architecture  and  physiology  of  the  brain, 
the  sensory  tract  is  mapped  out  with  great  detail.    Comparative  tables 
like  the  one  on  page  105  add  greatly  to  the  value  of  this  treatise.    The 
little  that  is  known  of  the  chemistry  of  the  brain  and  of  the  chemical 
processes  accompanying  nervous  action  is  stated  clearly.     Altogether 
this  first  chapter  bears  testimony  to  the  author's  scholarly  attainments. 
The  second  chapter  opens  with  a  brief  consideration  of  the  general 
pathology  and  etiology  of  nervous  diseases.    These  are  included  under 
a  few  general  heads,  such  as,  Developmental  Malformations;  Inflam- 
mations; Degenerations;  Tumors  and  Adventitious  Products;  Disease 
of  Blood-vessels;    Vascular  Disturbances;    and  Functional  Disorders. 
The  remarks  made  under  each  heading  help  to  establish  general  prin- 
ciples of  neuro-pathology,  of  which  our  physicians  and  students  are 
so  much  in  need.    Speaking  of  degeneration,  Mills  claims  "  that  prim- 
ary degeneration  may  be  due  to  embryonal  arrest,  or  it  may  be  in- 
fectious or  toxic."    The  first  half  of  this  statement  is  in  keeping  with 
views  recently  expressed  by  the  present  writer,  and  embodies  a  fact 
that  is  often   disregarded.     Inflammation   is   described   ^ither   as   an 
exudative  (serous,  fibrinous  or  purulent),  or  as  a  proliferative  process, 
the  latter  being  dependent  upon  syphilis  and  other  infectious  diseases. 
The  etiology  of  nervous  diseases  is  considered  very  fully,  to  the 
inclusions  of  seasonal   influences  and  other   Philadelphia  specialties. 
It  docs  not,  however,  appear  to  be  the  season  alone  which  has  this 
curious  influence  in  developing  infectious  diseases  in  those  predisposed 
by  neuropathic  constitutions ;  for  we  learn  that  the  tone  of  the  nervous 
system  becomes  lowered  "in  the  spring,  as  the  result  of  severe  and 
prolonged  labor"  (which  is  not  a  peculiarity  of  the  seasons),  "or  as 
the  effect  of  cold  and  exposure."    In  passing,  it  may  be  of  interest  to 
note  that  in  New  York  chorea,  for  instance,  according  to  the  statistics 
of  several  clinics,  begins  as  often  in  August  as  in  the  spring  months. 
The  consideration  of  the  microbic  origin  of  nervous  diseases,  and  the 
relation  of  the  infectious  processes  to  them,  is  thoroughly  in    accord 
with  recent  doctrines.     The  symptomatology  and  methods  of  investi- 
gations in  nervous  diseases  are  discussed  in  concise  form  within  the 
compass  of  ^  pag^s,  and  we  fail  to  find  any  serious  omissions.     In 
view  of  this,  electricity  is  treated  too  liberally,  being  spread  over  31 
pages.   Yet,  these  are  matters  of  which  too  much  should  not  be  made. 
Moreover,  47  pages  are  devoted  to  general  therapeutics.     How  thor- 
oughly "thumbed"  these  pages  will  be,  filled  as  they  are  with  an  ac- 
count of  almost  every  therapeutic  agent  ever  recommended,  with  a 
capital  table  of  the  "untoward  eflfectsof  some  of  the  more  potent  drugs," 
with  innumerable  formulae,  with  a  recommendation  of  Nuclein  Thera- 
py, and  with  a  cautious  mention  (fortunately  not  an  endorsement)  of 
Cercbrin  and  "  Testicular  Therapv."  The  "table  of  doses  of  the  potent 
and  newer  drugs  used   in  neurological  practice"   is  invaluable,   and 
we  record  with  pleasure  that  in  a  foot-note  the  author  does  full  justice 
to  the  late  Dr.  Sequin's  work  in  this  especial  field. 

With  Chapter  III.  begins  the  description  of  the  various  diseases 


296    .  BOOK  REVIEWS. 

of  the  brain.  The  arrangeqient  is  novel  in  many  respects.  Diseases 
of  the  membranes  are  discussed,  together  with  those  of  the  sinuses 
and  the  veins  of  the  brain,  and  the  chapter  closes  with  an  account  of 
encephalic  malformations  and  aberrations,  including  chronic  hydro- 
cephalus. Tubercular  and  cerebro-spinal  meningitis  are  discussed  un- 
der the -heading  of  Le pi o- Meningitis,  where  they  properly  belong. 
The  bacterial  origin  of  the  various  forms  is  given  due  weight.  In 
the  treatment  of  meningitis  Mills  is  inclined,  on  the  whole,  to  be 
conservative;  "Lanphear,  Keen  and  Senn  have  advocated  the  surgical 
treatment  of  tubercular  lepto-meningitis."  But.  does  Dr.  Mills  recom- 
mend it? 

The  next  chapter  is  one  of  the  best  in  the  book.  The  minute 
anatomy  of  the  cortex  precedes  the  discussion  of  cortical  localization, 
and  this  is  followed  by  a  study  of  the  lesions  and  diseases  of  the  larger 
ganglia,  by  an  account  of  cranio -cerebral  topography,  and  by  a  com- 
plete statement  of  the  manner  in  which  a  post-mortem  examination 
should  be  made,  in  order  to  verify  the  exact  site  of  a  lesion.  In 
discussing  cortical  locahzalion.  Mills,  naturally  enough,  adheres  to 
his  own  well-known  views  regarding  an  independent  sensory  area, 
hut  makes  reference  to  the  views  of  his  opponents.  He  also  decides 
that  the  evidence  is,  on  the  whole,  in  favor  of  setting  apart  a  special 
naming  centre,  and  he  would  place  it  in  the  third  temporal  convolu- 
tion. The  encyclopedic  character  of  the  book  is  brought  out  in  this 
chapter  by  the  publication  of  many  facts  which  the  student  o(  neurolo- 
gy IS  anxious  lo  have,  but  would  not  know  where  else  to  And;  such 
as  the  average  brain  weight  of  the  insane,  the  recorded  "brain  weights 
of  eminent  men,"  and  the  like. 

Encephalic  circulation  and  the  vascular  disturbances  and  diseases 
of  the  brain  are  described  in  a  masterly  manner  in  Chapter  V,.  It  is 
interesting  jo  compare  tne  table  of  dilTcrential  diagnosis  between 
hemorrhage,  thrombosis  and  embolism,  as  given  by  Mills,  with  one 
published  almost  simultaneously  by  von  Monakow.  In  the  main  they 
agree.  Mills  lays  stress  upon  the  pupillary  symptoms;  Von  Monakow 
scarcely  mentions  them;  but  the  latter  refers  in  greater  detail  to  the 
psychic  phenomena  preceding  and  following  the  attack,  which  Mills 
treats  less  elaborately. 

The  section  on  tumors  of  the  brain,  encephalitis,  cerebral  paralysis 
of  children  and  aphasia  show  the  author's  intimate  acquaintance  with 
each  special  subject.  The  various  forms  of  encephalitis  are  given  with 
as  much  detail  as  the  present  state  of  our  knowledge  permits;  but  in 
this,  as  in  almost  all  other  subjects,  the  reader  will  find  that  the  au- 
thor has  kept  a  close  watch  on  medical  progress,  without  exhibiting 
an  undue  fondness  for  theories  that  have  not  been  sufficiently  sub- 
stantiated. In  writing  upon  aphasia.  Mills  is  actuated  by  a  spirit  of 
fairness  to  those  who  do  not  accept  his  frequently  expressed  views. 
He  reiterates  his  belief  in  a  special  motor  graphic  center,  but.  at  the 
same  time,  does  full  justice  to  the  views  of  Dejerine,  Wernicke,  and 
others.  The  clinical  relations  of  aphasia  to  other  paralytic  phenomena 
Hre  brought  out  more  distinctly   than  by  the  majority  of  writers  on 

In  Chapters  VII.  to  X.  the  affections  of  the  special  senses  are 
described  in  connection  with  all  other  cranial  nerve  diseases.  We  say 
advisedly  that  we  know  oi  no  oiner  book  in  any  language  in  which 
this  part  of  the  subject  has  been  treated  with  equal  thoroughness. 
Diseases  of  the  auditor'-  and  optic  nerves  are  explained  in  such  a  way 
that,  we  trust,  oculists  and  aurists  will  regard  this  part  of  Mills'  treat- 
ise as  a  work  especially  -esigned  for  them.  We  commend  once  more 
the  satisfactory  n  anner  in  which  the  author  has  described  these  dis  ases 
always  prefacing  the  description  of  disease  by  a  thorough  account  of 
the  anatomy  of  the  perinheral   sense  organ   or  nerve  and  its  central 


BOOK  REVIEWS.  2<^J 

But  there  are  other  features  about  this  work  which  will  stamp  it 
as  one  of  unusual  excellence.  The  style  is  terse  and  clear  throughout. 
The  illustrations  are  good  and  abundant,  and  there  is  a  bibliographic 
index  which  might  well  be  called  "  The  Index  Medicus"  for  neurolo- 
gists. We  realize  the  stupendous  labor  bestowed  upon  the  preparation 
of  this  work,  and  it  is  evidently  planned  and  executed  with  the  utmost 
deliberation.  We  rejoice  heartily  in  the  publication  of  this  treatise, 
which  will  be  not  only  a  lasting  credit  to  its  author,  but  will  help  to 
place  the  study  of  nervous  diseases  upon  a  higher  plane.  We  shall 
await  anxiously  the  appearance  of  the  second  volume. 

B.  Sachs. 

The  Bui^i^etin  of  the  Ohio  Hospitai,  for  Epileptics.     Gallipolis^. 
Ohio,  January,  1898. 

To  Ohio  belongs  the  credit  of  having  been  the  first  State  in  the 
Union  to  establish  a  special  hospital  for  e-^ileptics.  The  management 
shows  a  progressive  spirit  in  attempting,  over  and  above  the  mere  care 
and  treatment  of  the  inmates,  to  conjoin  with  the  good  work  done 
there  scientific  investigation  as  to  the  causes  of  epilepsy.  It  must  be 
through  long-continued  effort  of  pathological  chemists  in  well-equip- 
ped laboratories  that  important  discoveries  will  be  made,  which  some 
day  will  elucidate  the  problems  of  epilepsy  and  indicate  better  means  of 
cure  than  we  now  possess.  We  are  glad  to  see  that  the  Ohio  institu- 
tion is  fully  alive  to  the  opportunities  afforded  it  by  the  vast  material 
at  its  disposition.  The  work  of  the  special  pathologist.  Dr.  Ohlmacher. 
as  presented  in  this  Bulletin,  is  to  be  commended  for  thoroughness  and 
precision.  The  first  forty  pages  are  taken  up  with  the  minute  details  of 
autopsies  upon  six  patients.  He  paid  especial  attention  to  the  condi- 
tion of  the  thymus  gland  in  these  cases,  finding  four  instances  of  per- 
sistent or  enlarged  thymus,  and  makes  the  relation  of  thymic  hyperplasia 
to  epilepsy  the  subject  of  a  second  article  in  the  same  number  of  the 
Bulletin.  In  his  conclusions  Dr.  Ohlmacher  says  that  these  morpho- 
logical anomalies  of  the  thymus  observed  in  his  cases  of  epilepsy,  and 
which  have  also  been  noted  in  thymic  asthma,  thymic  sudden  death 
and  possibly  exophthalmic  goitre,  will  be  found  to  have  something; 
more  than  an  accidental  relation.  We  trust  that  he  will  continue  his 
researches  in  this  direction,  and  that  others  engaged  in  similar  work 
will  follow  up  the  new  clue  in  the  attempt  to  unravel  the  secrets  of  this 
obscure  condition.  ' 

Dr.  Rutter,  the  superintendent,  devotes  a  few  pages  of  the  Bulletin 
to  "Colony  Care  of  the  Epileptic."  We  are  afraid  that  from  the  first 
the  management  of  the  Gallipolis  institution  has  not  kept  in  mind  the 
true  Colony  system.  Beginning  with  but  125  acres  of  land  there  have 
been  added  only  125  acres  since — ^an  acreage  too  small  for  the  number 
of  patients  already  in  the  hospital.  The  plan  adopted  was  originally 
that  of  a  pavilion-asylum — pot  a  colony  at  all.  It  consisted  of  stone- 
buildings,  each  for  fifty  patients,  symmetrically  arranged  about  an  ad- 
ministration building  and  connected  by  tunnels  with  central  power 
house,  kitchen  and  bakery,  and  flanked  by  two  congregate  dining 
rooms,  one  for  each  sex.  The  group  was  planned  for  1,000  patient©. 
While  there  has  been  some  modification  of  the  original  plan,  Dr.  Rut- 
ter^s  description  reads  as  follows: 

"The  buildings  will  then  consist  of  eleven  residence  cottages  with 
from  fifty  to  seventy-six  beds  each;  one  IsiXindry-cottage  for  seventy-five- 
resident  patients;  one  cottage  for  the  insane  with  a  capacity  of  two  hun-- 
4red,"  etc. 

The  italicization  of  the  word  "cottage"  by  the  reviewer  is  merely - 
to  indicate  an  apparently  wrong  use  of  the  word.     Surely  one  cannot 
designate  as  cottages  buildings  accommodating  from  fifty  to  two  hun— 


298  BOOK  REVIEWS. 

dred  patients!  The  same  misinterpretation  of  the  mcanii 
is  evident  in  the  misconceplion  of  the  term  colony  by  Dr 
Ohio  institution  is  not  a  colony.  It  is  a  special  hospital 
on  the  pavilion  plan,  and  seems  to  present  none  of  the  fi 
distinguish  Bielefeld  and  the  institution  at  Sonyea,  N,  Y 
in  the  true  sense  of  the  term.  The  Gallipolis  Hospital  I 
does  not  differ  essentially  from  the  asylums  at  Toledo  or 
as  regards  structural  arrangement.  We  emphasize  this  n 
there  is  a  vast  difference  between  an  asylum  or  pavilion-h 
village-community  or  colony.  We  emphasize  it  not  wii 
carping  criticism,  but  with  the  hope  that  the  managemen 
institution  may  yet  be  able  to  modify  the  scheme  of  its  de 
accordance  with  the  ideals  of  the  colony  system.  F. 


BOOKS  RECEIVED. 
"A  Compendium  of  Insanity,"  illustrated,  by  John  B.  C 
LL.D.    W.  B.  Saunders.  Phila. 

"  The  Surgical  Complications  and  Sequels  of  Typhoi 
William  M.  Keen,  M.D.,  LL.D.    W.  B.  Saunders,  Phila 

"Atlas  of  Methods  of  Clinical  Investigation  with  ar 
Clinical  Diagnosis  and  of  Special  Pathology  and  Treatmei 
Diseases,"  by  Christfried  Jakob,  M.D.;  translated  by 
Eshner,  M.D.    W.  B.  Saunders,  Phila. 

"A  Modern  Patholgical  and  Therapeutical  Study  of 
Gout,  Rheumatoid  Arthritis  and  Allied  Affections,"  by 
M.D. 

"  Mechano-Therapy  and  Resistance  Movements  in  tl 
of  Heart  Disease,"  by  Thos.  S.  Dowse,  M.D.,  F.R.C.P. 
&  Co.,  Bristol,  Eng. 


I'. 


i 


! 


300  If.  i-  WORCESTER. 

About  four  weeks  before  admission  she  began  to  com- 
plain of  numbness  in  her  hands.  She  manifested  no  diffi- 
culty in  using  them  until  about  a  week  ago.  On  the  gth 
inst.  she  spilled  some  medicine  she  was  trying  to  take,  and 
from  that  time  on  used  her  hands  but  little.  Two  days 
later  she  seemed  completely  paralyzed  in  all  the  extremi- 
ties. The  paralysis  was  considered  by  her  physician  to  be 
merely  a  hypochondriacal  delusion,  and  she  was  said  to 
have  been  noticed  to  make  movements  when  not  watched. 

Among  other  sedatives,  small  doses  of  sulphonal  and 
trional  had  been  given,  but,  according  to  her  physician's 
statement,  he  had  prescribed  nothing  of  the  sort  for  some 
weeks  before  her  admission. 

The  patient  had  suffered,  some  years  previously,  from 
paralysis  of  the  left  facial  nerve,  from  which  she  had  only 
partially  recovered. 

No  history  of  insanity  in  the  ancestry  was  obtained,  but 
a  son  of  the  patient  is  an  epileptic  idiot. 

On  admission  the  patient  was  found  to  be  a  slender 
woman,  not  markedly  emaciated.  No  evidence  of  disease 
of  the  thoracic  or  abdominal  viscera  was  found  on  physical 
examination.  There  was  a  moderate  degree  of  paralysis 
of  the  left  facial  nerve;  the  eye  could  not  be  completely 
closed,  and  the  innervation  of  the  mouth  was  inferior  to 
that  of  the  right  side.  Otherwise,  the  movements  of  the 
facial  muscles  seemed  unimpaired.  There  was  apparently 
almost  complete  paralysis  of  all  the  extremities.  •  On 
passive  motion  they  fell  into  positions  determined  entirely 
by  gravity.  In  all  the  extremities  the  paralysis  seemed 
to  increase  in  intensity  toward  the  trunk.  The  fingers 
and  toes  could  be  moved  a  little;  the  hands  and  feet  very 
slightly;  arms  and  forearms,  legs  and  thighs,  not  at  all. 
In  respiration  the  diaphragm  alone  was  active. 

The  pupils  reacted  normally  to  light.  Knee  jerks 
could  not  be  elicited.  There  was  no  response  to  tickling 
the  soles  of  the  feet. 

The  reaction  to  the  faradic  current  was  very  slight  in 


A  CASE  OF  LANDRY'S  PARALYSIS. 


30  r 


the  hands  and  forearms,  feet  and  legs,  of  both  sides.  Re- 
action was  less  on  the  right  than  the  left  side.  The  ulnar 
and  iTiedian  nerves  were  less  excitable  than  the  muscles 
supplied  by  them.  No  reaction  at  all  could  be  obtained 
by  the  full  power  of  the  (rather  weak)  battery  in  thighs, 
upper  arms  or  pectoral  muscles.  The  galvanic  battery 
^vas  found  not  to  be  in  working  order. 

There  was  great  impairment  of  sensation,  correspond- 
ing: in  distribution  to  the  motor  paralysis.    The  head  and 
*^ce  seemed  entirely  unaffected.     On  the  hands  and  feet 
^^uch,  pain   and  temperature  were  fairly  well  felt  and 
^caBzed;  on  the  forearms  and  legs,  there  was  very  marked 
^Pairment  of  all  forms  of  sensation;  on  the  upper  arms 
^   thighs,  only  very  firm  pressure  could  be  felt,  and  a 
^^  ^ould  be  thrust  through  a  fold  of  the  skin  without  her 
^    ^^ring  to  notice  it  at  all,  although,  when  questioned, 
^  ^^id  it  felt  like  something  sticking  in.     Over  the  ab- 
^'Ot^cn,  transfixion  of  a  fold  of  skin  felt  like  something  hot. 
The  visual  fields  were  not  narrowed,  and  there  seemed 
to  be  no  impairment  of  any  of  the  special  senses. 

Mentally,  the  patient  seemed  rather  apathetic.  She 
answered  questions  relevantly,  and,  so  far  as  could  be  de- 
termined, correctly,  but  seldom  spoke  otherwise.  Mem- 
ory appeared  rather  poor.  There  was,  at  the  time  of  the 
examination,  no  appearance  of  hypochondriacal  delusions, 
or  of  a  disposition  to  exaggerate  her  symptoms. 

A  specimen  of  her  urine  attracted  attention  at  once 
by  its  peculiar  appetirance.  It  was  of  a  claret  color,  very 
different  from  that  usually  imparted  by  blood;  acid  in 
reaction;  contained  a  trace  of  albumin  and  a  few  hyaline 
casts. 

No  change  was  noticed  in  her  condition  during  the 
night  of  the  15th.  At  9.30  of  the  morning  of  the  i6th 
she  asked  for  the  bed-pan,  in  order  to  have  a  movement 
of  the  bowels.  Immediately  afterward  the  nurse  noticed 
a  change  for  the  worse.  A  physician  was  called  at  once, 
but  when  he  reached  the  ward  respiration  had  ceased, 
although  the  heart  was  still  beating. 


302 


.  L.  WORCESIER. 


At  the  autopsy,  five  hours  after  death,  no  lesion  of 
the  nervous  system  could  be  discovered.  The  only  mor- 
bid appearances  found  were  slight  emphysema  and  a  ca- 
tarrhal condition  of  the  gastric  mucous  membrane. 

The  results  of  the  liistological  examination  were  as 
follows : 

Cerebrum. — The  only  changes  noted  were  in  the  large 
nerve-cells,  characteristic  of  the  excitable  region  of  the 
cortex.  A  large  proportion  of  these  presented  a  swollen 
appearance,  giving  the  impression  of  the  deposit  of  a  mor- 
bid material  in  their  interior.  In  specimens  stained  by 
the  Nissl  method  the  marking  was  confined  to  the  surface 
and  the  processes  of  the  cells.  Both  in  these  specimens 
and  in  those  hardened  in  bichromate  solution  and  stained 
with  carmine,  the  nuclei  of  these  cells,  were  displaced, 
either  into  one  of  the  processes,  or  to  the  surface  of  the 
cell,  in  which  latter  case  they  often  projected  beyond  the 
surface.  These  changes  are  familiar  enough  to  all  who 
have  done  such  work  with  the  Nissl  method,  and  are  ob- 
served in  a  variety  of  morbid  conditions.  No  morbid  al- 
terations were  detected  in  the  other  regions  of  the  brain 
examined,  and  the  nerve  fibres,  in  specimens  stained  by 
Pal's  method,  appeared  normal. 

Medulla  Oblongata. — Sections  at  different  levels, 
stained  by  Pal's  and  Van  Gieson's  methods,  appeared  nor- 
mal. 

Spinal  Cord. — Sections  from  the  lumbar  enlargement, 
stained  by  Nissl's  method,  showed,  in^  considerable  num- 
ber of  the  large  cells  of  the  anterior  horns,  an  apparent 
breaking  up  of  the  colored  substance  in  the  interior  of 
the  cells  into  fine  granules.  A  few  cells  presented  changes 
similar  to  those  described  in  the  brain.  Side  by  side  with 
these  were  numerous  cells  that  appeared  entirely  normal. 
Sections  from  various  parts  of  the  cord  stained  by  the 
Marchi  method  showed  a  few  degenerate  fibres,  but  not 
enough  to  account  for  any  serious  symptoms. 

Specimens  hardened  in  bichromate,  and  stained  with 


A   CASE  OF  LANDRY'S  PARALYSIS. 


303 


carmine  and  by  Pal's  and  Van  Gieson's  methods,  presented 
no  abnormal  appearances. 

Peripheral  Nerves. — The  sections  of  the  nerve  roots 
made  in  connection  with  those  of  the  spinal  cord  appeared 
normal  by  all  the  methods  of  staining  employed.  Speci- 
mens from  a  cord  of  the  lumbar  plexus  and  the  right  radial 
nerve  were  prepared  by  Marchi's  method.  A  few  varicose 
nerve  fibres  stained  faintly  with  the  osmic  acid,  but  there 
was  no  appearance  of  segmentation  of  myelin. 

Specimens  from  the  radial  nerv^e  and  several  muscular 
branches  were  preserved  in  solution  of  osmic  acid  and  dis- 
sociated. Many  of  the  fibres  showed  much  varicose  swell- 
ing, but  no  segmentation  of  myelin  was  found. 

Kidney. — The  only  abnormality  found  was  an  apparent 
flattening  of  the  epithelium  of  the  convoluted  tubules. 

We  have  here  a  rapidly  developing  motor  and  sensory 
paralysis,  the  former  predominating,  affecting  the  muscles 
of  the  trunk  and  extremities,  and  sparing  those  of  the 
head  and  face,  proving  fatal,  apparently,  by  arrest  of  res- 
piration.   Concurrently  with  this  was  observed  a  peculiar 
<^olor  of  the  urine,  attributed  by  her  physicians  to  blood. 
The   urine  contained  no  blood  corpuscles  at  the  time  of 
"^y   examination. 

It  seems  to  me  improbable  that  this  is  a  mere  coinci- 
dence. The  history  of  the  case  is  suggestive  of  a  toxic 
process,  and  it  seems  probable  that  the  change  in  color 
^f  the  urine  was  indicative  of  a  morbid  condition  of  the 
Mood.  I  at  once  suspected  porphorinuria  from  sulphonal 
intoxication,  but  was  unable  to  learn  that  she  had  taken 
more  than  a  few  doses  of  sulphonal  and  trional,  some  time 
before  the  symptoms  referred  to  made  their  appearance. 

The  anatomical  lesions  found,  though  they  may,  per- 
'iaps,  be  brought  into  connection  with  the  symptoms,  do 
^^t  seem  to  me  to  account  for  them  satisfactorily.     From 
^^^-  fact  that  stimulation  of  the  muscles  supplied,  for  in- 
stance, by  the  ulnar  nerve,  produced  stronger  contractions 
^Han  stimulation  of  the  nerve  itself,  it  seems  evident  that 


304 


fV.  L.  WORCESTER. 


the  lesion  could  not  have  been  confined  to  the  central 
nervous  system,  but  that  the  nerves  must,  at  least,  have 
participated  in  it.  The  fact  that  both  motion  and  sensa- 
tion were  involved  over  the  same  area  would  point  in  the 
same  direction.  Yet  no  unequivocal  morbid  appearances 
could  be  found  in  the  nerve' roots  or  their  peripheral  dis- 
tribution. 

The  question  of  classification  now  presents  itself,  and 
is,  to  me,  a  rather  perplexing  one.  So  far  as  I  have  been 
able  to  discover,  the  only  commonly  recognized  form  of 
nervous  disease  to  which  the  case  can  be  referred  is  that  to 
which  reference  has  already  been  made — the  acute  ascend- 
ing paralysis  described  by  Landry.  The  description  of 
this  disease  given  in  all  the  text-books  to  which  I  have 
access  agrees  with  the  definition  given  in  Gould's  Medical 
Dictionary,  which  I  will  quote:  "A  form  of  atonic  paraly- 
sis, described  by  Landry,  characterized  by  a  loss  of  motor 
power  in  the  lower  extremities,  gradually  extending  to 
the  upper  extremities  and  to  the  centres  of  circulation 
and  respiration,  without  characteristic  sensory  manifes- 
tations, trophic  changes,  or  variations  in  electrical  re- 
action." 

It  is  at  once  evident  that,  if  all  parts  of  the  foregoing 
definition  are  considered  essential,  my  case  is  excluded 
by  the  very  pronounced  impairment  of  both  sensation  and 
electrical  excitability, 

Walton,  in  a  paper  published  in  the  Boston  Medical  aitd 
Surgical  Journal,  December  26,  1895,  takes  the  ground 
that  Landry's  paralysis  is  really  a  multiple  neu- 
ritis. He  analyzes  the  published  cases  in  regard  to  sensa- 
tion and  electrical  reaction,  and  finds  that,  among  122 
cases,  disturbances  of  sensation  were  reported  in  74,  and 
that  only  in  16  was  it  definitely  stated  that  sensation  was 
unimpaired. 

In  a  large  number  of  the  reported  cases  the  electrical 
reactions  were  not  ascertained,  but  reaction  of  degenera- 
tion was  found  in  a  considerable  number.    Out  of  the  122 


A  CASE  OF  LANDRY'S  PARALYSIS. 


305 


cases  analyzed  by  Walton,  only  five  were  found  in  which 
sensation  and  electrical  reaction  were  both  stated  to  be 
normal.  It  is,  therefore,  apparent  that  if  the  above  defini- 
tion is  to  be  considered  authoritative  in  all  particulars,  a 
large  proportion  of  the  reported  cases  are  incorrectly  as- 
signed to  this  disease. 

Walton  proposes  the  following  description: 

"Landry's  paralysis  is  an  acute,  toxic  disease,  charac- 
terized by  rapid  loss  of  power  in  the  lower  extremities, 
trunk,  and,  to  a  less  degree,  in  the  upper  extremities,  af- 
fecting also  the  vagus  and  phrenic,  sometimes  other  cranial 
nerves.  The  affected  muscles  are  lax.  Pain,  paraesthesia, 
anaesthesia  and  tenderness  are  generally  present  in  vary- 
ing degrees,  though,  in  some  cases,  sensory  disturbances 
are  wanting.  Death  follows  in  more  than  half  (64^)  of 
the  cases.  Recovery,  when  present,  is  very  slow.  The  re- 
flexes, deep  and  superficial,  are  lost  at  an  early  stage;  wast- 
ing and  degenerative  reaction  appear  if  the  patient  sur- 
vives. The  process  is  a  toxic  affection  of  the  peripheral 
nerves  (neuritis),  cord  and  brain,  the  former  being  the 
essential  and  persistent  lesion." 

My  own  case  would  come,  easily  enough,  under  the 
foregoing  definition.  It  is  true  that  the  lesions  charac- 
teristic of  multiple  neuritis  were  not  found  in  the  nerves, 
but  the  electrical  reaction^  already  mentioned,  proves  con- 
clusively, to  myself,  that  their  function  was  impaired,  and 
it  is  quite  possible  that  the  case  had  not  lasted  long  enough 
for  the  development  of  the  characteristic  lesions. 

That  the  case  was  of  toxic  origin  can,  I  think,  hardly 
be  doubted.  The  nature  of  the  poison  is,  unfortunately, 
obscure,  but  it  seems  reasonably  certain  that  it  was  in 
some  way  connected  with  the  peculiar  color  of  the  urine, 
which  made  its  appearance  at  about  the  same  time  with 
the  paralysis.  It  seems  altogether  unlikely  that  this  is  the  ^ 
first  or  last  case  of  this  kind,  and  it  is  to  be  hoped  that 
some  future  observer  will  be  more  fortunate  than  I  in  this 
particular. 


GLIA  AND  GLIOMATOSIS. 
Bv  SIMON   FLEXNER,  M.D., 

Professor  of  Pathology  in  the  John  Hopkini  University. 

Abstract   of   remarks    made    before    the    Philadelphia    Neurological 
Society,  Feb.  28th,  1898. 

Embryologists  and  histologists  have  by  their  recent 
work  prepared  the  way  for  a  reconsideration  of  the  patho- 
logical features  relating  to  the  neuroglia.  They  have 
shown  that  the  "connective  tissue"  of  the  brain — to  use 
the  term  in  its  old  signification — is  an  ectodermal  struc- 
ture, that  its  blastodermic  precursor  is  the  same  as  for  the 
nerve  cells;  that  it  is  less  profoundly  specialized,  less  highly 
differentiated  than  the  nerve  cells,  and  that  it  subserves  a 
more  humble  purpose  than  these.  The  histologist  en- 
counters neuroglia  in  its  several  phases  as  it  passes  from  its 
embryonic  to  its  adult  state,  while  the  pathologist  meets 
with  it  in  the  developed  body  under  hardly  less  protean 
conditions.  A  complete  knowledge  of  the  histology  and 
histogenesis  of  neuroglia  must  embrace  all  the  conditions 
— normal  and  pathological — which  have  been  observed. 
To  the  pathologist  such  a  complete  knowledge  must  be 
of  the  first  importance,  since  upon  it  will  depend  his  con- 
ception of  the  origin  and  the  nature  of  a  group  of  new 
growths  occurring  within  the  central  nervous  system. 

In  order  that  the  pathological  facts  which  I  wish  to 
bring  before  you  may  be  presented  in  the  light  in  which 
they  appear  to  me,  I  shall  be  obliged  to  ask  your  attention 
to  a  brief  account  of  the  histogenesis  of  neuroglia,  which, 
for  our  present  purposes,  can  be  best  investigated  in  the 
spinal  cord.  The  cells  destined  to  become  glia  are  de- 
rived in  the  embryo  from  the  medullary  plate,  and  are  at 
first  of  the  same  value  as  the  elements  which  eventually 


GLIA  AND  GLIOMATOSIS.  307 

produce  nerve  cells.  The  possibility  that  cells  of  other 
values,  leucocytes  and  endothelial  cells,  may,  at  a  later 
period,  become  interpolated  between  the  elements  of  ecto- 
dermal origin,  and,  under  certain  pathological  conditions, 
act  as  tissue  formers,  while  admitted  by  so  good  an  au- 
thority as  Ramon  y  Cajal,  have  been  shown  to  be  im- 
probable by  the  researches  of  Schaflfer  and  v.  Lenhossek. 

The  glia  cells — or,  to  use  the  term  proposed  by  Fish 
in  this  country  and  v.  Lenhossek  in  German,  astrocytes — 
take  their  origin  in  the  lowest  and  highest  vertebrates 
from  the  ependyma  cells,  which  are  now  known  to  belong 
to  the  supporting  cell  structures  of  the  cord.  In  certain 
low  forms  (myxine,  amphioxus)  the  ependyma  cells  repre- 
sent the  total  of  the  supporting  cells,  while  in  the  higher 
forms  greater  or  less  numbers  of  astrocytes  supply  the 
chief  framework  of  the  organ.  In  mammals,  and  especially 
in  man,  astrocytes  may,  it  is  considered  by  some,  develop 
from  a  less  highly  differentiated  cell  than  ependyma  cells, 
which  yield  them  exclusively  in  the  lower  forms.  It  is 
proposed  to  call  the  intermediate  cells  (undeveloped  forms) 
astroblasts. 

The  several  different  forms  of  glia  cells,  those  possess- 
ing long  processes,  those  provided  with  short  processes 
(typical  astrocytes),  and  still  others  in  which  the  filaments 
come  off  from  one  or  both  poles  only  (brush  cells),  as 
well  as  the  true  ependyma  cells,  have  all  the  same  ultimate 
origin.  Since  Weigert's  publication  in  1890,  and  more 
especially  since  the  appearance  of  his  monograph  on  neu- 
roglia, much  attention  has  been  given  to  the  relation  ex- 
isting between  the  fibres  and  the  cells  in  neuroglia. 

The  pictures  given  by  the  Golgi's  silver  stain  seem 
to  show  a  close  union  between  processes  and  cell  bodies, 
and  to  indicate  that  the  former  are  mere  protoplasmic 
elongations  of  the  latter.  The  method  of  staining  intro- 
duced by  Weigert,  and  more  or  less  modified  by  Mallory 
and  Beneke,  would  seem  to  necessitate  a  modification  of 
these  views,  since  by  its  employment  differentiation  be- 


3o8  SIMON  FLEXNER. 

tweeii  fibres  and  cells  in  adult  neuroglia  has  been  ren- 
dered possible.  According  to  Weigert,  neuroglia,  in  hu- 
man beings,  consists  of  cells  showing,  protoplasmic  pro- 
cesses only  during  embryonic  life;  in  the  matured  or  adult 
condition,  it  is  made  up  of  a  mixture  of  cells  and  fibres, 
in  which  the  latter  so  greatly  predominate  that  they  are 
to  be  regarded  as  its  chief  constituent. 

If  we  now  turn  our  attention  to  the  subject  of  tumors 
developing  from  neuroglia,  we  have  no  difficulty  in  re- 
ferring certain  well-known  types  to  certain  forms  or  stages 
of  development  of  neuroglia.  The  spider-cell  or  Deiter- 
cell  glioma,  in  which  the  cell  processes  are  protoplasmic 
and  still  attached  to  the  cell  body,  and  those  tumors  in 
which  the  brush  celts  predominate,  agree  with  astrocytes 
in  the  condition  in  which  they  occur  during  embryonic  Hfe; 
while  such  gliomata  as  are  richer  in  fibres,  which  by  the  ap- 
plication of  the  new  staining  methods  alluded  to  are  separ- 
able into  still  further  differentiated  fibres  and  independent 
cells  devoid  of  processes,  may  be  taken  to  represent  the 
adult  neuroglia  in  human  beings.  It  is  further  probable 
that  a  tumor  corresponding  with  the  intermediate  cell, 
astroblast,  which  it  is  conceived  may  persist  in  human 
beings  as  a  simple  undifferentiated  cell,  may  also  arise. 
Such  a  tumor  would  have  features  in  common  vfith  cer- 
tain tumors  now  regarded  as  small-celled  sarcomata. 

Recently  I  have  come  into  possession,  through  the 
kindness  of  Drs.  W.  W.  Keen  and  H.  M.  Thomas  of  a 
brain  tumor  made  up  of  cells  which  resemble,  for  the  most 
part,  the  ependymal  type  of  cells  found  in  the  human 
embryonic  spinal  cord,  and  present  in  certain  animal  forms 
throughout  the  whole  lifetime  of  the  species.  These  cells 
are  arranged  in  a  radial  manner  around  blood  vessels,  to- 
ward which  their  protoplasmic  prolongations  are  directed. 
The  processes  come  together  just  before  the  vessel  wall 
is  reached,  giving  rise  to  a  minute  space  between  them 
at  their  points  of  junction  and  the  walls  of  the  vessels.  I 
am  of  the  opinion  that  these  cells  probably  agree  with 


GUA  AND  GLIOMATOSIS.  309 

early  ependymal  cells,  and  that  the  tumor  is  to  be  regarded 
as  a  form  of  ependymal  glioma.  Although  such  a  tumor 
has  not  yet  certainly  come  to  my  notice,  it  is  conceivable 
that  the  fully  developed  or  adult  ependymal  cells  may 
also  gpive  rise  to  tumors  whose  appearances  would  be  dif- 
ferent from  the  several  forms  already  described. 

The  tumor  formation  in  syringomyelia  may  not  im- 
probably be  found  to  agree  with  one  or  the  other  of  the 
types  described.  Indeed,  in  a  case  which  I  have  seen 
recently  the  tumor  mass  was  composed  largely,  if  not  ex- 
clusively, of  cells  of  an  early  ependymal  type.^ 

Finally,  the  tumors  of  the  retina,  which  agree  in  so 
many  ways  with  the  gliomata  of  the  brain  and  cord,  are 
capable  of  a  similar  classification.  There  is  less  that  is  re- 
markable in  this  statement  when  it  is  remembered  that 
the  retina  is  histologically  as  well  as  embryologically  brain 
substance.  Tumors  consisting  of  astrocytes  (spider  cells) 
are  known  to  develop  from  the  retina;  simpler  and  less 
highly  developed  gliomata,  perhaps  of  astroblastic  origin, 
are  more  common  still;  while  tumors  composed  of  cells 
which  resemble,  or  are  identified  with,  the  cells  of  the 
layer  of  rods  and  cones  (neural  epithelium),  of  which  I 
described  the  first  specimen  in  1891,  have  now  become 
generally  recognized.  The  layer  of  rods  and  cones  agrees 
histogenetically  with  the  epithelium  lining  the  central 
canal  of  the  spinal  cord  and  the  ventricles  of  the  brain; 
it  is,  therefore,  modified  ependyma.  If  the  rods  and  cones 
are  regarded  in  the  light  of  their  embryological  origin  and 
histological  relations,  then  the  tumors  composed  of  them 
are  ependymal-celled  gliomata;  if,  however,  they  are  re- 
garded in  the  light  of  the  physiological  functions  which 
they  perform,  in  which  they  behave  as  neural  epithelium, 
then  these  tumors  may  properly  be  denominated  neuro- 
epitheliomata.^ 


*  This  case  occurred  in  the  practice  of  Dr.  Hudson,  of  La  Fayette, 
Ala.,  who  will  soon  publish  it  in  detail. 

*  See  Flexner,  The  Johns  Hopkins  Hospital  Bulletin,  1891. 


Ctintcal  ®»8ts. 


DOUBLE  OPHTHALMOPLEGIA  CHRONICA  EX- 
TERNA. 

Reported  from  the  Clinic  of  Prof.  M.  Allen  Starr,  College  of  Phy- 
sicians and  Surgeons,   New  York.      By   Frederick 
Peterson,  M.  D.,  Chief  of  Clinic. 

The  following  is  the  clinical  history  of  a  case  of  chronic 
external  ophthalmoplegia,  recently  observed  at  the  Van- 
derbilt  Clinic,  the  notes  having  been  taken  by  Dr.  Good- 
hart  and  the  writer: 

W.  A.  G.,  male,  born  in  1872,  single,  came  to  the  clinic 
complaining  of  weakness  in  his  legs  and  inability  to  use 
his  right  hand  in  writing.  He  said  that  after  walking  a 
short  distance  his  legs  became  exceedingly  fatigued.  His 
employment  as  a  clerk  had  been  interfered  with  of  late 
because  of  tremor  in  his  right  hand,  so  that  since  August 
last  he  had  had  to  give  up  writing  altogether.  He  still 
keeps  his  position,  and  is  a  weighing-clerk  in  a  coal  office. 

There  is  nothing  in  the  family  or  personal  history  in- 
dicative of  hereditary  taint  or  predisposition  to  neuroses. 
He  has  never  had  syphilis.  He  has  always  been  temperate, 
even  abstemious,  as  regards  alcohol,  tobacco  and  venery. 
His  birth  was  normal,  though  protracted.  A  younger 
brother,  the  only  other  child  in  the  family,  is  living  and 
well.  In  early  childhood,  before  the  age  of  five  years,  he 
had  diphtheria,  measles  and  whooping-cough,  from  which 
he  recovered  fully.  His  early  mental  and  physical  develop- 
ment was  normal.  He  attended  school  until  the  age  of 
18  years,  and  received  a  good  common  school  education. 
About  the  age  of  5  years  the  patient  received  a  blow  in 
the  neighborhood  of  the  left  ear,  which  left  a  small  scar. 
.\t  the  age  of  12  years  he  had  what  seems  to  have  been  an 
enlarged  suppurating  gland  below  the  left  ear,  back  of 
the  ramus  of  the  jaw.     There  was  a  discharge  for  some 


Fig,  it 


Case  of  ophthalmoplegia  externa  at   present,   showing  marked  ptosis 
and  over-action  of  occipito- frontal  is.     Facies  expressive  of  mental 


DOUBLE  OPHTHALMOPLEGIA  CHRONICA  EXTERNA, 


3" 


time,  and  a  scar  remains  at  the  site  indicated.  There  was 
a  discharge  a1)out  the  same  time  from  the  left  ear.  He  is 
completely  deaf  in  the  left  ear,  and  the  drum  is  absent. 
Shortly  after  this  a  slight  drooping  of  the  left  eyelid  was 
noticed,  and  later  of  the  right.  Gradually,  from  this  time 
on,  movements  of  the  eyes  became  impaired,  but  neither 
the  patient  nor  the  family  can  give  the  order  of  affection 
of  the  various  muscles.  The  patient  asserts,  however,  that 
he  never  had  diplopia,  and  that  he  had  never  noted  any 
particular  inconvenience  in  the  use  of  his  eyes,  save  from 
the  drooping  of  the  lids.  The  patient  says  he  was  stouter 
in  proportion  as  a  child  than  at  present,  and  that  he  felt 
much  stronger  generally  then  than  now.  He  dates  a  gen- 
eral feeling  of  weakness  which  he  has  from  the  onset  of  the 
ptosis. 

The  examination  reveals  a  slimly  built,  rather  poorly 
nourished  physique.  He  is  markedly  stoop-shouldered, 
and  the  head  is  somewhat  elevated  in  order  to  assist  his 
vision.  The  face  is  rather  immobile,  and  the  expression 
of  countenance  suggests  a  mild  degree  of  mental  weak- 
ness. The  most  striking  feature,  as  shown  in  the  photo- 
graph, is  the  marked  double  ptosis.  The  eyes  would  be 
quite  closed  were  it  not  for  the  strong  over-action  of  the 
occipito-frontalis.  All  of  the  external  muscles  of  the  eye 
supplied  by  the  3d,  4th  and  6th  nerves  are  completely 
paralyzed,  so  that  the  picture  presented  is  that  of  ophthal- 
moplegia chronica  externa.  The  irides  are  not  involved 
in  the  paralysis,  and  react  normally  to  light  and  accommo- 
dation. The  pupils  are  equal.  A  peculiarity  noticed  when 
a  strong  light  is  thrown  upon  the  pupils  is  a  rapidly  alter- 
nating contraction  and  dilatation  (hippus).  Dr.  Carter  of 
the  Eye  department  reports  field  of  vision  normal,  myopia, 
and  posterior  staphyloma.  Vision,  R15/40 — 1D15/30. 
L15/100— 1D15/40. 

With  the  exceptions  mentioned,  all  of  the  cranial  nerves 
are  normal.  Sensation  of  all  kinds  is  unimpaired  over  the 
whole  body.    The  tendon  reflexes  of  the  upper  extremities 


312 


FREDERICK  PETERSON. 


are  normal,  perhaps  somewhat  hypertypical  on  the  right 
side.  The  patellar  reflexes  are  hypertypical,  and  there  is 
shght  ankle  clonus  on  both  sides.  These  reflexes  in  the 
lower  extremities  seem  to  vary  from  time  to  time  in  de- 
gree, being  more  pronounced  at  one  time  than  another. 
The  abdominal,  cremasteric  and  plantar  reflexes  are  nor- 
mal. The  sphincters  are  normal.  In  the  upper  extremi- 
ties there  is  no  marked  muscular  weakness,  though  with 
the  dynamometer  the  left  hand  is  stronger  than  the  right 
(the  patient  is  right-handed).  To  simple  tests  the  flexor 
muscles  of  the  thighs  appear  weak.  The  patient  has  no- 
ticed quick  exhaustion  and  weakness  in  his  legs  after  short 
walks  for  a  year.  Although  typical  Romberg  symptom  is 
absent,  a  peculitu-  rapid  swaying,  suggestive  of  tremor  of 
the  trunk  muscles,  is  observed  when  the  patient  stands 
with  his  eyes  closed.  The  usual  tests  reveal  considerable 
ataxic  or  intention  tremor  in  both  hands,  more  marked  in 
the  right.  There  is  a  similar  tremor  of  the  neck  muscles 
exhibited  upon  voluntary  movement  of  the  head  from  side 
to  side  or  when  bending  forward  to  take  a  drink.  The 
speech  shows  a  slight  hesitancy,  which  might  be  regarded 
as  an  approach  to  syllabic  utterance,  but  I  should  not 
call  it  sufficiently  typical  to  be  designated  as  "scanning 
speech."  The  tremor  of  the  right  hand  has  interfered  with 
his  penmanship  only  since  August,  1897.  He  has  never 
had  any  pain  in  his  head,  trunk  or  extremities.  He  has 
never  suffered  from  vertigo,  nausea  or  vomiting. 

I  have  seen  photographs  of  the  patient  at  various  ages. 
The  ptosis  first  showed  itself  in  mild  degree  at  the  age  of 
12  years.  Previous  to  this  age  the  appearance  of  the  face 
and  eyes  is  normal. 

Remarks. — Since  von  Graefe,  in  1856,  first  described 
the  syndrome  known  as  ophthalmoplegia  externa,  over 
300  cases  have  been  reported  in  literature,  many  with  au- 
topsies. The  pathological  process  underlying  the  disorder 
is  not  uniform.  Peripheral  lesions  of  the  oculo-motor 
nerves,  tumors  at  the  roots  of  these  nerves,  and  growths 


DOUBLE  OPHTHALMOPLEGIA  CHRONICA  EXTERNA. 


313 


or  softenings  in  the  quadrigeminal  region  may  present  a 
similar  clinical  picture.  Furthermore,  acute  or  chronic 
nuclear  lesions  are  frequently  at  the  basis  of  an  ophthal- 
moplegia, and  to  this  class  of  cases  the  term  polioenceph- 
alitis' superior  has  been  applied,  because  of  the  homology 
between  some  of  the  cases  and  cases  of  poliomyelitis.  In 
acute  lesions  some  ependymitis  with  punctate  hemorr- 
hages in  the  gray  matter  of  the  floor  of  the  aqueduct  of 
Sylvius  has  been  found.  The  chronic  form  of  ophthalmo- 
plegia, to  which  the  case  just  described  belongs,  is  ob- 
served as  an  associated  symptom  in  some  of  the  chronic 
degenerative  diseases  of  the  nervous  system,  like  tabes  and 
general  paresis.  The  chronic  form  is  also  met  with  in  cer- 
tain toxic  dyscrasias  (syphilis,  diabetes,  diphtheria,  etc.). 
It  is  rather  the  rule,  at  least  in  the  early  stages,  for  the  pu- 
pillary reactions  to  remain  normal  in  chronic  ophthalmo- 
plegia dependent  upon  dyscrasias  or  focal  lesions;  where- 
as the  internal  muscles  of  the  eye  soon  suffer  in  tabes  and 
paresis.  It  is  still  doubtful  if  we  have  such  a  pathological 
entity  as  a  true  chronic  degenerative  process  affecting 
only  the  nuclei  of  the  various  oculo-motor  nerves,  inde- 
pendently of  any  disorder  elsewhere  in  the  nervous  system. 
The  case  above  reported  presents  certain  interesting 
symptoms  in  addition  to  the  ophthalmoplegia  externa  (in-  , 
tention  tremor,  increased  reflexes,  ankle  clonus,  slight 
hesitation  in  speech,  and  suggestive  dulness  of  expression), 
which  would  make  a  multiple  sclerosis  more  probable  than 
any  other  cerebral  disorder.  It  seems  to  the  writer  that 
sclerosis,  with  an  unusual  dissemination  of  the  plaques, 
would  explain  all  of  the  symptoms  exhibited. 


Critical  flgcBt. 


ON    MULTIPLE    SCLEROSIS.  WITH    ESPECIAL 
REFERENCE  TO  ITS  CLINICAL  SYMPTOMS, 
ITS  ETIOLOGY  AND  PATHOLOGY. 
By  B.  SACHS.  M.D. 

Multiple  or  disseminated  cerebro-spinal  sclerosis  has 
for  many  years  been  considered  to  be  one  of  the  most 
easily  recognizable  diseases  of  the  central  nervous  system. 
Under  the  leadership  of  Cruveilhier'  and  of  Charcot,  the 
French  school  described  the  disease  so  accurately  that 
there  appeared  to  be  little  to  add  to  the  accounts  as  given 
by  them.  The  typical  forms  are  indeed  unmistakable,  but 
thediseaseappears  so  often  under  all  sorts  of  disguises  that 
its  recognition  may  be  by  no  means  easy.  Moreover,  the 
interest  in  it  is  not  exhausted  by  the  establishment  of  the 
diagnosis,  for  it  has  important  bearings  to  other  diseases, 
and  its  etiology  and  pathology  present  many  points  tor 
further  elucidation.  In  America  the  disease  is  not  as 
frequent  as  in  France  and  in  Germany;  at  all  events,  very 
few  contributions  have  been  made  to  the  subject  by  Amer- 
ican writers,  and  up  to  the  present  time  I  have  found  but 
one  post-mortem  record,  and  that  an  incomplete  one  (by 
Seguin),  published  in  this  country.  The  time  seemed  ripe, 
therefore,  for  a  consideration  of  the  disease;  but  the  pres- 
ent writer  will  refer  only  to  the  more  important  questions 
that  have  been  raised  regarding  it  during  the  last  few 
years,  as  the  work  of  preceding  years  has  been  well  sum- 
marized in  the  publications  of  Charcot,  Marie,  Gowers, 
Oppenheim,  Dana.  Pritchard,  and  Gray. 


CRITICAL  DIGEST.  31^ 

CLINICAL  SYMPTOMS. 

The  following  table  of  symptoms,  as  given  by  Charcot, 

may  be  taken  as  a  starting  point  for  the  consideration  of 

the  symptomatology  of  multiple  sclerosis.    It  need  not  be 

said  that  all  the  symptoms  are  rarely  present,  and  that, 

according  to  the  predominencc  of  the  several  series  of 

symptoms,  the  disease  may  be  divided  into  a  spinal,  a 

cerebraJ,  and  a  cerebro-spinal  type. 

1.  Spinal  Symptom.s. 

Tremor  on  voluntary  movements  of  the  ex- 
tremities — **  Intention  tremor  "  (arms  and 
head;  more  rarely  of  legs). 

Titubation. 

Paresis  (spasmodic)  of  the  extremities. 

Contracture,  with  exaggeration  of  the  reflexes 
— spastic  rigidity. 


Positive. 


disturbance. 


No   sensory  symptoms,   or   only  very  slight 

disturbance. 
Vesical  disturbance,  none  or  very  slight. 

"   CER.E.BXAL  Symptoms. 

Dysarthria — slowness  of  speech;  scanning  of 
words. 

Nystagmus — blank  expression. 

Attacks  of  vertigo — spasmodic  myosis. 

Transitory  amblyopia — white  atrophy  of  the 
papillae. 

Diplopia — ^associated  paralysis  of  ocular  mus- 
cles. 

Mental  enfeeblement. 

Apoplectiform  and  epileptiform  attacks. 

Difficulty  in  deglutition. 

^^>^OHMAL  OR  UNUSUAL  SYMPTOMS. 

^^^^ic.  J   Muscular  atrophies  (amyotrophies),  bedsores^ 

f  Lightning  pains. 
'P  «  ^  I    Romberg  symptc  m, 

^"^^ic.  -J    Anesthetic  areas. 

Vesical  and  rectal  parei-ir. 
1   Gastric  crises. 

^^tient  remission  of  all  the  symptoms. 
^^'"cot  recognized  three  distinct  periods  in  the  de- 
velopTn^nt  of  the  disease: 

"^t"st  period.     The  disease  may  begin  with  cerebral 
sy^^'^^nis  (attacks  of  vertigo,  transitory  diplopia,  scan- 


3l6  B.  SACHS. 

iiing  speech  and  nystagmus);  more  frequently  the  spinal 
symptoms  are  the  first  (a  slowly  progressive  paresis  to 
which  intention  tremor  is  soon  added);  in  rare  instances 
there  is  an  apoplectic  attack,  preceded  by  vertigo  and 
headaches,  and  followed  by  hemiplegia.  The  rarest  of  all 
onsets  is  the  one  with  .gastric  crises,  which  are  followed  by 
other  more  characteristic  symptoms.  During;  the  second 
period  the  typical  symptoms  are  developed,  and  after  years 
contractures  set  in.  The  third  period  is  characterized  by 
mental  enfeeblement,  speech  becomes  almost  unintelli- 
gible, great  physical  weakness  is  developed,  and  finally 
there  are  vesical  troubles,  with  subsequent  cystitis,  bed- 
sores, pyemic  conditions — death.  Babinski  claimed  that 
an  ascending  acute  myelitis  was  an  occasional  cause  of 
death. 

Marie  has  insisted  upon  a  division  into  four  different 
types,  according  to  the  mode  of  progression:  i.  The 
chronic  progressive  type— a  verj-  gradual  increase  in  all 
the  symptoms  and  covering  a  period  of  years.  2.  The 
chronic  type,  with  exacerbation,  marked  by  the  occurrence 
of  hemorrhages,  sudden  amblyopia,  and  the  like.  3.  The 
chronic  remitting  type — -the  progress  is  very  slow,  with 
only  slight  exacerbations  from  time  to  time.  4,  The  type 
characterized  by  permanent  improvement  and  even  cure. 
Almost  all  of  the  chronic  disorders  of  the  nervous  system, 
tabes,  for  instance,  could  be  subdivided  in  the  same  way. 
These  divisions  do  not  appear  to  be  distinctive;  and  of  the 
type  leading  toacompletecurewehaveseeniioinstance,and 
its  existence  is  only  a  little  short  of  conjectural.  To  Char- 
cot we  owe  the  recognition  of  imperfect  forms  of  multiple 
sclerosis,  in  which  the  symptoms  that  have  existed  have 
disappeared.  In  these  abortive  forms  (formes  frustes) 
some  of  the  important  symptoms,  as  we  shall  see  later  on, 
are  never  developed,  and  in  others  the  symptomatology 
is  obscured  by  the  occurrence  of  hemiplegic,  tabic  or  of 
amyotrophic  symptoms.  Oppenheim  has  at  various  times 
directed  special  attention  to  the  variability  of  the  symp- 


CRITICAL  DIGEST. 


317 


toms,  the  apoplectiform  and  vertiginous  attacks,  and  to 
fundus  lesions  without  functional  defect. 

Tlie  preceding  statement  is  sufficient  to  show  the  ex- 
treme variability  of  the  clinical  pictures  as  a  whole,  and 
explains  the  possibilities  of  mistaken  diagnosis.     During 
the  past  few  years  some  of  the  special  symptoms  enumer- 
ated in  Charcot's  table  have  received  further  elucidation. 
Striiempell,  who  has  a  way  of  upsetting  old  medical  be- 
liefs, has  maintained  that  the  intention  tremor  of  multiple 
sclerosis  differs  little,  if  at  all,  from  ordinary  ataxia.     I 
have  paid  close  attention  to  this  point  during  the  past  year 
and  have  at  present  under  observation  three  undoubted 
cases  of  multiple  sclerosis,  whose  movements  are  distinctly 
ataxic.    On  the  other  hand,  it  cannot  be  denied  that  there 
are  other  patients  suffering  from  multiple  sclerosis,  whose 
disturbance  of  motion  is  more  in  the  nature  of  a  tremor. 
We  believe,  too,  that  a  typical  tremor  is  often  present  at 
the  beginning  of  the  disease,  and  as  the  disease  progresses 
the  tremor  becomes  coarser,  and  then  is  scarcely  to  be 
distinguished  from  ataxic  movements. 

Struempell's  proposition  loses  some  of  its  apparent 

originality  if  we  recall  to  mind  the  fact  that  Gowers  in  a 

foot-note  (vol.  ii.,  p.  548)  states  that  ataxic  tremor  is  the 

best  translation  for  "  Intentions-Zittern.''    To  be  sure,  he 

c/iose  the  term  Ataxic  Tremor,  "  because  there  is  no  ataxia 

'v'itliout  voluntary  movements."     The  difference  between 

ataxiia  and  tremor — a  difference  in  degree  only — can  be 

'^'"oiight  out  by  asking  the  patient  to  write  with  chalk  or 

lea.cl  pencil,  when  it  will  be  found  that  the  ataxic  patient 

i^carcely  succeeds  in  the  attempt  to  write,  w*liile  the  patient 

^vith  tremor  writes  with  some  difficulty  and  in  a  jerky 

tasHion. 

The  ocular  symptoms  of  multiple  sclerosis  have  not  re- 
ceived the  attention  they  deserve.      The  other  morbid 
Signs  had  been  well  understood  long  before  these  symptoms 
^^ere  properly  described.      Our  knowledge  of  them  was 
tuarkedly  advanced  by  the  publication  of  Parinaud,  who 
reported  upon  the  findings  in  Charcot's  cases,  and  by  the 


3l8  B.  SACHS. 

monograph  of  Uhthoff,  who  described  with  great  detail 
the  clinical  and  anatomical  findings  in  the  eyes  of  patients 
siifTering  from  multiple  sclerosis.  Recent  contributions 
to  this  special  subject  have  been  made  by  Luebbers — a 
pupil  of  UhthofT,  by  Guenther,  Nagel,  Kunn  and  Schwarz. 

The  commonest  of  the  eye  symptoms  are  the  nystag- 
mus and  the  nystagmus-like  movements.  These  are  most 
apt  to  appear  on  extreme  lateral  movements  of  the  eyes, 
and  are  generally  associated  in  character.  While  occa- 
sional twitching  movements  of  the  ocular  muscles  may 
occur  in  healthy  persons,  regularly  developed  oscillatory 
movements  upon  each  lateral  excursion  are  characteristic 
of  the  disease.  Of  course,  it  should  be  borne  in  mind  that 
the  symptom  is  present  in  other  diseases  of  the  nervous 
system,  of  which  mention  will  be  made  later  on. 

Kunn  described  a  condition  which  he  calls  a  "  fixation 
tremor"  setting  in  when  the  eyes  are  moved  from  vision 
straight  ahead  to  the  fixation  of  a  definite  object.  The 
same  aulhor  calls  attention  to  a  concomitant  strabismus 
which  he  interprets  to  be  a  dissociation  of  ocular  move- 
ments that  were  previously  associated. 

Luebbers  mentions  a  case  in  which  the  nystagmus  ap- 
peared with  converging  movements  of  the  eye;  but  this  is 
entirely  exceptional.  The  nystagmus  may  be  horizontal, 
vertical,  diagonal  or  rotary.  Raehlman  and  Schwarz  dwell 
upon  the  special  form  of  ataxic  nystagmus,  which  is  prac- 
tically an  uncertainty  of  movement,  the  eyes  simply  over- 
leaping the  mark  in  passing  from  one  point  of  fixation  to 
another.  The  same  phenomenon  is  observed  in  Fried- 
reich's disease,  and  can  be  distinguished  from  the  more 
rapid  movements  of  typical  nystagmus.  True  nystagmus 
occurs  in  a  majority  of  cases  of  multiple  sclerosis  (accord- 
ing to  Uhthoff,  in  58  per  cent.,  and  according  to  Marie,  in 
70  per  cent,  of  all  the  cases).  The  variations  in  the  per- 
centages are  accounted  for  by  the  fact  that  Uhthoff  draws 
a  distinction  between  nystagmus  and  nystagmus-like 
movements.  These  oscillatory  movements  of  the  eyes 
constitute,  therefore,  one  of  the  most  constant  and  reliable 


CRITICAL  DIGEST. 


319 


pie  sclerosis.  In  view  of  their  frequency, 
ivell  to  remember  that  they  occur  with  dif- 
[  congenital  defective  development  (idiocy, 
Stic  paraplegia,  etc.),  also  in  Friedreich's 
ditary  cerebellar  ataxia,  and  in  a  few  cases 
ia.  Its  occurrence  in  these  various  diseases 
:or  much  of  the  confusion  that  has  arisen 
to  differentiate  between  them, 
esponsible  for  the  statement  that  affections 
lerve  are  frequently  associated  with  true 
multiple  sclerosis,  whereas  we  are  more 
ystagmus  alone  without  such  atrophy  in 


cause  of  nystagmus  has  not  yet  been  fath- 
f  thought  it  was  due  to  lesions  in  the  brain, 
y  in  the  medulla  oblongata;  but  he  also 
t  niight  be  due  to  changes  in  the  peripheral 
ig  the  ocular  muscles.  A  lesion  involving 
ngitudinal  fasciculus  was  supposed  by  some 
occurrence  of  nystagmus;  but,  as  Redlich 
!t,  this  tract  has  been  entirely  exetiipt  in 
e  sclerosis  with  marked  nystagmus,  and  in 
which  nystagmus  was  never  present,  this 
as  found  to  be  seriously  affected.  In  all 
'  lesion  interfering,  by  lesions  of  the  nuclei 
iating  tracts,  with  the  regular  movements 
luscles.  would  be  sufficient  to  account  for 


■  the  ocular  muscles  is  not  an  infrequent 
:  of  multiple  sclerosis.  It  has  been  present 
cases  which  have  come  under  my  obser- 
the  past  two  years.  The  abducens  is 
y  affected.  Next  in  order  of  frequency 
lo-motor  nerve,  which  is,  however,  rarely 
mtirety.  Occasionally  the  trochlear  (IV.) 
ed.  A  point  of  some  importance  is  that 
e  variable,  disappeamig  in  some  weeks  or 


320  o.  SAlHS. 

months,  and  occasionally  returning  again  to  as  marked 
a  degree  as  before.  The  remission  in  this  one  symptom 
is  as  characteristic  of  multiple  sclerosis  as  the  remission  in 
most  of  the  other  symptoms,  and  it  is  the  occurrence  of 
such  remissions  that  makes  it  particularly  difficult  to  dis- 
tinguish between  disseminated  sclerosis  and  multiple  cere- 
bro-spinal  syphilis  (Oppenheim,  Sachs). 

In  addition  to  single  ocular  palsies,  there  may  also  be 
paresis  or  paralysis  of  associated  movements.  The  upward 
and  downward  movements  are,  as  a  rule,  not  affected  (Pa- 
rinaud,  Marie,  Uhthoff,  and  Luebbers).  Parinaud  claimed 
that  paralysis  of  convergence  was  frequent,  but  Uhthoff 
found  this  condition  in  only  three  per  cent,  of  his  cases. 
A  complete  ophthalmoplegia  externa  has  not  been  de- 
veloped in  multiple  sclerosis.  The  direct  cause  of  ocular 
palsies  is  to  be  found  in  the  slerotic  patches  occupying 
the  region  of  the  various  ocular  nuclei.  Positive  and 
anatomical  proof  of  this  would  still  be  welcome. 

By  way  of  contrast  with  the  early  appearance  of  ocular 
palsies  in  tabes  dorsalis,  it  may  be  noted  that  in  multiple 
sclerosis  the  palsies  do  not  appear,  as  a  rule,  until  long 
after  unmistakable  symptoms  of  the  disease  have  appeared. 
The  pupils  may  be  unequal,  and  sometimes  react  sluggishly 
to  light  and  during  accommodation,  but  iridoplegia  is 
very  rare,  Charcot  insisted  upon  the  great  value  of  this 
preserved  light  reflex  as  a  factor  in  differential  diagnosis. 
Damtsch  claimed  that  the  condition  of  hippus — a  constant 
changing  from  contraction  to  dilatation  of  the  pupil — is 
often  found  in  multiple  sclerosis.  He  likens  the  hippus 
to  the  increase  of  the  tendon  reflexes,  but  the  analogy  is 
not  a  very  happy  one. 

Much  more  characteristic  of  multiple  sclerosis  than 
any  and  all  of  the  preceding  ocular  symptoms  are  the 
changes  in  the  visual  power,  v.-  the  visual  fields,  and  in 
the  structure  of  the  papillje  and  the  optic  nerves.  The 
subjective  disturbances  are  entirely  out  of  proportion  (i.  e., 
relativelv  less),  to  the  objective  changes.    Complete  blind- 


CRITICAL  DIGEST. 


321 


ncss  is  the  rarest  of  all  occurrences,  although  transitory 
blindness  has  been  observed  (Schwarz).  Complete  recovery 
from  the  visual  defect  of  multiple  sclerosis  is  possible. 
According  to  Uhthoff,  Luebbers  and  others,  central  scoto- 
mata  are  most  frequent.  In  this  area  the  color  sense  is  the 
one  most  disturbed — generally  for  red  and  green,  some- 
times for  all  colors.  These  central  anesthetic  areas  may 
occur  together  with  the  normal  peripheral  fields,  or  with 
a  mere  diminution  of  peripheral  vision.  In  some  cases 
there  may  be  a  peripheral  contraction  of  the  visual  field 
with  normal  central  vision.  Concentric  limitation  of  the 
fields  has  been  described  by  Oppenheim,  Thomsen,  Buz- 
zard and  Uhthofif,  but  only  in  cases  in  which  an  hysterical 
or  a  functional  condition  was  superimposed  upon  dissem- 
inated sclerosis.  Almost  every  writer  who  has  investigated 
this  special  subject  refers  to  the  disproportion  existing 
between  the  visual  defect  and  the  ophthalmoscopic  ap- 
pearances. In  one  of  Luebbers'  cases  the  visual  defect 
was  in  keeping  with  the  changes  in  the  papilla,  but  in  two 
others  there  was  only  a  very  slight  atrophy  of  the  papilla, 
and  yet  vision  was  much  diminished  and  the  visual  fields 
were  distinctly  affected.  In  still  another  instance  there 
was  a  marked  functional  disturbance  without  ophthalmos- 
copic change.  A  few  other  authors  have  described  dis- 
tinct changes  in  the  papilie  without  any  functional  dis- 
turbance. The  visual  symptoms  generally  appear  long 
after  the  others  have  been  developed,  but  may  come  on 
with  extreme  suddenness  (Uhthoff  and  Buss). 

Gowers  and  Marie  have  called  attention  to  the  fact 
that  the  visual  disturbance  of  multiple  sclerosis  may  be 
unilateral. 

Ophthalmoscopic  examination  has  revealed  several 
peculiar  changes.  Complete  atrophy  of  the  optic  nerves  is 
very  rare.  Uhthoff  found  it  in  only  3  of  100  cases.  The 
rarity  of  this  is  worthy  of  note,  and  is  probably  due  to  the 
frequent  preservation  of  the  axis  cylinders,  in  spite  of  the 
destruction  of  the  medullary  sheath.    Incomplete  atrophy 


322  B.  SACHS. 

— discoloration  of  the  entire  papilla — the  peripheral  parts 
being  more  distinctly  altered  than  the  nasal  half,  occurs 
in  about  50  per  cent,  of  all  cases.  Atrophy  of  the  temporal 
halves  of  the  papillcc  is  almost  pathognomonic  of  multiple 
sclerosis.  Charcot  insisted  that  the  papilla  retained  a 
yellowish  color  in  contradistinction  to  the  white  appear- 
ance in  the  atrophy  of  tabes.  Optic  neuritis  has  been 
found  in  a  number  of  cases  (in  three  of  Luebbers'  cases). 
Partial  temporary  atrophy  is,  according  to  Uhthoff,  a 
common  symptom  in  intoxication  of  amblyopias,  tobacco 
and  alcohol);  but  in  these  the  atrophy  is  always  bilateral, 
whereas  it  is  frequently  unilateral  in  multiple  sclerosis. 
This  special  resemblance  to  the  intoxication  amblyopias 
is  of  interest,  if  we  remember  that  multiple  sclerosis  has 
been  shown  to  be  at  times  of  toxic  origin. 

The  anatomical  examination  of  the  eyes  (UhthoflF, 
Luebbers,  and  others)  has  revealed  conditions  as  variable 
as  are  the  functional  disturbances.  It  has  been  shown  that 
there  are  widespread  atrophic  changes  in  the  optic  nerves, 
depending  probably  upon  the  proliferating  process  ema- 
nating from  the  connective  tissue,  and  gradually  involving  . 
the  nerve  fibres;  the  sheaths  are  often  destroyed,  but  the 
axis  cylinder  is,  as  a  rule,  not  affected;  in  other  words,  the 
process  is  interstitial  in  origin,  the  changes  in  the  nerves 
being  secondary.  In  consequence  of  this  preservation  of 
the  axis  cylinders,  the  secondary  degeneration  does  not 
,ensue,  and  the  nerve  fibres  do  not  forfeit  their  functional 
power. 

It  is  very  evident,  as  will  be  shown  in  the  section  on 
pathology,  that  the  sclerotic  changes  in  the  optic  nerves 
are  very  much  the  same  as  in  the  other  parts  of  the  central 
nervous  system.  The  next  question  is,  whether  or  not 
the  changes  in  the  connective  tissue  are  due  to  the  disease 
of  the  blood-vessels.  No  unanimity  of  opinion  has  as  yet 
been  reached  on  this  point,  and  it  is  more  than  probable 
that  the  process  begins  differently,  according  to  the  vary- 
ing etiology  of  the  cases,  UhthofF.  Buss,  Taylor  and  others 


I 


CRITICAL  DIGEST. 


323 


have  paid  especial  attention  to  the  behavior  of  the  blood- 
vessels. Several  of  these  writers  have  found  an  increase 
in  the  number  of  the  finer  blood-vessels,  and  a  change  in 
their  walls,  followed  by  a  proliferating  process  in  the  sur- 
rounding tissue. 

Nolda,  who  studied  the  relations  of  multiple  sclerosis 
to  infectious  diseases,  thinks  that  the  sclerotic  patches 
take  their  origin  from  the  walls  in  the  blood-vessels.  Lueb- 
bers,  in  comparing  the  changes  in  multiple  sclerosis  with 
those  found  in  the  primary  optic  atrophy  of  tabes  dorsalis, 
finds  that  in  multiple  sclerosis  there  is  more  of  a  focal  de- 
generation than  in  tabes,  and,  above  all,  there  is  in  tabes 
no  such  number  of  normal  axis  cylinders  as  in  multiple 
sclerosis.    The  optic  atrophy  of  tabes  is  due  to  the  primary 
degeneration  of  the  optic  ner\'e  fibres,  while  in  multiple 
sclerosis  the  atrophy  is  the  result  of  an  interstitial  neuritis, 
and  this  in  turn  may  be  due  to  a  disease  in  the  blood-ves- 
sels.   In  multiple  sclerosis,  it  may  be  added,  the  retinal 
tlements  are  not  affected. 

Scamiing  speech  has  long  been  considered  a  character- 
istic  symptom  of  multiple  sclerosis;  but  it  would  be  a 
mistake  to  suppose  that  this  is  the  only  speech  disturbance 
common  to  this  disease.    Putting  it  broadly,  almost  every 
form  of  dysarthria  is  possible  in  multiple  sclerosis,  for  the 
disturbance  is  due  to  lesions  in  the  pons  or  medulla  inter- 
fering with  the  speech  mechanism.    Leube  found  a  disturb- 
ance of  innervation  of  the  vocal  cords  in  one  instance,  and 
^  have  recently  seen  a  typical  case  of  the  disease  in  which 
the    opposition  of  the  vocal  cords  was  so  imperfect  that 
the  patient  spoke  in  whispers.    In  other  cases  nasal  speech 
'^^s  been  noted,  and  in  still  others  true  bulbar  speech  has 
'^^ri  reported.     In  the  writer's  own  experience,  there  is 
^^ten  an  evident  speech  tremor  not  unlike  that  observed 
^^  the  early  stages  of  general  paresis,  and  reminding  one 
^otTiewhat,  too,  of  the  peculiarities  of  speech  in  some  pa- 
^^ents  suffering  from  Friedreich's  disease.     Disturbances 
^i  articulation,  if  excessive,  are  apt  to  be  associated  with 


« 


f: 


I- 


M 


• 


324 


.  SACHS. 


Other  symptoms  pointing  to  an  involvement  of  the  various 
nerve  nuclei  in  the  pons  and  the  medulla  oblongata  (cases 
of  Joffroy,  Leyden,  Berlin,  Fuerstner,  Redlich  and  others). 
If  these  symptoms  predominate,  they  constitute  the  special 
bulbar  form  of  multiple  sclerosis.  This  type  was  carefully 
considered  by  Hatlopeau. 

An  interesting  example  of  this  class  of  cases  was  re- 
cently reported  with  autopsy  by  Schuster  and  Bielchows- 
ky.  In  this  instance  nasal  speech  was  associated  with  par- 
esis of  the  left  arm  and  the  left  leg,  with  dyspncea,  head- 
aches and  double  vision.  There  was  also  divergent  strabis- 
mus of  the  right  eye,  as  well  as  paralysis  of  both  sixth 
nerves.  The  pupils  and  fundi  were  normal.  A  focal 
lesion  in  the  pons  was  suspected,  but  the  autopsy  revealed 
multiple  sclerotic  foci  in  the  pons  and  medulla  and  in  other 
parts  of  the  brain. 

Aside  from  the  peculiarities  in  the  development  of 
single  symptoms,  abnormalities  occur  in  the  development 
of  the  entire  clinical  picture  of  multiple  sclerosis.  In  the 
literature  of  the  subject  the  formes  frustes — the  aborted 
types  of  multiple  sclerosis — have  given  rise  to  considerable 
discussion.  It  is  well  to  bear  in  mind  that  there  is  ho 
regularity  in  the  development  of  sclerotic  patches,  whence 
it  follows  that  departures  from  the  typical  forms  of  the 
disease  will  occur  readily  enough.  Slightly  irregular  forms 
do  not,  therefore,  deserve  the  designation  "formes 
fnistes." 

Charcot  was  the  first  to  dilate  upon  these  special  types, 
referring  particularly,  i.  to  cases  in  which  certain  symp- 
toms, which  had  existed,  had  disappeared;  2.  to  cases  of 
which  the  symptomatology  had  never  been  complete — 
such  cardinal  symptoms  as  the  tremor  or  the  nystagmus 
never  having  developed;  3.  to  cases  in  which  the  type  has 
been  altered  by  the  intervention  of  other  symptoms  of  an 
hemiplegic,  tabic  or  amyotrophic  order. 

The  establishment  of  the  formes  frustes  has  opened  the 
door  to  diagnostic  errors;  for  a  multiple  sclerosis  may  ap- 


CRITICAL  DIGEST. 


325 


pear  under  the  guise  of  an  hemiplegia,  of  a  transverse 
myelitis,  or  of  an  amyotrophic  lateral  sclerosis.  In  the 
opinion  of  the  present  writer,  the  diagnosis  of  multiple 
sclerosis  should  be  made  only  if  the  cardinal  symptoms 
of  the  disease,  such  as  nystagmus,  scanning  speech,  inten- 
tion tremor  are  present  in  addition  to  the  other  symptoms 
of  myelitis,  hemiplegia,  etc.  The  variability  of  the  symp- 
toms (Oppenheim)  argues  in  favor  of  multiple  sclerosis, 
as  do  also  the  recurrent  apoplectic  and  vertiginous  seiz- 
ures. Oppenheim  has  laid  especial  stress  upon  the  occur- 
rence in  such  cases  of  the  characteristic  changes  in  the 
fundus,  with  little  or  no  functional  impairment  of  vision. 

Apoplectic  attacks  may  occur  in  the  course  of  a  mul- 
tiple sclerosis,  but  occasionally,  as  in  a  case  now  under  my 
observation,  hemiplegia  is  developed  slowly  at  the  outset 
oi  the  disease,  and  is  then  scarcely  to  be  differentiated 
tram  other  forms  of  apoplexy;  excepting  that  in  these 
cases  which  affect  men  and  women  in  middle  life  the  usual 
biological  factors  of  an  apoplectic  seizure,  cardiac  disease, 
or  specific  endarteritis  are  generally  absent.    If  the  person 
who   has   suffered   from   an   apoplectic   attack    develops 
/narked  nystagmus,  scanning  speech  or  ataxic  movement 
^n    the  paralysis  of  the  upper  extremity,  the  suspicion  of 
Multiple  sclerosis  may  well  be  entertained.     Cases  of  this 
character  have  been  described  by  Werner,  Bikeles  and 
^^hers.    The  question  arises  whether  these  apoplectic  at- 
^^<^lc:s  in  multiple  sclerosis  are  due  to  vascular  disturbances 
^^  to  a  peculiar  localization  of  the  sclerotic  patches.    I  am 
I'^olined  to  side  with  Charcot,  Redlich  and  Babinski,  who 
^^li^ve  that  these  forms  are  due  to  the  early  development 
^*  Sclerotic  patches  in  the  pons  and  medulla  oblongata,  al- 
l^'^oxiigh  Taylor  has  shown  that  such  patches  also  occur 
^^    the  cortex  and  other  parts  of  the  brain.     Witzel  has 
P'^^blished  a  case  in  which  there  was  a  crossed  paralysis  of 
^^^  facial  and  abducens  nerve  of  the  opposite  side. 

Many  writers  have  conceded  the  occurrence  of  acute 
^nd  chronic  cases  of  multiple  sclerosis,  presenting  none 


3a6  B.  SACHS. 

but  spinal  symptoms  {Boumevitle,  Guerard,  Leyden  and 
Oppenheim  have  recorded  cases  of  acute,  transverse  myeli- 
tis which  were  eventually  proven  to  be  cases  of  multiple 
sclerosis).  In  the  absence  of  the  ordinary  etiological  fact- 
ors (transverse  myelitis  trauma,  syphilis,  vertebral  disease) 
the  suspicion  of  disseminated  sclerosis  may  be  entertained, 
but  the  cardinal  symptoms  of  the  disease  must  be  in  evi- 
dence to  prove  the  suspicion. 

The  purely  spinal  and  chronic  forms  may  appear  under 
the  clinical  guise  of  a  spastic  spinal  paralysis.  For  months, 
and  even  years,  no  other  symptoms  may  be  forthcoming. 
No  doubt,  some  of  the  cases  of  primary  lateral  sclerosis 
were  in  reality  early  forms  of  multiple  sclerosis.  Cases  of 
this  description  have  been  reported  by  Krueger,  Ormerod, 
I-apinski  and  Redlich.  A  very  typical  case  of  this  character 
was  oKserved  recently  in  my  department  at  the  Polyclinic, 
to  which  it  had  been  referred  by  Dr.  A.  Wiener.  In  all 
such  cases  the  occurrence  of  the  charcteristic  changes  in 
the  fundus  will  lend  valuable  support  to  the  diagnosis  of 
multiple  sclerosis.  However  clearly  the  symptoms  may  be 
developed,  and  however  carefully,  multiple  sclerosis  may 
be  confounded  with  other  diseases,  above  all  with  cerebral 
spinal  syphilis  (Oppenheim,  Sachs  and  others).  The  re- 
missions in  the  symptoms,  the  preponderance  of  the  spas- 
ticity over  the  paralysis, the  apoplecticseizuresmaybe char- 
acteristic of  both  diseases.  Greater  stress,  in  my  opinion, 
should  be  laid  upon  the  pupillary  changes  in  syphilitic 
affections  (absolute  immobility,  unilateral  pupillary  symp- 
toms and  irregular  contour  of  the  pupils),  and  the  pres- 
ence in  multiple  sclerosis  of  nystagmus,  intention  tremor 
and  scanning  speech,  which  are,  after  all,  extremely  rare 
in  syphilis  of  the  brain  and  of  the  spinal  cord. 

There  will  be,  as  a  rule,  no  difficulty  in  differentiating 
between  multiple  sclerosis  and  paralysis  agitans;  but 
Schultze  and  Sachs  have  reported  upon  cases  in  which 
the  symptoms  of  multiple  sclerosis  have  been  associated 
with  those  of  paralysis  agitans:  in  one  young  patient  of 


CRITICAL  DIGEST. 


2,^7 


the  latter  writer,  who  exhibits  most  of  the  symptoms  of 
paralysis  agitans,  there  are  also  a  nystagmus  and  marked 
nasal  speech.  In  another  patient,  whose  condition  was  at 
first  diagnosticated  (by  competent  observers)  as  func- 
tional tremor,  then  as  intention  tremor  of  multiple  scle- 
rosis, later  developments  have  shown  the  disease  to  be 
a  typical  form  of  paralysis  agitans.  In  view  of  such  ex- 
periences, we  may  maintain  that  the  clinical  distinction 
between  multiple  sclerosis  and  paralysis  agitans  is  not  as 
absolute  as  it  has  been  supposed  to  be  since  the  days  of 
Charcot. 

We  may  concede  that  hysteria  may  simulate  multiple 
sclerosis.  More  often  hysterical  symptoms  are  present  in 
addition  to  those  of  multiple  sclerosis.  The  differentia- 
tion will  depend  largely  upon  the  presence  of  such  dis- 
tinctly hysterical  stigmata  as  are  foreign  to  the  pure  type 
of  multiple  sclerosis.  Westphal's  two  cases,  in  which  the 
anatomical  changes  were  wanting,  although  the  patients 
exhibited  all  the  symptoms  of  the  disease,  have  led  to 
much  discussion. 

French  writers  have  called  them  hysterical  without 
much  hesitation,  and  Struempell  has  chosen  to  establish  a 
separate  form  of  psendo-sclerosis,  bringing  under  this  head 
what  appears  to  us  a  rather  heterogeneous  number  of 
cases.  He  has  allied  with  this  form  a  diffuse  sclerosis  of 
children;  but  the  clinical  types  which  he  attempts  to  es- 
tablish need  careful  examination  before  they  can  be 
adopted. 

This  leads  to  the  consideration  of  multiple  sclerosis  in 
early  life.  The  differential  diagnosis  between  it  and  other 
diseases  of  infancy  presents  so  many  difficulties,  that  much 
care  shouM  be  exercised  in  making  the  diagnosis,  or  in 
accepting  it  when  offered  by  others.  In  a  recent  article 
by  Struempell,  in  which  the  author  challenges  criticism 
on  other  points,  he  insists  that  the  diagnosis  of  multiple 
sclerosis  in  children  is  not  certain,  unless  corroborated  by 
post-mortem  findings,  and  to  this  conservative  view  we 
are  inclined  to  subscribe. 


328  ^    SACHS. 

The  first  case  of  multiple  sclerosis  in  a  child  appears 
to  have  been  described  by  Schuele  (1871).  This 
was  followed  by  reports  of  Dreschfeld,  Bristowe  and  Te^ 
Cate  Hoedeinaker,  Marie,  in  1883,  reported  upon  cases 
of  his  own.  and  collected  13  in  all.  In  1887  Unger  had 
increased  this  list  to  19.  Six  years  later,  Totzke,  reporting 
2  cases  of  his  own,  tabulated  39  in  all.  One  case  was  re- 
ported by  the  present  writer  in  his  book  on  the  "Nervous 
Diseases  of  Children,"  which  Stieghtz  has,  through  a 
printer's  error,  called  a  doubtful  case  in  the  latest  publica- 
tion on  this  subject.  Stieglitz  cites  three  cases  of  his  own, 
and  tabulates  35,  evidently  excluding  some  which  he  con- 
sidered doubtful.  In  addition  to  those  diseases  of  the 
adult  which  enter  into  the  discussion  of  the  differential 
diagnosis,  such  as  syphilis,  transverse  myelitis,  hysteria, 
we  must  especially  consider  the  infantile  spastic  palsies, 
hereditary  spinal  ataxy  (Friedreich's  disease),  hereditary 
cerebellar  ataxy  and  hereditary  spastic  paralysis — the  last 
has  been  omitted  from  Stieglitz's  carefully  prepared  list. 

As  for  the  infantile  cerebral  palsies,  the  ordinary  para- 
plegias (birth  cases  and  cases  of  defective  development) 
will  generally  be  ruled  out  by  the  history  of  early  onset, 
by  the  frequent  occurrence  of  convulsions  and  by  defec- 
tive development,  which  is  more  marked  than  in  cases  of 
multiple  sclerosis. 

The  acute  hemiplegias,  with  their  characteristic  symp- 
toms, cannot  give  rise  to  any  confusion.  Some  doubt 
could  be  entertained,  however,  with  respect  to  the  cerebral 
diplegias.  Nystagmus  is  common  enough  in  these;  in- 
tention tremor,  or,  rather,  ataxic  movements,  are  ob- 
served frequently,  and  disturbances  of  speech  (bradylalia) 
are  very  common.  It  is  very  rare,  on  the  other  hand,  to 
Jind  any  two  of  these  symptoms  in  a  case  of  diplegia. 
Furthermore,  it  should  be  remembered  that  a  cerebral 
diplegia  of  an  acute  onset  is  a  rare  occurrence,  and  rarest 
of  all  in  patients  beyond  the  age  of  five  to  seven  years. 
These  cerebral  diplegias  present  extreme  contractures  and 


CRITICAL  DIGEST. 


329 


post-paralytic  disturbances  of  motion  (athetosis  and  the 
like),  which  seldom  occur  in  multiple  sclerosis.    As  a  mat- 
ter of  fact,  of  the  large  number  of  cases  of  cerebral  diplegia 
which  the  present  writer  has  seen,  there  has  not  in  a  single 
instance  been  reason  to  suspect  the  presence  of  multiple 
sclerosis.     In  making  the  diagnosis,  the  entire  congeries 
o(  the  symptoms  should  be  considered,  and  not  any  one 
chnical  sign.     Stieglitz  says,  correctly,  that  the  question 
is  whether  infantile  cerebral  palsy  has  been  excluded  in 
cases  diagnosticated  as  multiple  sclerosis. 

From  Friedreich's  disease  differentiation  is  generally 
easily  made,  although  every  now  and  then  patients  come 
under  one's   observation   whose   clinical   symptoms   may 
leave  some  doubt  as  to  the  presence  of  one  or  the  other 
of  these  diseases.    A  resemblance  may  be  due  to  the  pe- 
culiarities of  speech,  to  the  awkward  movements  of  the 
upper  extremities  in  Friedreich's  disease,  which  may  simu- 
late an  intention  tremor,and  to  the  presence  of  nystagmus; 
Ijut  the  condition  of  the  reflexes  in  disseminated  sclerosis, 
^he   optic  atrophy  and  the  absence  of  true  ataxia  of  the 
lower  extremities  will  help  to  estabhsh   the  differential 
^'^grnosis;  and,  after  all,  in  Friedreich's  disease  the  dis- 
fLirbances  of  speech  are  slow  and  labored,  but  rarely  of 
typical  scanning  order. 
«"\t  a  recent  meeting  of  the  Neurological  Society  I  pre- 
s^nted  an  adult  patient  in  whom  the  symptoms  pointed 
^  ^Friedreich's  ataxia,  and  yet  there  was  a  bare  possibility 
his  having  a  bulbar  form  of  multiple  sclerosis.     This 
^^^ient  was  39  years  of  age,  his  past  history  was  good, 
^^thiout  any  evidence  of  preceding  syphilis.     At  the  age 
*  ^O  he  was  weak  in  the  knees,  and  frequently  made  mis- 
^^^Ps.    In  1887  he  had  sought  medical  advice  because  of 
^^flficulty  of  locomotion,  noticed  especially  in  climbing 
^^a.irs.    When  examined  in  March,  1895,  he  complained 
chiefly,  while  walking,  of  weakness  in  the  extremities  and 
^■^^grht  difficulty  in  speech.    He  exhibited  an  ataxic  spastic 
^^\\.  and  static  ataxia.     The  pupils  reacted  to  light  and 


1! 


330  tJ.  S/ICHS. 

during  accommodation.  The  patellar  reflexes  were  ab- 
sent. There  was  distinct  ataxia  of  the  right  upper  ex- 
tremity. He  had  a  form  of  speech  which  was  midway  be- 
tween a  slow  and  a  bulbar  speech.  There  was  slight 
atrophy  of  the  optic  nerves.  The  case  was  at  first  sup- 
posed to  be  one  of  locomotor  ataxia,  but  the  further  de- 
velopment of  the  disease  showed  that  it  was  either  Fried- 
reich's ataxia  or  a  bulbar  form  of  multiple  sclerosis.  The 
intention  tremor,  the  optic  atrophy  and  the  peculiarities 
of  speech  would  be  in  harmony  with  the  diagnosis  of  mul- 
tiple sclerosis;  but  the  absence  of  the  knee-jerks,  ataxia 
of  the  upper  extremities,  which  was  not  a  typical  intention 
tremor,  and  the  normal  behavior  of  the  pupillary  reflex 
were  in  keeping  with  Friedreich's  ataxia,  which  appears, 
however,  as  a  rule,  early  in  life.  The  first  symptoms  in  this 
patient's  case  appeared  at  least  as  early  as  the  age  of  20 
years,  and  possibly  earlier. 

Still  greater  difficulty,  however,  is  experienced  in  the 
attempt  to  differentiate  multiple  sclerosis  from  hereditary 
cerebellar  ataxia  (type,  Nonne-Marie),  This  is  well  il- 
lustrated by  Stieglitz's  Case  II.,  in  which  the  diagnosis 
of  multiple  sclerosis  hangs  by  a  hair,  and  the  author  him- 
self does  not  appear  to  be  firmly  convinced  of  the  diag- 
nosis. If  a  previous  history  of  ptosis,  of  a  paresis  of  the 
internal  rectus  muscle  and  the  Romberg  symptom  do  not 
support  the  diagnosis  of  hereditary  cerebellar  ataxia,  it  is 
also  certain  that  swaying  of  the  body,  with  the  eyes  open 
and  closed,  is  not  very  usual  in  multiple  sclerosis.  In  a 
case  like  this,  as  well  as  in  the  one  cited  above  by  me. 
the  post-mortem  examination  alone  wilt  satisfactorily  de- 
termine the  nature  of  the  disease.  It  is  well  to  insist  again 
upon  the  fact  that  the  mode  of  onset,  the  time  of  life  at 
which  the  disease  is  developed,  as  well  as  the  history  of 
some  preceding  illness,  will  often  help  us  to  differentiate 
between  the  two  diseases. 

Hereditary,  spastic  paralysis,  as  described  by  Newmark. 
Pelizaeus  and  others,  should  be  considered  in  this  con- 


CRITICAL  DIGEST. 


331 


nection.  There  is  a  striking  resemblance  in  the  symptoms, 
but  nystagmus,  intention  tremor  and  scanning  speech  are 
not  typical  of  the  hereditary  form  of  spastic  paralysis. 
Only  a  few  months  ago  a  boy.  12  years  of  age,  came  under 
my  observation,  who,  after  a  fright,  had  developed  marked 
spastic  paralysis  of  the  lower  extremities,  with  slight 
ataxic  movements  of  the  right  upper  extremity,  and  a 
peculiarity  of  speech,  which  was  slow  and  deliberate,  rather 
than  scanning.  There  were  no  nystagmus,  no  pupillary 
abnormalities,  no  optic  atrophy — in  short,  no  symptoms 
that  were  at  all  characteristic  of  multiple  sclerosis,  ex- 
cept the  speech.  In  this  case  the  fact  that  the  boy  was 
absolutely  well  until  the  age  of  12,  that  there  was  no  his- 
tory of  any  similar  occurrence  in  any  member  of  his  fam- 
ily, and  that  the  disease  came  on  in  rather  abrupt  fashion, 
argued  largely  in  favor  of  multiple  sclerosis;  and  yet,  but 
for  the  slight  ataxic  movements  of  the  right  upper  ex- 
tremity and  the  peculiarities  of  speech,  there  was  little 
to  throw  the  balance  in  favor  of  disseminated  sclerosis. 
In  cases  of  this  description  time  is  needed  for  the  develop- 
ment of  further  symptoms,  which  will  enable  one  to  es- 
tablish a  diagnosis  with  some  degree  of  certainty. 

(  To  be  concluded  in  the  June  number. ) 


jloctetg  Reports, 

NEW  YORK  NEUROLOGICAL  SOCIETY. 

Stated  Meeting,  April  5th,  1898. 

B.  Sachs,  M.D.,  President. 

REPORT  OF  TWO  CASES  OF  BRAIN  TUMOR. 

Dr.  Alfred  Wiener  read  this  report.  In  the  patient 
presented,  the  tumor  was  revealed  by  operation;  in  the 
other  tlie  specimen  was  obtained  by  autopsy. 

Case  I.  A  male,  twenty  years  of  age,  was  brought  to 
his  clinic  in  June,  1897.  He  was  bom  of  apparently  healthy 
parents,  but  the  father  was  alcoholic.  He  was  a  seven- 
months  baby,  but  was  bom  apparently  in  a  normal  manner. 
He  was  slow  in  learning  to  walk  and  talk.  When  about 
seven  years  old,  he  had  otitis  media,  followed  by  a  profuse 
otorrhoea.  The  present  trouble  first  announced  itself  while 
he  was  playing  cards;  suddenly  the  cards  dropped  from  his 
hands,  and  his  face  "  felt  stiif."  He  insisted  that  he  did 
not  lose  consciousness,  and  that  he  felt  as  usual  by  the 
next  day.  Previous  to  this  he  had  suffered  from  frequent 
and  severe  headaches,  associated  with  vomiting.  The  pain 
was  usually  frontal.  One  month  after  the  attack  just  de- 
scribed, there  was  a  second  and  more  severe  attack.  He 
remained  dazed  for  about  two  hours;  speech  was  slow, 
and  he  could  express  his  thoughts  only  with  difficulty. 
He  slowly  became  weaker,  and  vision  failed.  When  first 
examined,  there  was  no  perception  of  light  in  the  right 
eye:  with  the  left  eye  he  could  see  fingers  at  four  feet;  the 
pupils  reacted  to  light:  the  veins  were  engorged;  the  disk 
was  swollen  and  hazy.  The  tongue  was  protruded  straight. 
The  dynamometer  showed  marked  loss  of  power  on  the 
right  side.  The  patellar  reflexes  were  absent  on  both  sides. 
There  was  motor  aphasia.  Physical  examination  showed 
the  heart,  lungs,  kidneys  and  spleen  to  be  normal,  and  the 
blood  examination   revealed  a  leucocytosis.     There   was 


NEJV  YORK   NEUROLOGICAL   SOCIETY.  333 

increased  excitability  on  the  right  side  to  the  electric  cur- 
rent. The  boy  appeared  fairly  well  nourished,  but  was 
distinctly  apathetic.  Smell,  and  taste,  and  muscular  sense 
were  unimpaired.  These  symptoms  pointed  to  a  tumor. 
Abscess  was  excluded  for  the  reason  that  there  was  no 
source  of  infection.  The  history  was  negative  regarding 
tubercular  and  syphilitic  infection.  He  had  been  unwilling 
at  first  to  venture  upon  the  diagnosis  of  the  location  of 
the  neoplasm.  The  possibility  of  multiple  tumors  was 
borne  in  mind.  After  four  weeks  the  reflexes  in  the  lower 
extremities  began  to  return.  The  headaches  became 
more  severe  and  the  disturbance  of  speech  more  positively 
that  of  motor  aphasia.  He  had,  therefore,  come  to  the 
conclusion  that  the  tumor  was  a  cortical  one,  involving 
the  face  and  arm  centres,  and  the  posterior  extremity  of 
the  third  frontal  convolution — i.  e.,  the  speech  centre. 
During  this  time  the  man  had  been  on  anti-syphilitic 
treatment,  but  with  negative  results.  The  slow  growth 
of  the  neoplasm  led  him  to  believe  that  it  was  a  glioma. 
An  operation  was  advised  because  he  was  reasonably  sure 
of  the  location  of  the  growth,  and  because  a  trephine 
operation  seemed  justifiable  evn  if  the  tumor  could  not 
be  removed.  The  patient  was  operated  upon  by  Dr.  A. 
G.  Gerster  on  July  31,  but  the  operation  through  the 
scalp  and  skull  was  attended  by  such  great  loss  of  blood 
that  further  interference  was  postponed.  A  few  days  later 
the  operation  was  resumed  by  Dr.  H.  Lilienthal.  A  piece 
of  the  tumor  was  removed,  and  proved  on  microscopical 
examination  to  be  a  telangeiectatic  glioma.  Any  attempt 
at  manipulating  it  resulted  in  severe  hemorrhage.  Some 
days  after  the  operation  a  small  abscess  was  found  near 
the  surface,  and  this  was  incised  and  evacuated.  After 
this  improvement  was  more  manifest.  On  October  12th 
it  was  noted  that  the  patient  was  irritable  and,  at  times, 
quite  excited.  He  showed  some  ataxia  in  his  movements; 
the  speech  was  distinctly  hesitating;  the  patellar  reflexes 
were  present,  but  much  diminished.  His  muscular  sense 
was  still  present.  On  November  ist  another  localized 
abscess  was  detected  and  evacuated.  The  tumor  had  been 
steadily  growing  out  through  the  wound.  On  January 
18th  it  w^as  noted  that  the  patient  could  no  longer  express 
the  names  of  familiar  objects.  On  January  28th  the  mass 
measured  4f  inches  in  length,  2f  inches  in  width  at  the 


334  ^^^  yjl^^  NEUROLOGICAL  SOCIETY. 

upper  portion,  and  3:1  inches  at  the  lower  part.  On  Feb- 
ruary 8th,  when  he  was  just  recovering  from  an  attack  of 
influenza,  it  was  found  that  he  could  no  longer  wait  alone, 
and  that  he  was  much  slower  in  comprehension  than  form- 
erly. On  February  23d  the  tumor  measured  5  inches  in 
length,  3  inches  in  width  at  the  upper  portion,  and  3J 
inches  at  the  lower  portion.  During  the  month  of  March 
he  became  more  apathetic,  and  could  not  repeat  his  own 
name.  At  the  present  time,  there  is  paresis  of  the  left 
facial  and  right  upper  and  lower  extremities;  the  patellar 
reflex  is  present  on  both  sides;  there  is  double  abducens 
palsy,  more  marked  in  the  left  eye;  there  is  still  a  tend- 
ency to  fall  toward  the  right  side  and  backward.  The 
muscular  sense  on  the  right  side  is  very  much  affected. 
The  tumor  now  measures  5  inches  in  length,  3^  inches 
in  width  at  the  upper  part,  and  3J  inches  at  the  lower  part. 
There  have  been  no  severe  headaches  or  epileptic  seizures. 
It  is  probable  that  the  tumor  has  been  growing  just  as 
extensively  within  the  skull  as  on  the  outside.  The  forced 
laughing,  the  double  abducens  palsy  and  the  aphasia  all 
point  to  extensive  involvement  of  the  cortex  by  the 
growth. 

Case  II.  A  boy  of  seven  years,  seen  first  on  October 
19th,  1897.  The  child  was  born  of  healthy  parents,  but 
the  father  was  alcoholic.  The  patient  was  the  second 
child,  and  was  born  after  a  normal  labor  at  full  term.  He 
was  perfectly  well  up  to  twenty  months  old,  at  which  time 
he  apparently  had  an  attack  of  rheumatism,  lasting  five 
weeks.  From  then  up  to  a  short  time  before  coming  under 
observation  he  was  well  developed,  both  physically  and 
mentally.  It  was  then  noticed  that  he  went  down  stairs 
clumsily.  About  this  time  he  came  home  one  day  with 
a  marked  swelling  over  the  right  frontal  and  parietal 
region,  and  said  that  a  man  had  struck  with  his  fist  over 
this  part  of  the  head.  After  this  he  suffered  from  severe 
headaches,  and  about  the  same  time  it  was  noticed  that 
he  was  not  as  bright  as  formerly.  It  was  next  noticed 
that  fluids  would  run  out  of  the  mouth  while  he  was  drink- 
ing. On  October  igth,  examination  revealed  a  paresis 
of  the  two  lower  branches  of  the  right  facial  nerve,  with- 
out any  electrical  change.  The  tongue,  when  protruded, 
deviated  toward  the  right.  There  were  analgesia  and 
slight  dullness  to  touch  on  the  right  side  of  the  face.    The 


NEW  YORK  NEUROLOGICAL  SOCIETY.  335 

patellar  reflexes  were  absent  on  both  sides.  There  was 
no  bladder  or  rectal  trouble,  and  there  had  been  no  epi- 
leptic seizures.  Although  appearing  distinctly  apathetic, 
he  was  fairly  intelligent.  There  was  also  a  double  optic 
neuritis.  No  evidence  of  syphilis  or  tuberculosis  could  be 
found.  Abscess  was  excluded  for  the  same  reason  as  in 
the  first  case.  On  account  of  the  complete  hemi-paresis 
and  hemi-anesthesia,  without  loss  of  the  muscular  sense, 
the  tumor  was  thought  to  be  subcortical,  and  located  near 
the  internal  capsule.  The  tumor  was  suspected  to  be  a 
glioma  on  account  of  location  and  the  symptoms.  He 
was  put  upon  antisyphilitic  treatment.  On  October  23d 
the  patellar  reflexes  were  found  to  be  present,  but  very 
much  diminished,  and  anesthesia  was  more  prominent, 
especially  in  the  right  upper  extremity.  On  November 
iith  the  optic  disks  on  both  sides  showed  marked  atrophy, 
and  small  hemorrhages  could  be  seen  in  the  retina.  He 
walked  with  a  distinct  hemiplegic  gait.  On  November 
16th,  anesthesia  was  quite  marked  in  the  hand  and  face, 
and  the  right  arm  was  totally  paralyzed.  Up  to  December 
2d  the  condition  remained  about  the  same.  The  patellar 
reflexes  were  exaggerated  on  both  sides.  On  account  of 
the  extensive  paralysis  of  the  arm  and  face,  and  slight 
involvement  of  the  leg,  he  had  been  inclined'  to  believe 
that  the  greater  part  of  the  tumor  occupied  the  centrum 
ovale.  The  antisyphilitic  treatment  had  been  given  a  fair 
trial  without  the  slightest  improvement.  On  January 
20th.  having  recovered  meanwhile  from  an  attack  of  scar- 
let fever,  it  was  found  that  there  was  spasticity  on  the 
paralyzed  side,  that  he  was  unable  to  walk  and  was  totaljy 
blind.  On  February  7th  he  died,  having  been  intelligent 
to  the  last  moment.  The  autopsy  was  made  by  Dr.  Wiener 
_  four  hours  later.  The  abdominal  and  thoracic  organs  were 
norma!.  The  brain  weighed  52  ounces.  The  convolutions 
over  the  left  hemisphere  were  very  much  flattened. 
The  left  hemisphere  was  decidedly  softened,  and  hori- 
zontal sections  through  it  revealed  -a  soft,  infiltrating 
tumor  occupying  the  entire  centrum  ovale.  In  the  lower 
portion  of  the  hemisphere  the  tumor  was  mainly  frontal. 
The  microscopical  examination  showed  it  to  be  a  glio- 
sarcoma. 

Dr.  Wiener  said  that  the  absence  of  the  patellar  reflexes 
had  been  reported  by  others,  but  no  satisfactory  explanation 


336  NEfV  YORK  NEUROLOGICAL  SOCIETY. 

had  been  offered  for  this  phenomenon  up  to  the  present  time. 
Frontal  ataxia,  which  was  really  due  to  involvement  of  the 
trunk  muscles,  which  have  their  location  in  this  particular  por- 
ti(Mi  of  the  brain,  was  another  interesting  point.  It  was  worthy 
of  note  that  in  both  cases  the  father  was  alcoholic.  In  the 
second  case,  as  there  was  one  symptom  present  before  the 
trauma,  he  was  inclined  to  believe  that  the  trauma  only  served 
tomake  the  patholc^ical  conditicm  manifest.  The  relief  aflforded 
by  the  trephining  was  evident  in  the  first  case. 

Dr.  C.  L.  Dana  said  that  in  the  specimen  he  noticed  a  por- 
tion of  the  tumor  lying  back  of  the  Rolandic  fissure.  This,  he 
thought,  might  explain  the  ataxia.  He  had  recently  seen  a 
large  abscess  of  the  frontal  lobe  in  which  there  had  been  no 
history  of  ataxia.  It  seemed  to  him  straining  the  point  to  try 
and  make  it  a  frontal  ataxia.  It  could  not  be  from  the  involve- 
ment of  the  trunk  muscles. 

Dr.  Arthur  Booth  said  that  in  the  three  cases  of  frontal 
tumor  that  he  had  seen,  there  had  been  no  ataxia,  and  the  re- 
flexes had  been  absent  after  the  symptoms  had  been  well  de- 
veloped. 

Dr.  Joseph  Fraenkel  said  that  he  was  convinced  that  the 
condition  of  the  knee-jerks  was  entirely  dependent  upon  the 
contraction  of  the  muscles.  Another  factor,  of  course,  is  the 
muscular  sense,  and  still  another  is  the  difficulty  of  determining 
clinically  slight  disturbances  of  deep  sensibility.  In  the  case 
under  discussion  he  would  explain  it  by  invasion  of  the  frontal 
and  parietal  lobes,  and  the  probable  more  or  less  marked  dis- 
turbance of  the  deep  sensibility. 

Dr.  W.  M.  Leszynsky  said  that  the  more  he  tested  the  knee- 
jerks,  the  more  he  thought  the  theory  of  inhibition  could  be, 
to  a  great  extent,  sustained.  This  had  been  particularly  notice- 
able in  cases  of  meningitis  in  children  that  he  had  observed 
in  the  early  stages.  These  children  had  been  previously  tested 
for  their  knee-jerks  as  a  matter  of  routine.  When  the  signs  of 
pressure  had  set  in  later,  the  knee-jerks  had  become  exagger- 
ated, and  this  he  attributed  to  the  irritation  within  the  brain. 
A  similar  explanation  could  be  offered  in  connection  with  the 
case  now  under  discussion. 

Dr.  B.  Sachs  thought  the  question  of  ataxia  in  these  cases 
could  not  be  settled  by  the  supposition  that  it  was  wholly  due 
to  the  invasion  of  the  tracts  lying  in  the  vicinity  of  the  parietal 
lobule,  for  the  reason  that  ataxia  had  been  noted  in  other  cases 
of  frontal  tumor  in  which  there  I-ad  been  no  involvement  of 
that  particular  region.  It  seemed  to  him,  therefore,  that  the 
ataxia  had  come  to  be  looked  upon  as  a  symptom  of  frontal 
tumor.  The  behavior  of  the  reflexes  in  the  cases  reported 
seemed  to  him  very  remarkable.  In  his  own  mind  the  older 
theories  were  of  greater  help  than  the  theory  suggested  by  Van 


NEiy  YORK  NEUROLOGICAL  SOCIETY.  337 

Gehuchten,  or  that  propounded  by  Fraenkel.  He  believed  Dr. 
Fraenkel  was  confounding  things  which  are  coincident,  with- 
out necessarily  being  related  as  cause  and  effect.  It  would 
not  do  simply  to  assume  that  there  were  changes  in  the  deep 
sensibility  which  we  were  as  yet  unable  to  detect  cHnically. 
He  was  inchned  to  believe  that  the  same  causes  which  produce 
loss  of  reflex  are  also  responsible  for  the  changes  in  the  tonus 
and  in  the  deep  sensibility.  There  was  probably  some  additional 
fact  in  the  explanation  of  the  reflexes  which  was  yet  lacking, 
but  we  should  not  endeavor  to  make  the  facts  fit  the  theory. 
Another  interesting  point  in  this  case  was  the  certainty  with 
which  it  was  diagnosticated  as  a  subcortical  tumor.  The  hope 
of  an  excision  had  been  abandoned  at  a  very  early  day.  The 
diagnosis  of  its  situation  had  been  largely  based  upon  the  non- 
occurrence of  epileptiform  seizures  from  the  beginning  to  the 
end  of  this  disease. 

Dr.  Wiener,  in  closing,  said  in  reply  to  Dr.  Dana,  that  he 
did  not  doubt  that  there  might  be  tumors  of  the  frontal  lobe 
without  any  ataxia,  but  it  had  been  shown  when  the  portions 
bordering  on  the  frontal  convolutions  were  destroyed,  there 
was  this  peculiar  cerebellar  gait.  If  Dr.  Fraenkel's  theory  re- 
garding the  reflexes  were  correct,  he  could  not  understand 
why, in  the  case  just  reported,  the  reflexes  should  have  returned 
afterward.  He  thought  the  increased  reflexes  were  due  to  the 
destruction  of  the  normal  inhibitory  influence. 

A  CASE  OF  SUBCORTICAL  VISUAL  APHASIA. 
Dr.  Joseph  Collins  reported  such  a  case,  and  presented 
the  brain.  The  patient,  a  male,  fifty-eight  years  of  age, 
had  not  had  syphilis,  rheumatism  or  gout;  nevertheless 
the  vessels  showed  well-marked  arterial  sclerosis.  For 
five  months  he  had  been  complaining  of  headache  and 
vertigo.  Then,  without  warning,  he  Jjecame  unconscious, 
and  lay  in  a  stuporous  condition  for  about  three  weeks. 
After  this  he  recovered  his  mental  balance,  but  was  un- 
able to  return  to  work  because,  it  was  said,  of  his  "weak- 
ness." Examination  of  the  eyes  showed  complete  right 
lateral  homonymous  hemianopsia.  There  was  complete 
word  blindness,  and  almost  complete  letter  blindness. 
He  could  not  mark  a  word  off  into  syllables.  There  was 
no  object  blindness.  He  recognized  things  and  called 
them  by  their  right  names.  He  wrote  very  badly  to  dic- 
tation, and  this  showed  that  he  could  not  retain  the  words 
in  mind  long  enough.  When  asked  to  read  what  he  had 
written,  he  pointed  to  each  word  and  said:  "I  would  like 
very  much  to  read,"  and  continued  to  repeat  this  again 


338  NEW  YORK  NEUROLOGICAL  SOCIETY. 

and  again.  He  did  not  give  the  slightest  heed  to  words 
put  in  writing,  although  he  responded  promptly  to  spoken 
commands.  Spontaneous  speech  was  not  materially  dis- 
ordered. The  symptoms  pointed  to  a  lesion  between  the 
angular  gyrus  and  the  visual  centres,  situated  in  the  pos- 
terior end  of  the  left  hemisphere.  If  the  lesion  were  in 
the  primary  visual  centre,  there  would  be  object  blind- 
ness. 

The  patient  had  been  admitted  to  the  City  Hospital, 
and  extended  observation  showed  no  material  ch^tige  in 
the  above  findings.  He  was  easily  excited.  On  November 
8th,  1897,  he  suddenly  fell  over  in  a  general  convul- 
sion. He  did  not  recognize  any  one  after  that,  and 
soon  developed  a  right-sided  hemiplegia.  The  autopsy 
was  made  a  few  hours  after  death.  There  was  no  notice- 
able abnormality,  aside  from  the  brain,  except  an  exten- 
sive arterial  sclerosis.  The  entire  occipital  lobe  was  red- 
dish-yellow, and,  with  the  exception  of  the  extreme  pos- 
terior cortex,  the  brain  was  replaced  by  a  cystic  forma- 
tion. N'early  all  of  the  lingual  gyrus  and  the  cuneus 
had  been  destroyed — in  short,  the  cystic  formation  in- 
volved the  whole  posterior  part  of  the  left  hemisphere 
save  the  very  apex  of  the  cnneus,  and  particularly  the 
inner  surface.  The  remainder  of  the  left  hemisphere  was 
apparently  normal.  The  temporal  lobes  were  not  im- 
plicated. The  depth  of  the  lesion  was  almost  through 
the  thickness  of  the  white  matter  and  into  the  ventricles. 
Both  lateral  ventricles  were  distended  with  clots. 


DELPHIA  NEUROLOGICAL  SOCIETY. 

February  28th,  1898. 
'resident,  Dr.  F,  X.  Dercum,  in  the  chair. 
;mon  Flexner,  of  Johns  Hopkins  University,  read 


GLIA  AND  GUOMATOSIS.     (See  p.  306). 

ieph  Sailer  said  that  Dr.  Flexner's  paper  had  brought 
some  novel  ideas  in  regard  to  the  histology  and  de- 
:  of  gliomata.  He  wished  to  know  whether  Dr.  Flex- 
;  study  of  these  various  forms  of  gliosis,  had  not  ob- 
lls  that  in  some  respects  were  atypical,  and  which 
ardly  be  fair  to  regard  as  ependymai  in  their  origin. 
ecently  found  cells  showing  a  shght  projection  on 
1  the  cortical  region  of  the  brain.  These  were  large, 
:ontained  a  large  faintly-stained  nucleus.  This  tissue 
be  hardened  and  stained  so  as  to  show  the  relation 
i  to  the  neuroglia  fibres.  Deeper  down  he  had  found 
ells,  pyramidal  in  shape  and  quite  irregular  in  type. 
ns  were  situated  in  hyperplastic  neuroglia  tissue, 
of  bundles  of  fibres  arranged  irregularly  with  large 
rween  them.  He  thought  that  these  resembled  the 
ihed  as  ependymai. 

liller  stated  that  the  undifferentiated  glia  cells  of  v. 
i,  which  are  supposed  to  give  rise  to  the  cells  of  the 
are  purely  hypothetical,  and  that  since  we  know 
ells  and  fibres  are  separate  from  one  another,  these 
■al  cells  are  not  needed  to  enable  us  to  understand 
ration  of  the  glia.  He  referred  to  the  recent  excel- 
s  by  Rossolimo,  Henneberg  and  E.  W.  Taylor  on 
ts  of  glia  and  glioniatosis,  and  spoke  of  the  gliosis 
o  commoTtly  seen  about  the  central  canal  in  spinal 
ch  do  not  seem  to  be  abnormal  in  other  respects, 
is  may  have  some  bearing  on  syringomyelia.  He 
lat  if  we  had  methods  well  adapted  to  the  study  of 
glia  in  animals,  we  should  find  that  the  fibres  are 
ly  separated  from  the  cells  as  they  are  in  man.  Glio- 
be  composed  largely  of  fibres,  but  may  also  contain 
i.     In  a  glioma  which  he  had  been  studying  he  had 


340  PH!LADELPHIA  NEUROLOGICAL  SOCIETY. 

found  numerous  hypertrophied  glia  fibres  and  many  cells; 
some  of  the  later  were  round  and  some  more  or  less  elongated. 
He  had  found  certain  elements  which  looked  as  though  they 
were  in  a  transitional  stage  from  cells  to  fibres;  they  were  long 
like  fibres  and  yet  seemed  to  contain  a  nucleus. 

Dr.  Spiller  spoke  of  the  peculiar  sharpness  of  outline  of  the 
gliotic  tissue  and  symmetry  of  the  proliferation  in  multiple 
sclerosis,  and  exhibited  specimens  illustrating  these  points. 
The  microscope  shows  that  the  proliferated  neuroglia  is  not 
so  sharply  separated  from  the  normal  tissue  as  it  appears  to  be 
to  the  naked  eye.  He  said  he  had  observed  very  distinct  round- 
cell  infiltration  about  the  vessels  within  the  gliotic  patches, 
which  might  well  raise  the  question  of  the  relation  of  dissem- 
inated myelitis  to  disseminated  sclerosis. 

Dagonet  had  recently  spoken  of  the  hypertrophy  of  the 
processes  of  ependymal  cells  in  general  paralysis  as  a  return 
to  embryonic  conditions.  This  would  be  in  accordance  with 
Dr.  Flexner's  views.  There  seemed  to  be  no  reason  why  the 
proliferating  gHa  cells  should  not  assume  a  primitive  form. 

Dr.  Spiller  said  he  had  observed  cells  in  syringomyelia 
which  were  evidently  very  much  like  those  described  by  Dr. 
Councilman  in  epidemic  cerebrospinal  meningitis.  They  were 
quite  large  round  cells,  containing  two,  three  or  four  nuclei 
and  a  considerable  amount  of  cytoplasm,  and  were  situated 
at  the  outer  border  of  the  gliotic  tissue.  They  seemed  to  be 
glia  cells. 

Dr.  Flexner  thought  that  the  case  described  by  Dr.  Sailer 
might  be  an  instance  of  a  pathological  growth  of  cells  of  the 
type  of  ependymal  cells.  But  if  the  process  were  a  reparative 
one  rather  than  a  true  tumor  formation,  he  would  not  expect 
to  find  either  immature  or  adult  ependymal  cells  in  it.  His 
idea  was  that  we  should  think  of  heuroglia  somewhat  in  the 
same  way  as  we  are  in  the  habit  of  regarding  the  ordinary 
connective  tissues.  We  distinguish,  for  example,  between 
fibrosis  and  fibromatosis,  and  between  granulation  tissue  and 
sarcoma.  A  diffuse  growth  of  fibrous  tissue,  especially  if  it  is 
reparative  in  nature,  is  not  a  tumor,  not  a  fibroma.  In  the  same 
way  he  would  limit  the  conceptions  gliosis  and  gliomatosis. 
It  remains  to  be  proven  that  the  newly-formed  glia,  which 
has  nothing  to  do  with  tumor,  goes  through,  in  the  course  of 
its  evolution,  the  earlier  stages  of  its  ontogeny,  just  as  growing 
fibrous  tissues  often  repeat  the  stages  of  its  embryologica! 
development. 

The  limited  time  at  his  command  did  not  permit  of  a  full 
consideration  of  the  points  raised  by  Dr.  Spiller.  He  was 
disposed,  however,  to  consider  that  they  agreed  in  the  main 
questions  at  issue. 


■*■ 


f  •> 


PHILADELPHIA  NEUROLOGICAL  SOCIETY, 


341 


ACROMEGALY  AND  HYPERTROPHIC  PULMONARY 

OSTEO-ARTHROPATHY. 

Dr.Thayer,of  Johns  Hopkins  University,  demonstrated 
a  case  of  Marie's  hypertrophic  pulmonary  osteo-arthro- 
pathy,  showing  photographs  of  three  similar  instances 
which  had  been  under  observation  at  the  Johns  Hopkins 
Hospital.  These  were  accompanied  by  radiographs  illus- 
trating the  bones  of  normal  individuals  and  of  two  patients 
with  hypertrophic  osteo-arthropathy  as  well  as  of  one  in- 
stance of  acromegaly.  The  radiographs  of  the  hands  and 
arms  showed  striking  differences  between  the  bones  in 
acromegaly  and  osteo-arthropathy.  In  the  former  there 
was  a  general  plumpness  with  an  exaggeration  of  the 
normal  irregulariti^  in  outline,  and  of  the  points  of  mus- 
cular and  tendinous  attachment,  together  with  a  tend- 
ency to  roughness  and  tufting  of  the  bone  about  the  epi- 
physes. This  was  especially  marked  at  the  ends  of  the 
terminal  phalanges.  In  the  hands  and  arms  of  the  patients 
with  osteo-arthropathy  a  more  or  less  general  diaphysial 
enlargement  of  the  long  bones,  particularly  toward  their 
distal  extremities,  was  to  be  made  out.  The  terminal  phal- 
anges were  quite  unaffected,  and  the  enlargement  of  the 
other  bonesof  thehand  was  entirely  limited  to  thediaphyses. 
Especially  striking  was  this  enlargement  in  the  metacarpal 
bones,  in  some  of  which  the  lower  thirds  of  the  diaphyses 
were  nearly  as  large  as  the  distal  epiphyses.  Autoosies  in 
twenty  instances  have  shown  that  this  enlargement  in  os- 
teo-arthropathy consists  of  an  ossifying  periostitis,  limited 
almost  entirely  to  the  diaphyses  of  the  long  bones  of  the 
hands,  feet,  arms  and  legs.  Radiographs  were  then  ex- 
hibited of  an  acute  case,  which  showed  clearly  the  newly 
formed  bone  as  a  somewhat  irregular  shadow  along  the 
diaphyses  of  the  long  bones  of  the  arm  and  hand,  ex- 
actly in  the  areas  of  the  tenderness  and  palpable  enlarge- 
ment. 

The  various  theories  as  to  the  ultimate  cause  of  this 
affection  were  then  discussed.  It  is  undeniable  that  a 
certain  proportion  of  cases  occur  without  any  preceding 
pulmonary  disorder.  In  a  study,  however,  of  55  typi- 
cal cases  of  hypertrophic  pulmonary  osteo-arthropathy, 
43  showed  a  preceding  pulmonary  affection.  Of  the  12 
remaining  cases,  3  cases  followed  syphilis,  3  cases  fol- 
lowed valvular  heart   disease,  2   cases  followed  chronic 


4 
» - 


ilJ 


34^  PHILADELPHIA  NEUROLOGICAL  SOCIETY. 

diarrhoea,  i  case  followed  spinal  caries,  3  cases  followed 
unknown  causes. 

The  weight  of  evidence  appears  to  be  in  favor  of  a 
modification  of  Marie's  and  Ban^berger's  theory  of  the 
toxic  origin  of  these  changes.  The  majority  of  the  re- 
ported cases  have  followed  conditions  favorable  to  the 
retention  of  purulent  secretions  within  the  economy. 

Even  if  we  accept  such  a  theory,  however,  it  is  at 
present  impossible  to  say  what  the  toxic  substance  or 
substances  may  be,  how  they  may  arise,  or  why  they 
should  be  more  frequently  present  in  pulmonary  affections 
than  in  suppuration  elsewhere.  The  position  which  we 
occupy  with  regard  to  this  affection  is  not  dissimilar  to 
that  in  which  we  stand  with  regard,  for  instance,  to  amy- 
loid degeneration.  Thus,  amyloid  degeneration  follows 
commonly  chronic  suppuration,  particularly  suppuration 
of  bone,  but  it  is  not  infrequently  found  in  syphilis  where 
there  has  been  relatively  Httle  suppuration,  as  well  as  in 
other  cases  of  chronic  cachexia  due  to  malignant  disease, 
or  in  chronic  malarial  cachexia,  while,  lastly,  in  a  certain 
proportion  of  cases,  no  distinct  cause  can  be  found.  In 
the  same  manner  we  have  learned  that  secondary  osteo- 
arthropathies are  particularly  frequent  in  chronic  sup- 
purative processes  connected  with  the  lungs,  but  the  dis- 
ease has  also  occurred  in  several  instances  of  syphilis,  2 
instances  of  chronic  diarrhcea  and  3  instances  of  valvular 
heart  disease,  and,  lastly,  occasionally  where  the  condition 
has  seemed  to  develop  spontaneously.  In  both  instances 
we  are  led  to  believe  that  the  process  owes  its  origin  to 
some  toxic  substance  arising  within  the  ceconomy.  What 
this  may  be  we  are  at  present  unable  to  say. 

There  would  appear  to  be  little  evidence  in  favor  of  the 
idea  that  the  condition  may  be  due  to  primary  or  even 
secondary  changes  in  the  nervous  system.  There  can  be 
no  dpubt  that  the  name  proposed  by  Massalongo,  "sec- 
ondary hypertrophic  osteo-arthropathy,"  is  much  better 
than  that  originally  proposed  by  Marie,  but  it  is  a  questicHi 
whether  it  will  be  possible  to  change  a  term  which  has 
come  into  such  general  use. 

Dr.  F.  A.  Packard  said  he  had  been  particularly  interested 
in  the  last  case  with  the  evidently  recent  changes  shown  by 
Dr.  Thayer,  who  had  been  remarkably  fortunate  in  getting 
the  skiagraph  at  that  stage.     He  was  sorry  that  he  had  not 


PHILADELPHIA  NEUROLOGICAL  SOCIETY. 


346 


brought  with  him  the  specimens  from  a  case  of  pulmonary 
osteo-arthropathy  which  he  reported  in  1892.  In  this  case 
t}ie  tibia  distinctly  shows  this  thickening  of  the  subperiosteal 
portion  of  the  bone  most  marked  in,  or  almost  restricted  to, 
its  lower  half.  Dr.  Packard  had  only  been  able  to  obtain  the 
tibia  in  this  case,  as  he  was  away  from  home  at  the  time  of 
the  necropsy,  and  the  patient's  brother  had  objected  to  the 
proposed  examination  of  the  rest  of  the  skeleton,  notwith- 
standing the  fact  that  the  patient  himself  had  bequeathed  his 
body  to  Dr.  Packard. 

Dr.  Lewellys  F.  Barker,  of  Johns  Hopkins  University, 
showed  a  number  of 

SPECIMENS  ILLUSTRATING  THE  MEDULLATING  CERE- 
BRUM IN  HUlClAN  BEINGS. 

The  method  of  preparation  was  described.  The  brain 
of  a  baby  shortly  after  birth  had  been  hardened  in  Miiller's 
fluid,  imbedded  in  celloidin,  and  divided  by  a  laboratoj;*y 
assistant  into  a  series  of  some  four  hundred  sagittal  sec- 
tions in  the  Anatomical  Laboratory  at  Baltimore.  These 
were  stained  by  the  Weigert-Pal  method  and  mounted  in 
balsam  upon  ordinary  window  glass,  sheets  of  mica  being 
used  instead  of  glass  cover  slips.  The  glassware  and  mica 
needed  for  such  a  set  of  serial  sections  can  be  provided  at 
very  little  expense.  The  sections  are  kept  in  boxes  made 
for  holding  photographic  negatives. 

Sections  chosen  at  some  twenty  levels  in  the  hemi- 
sphere were  exhibited.  Only  a  few  of  the  fibres  are  medul- 
lated  at  this  stage  of  development.  A  portion  of  the  up- 
ward continuation  of  the  tegmental  radiations,  the  pyra- 
midal tracts,  the  optic  tracts,  and  part  of  the  optic  radia- 
tions already  possess  myelin  sheaths.  The  exact  distribu- 
tion of  the  sensory  fibres  can  be  easily  followed,  and  the 
somaesthetic  and  visual  sense  areas  of  the  cortex  are  sharp- 
ly marked  oflf  from  other  regions.  The  specimens,  as  far 
as  they  go,  are  confirmatory  of  the  anatomical  discoveries 
of  Flechsig,  and  illustrate  the  value  of  the  embryological 
method  for  outlining  tracts  ending  and  originating  in  the 
pallium. 

Dr.  H.  M.  Thomas,  of  Johns  Hopkins  University,  read 
a  paper  on 

RECURRENT  MULTIPLE   NEURITIS. 
The  patient,  a  merchant,  28  years  old,  had  been  at- 


« 


344  PHILADELPHIA  NEUROLOGICAL  SOCIETY. 

tacked  on  five  different  occasions  by  multiple  neuritis. 
These  attacks  had  all  commenced  in  the  month  of  June, 
and  had  lasted  for  from  five  to  six  months.  The  disease 
had  recurred  every  year,  except  on  one  occasion,  when  the 
interval  had  been  two  years.  The  symptoms  consisted' in 
numbness,  swelling  and  weakness  of  the  feet  and  legs,  with 
a  slight  sense  of  numbness  in  the  hands,  except  in  the  last 
attack,  when  the  hands  were  also  markedly  affected.  Upon 
examination,  he  presented  a  typical  picture  of  a  wide- 
spread multiple  neuritis. 

No  etiological  factor  could  be  determined.  There  was 
no  possibility  of  poisoning  by  alcohol,  nor  did  there  seem 
to  have  been  any  definite  exposure  to  lead  or  arsenic.  The 
fact  that  the  paralysi.s  had  been  confined  in  four  attacks 
to  the  legs,  and  that  there  was  no  lead  line  present,  was 
tlioiight  to  exclude  the  probability  of  lead  poisoning,  al- 
though the  cistern  from  which  the  water  at  his  home  was 
oijtained  was  connected  with  a  lead  pipe. 

In  a  review  of  the  literature,  very  few  articles  were 
found  in  which  the  recurrence  of  multiple  neuritis  had 
been  particularly  considered,  the  papers  by  Sherwood,  Tar- 
gowla  and  Sorgo  practically  completing  the  list. 

Dr.  Sherwood's  supposition  that  the  first  attack  of 
neuritis  left  the  nerves  with  a  lowered  power  of  resistance, 
and  so  liable  to  recurrences,  had  received  a  certain  amount 
of  confirmation  from  the  result  of  the  autopsy  in  Sorgo's 
case.  In  his  case  there  were  marked  changes  in  the  blood 
vessels  of  the  nerves  and  spinal  cord.  The  patient  had  died 
during  the  third  attack  of  multiple  neuritis.  In  lead 
poisoning  recurrent  paralyses  are  common,  when  there  is 
a  renewed  exposure  to  the  lead,  and  they  also  do  at  times 
occur  when  there  has  been  no  re-exposure  (Bernhardt); 
and  it  would  seem  that  one  attack  does  predispose  to 
another  in  the  case  of  this  poison. 

In  alcoholic  paralysis,  on  the  contrary,  recurrences 
seem  to  be  rare,  and  it  is  remarkable  how  very  generally 
the  cases  which  are  treated  are  seen  in  their  first  attack. 

In  the  records  of  the  Johns  Hopkins  Hospital  there 
has  been  but  one  typical  case  of  alcoholic  paralysis  which 
was  seen  in  the  second  attack.  There  have,  however,  been 
two  cases  of  the  ataxic  form  of  alcoholic  neuritis  which  have 
shown  recurrences,  and  one  patient  who  had  had  an  ar- 
senical neuritis  was  treated  in  a  second  attack  brought  on 
by  the  misuse  of  alcohol.    The  recurrence  of  facial  paraly- 


^WBLPHIA  NEUROLOCiCAL  SOCiETY. 


345 


h  not  common,  does  happen.  Among  eighty 
were  five  second  attacks,  but  in  two  of  these 
e  side  was  affected,  so  there  were  but  three 
irrences, 

ases,  although  showing  that  in  certain  indi- 
tiple  neuritis  is  likely  to  recur,  do  not  prove 
tack  of  the  disease  predisposes  to  the  second 
e  first  attack  must  be  explained  as  well  as  the 
e  questions  of  the  susceptibility,  the  resistance 
lunity  of  the  tissues  are  involved  in  the  answer 
lem.  A  careful  study  in  this  relation  of  a  large 
cases  of  multiple  neuritis  would  give  at  least 
ipon  which  to  build  a  plausible  hypothesis,  but 
lo  such  study  has  been  made,  and  the  question 
:  open. 

irton  Siiikler  said  that,  so  far  as  his  experience 
homas'  case  was  unique.  From  his  own  observa- 
ild  judge  that  recurrences  in  lead  and  alcoholic 
not  common.  He  recalled  only  one  case  in  which 
currence  in  lead  neuritis,  and  that  was  in  a  house 
temperate  habits,  who  had  had  two  attacks.  He 
,  also,  one  case  of  neuritis  in  an  ajcoholic  patient, 
]  a  previous  attack.  He  thought  that  there  is  no 
Icohol  does  predispose  to  attacks  of  multiple  lead 

er  desired  to  know  whether  the  recurrent  oculo- 
I'sis,  of  which  he  had  seen  a  good  example,  might 
Tht  to  have  some  resemblance  to  the  case  just  re- 

nas  replied  that  Dr.  Mary  Sherwood,  in  her  thesis, 
cases  of  recurrent  oculomotor  paralysis,  and  gives 
;  of  the  subject.  As  we  do  not  know  the  lathology 
iC,  the  relation  which  it  bears  to  recurrent  multiple 
lot  be  stated.  There  are  several  other  forms  of 
rvous  diseases  that  it  would  have  been  interesting 
lad  there  been  time. 


With  the  AsSKttmct  of  th*  Folkmmg  CoUabor atari: 

Cuas.Lewi5  ALLEN,M.D.,Wash.,D.C.R.  K.  Macalester,  M.D.,  N.Y. 
J.  S.  Christison,  M,D.,  Chicago,  III.  1.  K.  Mitchell,  M.D.,  Phila,,  Pa 
A.  Freeman,  M.D.,  New  York.  H.  Patrick,  M.D.,  Chicago,  111. 

S.  E.  Jelljffe,  M.D.,  New  York.  Joseph  Sailer,  M.D.,  Phila..  Pa. 
Wm.C.Krauss,M,D.,  Buffalo,  N.Y.  Hehry  L.  Shivelv,  M.D.,  N.Y. 
W.  M.  Leszynsey,  M.D.,  New  York,  A.  Sterhe,  M.D.,  Indianapolis. 

ANATOMY. 

io6.    Uebf.r    den    Kern    des    Nervus    accessorius       (Concerning 
the    Nucleus    of   the    Accessory    Nerve).      Emi]    Bunzl-Federn 
(Monatsschrift  fiir  Psychiatric  und  Neurologie,  2,  1897,  p.  427). 
In   a  number  of  rabbits  the  external   branch   of   the   accessorius 
was  cut  in  the  neck  near  its  exit  from  the  jugular  foramen;  in  others 
the  roots  of  the  accessorius  were  cut  within  the  spinal  canal.     The 
animals  were   killid   iourteen   days  later,   examinalion   of  the   larynx 
having  first  been-  made.     The   movements   of  the   vocal   cords   were 
normal.    The  method  of  Nissl  was  employed,  as  by  this  stain  degen- 
erative changes  within  a  cell  are  seen  soon  after  its  axis  cylinder  is 

Bunzl-Federn  finds  that  the  cells  of  the  accessorius  nucleus  begin 
in  the  lateral  horn  near  its  base  just  above  the  exit  of  the  fifth  cervical 
nerve,  and  soon  assume  a  position  on  the  lateral  and  posterior  border 
of  the  horn;  that  higher  they  form  two  groups  more  anteriorly  located, 
one  of  which  is  more  towards  the  centre;  and  that  still  hiirher  ihe 
median  group  disappears  and  degenerated  cells  are  present  in  the 
anterior  part  o(  the  anterior  horn,  which  later  take  a  more  central 
position  within  the  horn.  Degenerated  cells  were  only  noticed  on 
the  side  of  the  operation.  The  accessorius  nucleus  ends  just  below 
the  lowest  part  of  the  hypoglossus  nucleus,  and  extends,  therefore, 
far  into  the  oblongata.  Most  of  the  spinal  portion  and  the  lowest 
portion  of  the  oblongatal  roots  of  the  accessorius  pass  into  the  external 
branch  of  this  nerve,  but  a  few  pass  into  the  vagus.  The  uppermost 
fibres  of  the  accessorius  nucleus  of  the  oblongata  enter  the  internal 
branch  of  the  accessorius  and  thus  form  part  of  the  vagus.  The  acces- 
sorius, however,  has  nothing  to  do  with  the  motor  innervation  of 
the  larynx,  for  the  vocal  cords  were  not  affected  after  the  accessorius 
roots  had  been  cut.  and  only  in  one  of  many  cases  was  degeneration 
of  accessorius  cells  found  after  the  recurrent  laryngeal  nerve  had  been 
cut,  Spiller. 

107.  Ueber  die  Kerne  drr  mit  den  Augenbewecungen   in   Be- 

ZIEHUNG  STEHENDEN  NERVEN  UND  iJBER  DIE  VerBINDUNG   DER- 

SELBEN  UNTER  EiNANDER  (On  the  Nuclei  of  the  Motor  Nerves 
of  the  Eyes  and  their  Relations  to  one  another).  W.  von  Bech- 
terew  (Arch.  f.  Anat.  u.  Entwicklungsgeschichte,  10.  1897,  Hefte 
5  ti.  6). 


PERISCOPE.  347 

Bcchterew  claims  four  nuclei  for  the  oculo-inotorius.  The  main 
nucleus  is  dorsal,  situated  just  beneath  the  anterior  corpora  quadri- 
gemina  and  is  paired.  There  is  an  unpaired  median  nucleus,  an  anterior 
mesial  accessory  nucleus  and  a  posterior  lateral  nucleus.  He  claims 
that  the  upper  nucleus,  described  by  Darkschewitsch  as  the  nucleus 
centralis  posticus  nervi  oculomotorii  is  in  reality  a  part  of  the  troch- 
learis. 

The  different  nuclei  of  the  oculo-motorius  have  numerous  asso- 
ciation fibres,  and  he  traces  fibres  of  communication  between  the 
nuclei  of  the  abducens  and  those  of  the  oculo-motorius. 

Jelliffe. 

io8.    The    Anatomical    Connections    ok    the    Frontai,    Lobes 
Joukowski  (Revue  de  Psych.,  Russian),  1897,  Rev.  Neur. 

The  researches  of  the  author  were  made  by  the  method  of  extir- 
pation and  the  study  of  secondary  degenerations.  The  following  con- 
clusions are  given. 

The  frontal  lobes  are  in  immediate  connection, 

1.  With  the  convolutions  of  the  cingulum  and  the  subcallosal 
fibres  by  means  of  fibres  of  different  lengths. 

2.  With  the  anterior  region  of  the  optic  thalamus  by  means  of 
fibres  which  pass  in  the  internal  capsule. 

3.  With  the  substantia  nigra,  notably  its  internal  portions. 

4.  With  the  anterior  part  of  the  protuberance,  by  means  of  the 
"fronto-protuberantial"  fibres  which  pass  in  the  internal  parts  of  the 
cerebral  peduncles. 

5.  Connection  between  the  two  frontal  lobes  is  afforded  by  fibres 
which  pass  in  the  corpus  callosum  at  its  anterior  end. 

6.  In  the  rabbit  the  connections  between  the  two  frontal  lobes 
are  reinforced  by  a  fascicle  of  fibres  which  passes  in  the  internal 
capsule  and  the  anterior  commissure. 

7.  There  exists  a  connection  between  the  gyrus  fornicatus  and  the 
fornix,  by  means  of  fibres  passing  from  the  former  through  the  corpus 
callosum  to  the  swelling  of  the  fornix.  Vogel. 

109.  Ox  A  Modification  of  the  Subwmate  Method  for  the  De 
ijNEATioN  of  Nervous  Tissues  W.  Bevan  Lewis  (Edinburgh 
Medical  Journal,  August,   1897). 

The  author  describes  the  following: — Pieces  of  cortex  are  hard- 
ened for  from  two  to  three  months  in  Cox's  fluid, 

5  per  cent,  solution  potass,  bichrom 20 

5  per  cent,  solution  hydrarg.  bichlor 20 

5  per  cent,  solution  potass,  chromate 16 

Water    30-40 

They  are  then  washed  in  alcohol  for  a  hall  hour,  mounted  and 
cut.  The  sections  are  brought  upon  a  slide,  a  drop  or  two  of  liq. 
potassae  is  added  to  them,  and  immediately  washed  oflF  by  inclining 
the  slide,  and  allowing  water  from  a  pipette  to  flow  over  the  specimen. 
They  are  then  dehydrated  in  alcohol,  cleared  in  oil  of  cloves,  and 
mounted  in  balsam  as  usual.  The  addition  of  the  potash  has  the  effect 
of  bringing  out  the  tissue  elements  with  intense  blackness,  and  reveals 
the  finest  details  of  structure  more  surely  and  with  greater  clearness 
than  the  modified  sublimate  or  chrome-silver  methods.  Allen. 

110.  On  the  Nature  of  the  WiEGERT-PAL  Method.  J.  S.  Boltou 
(Jour,  of  Anat.  and  Physiol.,  32.  1898,  p.  247). 

The  author  presents  a  very  valuable  discu<^sion  of  the  whys  and 
wherefores    of    the    Weigert-Pal    methods    of    staining,    with    severrl 


7 


f:  • 


348  PERISCOPE, 

serviceable  modifications.     He  concludes  his  extensive  studies  thus: — 

1.  The  Weigert-Pal  process  consists  in  the  incomplete  oxidation 
of  a  stain  from  mordanted  fibrils  containing  it  as  a  lake,  and  bears  no 
necessary  relation  to  the  occasional  presence  of  a  medullary  sheath 
round  these. 

2.  If  an  ordinary  mordant  dye.  such  as  logwood,  be  used,  a  me- 
tallic salt,  to  mordant  the  fibres  previously,  is  necessary. 

3.  If  a  basic  dye,  such  as  methylene  blue,  soluble  in  water,  be 
used,  double  mordanting  with  tani'ic  acid,  and  afterwards  with  tartar 
emetic   is   necessary. 

4.  The  ordinary  Weigert-Pal  result  can  he  obtained  by  the  use  of 
osmic  acid  alone,  as  this  forms  a  jet  black  lake  with  hemaloxyhn  in  the 
absence  of  other  metals. 

5.  Almost  as  good  or  equally  good  results  can  be  obtained  by  the 
use  of  a  2  per  cent,  solution  of  iron-alum,  ammonium  molybdate, 
ferric  chloride,  stannous  chloride,  sodium  tungstate.  uranium  acetate 
and  potash  alum;  and  much  inferior  results  arranged  in  order  of  their 
value  can  be  obtained  by  the  use  of  similar  solutions  of  nickel  sul- 
phate, chrome  alum,  and  the  chromates.  copper  acetate,  cobalt  nitrate. 
citrate  of  bismuth  and  ammonia,  ammonia  alum,  manganese  sulphate 
and  zinc  sulphate. 

6.  Osmic  acid  and  usually  iron  alum  cause  a  practically  equal 
staining  of  the  medullary  sheath  and  of  the  axis  cylinder,  whilst  the 
other  metals  chiefly  cause  staining  of  the  axis  cylinder,  the  medullary 
sheaths  being  either  slightly  stained  or  quite  unstained,  according  to 
the  melai  employed.  Jelliffe. 

Ilr.    UEBER    die    MARKSCHKIDENBItnUNG    DER    GEHIRNNERVEN    DES 

Mknschev     (On  the  Development  of  the  Myelin   Sheath  in  the 
Human  Brain).    A.  Westphal  (Arch,  f  Psych.,  ig.  1897.  p.  474)- 
The  author  has   studied  the  development  of  the   myelin   sheaths 

in  the  brains  of  newly-born  children  and  in  the  foetus.     He  eome.s  to 

the  following  general  results: — 
fat  The  Cranial  Nerves. 
T.  Two  groups  are  here  to  be  distinguished  with  reference  to  the 

development  of  the  medullary  sheath.     The  motor  cranial  nerves  are 

myelinated  at  birth,  the  sensory  and  mixed  nerves  are  not  myelinated. 

with  the  exception  of  the  acoustic,   which  is  myelinated  early.     The 

optic  nerve  at  its  distal  end  develops  latest. 

2.  The  process  of  myelination  proceed?  from  the  central  nervous 
system  towards  the  periphery. 

3.  With  the  exception  of  the  optic,  the  calibre  of  the  nerve  fibres 
increases  with  age.  so  that  at  maturity  the  calibre  may  have  increased 

(b)   Comparison  with  the  peripheral  spinal  system. 

1.  Myelination  occurs  earlier  in  the  cranial  nerves  than  in  the 
peripheral  nervous  system. 

2.  The  ditTcrences  found  existing  between  motor  and  sensory 
nerves  in  the  cranial  nervous  system  could  not  be  found  for  the 
peripheral  spinal  system.  Jelliffe. 

PHYSIOLOGY. 

112.  The  Theory  of  the  Movement  of  the  Neuron  as  Appi.ied 

TO    NORMAT,   AND    PATHOI.OGIC    MENTAI,  AND  NEBVOrS  PROCESSES. 

F.  X.  Dercum,  M.D.  (Gaillard's  Med.  Jour..  66.  1897.  p,  .142)- 
The  behavior  of  the  neurons  in  a  case  of  transient  hysterical 
paralysis  may  be  given  as  an  illustration  of  the  simplest  expression 


PERISCOPE. 


349 


of  this  theory.    What  is  it  that  happens  in  the  nervous  system  when 
an  arm,  for  instance,  is  suddenly  paralyzed,  remains  so  for  a  time, 
and  again  suddenly  recovers  its  functions?    The  neurons  of  the  motor 
area  of  the  cortex  present  not  only  protoplasmic  extensions  directed 
towards  the  surface  of  the  cortex,  but  also  an  extension  downward, 
which  becomes  a  nerve  fibre,  but  which  is,  properly  speaking,  a  pro- 
cess of  the  cell  body.    This  process  extends  downward  through  the 
white  matter  of  the  brain  and  terminates  in  the  cord  in  a  brush-like 
extremity.     By  means  of  this  end  tuft  the  cortical  cell  is  brought 
into  relation  with  the  motor  nerve  cells  in  the  cord.     The  relation 
between  this  end  tuft  and  the  nerve  cell  in  the  anterior  horn  of  the 
cord  is  probably  one  of  contact,  and  not  actual  continuity  of  struct- 
ure. In  a  case  of  hysterical  paralysis  of  the  arm,  resulting,  for  instance, 
from  an  emotional  shock  the  neurons  of  the  arm  centre  of  the  cortex 
retract  their  processes  in  such  a  way  that  their  end  tufts  in  the  spinal 
cord  no  longer  bear  their  normal  relation  to  the  spinal  neurons,  and 
the  connection  between  the  cells  is  broken.     The  disappearance  of 
the  paralysis  is  due  to  the  extension  of  the  processes  previously  re- 
tracted—that is,  the  end  tufts  resume  their  normal  relations  with  the 
spinal  neurons  and  function  is  re-established.     Sleep  has  been  com- 
monly attributed  to  an  anaemia  of  the  brain,  notwithstanding  the  fact 
that  true  cerebral  anaemia,  such  as  follows  great  loss  of  blood,  is 
attended  with  insomnia.    The  movements  of  the  neurons  will  account 
for  sleep.    When  functionally  active  they  must  be  in  relation  with  one 
another  and  their  processes  either  in  contact  or  nearly  so.    Evidently 
this  condition  is  a  perquisite  of  consciousness.    When  the  nerve  cells 
are  exhausted  by  fatigue,  their  volume  and  contents  diminish,  as  we 
have  every  reason  to  infer  from  the  experiments  of  Hodge.     In  sleep 
the  neurons   have  their  processes   retracted;   in   consciousness  their 
processes  are  extended.    This  theory  also  enables  us  to  explain  patho- 
logic  unconsciousness,  such,   for  instance,   as  attends  cerebral   con- 
cussion.   A  man  receives  a  blow  upon  the  head;  the  neurons  suddenly 
retract  their  processes  and  unconsciousness  results.     It  is  extremely 
probable  that  the  unconsciousness  of  chloroform  or  ether  anaesthesia, 
o*"  the  sleep  produced  by  drugs  may  be  explained  similarly.     A  se- 
quence  of  sound  vibrations  impinging  upon  the  peripheral  auditory 
''^urons  produces  a  change  that  affects  the  relations  which  their  cen- 
*'''Petal  processes  bear  to  the  nerve  cells  of  the  auditory  nuclei  of  the 
^cdulla,  and  secondarily  to  the  neurons  in  the  auditory  area  of  the 
ortex.     It  is  probable  that  the  effect  produced  upon  the  latter  is  such 
-^1*^*^  cause  them  to  retract,  extend  or  otherwise  move  their  processes. 
Y^  same  sequence  of  sound  vibrations  must  always  produce  the  same 
jnangr^g  in  the  cortical  neurons.     The  physiology  of  conception  evi- 
Jfritl^r    consists  in  the  reforming  among  the  neurons  of  an  old  com- 
''"^ation — that  is,  the  combination,  the  same  as,  or  similar  to,  what 
*^s   Originally  produced  by  a  physical  impression  upon  the  organs  of 
th^^^'   but  which  is  now  produced  by  some  other  agency.    To  explain 
.?    Phenomena  of  memory,  we  will   say  that  a   sequence   of  sound 
vibrations  has  impinged  upon  the  peripheral  auditory  neurons  and 
in  turn  has  caused  the  neurons  of  the  auditory  cortex  to  move  their 
processes.     Other  things  equal,  the  degree  of  the  excitation  depends 
^Pon  the  intensity  of  the  physical  impact  upon  the  auditory  apparatus. 
^^idently  the  number  of  auditory  neurons  aroused  into  action  varies 
P'^atly.  and  the  movement  does  not  cease  in  the  auditory  area  of  the 
cortex,  but  is  diffused  among  distant  neighboring  areas.     Suppose  a 
■^^Uence   of  sound   vibrations   has   caused   the   auditory   neurons   to 
assume  new  relations  with  one  another.     These  relations  will  depend 
^^^Kcly.  whether  or  not  a  similar  sequence  of  impressions  has  passed 


IC 


• 


...JtL- 


350  PERISCOPE. 

throiigli  ihose  ntiiroiif  beiore.  If  so.  tlie  old  combiiiatious  will  he 
reformed,  and  as  a  corollary,  there  follows  the  recognition  by  the 
ego  of  the  sounds  as  sonietliing  heard  before.  Sequence  of  thought 
may  also  be  explained  by  the  movenienls  of  the  neurons.  If  they 
are  constantly  changing  from  the  hour  of  awakening  and  responding 
to  stimuli  from  without  by  changes  in  their  relation  to  one  another, 
it  follows  that  the  sequence  of  thought  depends  upon  the  sequence 
of  these  changes.  Herein  also  lies  the  explanation  of  the  continuity 
of  thought.  This  theory  is  also  applicable  to  various  pathologic 
conditions.  An  hallucination  is  the  spontaneous  formation  of  an  old 
combination  among  the  neurons  representing  a  former  perception  or 
conception  as  (he  result  of  pathologic  conditions  and  not  in  response 
to  normal  stimuli  from  within,  such  as  preceding  and  connected  trains 
of  thought,  or  other  normal  psychic  processes.  The  combination 
representing  an  hallucination  reacts  in  such  a  manner  upon  the  general 
neurons  of  the  cortex  as  to  give  rise  to  the  beUef  in  the  reality  of  the 
manifestation.  An  illusion  is  such  a  faulty  combination  of  the  neurons 
as  to  lead  to  an  imperfect  recognition  by  the  ego  of  the  object  per- 

It  is  probable  that  the  explanation  of  the  pathology  oi  a  delusion 
is  to  be  sought  in  disease  of  the  structure  of  the  neuron  and  especially 
of  its  processes.  A!l  the  symptoms  presented  by  hysteria,  and  even 
the  convulsions,  can  be  explained  by  this  theory.  The  mobility  of 
the  neuron  is  the  only  theory  that  affords  a  rational  explanation  of 
hypnotism.  Hypnotism  is  a  partial  sleep,  in  which  only  a  portion  of 
the  neurons  have  their  processes  retracted.  When  hypnosis  is  induced 
by  staring  fixedly  at  an  object,  while  suggestion  of  sleep  is  made,  it 
happens  by  reason  of  the  elTort  oi  visual  and  auditory  attention  that 
the  neurons  of  the  corresponding  regions  in  the  cortex  are  thrown 
into  certain  relations  with  one  another,  corresponding  first  to  the 
action  upon  the  ocular  apparatus  and,  second,  to  the  words  of  the 
operator.  Soon,  by  reason  of  visual  fatigue  and  under  suggestion  of 
sleep,  the  neurons  of  the  visual  area  retract  their  processes,  and  the 
partial  sleep  of  hypnosis  begins.  Gradually  it  grows  deeper,  by  reason 
of  the  same  influence,  the  other  neurons  of  the  cortex  gradually  re- 
tract their  processes,  with  the  single  exception  of  those  by  means  of 
which  the  verbal  suggestion  of  sleep  has  been  received,  namely  the 
auditory  channels.  Freeman, 

113.  SxiLW  FisioLOGiA  BEI  TALAMI  oTTlci     (The  Physiology   of   the 

Optic  Thalamus).     Lo  Monoco  (Riv.  di  patolog.  nerv.  e  mem.. 

2,   1897,   No.  8). 

The  author  reports  the  results  of  three  partial  excisions  of  the 
optic  thalamus  in  dogs,  the  operation  having  been  performed  in  the 
manner  detailed  by  him  in  a  former  communication.  In  two  cases 
only  the  inner  portion;  in  the  third,  both  outer  and  inner  portions 
of  the  dorsal  part  of  the  thalamus  of  one  side  were  removed.  Blind- 
ness, diminution  of  sensibility  and  impairment  of  muscular  power 
set  in  on  the  side  opposite  to  that  of  the  injury,  but  disappeared 
after  a  period  of  about  four  weeks. 

The  conclusion  of  the  author  is  that  the  optic  thalamus  is  the 
seat  of  a  visual  perception  centre  similar  to  the  one  found  in  the 
cortex,  but  with  the  difference  that  its  removal  does  not  cause  either 
dilatation  or  loss  of  contractile  power  of  the  pupil.  The  relation  of 
the  thalamus  to  sensation  and  mobility  is  similar  to  that  of  the  cor- 
tical centres,  Jelliffe. 


PERISCOPE.  351 

114.  The  Fu'Ttering  Produckd  by  thk  Juxtaposition  of  Certain 

Colors  anlof  Black  and  White.  W.  A.  Holden.  (Archives  of 

Ophthalmology,  27,  1898,  p.  i.) 

In  a  series  of  ingeniously  devised  experiments  the  author  shows 
that  "when  two  colors  of  nearly  eqtial  luminosity  are  juxtaposed,  one 
color  will  seem  to  dart  over  the  other  color,  and  the  margin  between 
them  will  appear  constantly  to  shift  as  the  eyes  or  colors  are  moved. 
This  fluttering  is  due  to  the  negative  after-images  of  each  color 
heing  projected  upon  the  other  color,  and  it  is  seen  best  when  the 
two  colors  are  nearly  equal  in  luminosity,  because  an  after-image 
of  an  object  arises  most  readily  when  surrounding  objects  are  of  the 
same  luFninosity,  and  also  because  after-images  are  perceived  most 
readily  when  projected  on  a  ground  of  the  .same  luminosity.  An 
after-image  of  shoi*  duration  gives  rise  to  an  appearance  of  flashing. 
An  after-image  of  longer  duration  projected  upon  a  background  of 
nearly  the  same  color  intensifies  that  color,  and  gives  rise  to  an  ap- 
pearance of  glowing.  The  after-images,  appearing  and  fading  away, 
and  shifting  with  each  movement,  give  rise  to  the  appearance  of  flut- 
tering. 

Different  colors  on  a  dark  ground  appear  to  stand  out  in  different 
degrees  of  relief,  and  this  has  been  confounded  by  some  authors 
with  the  phenomenon  of  fluttering.  But  apparent  relief  is  entirely 
independent  of  hue,  and  depends  solely  upon  relations  of  luminosity; 
it  being  greater  the  greater  the  difference  in  luminosity  between  ob- 
ject and  background,  while  fluttering  is  most  apparent  when  the 
difference  in  luminosity  is  least. 

Black  on  a  purely  white  ground  readily  gives  rise  to  white  after- 
images, which  cause  either  flashing  or  glowing,  according  to  their 
duration,  and  black  objects  on  white  thus  appear  to  flutter  as  do 
juxtaposed  colors  of  equal  luminosity.  Such  after-images  arising 
from  the  cumulative  fatigue  of  the  retina  in  reading  successive  lines 
of  print  give  rise  to  much  of  the  discomfort  experienced  in  reading 
badly  printed  pages,  and  the  printer's  aim  should  be  to  compose  a 
page  in  which  the  disturbing  effects  of  these  after-images  are  re- 
duced to  a  minimum."  Jelliffe. 

PATHOLOGY. 
115.  Weitere  Beitrage  zur  Pathologte  der  Nervenzelle.  III. 

I.     UEBER      GANGLIENZELL-VERANDERUNGEN     BEI     KtJNSTUCHKR 

vSteigerung  der  EigenwXrme.  H.  Moxter.  2.  Ueber  Ver- 
.  ANDERiTfGEN  DER  Nervenzellen  im  Fieber.  Goldschclder 
ani  E.  Flatau.  3.  Ueber  die  Veranderung  der  mensch- 
UCHEN  Nervenzeli,e  beim  Fibber.  S.  Goldscheider  and  F. 
Brasch,    (Fortschritte  der  Medicin,  16,  1898,  p.  121). 

A  scries  of  observations  are  made  in  these  short  contributions. 
The  first  series  was  made  upon  rabbits;  these  were  trephined,  and, 
after  recover}',  were  exposed  to  temperatures  ranging  from  39°  to  41* 
C.  with  the  following  results: 

ti.)  Changes  in  the  anterior  horn  cells  were  found  only  after 
22^  :>  hours'  exposure  to  a  temperature  of  between  40.5'  and  41.5"  C. 

(2.)  By  exposure  to  an  intermittent  temperature  of  between 
38°  and  41  °  C.  for  several  days  no  cell  changes  were  induced. 

^3^  After  an  exposure  of  2^  hours  to  temperatures  between 
392'  and  40.7"*  C.  no  changes  were  apparent. 

These  observations  confirm  those  previously  made  by  Gold- 
scheider and  Flatau  in  a  previous  number  of  the  Fortschritte  der 
Medicin. 


350  PERISCOPE. 

through  those  neurons  beiore.  If  so.  the  old  com  hi  nations  will  be 
reformed,  and  as  a  corollary,  there  follows  the  recognition  hy  the 
ego  ot  the  sounds  as  something  lieard  before.  Sequence  ol  thought 
may  also  be  explained  by  the  movements  of  the  neurons.  If  they 
are  constantly  changing  from  the  hour  of  awakening  and  responding 
to  stimuli  from  without  by  changes  in  their  relation  to  one  another, 
it  follows  that  the  sequence  of  thought  depends  upon  the  sequence 
of  these  changes.  Herein  also  lies  the  explanation  of  the  continuity 
of  thought.  This  theory  is  also  applicable  to  various  pathologic 
conditions.  An  hallucination  is  the  spontaneous  formation  of  an  old 
combination  among  the  neurons  representing  a  former  perception  ot 
conception  as  the  result  of  pathologic  conditions  and  not  in  response 
to  normal  stimuli  from  within,  such  as  preceding  and  connected  trains 
o(  thought,  or  other  normal  psychic  processes.  The  combination 
representing  an  hallucination  reacts  in  such  a  manner  upon  the  general 
neurons  of  the  corte.^:  as  to  give  rise  to  the  belief  in  the  reality  of  the 
manifestation.  An  illusion  is  such  a  faulty  combination  of  the  neurons 
as  to  lead  to  an  imperfect  recognition  by  the  ego  of  the  object  per- 
il is  probable  that  the  explanation  of  the  pathology  of  a  delusion 
is  to  be  sought  in  disease  of  the  structure  ol  the  neuron  and  especially 
of  its  processes.  All  the  symptoms  presented  by  hysteria,  and  even 
the  convulsions,  can  be  explained  by  this  theory.  The  mobility  of 
the  neuron  is  the  only  theory  that  affords  a  rational  e.\planation  of 
hypnotism.  Hypnotism  is  a  partial  sleep,  in  which  only  a  portion  of 
the  neurons  have  their  processes  retracted.  When  hypnosis  is  induced 
by  staring  fixedly  at  an  object,  while  suggestion  of  sleep  is  made,  it 
happens  by  reason  of  the  effort  of  visual  and  auditory  attention  that 
the  neurons  of  the  corresponding  regions  in  the  cortex  are  thrown 
into  certain  relations  with  one  another,  corresponding  first  to  the 
action  upon  the  ocular  apparatus  and,  second,  to  the  words  of  the 
operator.  Soon,  by  reason  of  visual  fatigue  and  under  suggestion  of 
sleep,  the  neurons  of  the  visual  area  retract  their  processes,  and  the 
partial  sleep  of  hypnosis  begins.  Gradually  It  grows  deeper,  by  reason 
of  the  same  influence,  the  other  neurons  of  the  cortex  gradually  re- 
tract their  processes,  with  the  single  exception  of  those  by  means  of 
which  the  verbal  suggestion  of  sleep  has  been  received,  namely  the 
auditory  channels.  Freeman. 

113.  Sulla  fisiologia  dei  taumi  otMci  (The  Physiology  of  the 
Optic  Thalamus).  Lo  Monoco  (Riv.  di  patolog.  nerv.  e  mem.. 
3.   189?.  No.  8). 

The  author  reports  the  results  of  three  partial  excisions  of  the 
optic  thalamus  in  dogs,  the  operation  having  been  performed  in  the 
manner  detailed  by  him  in  a  former  communication.  In  two  cases 
only  the  inner  portion;  in  the  third,  both  outer  and  inner  portions 
of  the  dorsal  part  bi  the  thalamus  of  one  side  were  removed.  Blind- 
ness, diminution  of  sensibility  and  impairment  of  muscular  power 
set  in  on  the  side  opposite  to  that  of  the  Injury,  but  disappeared 
after  a  period  of  about  four  weeks. 

The  conclusion  of  the  author  is  that  the  optic  thalamus  is  the 
seat  of  a  visual  perception  centre  similar  to  the  one  found  in  the 
cortex,  but  with  the  difference  that  Its  removal  does  not  cause  either 
dilatation  or  loss  of  contractile  power  of  the  pupil.  The  relation  of 
the  thalamus  to  sensation  and  mobility  is  similar  to  that  of  the  cor- 
tical centres.  Jelliffe. 


PERISCOPE.  351 

14,   THK  Fl.fTTKHINV.    PROIIfCKD 

Colors  xsi-ov  Black   a.vo  \' 

Ophthalmology,  27,   1898.  p.  I,) 

In  a  series  of  ingeniously  devised  experiments  the  author  shows 
;Iiat  "when  two  colors  of  nearly  equal  luminosity  are  juxtaposed,  one 
^olor  will  seem  to  dart  over  the  other  color,  antl  the  margin  between 
:hem  will  appear  constantly  to  shift  as  the  eyes  or  colors  are  moved, 
rhis  riuttering  is  due  to  the  negative  after-images  of  each  color 
leing  projected  upon  the  other  color,  and  il  is  seen  best  when  the 
wo  colors  are  nearly  eqtial  in  luminosity,  because  an  after-image 
if  an  object  arises  most  readily  when  surrounding  objects  are  of  the 
ante  luminosity,  and  also  because  after-images  are  perceived  most 
eadily  ivhen  projected  on  a  ground  of  the  same  luminosity.  An 
iter-image  of  shof*  duration  gives  rise  to  an  appearance  of  flashing. 
In  after-image  of  longer  duration  ■projected  upon  a  background  of 
leariy  the  same  color  intensifies  that  color,  and  gives  rise  to  an  ap- 
■fatance  of  glowing.  The  after-images,  appearing  and  fading  away, 
nd  shifting  with  each  movement,  give  rise  to  the  appearance  of  flut- 
(ring. 

Different  colors  on  a  dark  ground  appear  to  stand  out  in  different 
egrees  of  relief,  and  this  has  been  confounded  by  some  authors 
rith  the  phenomenon  of  fluttering.  But  apparent  relief  is  entirely 
idependent  of  hue.  and  depends  solely  upon  relations  of  luminosity; 
;  being  greater  the  greater  the  difference  in  luminosity  between  ob- 
:ct  and  background,  while  fluttering  is  most  apparent  when  the 
ilference-  in  luminosity  is  least. 

Black  on  a  purely  white  ground  readily  gives  rise  to  white  after- 
nages,  which  cause  either  flashing  or  glowing,  according  to  their 
uralion,  and  black  objects  on  white  thus  appear  to  flutter  as  do 
ixtaposed  colors  of  equal  luminosity.  Such  after-images  arising 
■om  the  cumulative  fatigue  of  the  retina  in  reading  successive  lines 
i  print  give  rise  to  much  of  the  discomfort  experienced  in  reading 
adiy  printed  pages,  and  the  printer's  aim  should  be  to  compose  a 
age  in   which   the   disturbing   elTects   of  these   after-images   are   re- 

P.\THOLOGY, 

5.  Weitere  BeitrXge  zur  Pathologie  deb  Nervenzelle.  III. 
I.  Ieber  Gasglienzell-veranderungen  bri  kunstlicher 
STEtCERt'NC    DER    ElGEKWARME.      H,    Moxter.     z.  Uhber   Ver- 

.  ANDERi'NGE'j    DER    Nervenzellen    im    Fieber.     GoldschddeT 

ant  E.   Flatau.       3.     UEBER    DIE    VeRANDERUNG      DER    MENSCH- 

UCHEN  Nervemzelle    beim    Pieber,      S,  Goldscheider   and    F. 

Brasch.     (Fortschritte  der  Medicin,  16,  ifk)8,  p,  121}, 

.\  series  of  observations  are  made  in  these  short  contributions, 
he  tirst  series  was  made  upon  rabbits;  these  were  trephined,  and, 
ter  recovery,  were  exposed  to  temperatures  ranging  from  .39°  to  41 
.,  with  the  following  results: 

IT.)  Changes  in  the  anterior  horn  cells  were  found  only  after 
;'';  hours'  exposure  to  a  temperature  of  between  40.5°  and  41,5°  C, 

I-'.  1  By  exposure  to  an  intermittent  temperature  of  between 
r  and  41°  C.  for  several  days  no  cell  changes  were  induced, 

'j.)  After  an  exposure  of  23  hours  to  temperatures  between 
I-.''  and  407°  C,  no  changes  were  apparent. 

These  observations  confirm  those  previously  made  by  GoM- 
heider  and    Platan   in   a   previous   number   of   the   Fortschritte   der 


{•ER/SCOPll. 

le  9«coDd  contribulion  takes  up  the  queslioii  from  the  human 
oint.  The  authors  try  to  show  the  effect  of  fever  upon  the 
in  cells  Id  six  cases,  in  which  the  fever  varied  from  37°  10 
C,  the  cords  were  studied  by  means  of  the  Nissl  methods, 
'ontid  that  numbers  of  the  cells  of  the  anterior  horns  were  en- 
,  and  that  they  stained  less  leadily.  There  was  marked  chro- 
'sis  throQghoat.  The  granules  of  the  protoplasmic  processes 
tbsent  also.  The  nucleus  remained  in  the  centre  of  the  cell 
lowed  no  marked  deviations  from  the  normal.  All  levels  of 
rd  were  affected,  the  cells  of  the  anterior  and  posterior  horns 
1  as  those  of  Clarke's  columns.  Jelliffe. 

ESioNS  in  Hereditary  Chorea.  Dr.  Lannois  (Medical  Week, 
igust   [Jth,   1897). 

.  the  French  Congress  of  Alienists  and  Neurologists  the  author  re- 
post-mortem  examinations  of  two  female  palie  its  suffering  wilh 
tary  chorea.  In  both  there  was  pachymeningitis,  recent  hxma- 
and  very  marked  atrophy  of  the  brain.  Under  the  microscope 
lion  appeared  to  consist  very  distinctly  of  an  infiltration  o(  small 
cells  made  up  almost  exclusively  of  a  large  nucleus,  found  in 
anmbers  in  the  area  of  polygonal  cells,  increased  in  the  area  of 
pyramidal  cells,  and  reaching  its  full  development  in  the  area 
{e  pyramidal  cells.  These  round  cells  were  also  met  with  in  the 
ent  white  substance.  They  were  mostly  arranged  in  groups 
d  the  pyramidal  cell,  invading  its  lymphatic  space,  or  around 
'Ssds.  and  inside  or  around  the  peri-vascular  sheath.  The  spinal 
ippeared  also  to  be  slightly  diseased  in  the  descending  column*, 
centro-tateral  regions,  and  in  the  direct  cerebellar  tract.  The 
r  considers  that  the  motor  as  well  as  the  mental  disturbances 
;h  cas«s  are  fully  accounted  for  by  irritation  of  the  neurons 
;he  invasion  of  the  nuclei  into  the  pericellular  sheaths. 

Mitchell. 

PEmcXcE  int  Lebre  vom  Wesen  der  Huntingtonsche^ 
p<OitE.\     ( Contributions  to  the  Study  of  Huntington's   Chorea). 

C.  Facklam  (.^rchiv.  f.  Psychiatric,  30,  1898,  p.   137). 
he  present  dissertation   is  a  careful  and  extensive   contribution 
-  knowledge  of  Huntington's  Chorea,  both  from  the  clinical  and 
lo)(ical  standpoints. 

he  author  gives  a  historical  sketch  of  the  two  typts  of  chorea, 
led.  and  the  histories,  in  extenso,  of  eight  cases  ofHuntington's 

rr>m  the  pathological  point  of  view  the  author  is  of  the  opinion 
he  disease  is  exclusively  confined  to  the  cortex,  and  that  the 
x<  -ire  of  the  chronic  diffuse  eniephalitis  type  though  differing 
the  "ijisseminated"  type  of  Oppenheim.  or  the  "diffuse  encephal- 
Jestribed  by  Kalischer.  The  author  sums  up  wilh  a  brief  di»- 
n  oi  the  differential  diagnosis,  in  which  little  new  appears.     He 

That  whereas  Huntington's  chorea  is  a  disease  of  adults.  Syden- 

^•ti.^rea  is  found  mainly  in  childhood. 

Huntington's  chorea  almost  invariably  shows  an  hereditary  hist- 
whereas  according  to  the  gret  "r  number  of  the  more  recent 
igaiors,  chorea  minor  is  to  be  looked  at  in  the  light  of  an  in- 

Huntiugti<n'5  chorea  is  invariably  a  chronic  affection  and  non- 
;e.  nht-rtji  chorea  minor  is  acute  and  readily  curable,  the  !^ub- 
..'r  chronic  cases  usually  recovering. 


♦        r 


PERISCOPE. 


353 


4.  The  main  point  of  distinction  is  to  be  seen  in  the  mental  symp- 
toms. Huntington's  chorea  being  markedly  chronic  leads  to  mental 
deterioration  and  ultimately  to  dementia,  whereas  the  psychical  changes 
in  chorea  minor  are  rarely  marked. 

The  feature  in  common,  that  of  the  choreic  movements,  is  one  in 
name  more  than  in  fact,  for  the  movements  are  essentially  different. 
The  motions  in  Huntington's  chorea  being,  as  a  rule,  slow  and  less 
active  than  in  chorea  minor,  although  both  have  a  like  place  of  origin, 
the  cerebral  cortex. 

Huntington's  chorea  is  to  be  regarded  as  an  individual  disease, 
distinct  and  independent  of  Sydenham's  chorea. 

Most  of  which  statements  are  found  in  American  text  books. 

The  article  is  concluded  by  a  fairly  complete  bibliography  and  is 
illustrated  by  one  lithographic  plate,  showing  the  changes  in  the 
blood  vessels  and  lymphatics.  Jelliffe. 


CLINICAL  NEUROLOGY. 

118.  De  i*a  choree  variabi^e  ou  poi^ymorphe  (Variable  or  Poly- 
morphous Chorea).  G.  Patry  (Gaz.  hebd.  de  med.  el  chir.,  2, 
1897,  p.  105). 

Expanding  the  observations  and  following  the  plan  of  Brissaud, 
the  author  in  his  thesis  (Paris,  1897),  endeavors  to  differentiate  a 
form  of  chorea  to  which  he  gives  the  above  name.  The  special  defin- 
ition is  as  follows:  '*  It  is  a  chorea  which  has  neither  uniformity  in 
its  actual  symptoms,  regularity  in  its  evolution,  nor  constancy  in  its 
duration.  It  goes  and  comes  alternately,  increases  and  diminishes, 
ceases  suddenly,  and  begins  again  with  equal  suddenness,  to  disappear 
once  more.  The  movements  are  sometimes  sharp,  and  sometimes 
slow,  and  without  any  preponderating  localization.  It  is  more  com- 
mon in  the  degenerate  type  of  individual,  that  is,  in  those  presenting 
the  physical  stigmata  of  degeneration,  and  whose  psychical  equilibri- 
um may,  therefore,  be  said  to  be  unstable.  It  occurs  at  an  age  some- 
what greater  than  that  at  which  ordinary  chorea  appears,  being  more 
commonly  observed  after  puberty." 

After  a  discussion  of  etiology  and  pathogeny,  he  goes  on  with  his 
observations  on  the  symptomatology;  as  it  occurs  in  degenerates,  the 
usual  psychical  lack  of  development  or  inequality  of  development  is 
found.  The  ordinary  signs  of  unstable  nervous  and  mental  condition 
were  present  in  many  of  his  cases — hysteria,  epilepsy,  hallucinations. 
All  the  patients  complain  of  vague  pains  of  varying  situation  and 
degree,  not  unlike  those  common  in  neurasthenic  cases.  The  move- 
ments, sometimes  large,  sometimes  small,  vary  in  amplitude  and 
frequency  of  occurrence  from  one  minute  to  the  next,  and  from  one 
day  to  the  next. 

They  changed  their  locality  as  well  as  their  intensity,  become 
general  or  limited,  or  even  disappear  without  a  hint  of  any  reason 
for  the  changes.  The  final  capital  symptom  is  the  very  decided  in- 
hibitory influence  which  patients  can  exercise  over  the  movements. 

As  may  be  supposed  from  these  statements,  the  disease  is  of  in- 
determinate duration,  and  the  tendency  to  disappear,  and  the  tendency 
to  relapse  make  prognosis  very  uncertain.  The  treatment  he  considers 
ptu^ely  moral,  that  is  to  say,  he  endeavors  to  point  out  to  patients  the 
possibility  of  control,  and  the  undesirability  of  making  a  spectacle 
of  themselves,  and  thus  encourages  them  to  use  the  undoubted  power 
of  inhibiting  the  movements  which  he  has  observed.         Mitchell. 


, 


Li 


The  histories  of  some  tliirty  cases  are  presented  in  this  short  study 
t  the  types  of  movements  to  be  distinguished  in  chorea.  Tliey  are 
rouped  so  as  to  present  four  kinds  of  movement.  These  types  are— 
.  Cases  of  chorea  which  show,  some  at  one  stage  of  the  disease. 


some  throughou 

t  iheir  course,  an  absence  of  movement  during  rest. 

requiring   mnsci 

liar  action   to   develop   what   may   be   either   mild   or 

severe  choreifor 

J.  There  are 

cases  in  which  the  movements  are  continuous  during 

rest,  but  become 

'  greatly  increased  on  intentional  effort. 

3.  There  are 

■  cases  with  severe  choreiform  movements  which  dis- 

appear  entirely  ■ 

A'lien   muscular  acts  are  performed. 

4.  In  some  c 

ases  the  movements  seem  to  be  unaltered  by  voluntary 

muscular  efforts 

5.     There  ar 

e  cases  which  present  during  their  course,  at  different 

times,  more  thac 

1  one  of  the  types  described.                           Jelliffe. 

120.  Choreic  Emboi.tsm       S,  S.  Adams  (Annals  of  Gynascoiogy  and 
■     Pediatry,  10,  1897,  p.  ajg). 

The  rarity  of  the  case  cited  induced  the  author  to  report  it, 
Arthur  D.,  aged  7  years  and  eleven  months,  white,  was  admitted 
to  the  Children's  Hospital  (Washington.  D.  C).  June,  1896.  Except- 
ing tuberculosis  in  his  maternal  grandfather,  his  family  history  was 
good.  The  boy  had  been  very  studious,  working  well  into  the  night. 
He  was  well  prior  to  Februaryj  1896,  when  he  was  taken  ill  with 
measles.  He  apparently  recovered  from  the  attack,  and  while  seem- 
ingly in  good  health,  he  was  suddenly  seized  with  vertigo,  photo- 
phobia, and  inability  to  walk.  He  complained  of  no  pain.  His  eyes 
became  crossed,  and  his  muscular  inability  grew  manifestly  worse. 
His  present  condition  is  fair.  He  sleeps  well,  though  very  sensitive 
and  peevish.  There  is  pronounced  strabismus  in  the  right  eye,  other- 
wise the  eyes  are  normal.  The  left  angle  of  the  mouth  droops,  and 
when  the  tongue  is  protruded,  it  deviates  to  the  left.  Articulation  is 
slow,  indistinct,  nasal,  but  questions  are  answered  intelligently.  There 
is  ptosis  and  paralysis  of  the  left  facial  muscles.  The  right  arm  is 
normal,  but  in  the  left  there  is  neither  motion  nor  sensation  of  ordi- 
nary touch,  brtt  a  pin  thrust  is  felt,  and  if  a  strong  irritant  be  applied 
to  the  fingers,  he  locates  it  accurately.  Reflex  motion  is  only  slightly 
impaired.  The  left  lower  extremity  is  only  partially  paretic,  but  seems 
to  be  increasing.  The  patellar  retiex  is  slight  on  the  affected  side, 
and  there  is  no  clonus,  but  there  is  constant  formication.  There  is  no 
profuse  sweat  at  night.  Other  svstems  normal.  On  (urther  and  later 
examination  a  slight  choreic  twitch  on  the  right  side  was  discovered. 
It  was  also  found  that  he  had  an  attack  of  chorea  sometime  before 
but  had  recovered.  The  reflexes  were  absent  on  the  left  side,  and  the 
surface  temperature  was  lower  than  on  the  right.  He  could  not  walk 
without  assistance.  While  in  some  respects  the  case  resembled  one  of 
posthemiplegic  chorea,  yet  the  previous  attack  of  chorea  made  the 
differential  diagnosis  easy  and  justifyable.  The  speedy  and  complete 
restoration  to  health  added  further  corroborative  evidence  to  the 
correctness  of  the  diagnosis,  Abrabams. 

131.  Seborkk<ea   Nigricans     (An    Unusual    Hysterica]    Disorder). 
J.  K.  Mitchell  (Phila.  Med.  Jour.,  r,  1898,  p.  117). 


f  5. 


PERISCOPE. 


355 


f 

tended  from  V/^  to  i^  inches  below  the  nasal  margin  of  the  lid,  the 
co^ir  always  being  less  on  the  upper  lids  than  on  the  lower. 

The  pigment,  which  imparted  a  sooty-like  sense  to  the  finger, 
could  be  removed  in  part  by  aporopriate  methods,  but  such  removal 
was  but  of  temporary  service  as  the  color  returned  in  a  few  hours. 
After  some  time  the  pigmentation  ceased,  but  some  months  later 
again  returned  at  a  time  when  the  patient  was  greatly  fatigued  and 
run  down.  The  case  is  considered  one  of  hysteria,  and  an  historical 
it?ume  of  the  subject  is  included  in  this  report.  A  microscopical 
and  bacteriological  examination  of  the  pigment  removed  was  practic- 
aily  negative.  Jelliffe. 


n': 


122.    Sl'R     UN     CAS    D'HKMIPI^EGIE      HYSTERIQUE      ACCOMPAGNEE     D*A- 

TROPHiE      (Hysterical    Paralysis    with    Atrophy).      Lyonnet  and 
Bonne  (Lyon  Medical.  86,  1897,  p.  286). 

As  nearly  as  one  may  judge  from  the  report,  this  is  quite  a  typical 
case  of  hysterical  hemiplegia,  occurring  in  a  nervous  young  woman 
of  20  years.  The  trouble  had  existed  for  8  months,  had  come  on 
gradually,  and  at  one  time  the  patient  could  not  *'  budge  "  the  left 
arm  or  leg.  The  character  of  the  patient,  the  mode  of  onset,  the  gait, 
the  distribution  of  the  paralysis  (face  exempt),  the  intensity  and  distrib- 
ution of  the  anesthesia,  as  well  as  absence  of  all  indications  of  organic 
disease,  indicated  hysteria  as  the  cause  of  the  paralysis.  In  the  par- 
alyzed members  there  was  a  generalized  and  rather  uniform  wasting 
of  the  muscles,  without  electric  change.  The  upper  arms  showed  a 
difference  in  circumference  of  ij^^  centimeters,  the  forearms  a  differ- 
ence of  2j^  centimeters,  and  the  thighs  and  legs  3  and  i  J^  centimeters 
respectively.  Patrick. 


123.  Contracture  hysterique    (Hysterical   Contracture).     Dejerine 
(La  Med.  Moderne,  8,  1898,  p.  38). 

The  author  exhibited  at  the  Salpetriere  a  case  which  brought  up 
the  general  question  of  hysterical  contracture.  The  accompanying 
stigmata  generally  suffice  to  differentiate  the  neurosis,  but  the  origin 
is  often  sufficiently  difficult  to  establish.  In  the  case  described  De- 
jerine found  a  contracture  of  the  adductor  muscles  of  the  thighs  in  a 
young  girl,  consequent  upon  an  attempted  assault,  of  such  intensity 
that  not  only  was  walking  impossible,  but  the  utmost  effort  could  not 
separate  the  limbs  in  the  smallest  degree.  The  contracture  yielded 
entirely  under  chloroform.  A  case  of  the  opposite  condition  was  also 
shown  in  which  the  neuropathic  character  of  the  disorder  was  less 
eWdent.  A  girl  of  eighteen  walked  with  the  limbs  separated  to  their 
utmost  extent,  the  thighs  being  in  the  most  extreme  abduction.  The 
articulations  showed  nothing  abnormal;  the  freest  movements,  except 
in  adduction,  could  be  obtained:  there  was  no  pain  nor  stiffness. 
The  hypothesis  of  ankylosis  of  the  coxo-femoral  articulations  was 
not  therefore,  acceptable.  There  was  decided  contraction  of  the 
abductor  muscles,  and  the  question  of  its  origin  arose.  The  patient 
stated  that  six  months  before  she  had  had  pains  in  the  joints,  and  her 
report  was  that  her  physician  had  said  that  she  had  albuminuria.  It 
was,  therefore,  possible  that  an  infection  had  some  relation  to  the 
beginning  of  the  trouble. 

Dejerine,  however,  thought  this  had  been  the  provocation  of  the 
condition,  not  the  cause.  The  patient  was  really  an  hysteric,  and  her 
difficulty  due  to  this  neurosis.  He,  therefore,  ordered  treatment  "  by 
isolation  and  suggestion."  with  \vhat  result  is  not  reported. 

Mitchell. 


356  PERISCOPE. 


134.   PARALYSIES   TRANSITOIRES    D'ORIGINE    CARDIACUE       (Transitory 

Paralyses  of  Cardiac  Origin).     MM.  Achard  and  Leopold    L.evi 

(La  Med.  Moderne,  7,  1897,  p.  656). 

MM.  Achard  and  Leopold  Levi  reported  their  observations  of 
two  cases  where,  apart  from  paralyses  due  to  gross  cerebral  lesions, 
transitory  palsies  occurred.  The  first  case  was  a  woman,  who  in  the 
course  of  an  attack  of  asystole  had  an  inferior  facial  paralysis  which 
lasted  four  days,  and  then  completely  disaiipcared.  She  was  seized 
some  days  later  with  hemiplegia  of  the  opposite  side,  and  died.  Histo- 
logical examination  showed  only  an  active  congestion  and  slight 
oedema,  specially  marked  at  the  base  of  the  lirst  frontal  convolution. 
The  second  case  was  that  of  a  patient  with  mitral  stenosis  who  had 
paralysis  of  the  limbs  of  one  side,  and  a  facial  palsy  of  the  peripheral 
ty(«,  together  with- paralysis  of  the  sixth  nerve,  upon  the  other  side. 
This  paralysis  lasted  for  four  days.  These  cases  are  related  to  those 
seen  m  the  course  of  uraemia  and  hepatic  intoxication,  in  which  the 
authors  say  that  they  have  also  observed  isolated  and  transitory  facial 
palsies.  Mitchelu 

185.  A  Case  of  Paralytic  Chorea.  M.  V.  Ball  (Phila.  Med.  Jour., 

I,   1898,  p.a99)- 

A  case  is  here  reported  of  a  child  of  seven,  who  suddenly  devel- 
oped pain  in  her  various  joiins,  followed  by  rapid  and  irregular  respir- 
ation and  heart's  action.  At  the  same  lime  fine  choreiform  movements 
developed  about  the  lips  and  arms.  There  was  slight  bronchitic  in- 
volvement which  soon  disappeared,  but  the  chorea  persisted  and  in- 
creased. All  the  limbs  were  involved,  and  talking  was  interfered  with. 
At  the  end  of  the  week  paralysis  of  the  limbs  developed,  and  the  child 
lay  passive,  unable  to  do  anything.  Arsenic  was  employed,  and  at  the- 
end  of  two  weeks  there  was  an  improvement,  and  at  the  end  of  six 
weeks  recovery  was  complete,  save  for  the  persistence  of  a  heart  lesion. 

Jelliffe. 

ja6.  A  PecUuar  Form  of  Tic  Convui,sif.    F.  G.  Finlay  (The  Mon- 
treal Medical  Journal,  25,  1897.  No,  9). 

The  author  reports  two  brothers  affected  with  a  peculiar  form  of 
family  tic  convulsif  with  nocturnal  exacerbations  and  epileptic  attacks. 
The  patient's  mother  suffered  from  chorea  in  childhood,  and  insanity 
of  pregnancy.  The  family  is  decidedly  neuropathic.  Previous  to  the 
onset  of  the  convulsive  movements  Jean  Degan,  23  years  old,  was 
impelled  to  execute  any  sudden  command,  even  to  render  a  person 
insensible.  His  trouble  dated  six  years  back.  At  present  the  patient 
is  dull  and  stupid.  He  is  muscularly  well  developed.  Every  few  sec- 
onds a  single  twitching  movement  of  one  or  the  other  side  of  the 
mouth,  or  a  single  similar  contraction  of  the  fingers  of  one  or  the 
other  hand  is  observed.  The  movements  are  slight  in  degree,  and  ap- 
parently unaffected  by  his  attention  being  drawn  to  them. 

In  addition  to  these  twitching  movements,  marked  jerking,  inco- 
ordinate clonic  movements  are  induced  when  he  attempts  to  perform 
anyaction.  During  sleep  both  the  twitching  and  thejerkingincoordinate 
movements  continue  and  are,  indeed,  much  increased.  The  motor 
power  is  shghtly  diminished:  sensation  is  unaffected;  the  knee-jerks 
are  increased,  and  the  pupils  react  well  to  light  and  accommodation. 
The  optic  disk  is  normal,  jnd  there  is  no  nystagmus.  One  night  he 
had  several  convulsive  attacks  which  lasted  about  half  an  hour  and 
were  accompanied  by  sounds  like  the  yelping  of  a  dog. 

The  second  case,  Alex  Degan,  20  years,  closely  resembles  the  first. 
In  both  cases  the  epileptic  attacks  followed  the  onset  of  the  convulsive 
movements,  and  in  view  of  the  neurotic  family  history  may  be  looked 
upon  as  expressions  of  hereditary  nervous  degeneration. 

Abrahams. 


•  : 


riiRl  scorn. 

PSYCHOLOGY  AND  PSYCHIATRY. 


357 


127.  A  Contribution  to  the  Study  of   ii,i,usions      Frederick  E. 
Bolton  (American  Journal  of  Psychology,  9,  1898,  p.  67). 

The  author  experimented  on  twenty-five  persons  and  found  they 
underestimated  the  size  of  circles  and  overestimated  the  size  of  squares 
as  a  rule.  Christison. 

128.  A  Study  of  Imaginations.     George    V.     Dearborn     (Ameri- 
can Journal  of  Psychology,  9,  1898,  p.  181). 

Dr.  Dearborn  tested  a  company  of  sixteen  persons,  comprising 
Harvard  professors  and  their  wives  and  some  students  from  the  Psy- 
chological Laboratory.  Chance  figures  formed  by  ink  drops,  which 
had  been  pressed  between  slips  of  paper,  were  one  by  one  presented 
for  the  imagination  to  decide  what  they  resembled  or  suggested. 
Several  of  the  tests  showed  that  no  two  persons  thought  alike  on 
the  resemblance  of  the  figures,  and  in  only  one  test,  which  was  a 
decidedly  human-like  figure,  did  as  much  as  40  per  cent,  of  the  com- 
pany correspond.     The  answers  were  made  in  writing. 

Christison. 

129.  Some   Effects  of   Size  on  Judgments  of  Weight.    H.    R. 
Wolfe  (Psychological  Rev.,  5,  1898,  p.  23). 

The  author  experimented  extensively  on  students,  both  male  and 
female,  with  pieces  of  lead  and  blocks  of  light  wood,  the  ratio  of 
weight  to  size  being  i  to  25.  His  experiments  were  repeated  during 
several  years,  and  showed  that  the  wood  blocks  were  invariably  judged 
to  be  lighter  than  they  really  were,  and  the  lead  pieces  heavier  than 
they  actually  were.  The  illusion  was  greater  for  women  than  for 
men,  and  greater  for  small  than  for  large  weights. 

The  variation  for  individuals  was  found  to  be  immense,  but,  by 
eliminating  10  per  cent,  of  the  subjects — those  known  to  be  abnormal 
— the  variation  is  gfreatly  reduced.  With  both  men  and  women  the 
ratio  of  wood  to  lead  at  first  increases  with  the  weight,  then  decreases 
more  rapidly,  till  for  the  heaviest  weight  the  ratio  is  about  two- 
thirds  as  great  as  for  the  lightest  weights.  For  example:  "The  men 
find  4.7  grams  of  lead  equal  to  15.5  grams  of  wood.  The  women  find 
3.1  grams  of  lead  equal  to  15.5  grams  of  wood.  The  men  think  229.2 
grams  of  lead  feel  as  heavy  as  525  grams  of  wood,  while  the  women 
select  lead  weighing  only  145.2  grams  as  equivalent  to  525  grams  of 
wood." 

"If  we  ascribe  one-half  of  the  error  to  each  substance,  we  find 
that,  in  comparing  lead  and  wood  weights,  men  estimate  the  lead  at 
about  twice  its  actual  weight,  and  that  they  estimate  the  wood  at  about 
two-thirds  its  actual  weight.  Under  the  same  conditions,  women  es- 
timate lead  at  more  than  three  times  its  real  value  and  wood  at  less 
than  three-fifths  its  real  value." 

Methods  of  lifting  did  not  seem  to  exert  any  appreciable  influence, 
As  a  rule,  the  lead  was  lifted  in  the  palm  of  the  hand  and  the  wood 
between  the  thumb  and  fingers  "If  the  weights  be  suspended  by  a 
cord  held  between  the  fingers,  so  as  to  give  no  intimation  as  to  which 
is  lead  or  wood,  and  the  eyes  be  closed  and  all  other  means  of  de- 
termining size  be  excluded,  the  judgment  immediately  improves,  until 
the  error  amounts  to  less  than  one-tenth  of  the  weight;  while,  with 
a  knowledge  of  the  relative  size,  the  error  may  rise  to  three  or  even 
ten  times  the  weight." 

Experiments  with  paper  bags  filled  with  cotton  or  air,  and  also 
with  brass  cylinders,  contain  the  same  factors  and  show  similar  re- 
sults. The  size  of  the  error  of  an  individual  is  a  function  of  his  per- 
sonality. Christison. 


e? 


\LL 


.kill 


35S  PERISCOPE. 

THERAPY. 

ISO.  Thk  VAI.IE  OF  Arsenic    and    Bku,auonna    in    the    Treat- 
MKNT   OF   Chokka.     W,  Overend  (Lancet,  2,  1897,  p.  248). 

1.  BeHadontia  apears  to  be  most  beneficial  in  recent  cases,  and 
its  influence  is  sometimes  verj-  marked  in  severe  forms. 

2.  In  obviously  rheumatic  cases  arsenic  in  large  doses  may  be 
given  a  trial,  or  may  be  combined  with  belladonna  from  the  firsL 
Belladonna  may  act  by  diminishing  the  excitability  oi  the  nerve 
centres  or  by  imparting  an  improved  tone  to  their  vascular  supply. 

In  the  wards  o(  a  hospital  it  is  perfectly  justiSable  to  givi    ' 
...  .  ofbc 


a  child  as  much  as  thirty  minims  or  more  of  the  tincture  of  bella- 
donna every  four  hours  for  ten  days,  or  even  longer.  Certain  precau- 
tions are  necessary.  The  patient  should  be  kept  In  bed,  and  the 
urine  should  be  daily  measured.  Small  doses  of  potassium  acetate 
may  be  added  if  it  becomes  much  diminished,  or  if  the  eyelids  show 
any  pufliness.  In  one  child  nocturnal  incontinence  occurred,  and 
the  dose  was  lessened.  Tlie  occurrence  of  the  papular  erythema, 
which  leaves  raised  circular  lumps  for  a  while,  does  not  necessitate 
any  diminution  of  the  dose.  Dryness  of  the  throat  and  swelling  of 
the  parotids,  should  they  occur,  are  merely  temporary.  The  influence 
of  the  belladonna  makes  itself  felt  after  about  four  days.  Should 
no  visible  improvement  occur  before  the  tenth  day,  it  would  be 
useless  to  continue  with  it.  But  in  eight  severe  cases  treated  belladonna 
was  of  benefit,  and  is  certainly  worthy  of  further  trial.  As  soon  as  the 
movements  become  trivial,  or  occur  only  during  exertion,  it  is  better 
to, omit  the  belladonna,  to  commence  massage  of  the  affected  muscles, 
and  administer  cod-liver  oil  and  syrup  of  phosphate  of  iron  or  other 
tonics.    The  arsenic  may  be  continued  for  a  week  or  longer. 


IJl,  TiLAITEMENT   CHIRUGICAI.   HE    I-^    NEURALGIS  FACIALE        (Sui^Cal 

Treatment    of    Facial     Neuralgia).     P.     Mouclaire    (La  Pressc 

Medicale,  5.  1897.  p.  261)- 

The  author  gives  an  excellent  resume  of  this  subject.  Consider- 
ing first  the  causes  of  facial  neuralgia,  he  then  proceeds  to  give  in  out- 
line the  various  operative  procedures  fo.r  its  relief.  As  illustrating  the 
results  of  extra  cranial  nerve  section,  the  analysis,  made  by  Bessard  in 
1882  of  244  cases,  with  7  cures,  23  ameliorations,  and  7  deaths,  is  not 
of  much  value,  as  the  operations  were  done  before  the  days  of  anti- 
septic surgery.  Better  are.  10  cases,  with  6  cures,  2  ameliorations,  and 
2  failures,  reported  by  Le  Deutu  in  1894, 

To  show  the  results  of  the  Intracranial  operation  of  removing  the 
Gasserian  ganglion,  the  author  combines  3  cases  collected  by  Beck  in 
1895  with  19  others  from  various  sources. 

There  were  30  cases  of  the  Hartley- Krause  operation  with  4  deaths, 
and  20  cases  of  the  operation  of  W.  Rose  with  j  deaths.  Removal  of 
the  Gasserian  ganglion  seems  to  give  an  almost  certain  cure.  It  does 
not  cause  serious  trophic  disturbance  in  the  eye  or  on  the  face,  and 
mastication  can  still  be  acomplished.  There  is  diminution  of  tactile 
sense  and  of  smell  and  Uste,  on  the  operated  side.  While  it  is  a  form- 
idable operation,  and  should  only  be  undertaken  by  a  skilled  sui^eon, 
the  suffering  in  facial  neuralgia  is  so  intense  as  to  justify  its  perhtim- 
ance  in  cases  not  relieved  by  change  or  by  intra-cranial  nerve  section. 

The  Hartley-Krause  operation  is  regarded  as  the  preferable  one. 
C.  L,  Allen. 


^ook  ^cuUws. 


RVEUSES     SYST^MATIQUES     ET     l.A     TKKORIK    DKS 

By  J.  M.  Gerest.  J.  B.  Baillierc  et  Fils.  Paris.  1898. 
writer  attempts  to  explain  the  various  affections  of  the  iier- 
tem  on  the  neuronic  theory.     He  divides  his  book  into  two 

the  first  he  treats  brieHv  the  diseases  of  the  motor  neurons, 
le  second,  those  of  the  sensory.  The  neuronic  theory  prob- 
rds  the  simplest  means  of  explaining  nervous  diseases,  but 
some  danger  in  making  use  of  this.  Man  loves  sharply  de- 
tures,  and  there  is  a  tendency  ever  present  to  separate  diseases 

that  nature  does  not  always  permit.  Especially  is  this  true 
I  to  the  maladies  of  the  nervous  system.  \Ve  constantiv  over- 
transitional  forms,  and  forget  that  where  a  diagnosis  depends 
n  the  location  of  the  lesion,  as  is  the  case  in  many  nervous 

we  must  expect  to  find  borderline  symptoms.  When  we 
he  neuronic  theory,  we  are  very  liable  to  consider  the  affec- 
the  central  neuron  as  distinct  from  those  of  the  peripheral; 
of  the  sensory  from  those  of  the  motor.  We  are  beginning  to 
lowever.  that  any  change  in  the  central  tract  or  in  the  sensory 
d  fibre,  affects  the  condition   more  or  less  of  the  peripheral 

Merest  has  treated  the  subject  in  a  skilful  manner,  and  his  book 
ably  make  the  affections  o(  the  nervous  system  more  compre- 
to  many.  Spiller. 

'EtirimG   DEK    .^CGENSTORrNGKN    FtJR    DIE    Di'agnosk    der 

i-  UND  RUCKENMARKS-KR.^NKHEITliN.  FtJR  AERZTE,  BE- 
ERS Neurologen  vuti  Oprthalmoukjen.  Von  Dr.  Otto 
yrarz.  Privatdocent  an  der  Universitat,  Leipzig.  S.  Karger. 
in,   1898. 

author  here  presents  in  a  short  and  practical  manner  those 
ices     in     the     functions     of     the     eye     which     are     of     im- 

ia  the  diagnosis  of  diseases  of  the  brain  and  spinal  cord, 
particular  stress  upon  the  methods  of  examination,  and  then 
I  the  diseases  of  the  brain  and  cord  singly,  laying  particular 
ipon  the  ophthalmoscopic  examination.  The  book  occupie^i 
le  ground  between  the  two  special  fields,  and  will  undoubtedly 

service  to  the  neurologist  and  the  general  practitioner. 

JEI 


present  essay  is  a  reprint  from  the  "Annales  de  la  Societe 
Chirurgicale  d'Anvers."  It  contains  much  of  interest  to 
ologist,  though  the  facts  have  been  fairly  well  given  in  most 
:st  modern  text  books.  Some  new  observations  are  recorded, 
paper  represent  a  careful  summary  of  our  present  knowledge 
cord  localisations.  Jei 


360  BOOK  jiEVIEIVS. 


t    XVII.    ET    XVIII.    SlfeCLES.       CTUDE    HISTOKIQUE    ET 

BrBUOGBAPHiguK.  Par  Mme.  G.  Abrkossoff,  Docteur  en  mede- 
cine  de  la  Faculte  de  Paris,  G.  Steinheil.  Paria,  1897. 
To  those  interested  in  the  historical  aspects  of  mental  epidemics 
this  well-prepared  brochure  will  prove  of  great  service.  The  author 
has  given  an  exceedingly  good  review  of  the  literature  and  has  done 
a  large  amount  of  Uterary  research  which  will  be  of  benefit  to  those 
following  in  similar  lines  of  work.  He  has  shown  that  the  disease 
was  well  recognized  in  these  centuries  and  has  brought  together  many 
obscure  writings  which,  to  consult  in  the  original,  would  involve  an 
immense  amount  of  labor.  Jelliffe. 

The  Psvchoi,ogv  of  the  Emotions.  By  Th.  Ribot.  London, 
Walter  Scott;  New  York,  Charles  Scribner's  Sons.  1897. 
This  important  work,  by  one  of  the  foremost  of  modem  psychol- 
ogists, can  best  be  delineated  in  the  short  space  at  our  command  by 
stating  the  author's  main  position  with  reference  to  the  affective  life. 
Rihot  is  one  of  the  advanced  school  of  physiological  or  biological 
psychologists.  There  is  little  of  the  metaphysician  or  schoolman 
about  him.  He  is  thoroughly  scientific,  and  regards  his  subject  as 
much  as  possible  as  among  objective  phenomena  to  be  analysed  and 
explained.  This  gives  his  work  great  value  to  the  neurologist  as  well 
as  to  the  psychologist.  All  such  readers  must  (eel  instinctively  from 
the  first  pages  that  Ribot  has  contributed  to  the  real  science  both  of 
neurology  and  of  psj;chology. 

For  Ribot  the  origin  of  the  emotional  life  coincides  with  the  very 
origin  of  the  physiological  life.  Every  emotion  is  represented  by — or 
reducible  to — first,  a  motor  element,  and  second,  a  mixed  element  of 
pain,  pleasure  or  indifference.  This  motor  element  is,  however,  the 
primordial  constituent  of  the  affective  hfe.  It  represents  the  impulset 
that  are  inherent  in  organic  matter;  and  Ribot  finds  its  origin  in  even 
the  lowest  protoplasmic  cells,  in  which  such  impulses  are  but  the 
workings  of  a  chemico-biological  life.  In  this  primitive  stage  these  im- 
pulsesof  attraction  and  repulsion  represent  merelythe  blind  unconscious 
or  sub-conscious  activities  of  nutrition,  and  are  not  far  removed  above 
the  mere  chemical  afhiiities  and  incompatibilities  of  inor^nic  substan- 
ces. It  is  only  later  in  the  evolution  of  the  animal  organism  that  there 
is  superadded  to  these  impulses  the  conscious  element  of  pleastire  and 
pain,  and  still  later  perhaps  the  conscious  element  of  intellection. 

Starting  with  this  profound  conception  of  the  affective  life,  Ribot,  by 


It  primitive  emotions  to  five  in  number. 
I,  the  : 


These  are  fear,  anger,  affection,  the  self-feeling  and  the  sexual  e 
These  are  named  in  the  order  of  their  appearance — and  the    dates    ol 
their  appearance  in   the  individual,  as   can   readily  be  seen,  are  by  no 
means  coincident. 

From  this  view  of  the  affective  life  it  naturally  follows  that  this  life 
is  the  first  in  the  order  of  development  of  the  psychic  functions.  It  ii 
deeper  seated,  and  in  every  sense  more  primitive  and  essential  in  the 
nerve-cell  than  the  mere  intellectual  life.  Thus  its  importance  appears 
vastly  greater  from  the  biological  standpoint  than  it  has  ever  appeared 
to  the  dogmatic  or  metaphysical  school  of  psychologists.  From  the 
logical  deductions  of  this  position  Ribot  does  not  shrink  for  a  moment 

His  logical  position  in  his  own  words  is  this:  There  is  a  pure  and 
autonomous  life  of  feeling,  independent  of  the  intellectual  life  and  hav- 
ing its  cause  below,  in  the  variations  of  the  coenaesthesia,  which  is  it- 
self the  resultant  and  concert  of  vital  actions.  Internal  sensations,  i.  e. 
such  as  arise  from  the  processes  and  needs  of  nutrition,  rather  than  ex- 
ternal sensations,  are  the  sources  of  this  emotional  life.  From  this  it 
follows  for  Ribot  that  there  is  an  emotional  state  unconnected  with  an 
inielleciual  state.     Hence  Ribot  1. laces  himself  in  direct  opposition  to 


BOOK  REVIEWS.  361 

th«  Intellectualtsts,  who  contend  that  there  can  be  no  pure  emo- 
tional state  without  an  intellectual  state.  For  these  latter  emotion 
has  always  been  secondary  to  intellection;  it  has  merely  existed,  to 
quote  Ribot,  as  a  sort  of  efflorescence  on  the  intellectual  life.  We  have 
seen,  from  the  brief  statement  already  made,  how  completely  tlie  bio- 
logical method  of  Ribot  reverses  this  position,  and,  seemingly  with  great 
accuracy  of  observation  and  analysis,  assigns  to  the  affective  or  emo- 
tional life  an  existence  not  only  independent  of,  but  prior  to,  the  intel- 
lectual life 

We  have  nowhere  seen  this  purely  biological  position  so  strongly 
and,  we  must  say,  so  convincingly  stated  as  by  Ribot.  Its  immense  im- 
portance to  the  scientist,  and  especially  to  the  pathologist  and  alienist, 
can  readily  be  seen.  Ribot  himself  is  thoroughly  alive  to  its  bearings 
on  psychology  and  neurology,  and  draws  largely  from  these  specialties 
for  argument  and  illustration.  If  the  emotional  life  is  so  truly  funda- 
mental and  primitive  in  the  evolution  of  the  brain-cell,  then  we  may  be 
prepared  to  accept  the  most  advanced  teachings  of  those  who  see  in 
some  forms  of  insanity  and  the  neuroses  the  most  radical  changes  in 
the  affective  life  quite  independent  of  disorder  of  the  intelligence. 

For  ourself  we  must  say  that,  while  feeling  the  force  of  Ribot's 
subtle  analysis  and  plausible  argument,  we  cannot  quite  divest  our  mind 
of  the  suspicion  that  after  all  the  argument  may  be  loo  analytical:  that 
we  may  be  under  the  spell  of  a  master  dialectician.  When  we  attempi 
in  either  an  objective  or  subjective  study  to  dissociate  the  intellect  and 
ihe  emotions,  we  are  always  driven  back  to  at  least  a  tentative  position 
irom  which  the  thing  seems  impracticable  and  even  inconceivable.  Pure 
emotion,  without  ideation  or  representation,  at  least  in  the  adult  mind, 
is  an  abstraction.  We  say  this  with  great  deference  to  the  author 
whom  we  are  reviewing — for  his  biological  argument  must  appeal 
strongly  to  every  scientist.  We  merely  ask,  is  it  not  possible  that 
Ribot  has  too  much  ignored  the  evolution  of  the  intellectual  life?  Even 
in  the  primordial  and  instinctive  impulses  of  the  very  lowest  forms  of 
life  is  there  not  in  every  such  act  some  element  also  of  representation, 
so  feeble  perhaps  as  to  defy  analysis,  but  forming  an  integral  part  of 
every  true  psychic  act? 

In  his  discussion  of  pleasure  and  pain  Ribot's  biological  method  is 
conspicuous. He  bases  this  study  on  a  careful  inspection  of  the  anatomy 
and  physiology  of  pain,  and  its  tracts  of  transmission  in  the  central 
nervous  system.  His  own  position  with  reference  to  some  of  the  com- 
plex problems  of  oain  and  pleasure  is  clear,  although  he  frankly  con- 
fesses that  he  leaves  the  subject  itself  in  some  points  obscure.  This  is 
anavoidable  as  yet  by  any  psychologist.  For  him  pleasure  and  pain 
are  not  emotions:  the  fact  that  they  were  ever  regarded  as  such  being 
due  to  the  great  perversion  and  misappropriation  of  terms,  so  common 
in  psycholoRieal  writing.  Pain  is  merely  an  epiphenomenon,  and  not 
an  essential  part  of  an  emotion.  Ribot  proves  this  from  actual  obser- 
vation. Hence  his  position  seems  to  be  that  pain  is  a  mere  quality  of 
3  menial  state.  The  same  emotion  may  be  painful  or  pleasurable  at 
rtifferent  times.  This  independence  of  the  pain -phenomenon  is  rejected 
hy  the  Intellectualists:  and  here,  again,  Ribot  takes  a  stand  at  variance 
with  tradition — a  stand  to  which  his  method  leads  him.  From  this 
stand,  too,  he  rejects  the  doctrine  that  pain  is  in  itself  a  sensation — al- 
though he  gives  due  weight  to  the  evidence  from  pathology,  as  in  syr- 
ingomyelia, etc.,  that  pain  and  common  sensation  may  be  dissociated, 
and,  hence,  appear  to  have  different  tracts  in  the  spinal  cord.  His  teach- 
ing, asalready  said,  seems  to  lead  to  the  quale  theory — which  he  discusses 
but  does  not  unreservedly  accept.  He  rather  views  with  favor  the 
theory  of  Oppenheimer  that  pain  is  caused  by  chemical  changes  in  the 
tissues,  i.  e.,  the  action  of  autogenous  toxins.  But  we  do  not  see  how 
this  throw*:  light  upon  the  real  psychology  of  the  subject.     It  merely 


362  BOOK  REi'lEil'S. 

removes  the  etiology  one  step  inwards.  Finally,  Ribot  makes  clear  ihe 
point  that  pain  is  essentially  the  same  thing,  whether  physical  or 
moral:  these  forms  differ  from  each  other  merely  in  the  iact  that  the 
former  is  connected  with  a  sensation,  the  latter  with  some  form  of  rep- 
resentation, i.  e.,  an  image  or  idea.  The  conditions  of  pain  and  pleas- 
ure seem  to  be  the  lowering  and  heightening  respectively  oi  the  vital 
energy.    The  question  is  thus  reduced  to  a  physiological  one. 

Ribot's  work  is  divided  into  two  parts.  The  first  is  devoted  to 
general  psychology — the  basis  for  which  we  have  attempted  to  state  in 
epitome  in  what  we  have  written.  We  have  designed  simply  to  give 
the  author's  l<owl  dcd^fiarf.  The  second  part  is  devoted  to  a  special 
study  of  all  the  various  emotions.  The  medical  reader  will  be  im- 
pressed with  the  value  attached  in  the  book  to  the  teachings  of  path- 
ology. In  these  special  studies  he  will  find,  moreover,  a  remark' 
able  presentation  of  the  atTective  life — written  in  a  most  attractive  style 
and  illustrated  in  the  happiest  and  most  appropriate  manner.  For  a 
purely  psychological  work,  indeed,  the  style  render?  it  one  oi  the  mo^t 
mteresting  books  that  we  hove  ever  read.  Throughout  its  pages  there 
Is  followed  a  strictly  scientific  method — and  an  emotion  is  dissected 
with  the  skill,  if  not  with  the  scalpel,  of  an  anj 


t. 


BOOKS  RECEIVED. 


"Analytical  Cyclopaedia  of  Practical  Medicine."  Chas.  E.  de  M. 
Sajous,  M.  D.    F.  A.  Davis  Co. 

"  Leitfaden  der  phisiologischen  Psychologic."  Ziehn.  Gustav 
Fischer,i898. 

"Internal  Medicine  and  Clinical  Diagnosis."  Jacob.  W.  B.  Saun- 
ders, Philadelphia,  1898. 

"Ueber  die  Tabes."  P.  J.  Moebius.    S.  Karger,  1897. 

"Die  Geschwiilste  des  Nervensystems."     S.  Karger,  1897. 

"Les  Hydrocephalies."    Leon  d' Astros.    G.  Steinheil,  Paris,  1898. 

"International  Medical  Annual."  E.  B.  Treat  &  Co.,  New. York, 
1898. 

"An  American  Text  of  Genito-Urinary  Diseases,  Syphilis 
and  Diseases  of  the  Skin,"  by  L.  B.  Bang,  M.  D.,  and  W.  A.  Harda- 
way,  M.  D.    W.  B.  Saunders,  Philadelphia. 

"The  Diseases  of  the  Stomach,"  by  J.  D.  Nisbet,  M.  D.,  and 
William  W.  Van  Valzah,  M.  D.     W.  B.  Saunders,  Philadelphia. 

"Lectures  on  Nervous  Diseases,"  by  C.  S.  Elliott.  A.  L.  Chatter- 
ton  &  Co.,  New  York. 


ii 


ANNUAL  MEETING  OF  THE  AMERICAN  NEUROLOGICAL 

ASSOCIATION. 

The  American  Neurological  Association,  which  is  to  meet  at  the 
New  York  Academy  of  Medicine,  No.  17  West  Forty-third  Street, 
on  Thursday,  Friday  and  Saturday,  May  26,  27  and  28,  1898,  an- 
nounces the  following  preliminary  programme. 

"A  Case  with  the  Combined  Symptons  of  Myxoedema  and 
Graves's  Disease,"  by  William  Osier,  M.  D. 

"A  Contribution  to  the  Surgery  and  Pathology  of  the  Gasserian 
Ganglion,"  by  W.  W.  Keen,  M.  D..  and  William  G.  Spiller,  M.  D. 

"A  Case  of  Syringomyelia,  and  Two  Cases  of  Tabes,  with  Sensory 
Dissociation  on  the  Trunk,"  by  Hugh  T.  Patrick,  M.  D. 

"Report  of  a  Case  of  Non-traumatic  Purulent  Pachymeningitis, 
with  Autopsy,"  by  W.  M.  Leszynsky,  M.  D. 

"A  Case  of  Landry's  Paralysis,  with  Necropsy  and  Microscopical 
Examination,"  by  Charles  K.  Mills,  M.  D.,  and  William  Spiller,  M.  D. 
"A  Case  of  Alcoholic  Meningitis  Simulatmg  Brain  Tumor,"  by 
Theodore  Dillcr,  M.  D. 

"A  Case  of  Friedreich's  Ataxia  Presenting  Some  Unusual  Fea- 
tures," by  Theodore  Diller,  M.  D. 

**On  Myotonia,"  by  George  W.  Jacoby,  M.  D. 
"A   Summary   of  the   Symptoms   Found   in   Sixty-one   Cases   of 
Locomotor  Ataxia,  with  Additional  Remarks,"  by  W.  H.  Riley,  M.  D. 
"The  Prognosis  and  Treatment  of  Compression  Lesions  of  the 
Cord,"  by  Graeme  M.  Hammond,  M.  D. 

"Congenital  Facial  Diplegia,"  by  H.  M.  Thomas,  M.  D. 
"On  Scleroderma,'*  by  F.  X.  Dercum,  M.  D. 
"A   Case   of   Amyotrophic    Lateral    Sclerosis    Presenting   Bulbar 
Symptoms,  with  Necropsy  and  Microscopical  Studies,"  by  F.  X.  Der- 
cum, M.  D.,  and  W.  G.  Spiller,  M.  D. 

"A  Consideration  of  the  General  and  Special  Clinical  Aspects  of 
Herpes  Zoster,"  by  Leonard  Weber,  M.  D. 


.w.i.. 


364      PROGRAM  OF  NEUROLOGICAL  A. 

'"The  Neurological  Aspect  of  Public  School 
Punton,  M.  D. 

"Kamily  Periodic  Paralysis,"  by  E.  W.  Ta> 

'"The  Pathological  Anatomy  of  Amaurotic 
William  Hirsch.  M.  D. 

"Some  Considerations  upon  the  Significani 
Granules  of  the  Neuron,"  by  Ira  Van  Gieson,  1 

"A  Case  of  Syphilitic  Multiple  Neuritis,"  by 

"Report  of  a  Case  of  Amaurotic  Family  Id 
by  Frederick  Peterson,  M.  D. 

"The  Pupil  in  Intracranial  Hemorrhage,"  b 

M.  d; 

"Report  of  a  Case  of  Cerebellar  Tuberculosi 
M.  D. 

"A  Note  on  the  Temperature  in  Nervous  and 
by  Smith  Baker,  M.  D. 

"Results  of  Thyreoidectomy  in  Eight  Cases 
by  J.  Arthur  Booth.  M-  D. 

"Presentation  of  a  Case  of  Graves's  D'-easi 
Neuritis  (Choked  Disks),"  by  J.  Arthur  Booth, 

"Experimental  Researches  on  the  Localize 
thetic  Nerve  in  the  Brain  and  Spinal  Cord,  with 
Physiology  of  the  Sympathetic,"  by  B.  Onuf, 
Collins,  M.  D. 

■■Reflections  on  the  Nosology  of  the  So-ca 
eases,"  by  Joseph  Collins,  M.  D.,  and  Joseph  Fr 

"Note  on  Detecting  in  Perspiration  the  Usi 
billies,"  by  Richard  Dewey,   M.   D. 

"A  Case  of  Huntington's  Chorea,  with  Ri 
priety  of  Naming  the  Disease  Dementia  Choi 
Hallock,  M.  D. 

"Long  Remissions  in  Epilepsy,  and  Their 
nosis,"  by  Wharton   Sinkler,  M.   D. 

"On  Cerebral  Tumor,"  by  Alfred  Wiener,  I 

"A  Case  of  Syringomyelia  with  Unusual  i 
Microscopical  Report,"  by  William  N.  Bullard.  I 

"On  Hysteria  in  Eirly  Life,"  by  B.  Sachs.  S 

"The  Bruce  Microtome."  by  C.  Eugene  Rigj 

"Pressure  Mvelilis  Due  to  Tubercular  Thor 
Eugene  Riggs.  M.  D. 

"Considerations  on  Amyotrophic  Lateral  St 
D.  Fisher,  M.  D. 

"Asthenic  Bulbar  Paralysis,"  by  Philip  Zenne 

"Regeneration  of  Nerve  Fibres  in  the  Centr 
by  W.  L.  Worcester,  M.  D. 

"Chlorosis  and  Retino-pupillitis,"  by  H.  M. 

"A  Case  of  Ery  thro  melalgia,  with  Microsi 
of  Tissue  from  an  Amputated  Toe,"  by  S.  Weir 
William  G.  Spilier,  M.  D. 

"Report  of  a  Case  of  Tabes  with  Hepatic  C 
by  William  C.  Krause,  M.  D. 

"Report  of  a  Case  of  Hemiatrophy  of  the  F 
Burr,  M.  D. 


iSijrc'tnm 


366  CHAS.  K.  MILLS  AND  IVM.  G.  SPILLBR. 

November  25th  he  was  completely  paralyzed  in  all  the  ex- 
tremities. He  began  at  this  time  to  have  considerable  diffi- 
culty in  breathing,  and  also  had  a  cough.  This  was  his  con- 
dition when  he  was  admitted  to  the  Philadelphia  Hospital,  to 
the  service  of  Dr.  Mills,  November  26th. 

When  he  was  examined,  November  27th,  he  was  perfectly 
conscious,  and  gave  intelligently  a  full  history  of  his  illness, 
but  he  suffered  from  intense  dyspnoea.  He  spoke  slowly  and 
distinctly.  He  was  able  to  move  the  pelvis  up  and  down  to 
a  slight  extent,  and  to  rotate  the  lower  limbs  a  little  at  the 
hip  joints,  but  otherwise  he  was  completely  ^.aralyzed  in  all 
four  extremities.  .  The  tendon  reflexes  in  the  lower  limbs  were 
entirely  lost,  and  in  the  upper  the  response  to  a  tap  over  the 
biceps  muscles  was  feeble  and  soon  exhausted.  The  limbs 
were  slightly  rigid.  The  dysphagia  was  great,  and  he  choked 
in  drinking.  The  sphincters  were  not  affected.  Numerous 
rales  were  heard  in  the  lungs.  The  expansion  of  the  chest 
was  good  on  both  sides.  The  percussion  revealed  nothing 
abnormal.  The  puise  was  rapid,  but  forcible.  The  apex  beat 
of  the  heart  was  in  the  fifth  interspace  and  was  strong.  No 
cardiac  murmurs  were  detected. 

Sensation  for  heat,  cold,  pain  and  touch  was  normal  every- 
where. He  had  complained  at  first  of  some  pain  in  the  pos- 
terior part  of  both  thighs,  and  especially  behind  the  knees. 
Pain  had  passed  away  at  the  time  of  examination,  except  in 
the  posterior  part  of  the  cervical  region,  especially  when  the 
head  was  not  supported.  No  tenderness  was  present  in  the 
back  of  the  neck  on  pressure,  or  over  any  of  the  nerve  trunks 
of  the  body  or  limbs,  except  in  a  small  area  on  the  right  side, 
under  the  outer  third  of  the  clavicle. 

The  ocular  muscles  were  not  paralyzed,  and  the  pupils 
responded  to  light  and  in  accommodation.  The  ophthalmos- 
copic examination  revealed  nothing  abnormal. 

The  patient  stated  that  he  had  noticed  swelling  of  the  face 
in  the  morning,  especially  under  the  eyes,  for  some  time.  The 
color  of  the  urine  was  reddish;  its  reaction  was  acid;  its  specific 
gravity  was  1024,  and  it  contained  a  little  sediment,  in  which 
bladder  cells  and  leucocytes  were  found,  but  neither  albumin 
nor  sugar  was  present. 

The  man  became  gradually  worse,  and  he  died  November 
27th.  1897. 

The  notes  of  the  necropsy,  made  twenty-four  hours  after 
death,  by  Dr.  William  B.  Jameson,  are  as  follows: 

The  heart  contained  fluid  blood  and  some  clots:  its  valves 
were  normal,  and  its  weight  was  400  grammes.  At  the  left 
apex  of  the  lung,  and  along  its  posterior  surface,  were  ex- 
tensive pleural  adhesions.  The  left  lung  was  markedly  em- 
physematous, and  showed  extensive  catarrhal  pneumonia  in 


ON  LANDRY'S  PARALYSIS.  367 

the  lower  lobe.  Its  weight  was  1,100  grammes.  The  right 
lung  showed  minute  patches  of  catarrhal  pneumonia  through- 
out. It  was  also  emphysematous,  but  less  so  than  the  left 
Its  weight  was  1,250  grammes.  Some  purulent  excretion  was 
noted  in  the  bronchi  of  both  lungs.  The  spleen  was  normal. 
The  left  kidney  was  distinctly  red  in  color,  and  the  capsule 
stripped  easily,  leaving  a  smooth  surface.  The  cortex  was 
normal  in  depth,  and  the  vessels  were  not  notably  thickened. 
No  gross  lesions  were  observed.  The  weight  was  180 
grammes.  The  right  kidney  presented  the  same  appearance 
as  the  left,  and  its  weight  was  190  grammes.  The  surface  of 
the  liver  was  smooth.  The  capsule  was  not  thickened.  Con- 
siderable hypostatic  congestion  and  numerous,  but  not  ex- 
tensive, areas  of  fatty  infiltration  were  observed.  Its  weight 
was  2,270  grammes.  The  meninges  of  the  cord  were  normal, 
and  no  gross  lesions  were  observed  in  the  cord  or  brain.  The 
cord  appeared  to  be  hyperaemic.  The  pia  matter  was  deeply 
injected.    The  weight  of  the  brain  was  1,450  grammes. 

The  gross  examination,  therefore,  showed  chronic  pleurisy 
of  the  left  side,  bilateral  catarrhal  pneumonia,  pericardial  ef- 
fusion (about  two  ounces  of  clear  serum),  emnhysema  and 
hyperaemia  of  the  gray  matter  of  the  cord,  pons  and  oblongata. 
One  of  the  external  popliteal  nen^es  was  examined  by  the 
method  of  "teasing"  and  staining  with  a  one  per  cent,  solu- 
tion of  osmic  acid.  Many  of  the  medullary  sheaths  were 
greatly  swollen,  and  in  some  fibres  the  myelin  was  entirely 
broken  up  into  black  balls.  The  nuclei  were  also  more  nu- 
merous. Many  of  the  fibres  appeared  normal,  or  only  slightly 
altered,  and  the  process  had  evidently  been  of  too  short  dura- 
tion to  cause  involvement  of  all  the  fibres. 

In  one  of  the  cutaneous  nerves  removed  from  the  sole  of 
the  foot  the  lesions  were  less  intense.  The  carmine  stain 
showed  many  small  axis  cylinders  in  the  external  popliteal 
nerve,  and  occasionally  one  or  more  axis  cylinders  somewhat 
swollen. 

The  cells  of  the  ventral  horns  throughout  the  cord  were 
tumefied  and  more  or  less  rounded;  their  centres  were  more 
homogeneous  than  normal,  and  contained  scattered  granules 
stained  purple  with  the  thionin  after  Lenhossek's  method;  the 
nucleus  was  displaced  to  the  periphery  of  the  cell,  but  hernia 
of  the  cell  was  not  observed.  The  nucleolus  stained  an 
intense  purple,  and  contained  often  one,  two  or  three  vacuoles, 
which  are  recognized  as  existing  in  normal  nucleoli.  At  the 
periphery  of  the  cells  the  chromophilic  elements  were  still  pre- 
served, and  the  dendrites  were  intact.  The  destruction  began 
in  the  chromophilic  elpments  situated  about  the  nucleus,  and 
evidently  had  not  involved  all  the  cellular  contents. 
Some  of  the  cells  of  the  ventral  horns  were  normal,  which 


368  CHAS.  K.  MILLS  AND  H-'il/.  G.  SPILLEK. 

we  should  expect,  in  view  of  the  fact  that  many  nerve  fibres 
were  preserved.  The  carmine  stain,  as  well  as  the  NissI  stain, 
showed  the  tumefaction  of  the  cells  and  the  displacement  of 
the  nucleus. 

The  cells  in  the  sacral  region  were  as  much  affected  as 
those  elsewhere  in  the  cord,  notwithstanding  the  absence  of 
vesica!  and  rectal  symptoms.  The  cells  of  the  column  of 
Clarke  appeared  to  be  normal. 

The  medullary  sheaths  in  the  anterior  and  posterior  roots 
were  stained  black  by  Marchi's  method,  and  this  was  noticed 
especially  in  the  extramedullary  portion.  A  slight  cellular  in- 
filtration was  seen  within  the  roots,  meninges  and  cord  in 
some  of  the  sections. 

In  the  thoracic  segments,  in  which  more  roots  were  ob- 
tained than  in  sections  from  other  parts  of  the  cord,  the  pos- 
terior roots  presented  a  number  of  swollen  axis  cylinders  when 
the  carmine  was  employed  as  a  stain;  a  few  swollen  ones  were 
also  found  in  the  anterior  roots,  but  they  were  not  as  nu- 
merous and  not  as  large  as  those  in  the  posterior  roots. 

Sections  from  the  cervical,  midthoracic  and  lumbar  regions 
stained  by  the  method  of  Marchi  revealed  numerous  black 
dots  scattered  all  over  the  transverse  area  of  the  cord,  but 
these  are  hardly  to  be  considered  as  indicative  of  degenera- 
tion. We  have  seen  sections  from  presumably  normal  spinal 
cords  stained  by  this  method  in  which  these  same  diffuse 
black  masses  were  present  in  moderate  amount.  The  swell- 
ing of  the  axis  cylinders  in  the  spinal  roots,  as  seen  by  the 
carmine  stain,  renders  the  pathological  nature  probable  of 
some  at  least  of  these  black  dots  in  the  roots. 

Some  of  the  cells  of  the  twelfth  and  of  the  motor  fifth  and 
tenth  nuclei  stained  diffusely,  but  this  may  have  been  due 
largely  to  postmortem  changes,  for  the  nuclei  within  these  cells 
were  not  displaced. 

One  or  two  prominent  accumulations  of  round  cells  were 
found  within  the  oblongata,  but  not  elsewhere. 

The  cerebral  cortex  appeared  to  be  intact,  and  the  giant 
cells  of  the  paracentral  lobule  were  normal. 

No  haamorrhages  were  observed  anywhere  within  the  cen- 
tral nervous  system. 

No  microorganisms  could  be  found,  either  by  the  thionin 
stain  or  by  Gram's  method,  and  cultures  made  from  the  spinal 
cord,  and  examined  by  Dr.  Samuel  S.  Kneass,  yielded  negative 
results. 

We  understand  by  Landry's  paralysis  a  disease  in  which 
the  rapid  loss  of  motor  power  usually  begins  in  the  lower 
limbs,  and  the  paraly.sis  is  flaccid  and  associated  with  par- 
Eesthesia  and  loss  of  the  tendon  reflexes.     The  upper  ex- 


ON  LANDRY'S  PARALYSIS.  369 

tremities  are  soon  involved,  and  bulbar  symptoms  develop 
after  a  few  days.  Pain  is  riot  a  prominent  symptom.  Death 
occurs  within  a  week  or  ten  days,  though  in  some  cases  it 
may  be  delayed,  and  in  others  more  rare  recovery  may 
ensue.  There  may  be  a  descending,  as  well  as  an  ascending 
form  of  paralysis.  The  electrical  reactions  are  normal,  and 
the  patients  are  perfectly  conscious  of  their  condition. 

This  may  be  considered  quite  a  characteristic  picture 
of  Landry's  paralysis,  but  the  lines  cannot  always  be  sharply 
drawn,  either  clinically  or  histologically.  Thus  Oppenheim^ 
says  that  spontaneous  pain  is  exceptional,  acknowledging 
thereby  that  it  may  occur.  He  likewise  says  that  in  some 
cases  reaction  of  degeneration  and  vesical  and  rectal  symp- 
toms are  noted.  Muscular  degeneration  has  also  been 
observed. 

It  is  evident  that  the  distinction  between  Landry's 
paralysis  and  polyneuritis  cannot  be  sharply  made  if  Op- 
penheim's  views  are  accepted,  and  this  is  especially  true 
if  we  follow  the  teaching  of  Nauwerck  and  Barth.^ 

Goldfiam  reports  a  case  of  Landry's  paralysis  which 
for  a  time  he  regarded  as  one  of  paroxysmal  paralysis.' 

Raymond,*  after  an  excellent  presentation  of  the  sub- 
ject of  acute  ascending  paralysis,  says  that  the  disease  may 
ascend  or  descend,  may  begin  or  end  with  bulbar  symp- 
toms, and  the  electrical  reactions  may  be  altered.  Disturb- 
ance of  sensation  may  be  absent,  slightly  pronounced,  or 
\try  marked.  Paraesthesia,  pain,  hyperaesthesia,  or  anaes- 
thesia may  be  present.  The  tendon  reflexes  may  be  pre- 
served or  abolished. 

Bailey  and  Ewing*  have  tabulated  a  large  number  of 
cases  of  Landry's  paralysis,  and  much  labor  will  be  spared 


*Oppenheim:    Lehrbuch  der  Nervenkrankheiten,  p.  357. 

'Nauwerck  and  Barth:   Ziegler's  Beitrage.  vol.  v. 

'Goldflam:  Deutsche  Zeitschrift  f.  Nervenlieilkunde,  vol.  xi,,  Nos. 
3.4. 

*  Raymond:  Lemons  sur  les  Maladies  du  Systeme  Nerveux,  Deuxi- 
eme  Scric.  1  \ 

'Bailey  and  Ewing:   The  New  York  Medical  Jour.,  1896,  No.  2. 


370 


CHAS.  K.  MILLS  AND  WM.  G.  SPILLER. 


future  writers  on  this  subject.  They  state  that  the  nerves 
were  examined  in  osmic  acid  only  in  two  of  the  sixteen 
cases  without  lesions,  and  in  none  of  these  cases  were  the 
most  improved  methods  for  staining  the  cells  employed. 
It  matters  little  how  skilled  an  investigator  may  be,  he 
will  be  unable  to  detect  very  early  cellular  changes  by 
the  carmine  stain,  or  early  nerve  lesions  by  the  ha;matox- 
ylin  stain  of  Weigert.  The  most  reliable  method  for  the 
determination  of  beginning  alteration  in  nerve  fibres  is 
the  method  of  "teasing"  and  staining  the  tissue  in  the 
fresh  state  with  osmic  acid. 

Bailey  and  Ewing  state  that  in  nine  of  the  fourteen 
cases  in  which  changes  were  found  in  the  cord  alone,  the 
nerves  were  not  examined,  and  in  only  one  of  these  nine 
cases  were  the  clinical  symptoms  of  neuritis  present.  This 
latter  statement  is  of  limited  value.  It  is  the  experience  of 
every  oculist  that  optic  neuritis  may  be  present  and  cause 
little  functional  disturbance,  or  that  impairment  of  sight 
may  be  noticed  with  clear  media  and  apparently  normal 
fundus.  Organic  changes  in  the  body  may  be  latent  for 
some  time.  The  symptoms  of  neuritis  may  be  chiefly 
those  of  involvement  of  motor  fibres,  as  in  this  case  we 
report. 

Bailey  and  Ewing  believe  that  the  remaining  five  cases 
conclusively  demonstrate  that  a  lesion  limited  to  the  cere- 
brospinal axis  may  produce  acute  ascending  paralysis. 
These  five  cases,  we  take  it,  are  those  of  Eisenlohr,  Hoff- 
mann, Immerniann,  Hlava,  and  CEttinger  and  Marinesco. 
Unless  the  nerves  were  examined  by  osmic  acid,  these 
cases  are  not  conclusive  of  the  exclusively  spinal  origin  of 
Landry's  paralysis. 

In  regard  to  Eisenlohr's*  case,  we  find  the  statement 
that  transverse  sections  of  the  anterior  roots  from  different 
parts  of  the  cervical  region,  stained  with  carmine,  pre- 
sented normal  fibres.     We  find  no  mention  of  a  careful 

'Eisenlohr;    Virchow's  Archiv,  vol.  Ixxiii.,  p.  73. 


ON  LANDRY'S  PARALYSIS. 


371 


examination  of  the  peripheral  nerves.     This  case,  there- 
fore, is  not  conclusive. 

In  Hoffmann's"^  case  pathological  changes  were  only 
found  in  the  facial  nerve;  all  the  other  nerves  examined 
were  normal.  The  intramedullary  portions  of  the  anterior 
roots  were  much  altered.  The  nerves  had  been  hardened 
in  Miiller's  fluid,  and  do  not  seem  to  have  been  examined 
in  the  fresh  state.  We  are  sure  that  early  lesions  of  nerve 
fibres  may  be  overlooked  in  preparations  hardened  in 
Miiller's  fluid. 

In  regard  to  Immermann's^  case,  the  muscles  and  peri- 
pheral nerves  were  intact.  No  mention  is  made  of  the 
method  of  examination  of  the  nerves.  Immermann  says 
that  the  case  shows  that  there  is  a  form  of  acute  anterior 
poliomyelitis  which  clinically  corresponds  to  Landry's 
paralysis. 
^  In  regard  to  Hlava's®  case,  the  sciatic  and  ulnar  nerves 

were  examined,  and  while  mast  cells  were  found  in  both, 
no  degeneration  was  detected.  Unfortunately  no  mention 
of  the  method  of  examination  of  the  nerves  is  given  in  this 
abstract,  and  the  original  paper  is  not  accessible  to  us. 

In  CEttinger  and  Marinesco's^®  case  the  alterations  in 
the  central  nervous  system  were  great,  without  appreciable 
lesions  in  the  peripheral  nerves. 

Of  the  six  cases  of  acute  anterior  poliomyelitis  which 
Bailey  and  Ewing  would  include  as  cases  of  Landry's  pa- 
ralysis, they  state  that  four  show  an  involvement  of  the 
cord  alone.  In  the  abstract  of  Rissler's^^  cases  we  find 
that  secondary  degeneration  of  motor  nerves  was  ob- 
served in  the  acute  cases,  and  that  in  the  more  chronic 
ones  the  roots  were  diminished  in  size. 

In  Redlich's  case  degeneration  was  noted  in  the 
brachial  plexus. 


*  Hoffmann:   Archiv  f.  Psychiatric,  vol.  xv.,  1884. 

*  Immermann:    Neurologisches  Centralblatt,  1885,  p.  304. 
•Hlava:   Schmidt's  Jahrbiicher,  1891,  232,  p.  244. 
"CEttinger  and  Marinesco:    Semaine  Medicale,  1895,  p.  45. 
"Rissler:   Neurologisches  Centralblatt,  1889,  p.  422. 


372 


CHAS.  K.  MILLS  AND  WM.  G.  SPILLEK. 


In  Goldscheider's  the  nerves  were  not  examined. 

In  Dauber's^'  case  of  poliomyelitis  it  is  distinctly  stated 
that  the  anterior  roots  were  pathologically  altered. 

In  regard  to  the  cases  collected  by  Bailey  and  Ewing, 
in  which  the  peripheral  nerves  alone  were  affected,  these 
writers  state  that  only  one  case  shows  that  a  lesion  limited 
to  the  peripheral  nerves  may  cause  typical  symptoms  of 
fatal  acute  ascending  paralysis.  This  is  evidently  De- 
jerine's  case,  which  was  examined  before  Nissl's  stain  was 
in  vogue. 

In  Eisenlohr's"  case  (Case  i)  the  central  nervous  sys- 
tem was  put  in  Miiller's  fluid,  and  Nissl's  stain  was  prob- 
ably not  employed. 

A  total  of  twenty-eight  recorded  cases  of  Landry's 
paralysis  in  which  lesions  were  found,  as  collected  by  these 
writers,  must  make  us  somewhat  sceptical  toward  the 
report  of  those  cases  in  which  no  lesions  were  noted.  Only 
in  a  few  cases  have  bacteria  actually  been  observed.  - 

In  the  case  of  Landry's  paralysis  reported  by  Bailey 
and  Ewing  (1,  c.)  intense  perivascular  cellular  infiltration 
was  found  within  the  cord,  which  we  have  not  noticed  in 
our  case,  except  in  one  or  two  regions  of  the  oblongata. 

The  changes  which  they  found  in  the  motor  cells  are 
not  unlike  those  described  by  us.  The  peripheral  nerves 
were  not  examined  by  them,  which  is  much  to  be  re- 
gretted. The  fact  that  the  nerve  roots  in  the  upper  tho- 
racic and  cervical  segments  were  intact,  especially  as  con- 
siderable cellular  infiltration  was  seen  within  them,  does 
not  exclude  the  possibility  of  peripheral  degeneration. 
It  is  very  true  that,  if  such  degeneration  had  been  present, 
it  might  have  been  secondary  to  the  cord  lesions;  but  it 
might  also  have  occurred  at  the  same  time  as  the  spinal 
lesions.  A  toxin  may  affect  the  most  distal  portion  of  the 
peripheral  neuron  simultaneously  with  its  attack  on  the 
cord.     We  question  the  possibility  of  deciding  from  the 

"Dauber:   Deutsche  Zeitschr.  f.  Nervenheilk.,  vol.  iv. 
"Eisenlohr:    Deutsche  med.  Woclienschrifl,  No.  38,  1890. 


ON  LANDRY* S  PARALYSIS.  373 

nature  of  the  cellular  lesions  whether  the  change  is  prima- 
rily within  the  cell  or  in  the  terminal  ramifications  of  the 
neuron. 

In  Hun's**  case,  which,  clinically,  was  quite  a  typical 
one  of  Landry's  paralysis,  a  slight  cerebral  and  spinal 
meningitis  of  quite  recent  origin,  a  degeneration  of  some 
of  the  fibres  of  the  anterior  roots  of  the  cauda  equina,  and 
a  thickening  and  infiltration  of  the  walls  of  the  anterior 
spinal  vein  were  noted.  Some  portions  of  the  cord  were 
hardened  in  alcohol,  but  no  detailed  statements  are  given 
of  the  condition  of  the  motor  cells  as  examined  by  Nissl's 
stain.  No  changes  were  found  in  the  peripheral  nerves 
by  osmic  acid. 

In  this  case  the  moderate  infiltration  of  the  spinal  pia 
and  its  vessels  with  small  round  cells  might  be  regarded 
as  the  early  stages  of  meningitis,  and,  had  the  patient  lived 
longer,  it  is  possible  that  meningitic  pains  would  have  been 
experienced.  We  may  thus  understand  how  easily  sen- 
sory symptoms  are  added  to  the  purely  motor  ones  of 
Landry's  paralysis. 

Hun  believes  that  his  case  goes  far  to  prove  that  acute 
ascending  paralysis  may  exist  without  any  appreciable 
lesion.  In  view  of  this  statement,  we  cannot  help  re- 
regretting  that  more  exact  information  of  the  condition  of 
the  cells,  as  stained  by  Nissl's  method,  could  not  be  given. 

Dejerine**^  states  that  certain  toxins  cause  paralysis 
without  neuritis  histologically  appreciable,  and  from  the 
text  it  is  evident  he  has  not  in  mind  myelitis  as  the  cause 
of  such  paralysis.  He  refers  to  the  experiments  of  Charrin 
as  a  proof  of  his  statement.  Babinski  and  Charrin*®  pro- 
duced motor  paralysis  in  rabbits  by  the  injection  of  the 
bacillus  pyocyaneus,  or  merely  the  soluble  products  of 
this    microorganism    obtained    by    cultures.      They    ex- 


"  Hun :  The  New  York  Medical  Journal,  vol.  liii.,  p.  609. 
"Dcjerine:    La  Medecine  Moderne,  Dec.  21,  1895. 
*•  Babinski  and  Charrin :  Comptes  rendus  de  la  Societ6  de  Biologie, 
1888,  p.  257. 


374  CHAS.  K.  MILLS  AND  WM.  G.  SFILLER. 

amined  the  muscles,  nerves  and  central  nervous  system 
of  these  animals  at  different  periods  of  the  paralysis,  even 
after  two  months  had  elapsed,  and  employed  various  meth- 
ods, but  their  results  were  absolutely  negative.  These 
experiments  show  us  that  we  may  expect  negative  find- 
ings in  some  cases  of  Landry's  paralysis. 

Hun  (i.  c.)  states  that  in  every  reported  case  of  Lan- 
dry's paralysis  due  to  neuritis  few  or  no  symptoms  of  bul- 
bar paralysis  were  observed,  and  that  these  cases  also  pre- 
sented decided  disturbance  of  sensibility,  manifested  by 
severe  pain  or  by  extensive  anjesthesia,  or  paralysis  of  the 
sphincters,  or  atrophy  of  the  muscles,  with  more  or  less 
well-marked  electrical  reaction  of  degeneration,  and  ten- 
derness on  pressure. 

In  our  case,  in  which  polyneuritis  was  certainly  pres- 
ent, although  equally  marked  changes  were  found  in  the 
cell  bodies  within  the  cord,  bulbar  symptoms  were  mani- 
fested in  great  dyspnoea  and  dysphagia.  No  disturbances 
of  objective  sensation  were  present,  and  only  slight  pain, 
if  we  include  the  pain  experienced  for  a  short  time  and  lim- 
ited to  one  or  two  regions.  Parxsthesia  was  noted,  but 
no  involvement  of  the  sphincters,  no  muscular  atrophy, 
and  no  tenderness  on  pressure,  except  in  one  very  limited 
area.  Unfortunately  the  electrical  reactions  were  not 
taken.  This  absence  of  tenderness  of  the  muscles  on  pres- 
sure is  interesting,  as  a  number  of  writers  state  that  even 
in  the  motor  form  of  neuritis  in  which  sensation  is  appar- 
ently normal,  pressure  of  the  affected  muscles  usually 
causes  pain. 

The  case  reported  by  Ballet  and  Dutil'^  may  possibly 
be  regarded  as  representing  a  later  stage  of  a  condition 
similar  to  that  in  Hun's  case.  Sensation  in  all  its  forms 
was  intact.  The  spinal  vessels,  especially  those  in  the 
anterior  horns,  were  enormously  dilated,  and  considerable 
leucocytic  infiltration  was  found.  The  cells  of  the  posterior 


ON  LANDRTS  PARALYSIS.  375 

horns,  those  of  the  columns  of  Clarke,  and  especially  those 
of  the  anterior  horns,  presented  destruction  of  the  chromo- 
philic  elements,  cloudiness  of  the  cell  protoplasm,  destruc- 
tion or  rupture  of  the  cellular  processes,  and  nuclear 
changes.  It  was,  therefore,  a  case  of  diffuse  myelitis.  The 
roots  and  peripheral  nerves  showed  an  early  stage  of  de- 
generation.   No  microbes  could  be  found. 

The  case  reported  by  Marie  and  Marinesco*®  also  shows 
that  ascending  paralysis,  especially  in  the  wider  acceptation 
of  the  term,  may  be  due  to  disease  of  the  central  nervous 
system,  although  Nauwerck  and  Barth  stated,  at  the  time 
they  wrote  their  paper,  that  the  proof  of  such  an  origin 
of  the  disease  had  not  been  given. 

This  case  reported  by  Marie  and  Marinesco  was  quite 
a  typical  one  of  Landry's  paralysis,  except  that  the  patient 
suffered  intense  pain  in  the  entire  body.  Objective  sen- 
sation was  diminished  only  for  a  time.  Intense  mono- 
nuclear leucocytic  infiltration  was  observed  in  the  anterior 
horns  as  well  as  infiltration  of  a  less  intense  degree  in  the 
posterior.  Some  of  the  ganglion  cells  of  the  anterior  horns 
were  swollen  and  the  chromophilic  elements  had  disap- 
peared. Some  of  the  processes  and  cell  bodies  were 
divided.  In  the  cervical  region  where  the  disease  was  not 
so  far  advanced,  it  was  easy  to  see  that  the  elements  near- 
est the  nucleus  had  disappeared,  while  those  at  the  per- 
iphery of  the  cell  were  preserved.  The  nucleus  was  dis- 
placed.   The  peripheral  nerves  seemed  to  be  intact. 

We  have  mentioned  this  case  somewhat  in  detail  on 
account  of  its  importance.  It  presents  cellular  changes 
from  myelitis,  some  of  which  are  very  much  like  those 
seen  when  the  axis  cylinder  is  cut,  and  it  shows  the  diffi- 
culty in  deciding  as  to  the  primary  or  secondary  nature  of 
the  cellular  changes.  It  proves  that  the  peripheral  nerves 
are  not  always  diseased  when  the  cell  body  is  much  altered; 


"•  Marie  and  Marinesco:  Bulletins  et  Memoires  de  la  Soci6t6  M6di- 
cale  des  Hopitaux  de  Paris,  1895,  P-  659. 


376  CHAS.  K.  MILLS  AND  WM.  G.  SPILLER. 

and  it  shows,  finally,  that  Landry's  paralysis  may  be  due 
to  purely  central  lesions. 

The  central  form  of  Landry's  paralysis,  according  to 
Eruns,'*  is  chiefly  in  the  area  of  the  cord  nourished  by  the 
central  arteries.  This  central  form  of  Landry's  paralysis, 
like  the  acute  anterior  poliomyelitis,  may  be  due  to  a 
poison  which  gains  entrance  to  the  cord  chiefly  through 
the  anterior  spinal  arteries,  which  we  know  nourish  the 
gray  matter.  It  is  not  necessary  that  the  bacteria  them- 
selves should  be  found  within  the  cord, as  numerous  experi- 
ments have  shown  that  the  toxins  alone  are  suflicient  to 
produce  such  changes.  Ballet,*"  PhisaUx  and  Charrin,'' 
refer  to  a  number  of  these  investigations. 

The  case  reported  by  ffittinger  and  Marinesct^^  was 
due  to  central  lesions  also,  and  the  peripheral  nerves  did 
not  present  any  appreciable  alteration.  Sensation  for 
touch,  pain  and  temperature  was  much  diminished.  Bac- 
teria were  numerous  within  the  cord.  Marie  in  discussing 
this  case  (1.  c.)  says  that  certain  authors  have  been  wrong 
in  stating  that  acute  ascending  paralysis  is  due  to  peri- 
pheral neuritis,  but,  "in  reaHty,  it  is  due,  purely  and  simply, 
to  lesions  of  the  nervous  centres."  Our  case  would  hardly 
support  this  statement. 

The  close  connection  of  Landry's  paralysis  and  typical 
polyneuritis  may  be  seen  in  a  case  reported  by  Raymond." 
The  paralysis  was  not  of  the  ascending  type,  but  he  states 
that  no  clinician  would  have  hesitated  at  first  to  call  the 
case  one  of  Landry's  paralysis,  although  the  later  develop- 
ments of  the  case  made  this  diagnosis  untenable.  The 
muscles  and  nerves  of  the  lower  extremities  became  very 

"Bruns:  Allgemeine  Zeitschrift  fur  Psychiatric,  vol.  liii. 

"Ballet:    Psychoses  et  Affections  Nerveuses. 

"  Phisa!ix  and  Charrin:  Comptes  rendus  de  la  Societe  de  Biologic, 
No.  3,  1898. 

"CEttinger  and  Marinesco:  Bulletins  «  Memoires  de  la  Sociiti 
Medicale  des  Hopitaux  de  Paris,  189S,  p.  63. 

"  Raymond;  Lemons  sor  les  Maladies  du  Systeme  Nerveux,  Deux- 


ON  LANDRY'S  PARALYSIS. 


377 


painful  on  pressure,  the  muscles  of  the  extremities  atro- 
phied, and  presented  the  reaction  of  degeneration. 

The  changes  which  occur  within  a  nerve  in  parenchy- 
matous inflammation  are  like  those  of  descending  degen- 
eration and,  notwithstanding  the  many  causes  of  peripheral 
neuritis,  the  lesions  of  most  forms  are  similar,  though  pos- 
sibly the  perfection  of  our  methods  of  examination  may  re- 
veal a  variety  of  histological  forms.  The  changes  in  a  nerve 
undergoing  degeneration  consist  of  multiplication  of  the 
nuclei  of  the  sheath  of  Schwann,  increase  in  the  amount 
of  protoplasm  within  the  fibre,  destruction  of  the  myelin 
with  the  formation  of  balls  of  various  sizes,  and  destruction 
of  the  axis  cylinder.  When  the  neuritis  is  due  to  trauma- 
^ism,  the  inflammation  is  said  to  be  chiefly  in  the  connec- 
^'ve  tissues  and  vessels  of  the  nerves,  and  the  parenchyma 

's  Only  secondarily  affected. 

Babinski  voices  the  opinion  of  many  neuropathologists 

^^n  he  says  that  in  peripheral  neuritis — as  distinguished 
^    central  or  secondary  neuritis  in  which  the  nerves 

^t^    altered    secondarily    to    lesions    within    the    spinal 
^ofd — the  nerves  are  only  altered  at  their  periphery,  and 
their  trophic  centres  appear  perfectly  normal,  or,  at  least, 
are  only  slightly  altered. 

It  is  exceedingly  difficult  when  the  neuritis  is  supposed 
to  be  due  to  a  toxic  or  infectious  agent,  to  decide  whether 

.  the  cell  of  origin  is  altered  primarily  or  secondarily. 
Experimentally  it  has  been  shown  that  very  decided 
changes  occur  within  the  cell  when  its  fibre  has  been  cut 
(J.  Babinski,^*  p.  662).  Ballet^**  discusses  the  subject 
quite  fully.  He  says  peripheristes  believe  that  the  nerve 
may  be  altered  independently  of  the  cell  body,  i.  e.,  the 
peripheral  part  of  the  neuron  is  to  a  certain  extent  more 
susceptible  to  morbid  processes  than  the  corpus.  He  cites 
as  supporters  of  this  view  Leyden,  Dejerine,  Pitres  and 


"Babinski:   Traite  de  Medecine,  vol.  vl 
"Ballet:    Psychoses  et  Affections  Nerveuses. 


378  CHAS.  K.  MILLS  AND  WM.  G.  SPILLER. 

Vaillard,  and  Striimpell.  These  authors  support  their 
opinion  on  the  fact  that  more  or  less  pronounced  lesions 
of  the  peripheral  nerves  may  be  found  with  few  changes 
in  the  roots,  and  none  in  the  cord. 

The  centralistes,  on  the  other  hand,  beHeve  that  the 
cell  is  also  involved,  though  perhaps  only  functionally. 
Among  these  may  be  mentioned  Erb,  Remak,  Eisenlohr, 
Charcot,  Brissaud,  Babinski  and  Marie.  These  base  their 
opinion  on  the  bilaterality  and  symmetry  of  the  nerve 
lesions;  on  the  topography  of  the  sensory  or  motor  dis- 
turbances which  does  not  always  correspond  to  the  distri- 
bution of  the  nerve  trunks,  as  seen,  for  example,  in  the 
escape  of  the  supinator  longus  muscle  in  lead  palsy;  and 
on  the  degenerative  rather  than  the  inflammatory  char- 
acter of  the  nerve  lesions  (Erb).  Babinski  and  Ballet  state 
that  it  is  quite  possible  to  have  a  truly  inflammatory  neur- 
itis localized  to  a  limited  area,  and  that  the  changes  within 
the  nerve  below  this  point  are  of  a  degenerative  character. 

Ballet  (1,  c.  page  359)  reports  a  case  which  shows  in 
some  of  the  features  a  resemblance  to  Landry's  paralysis, 
though  of  long  duration.  A  man  became  weak  in  the 
lower  limbs  from  unknown  cause,  and  had  numbness  and 
tingling.  Within  a  few  weeks  the  weakness  became  par- 
alysis and  atrophy  was  noticed.  The  upper  limbs  also  be- 
came involved,  and  reaction  of  degeneration  was  noted. 
With  the  exception  of  numbness  and  tingling  the  sen- 
sation was  normal.  The  tendon  reflexes  were  absent,  and 
the  sphincters  were  intact.  The  peripheral  nerves  were 
found  much  degenerated,  and  the  anterior  roots  were  only 
sHghtly  affected.  In  the  anterior  horns  of  the  cord  the 
cells  were  less  numerous  than  normal ;  they  were  swollen, 
and  the  nucleus  was  displaced  toward  the  periphery.  The 
symptoms  had  lasted  eight  months. 

The  cellular  changes  which  Ballet  found  in  this  case 
(1.  c,  p.  365)  were  very  much  like  those  we  describe.  He 
speaks  of  the  destruction  of  the  chromophilic  elements,  at 
first  of  those  about  the  nucleus,  and  finally  of  all  within 


ON  LANDRY* S  PARALYSIS.  3  79 

the  cell ;  and  of  displacement  and  change  of  form  and  more 
intense  staining  of  the  nucleus.  The  vessels  and  neuroglia 
of  the  cord  were  normal. 

Ballet  (1.  c.)  after  referring  to  the  experimental  work 
of  Nissl,  B.  Onufrowicz,  and  Marinesco,  reports  cellular 
changes  very  similar  to  those  in  his  case  of  neuritis;  changes 
which  were  found  by  Dutil  in  guinea  pigs  after  section  of 
the  sciatic  nerve.  Only  in  one  of  the  three  animals  was 
degeneration  of  the  central  end  of  the  cut  nerve  found, 
and  this  animal  was  killed  thirty-seven  days  after  the  oper- 
ation. Some  of  the  cells  of  the  anterior  horn  had  disap- 
peared. This  degeneration  of  the  central  end  of  the  cut 
nerve  was  not  found  when  the  guinea  pigs  were  killed  six 
days  or  seventeen  days  after  the  operation.  Ballet  believes 
that  this  degeneration  was  secondary  to  the  cellular 
changes,  and  was  not  an  ascending  degeneration.  He 
states  that  the  cases  of  neuritis  in  which  the  cells  of  origin 
within  the  cord  have  been  found  normal  have  not  been 
studied  by  Nissl's  method,  though  in  some  cases  the 
neuritis  may  not  be  sufficiently  intense  to  cause  cellular 
I  alteration. 

Marinesco  also  has  explained  the  so-called  ascending 
'  degeneration  of  the  central  end  of  a  cut  nerve  on  the  sup- 

position that  it  is  secondary  to  changes  within  the  cell 
body,  and  is  really  of  the  nature  of  Wallerian  degeneration, 
Marinesco   Says  that   CEttinger,   Korsakoff,   Kopper, 
Schaffer,  ErUtzky,  Achard  and  Soupault  have  described 
I  lesions  of  the  cells  of  the  anterior  horns  in  alcoholic  paral- 

ysis; Dejerine  and  CErtel  in  diphtheria;  Oppenheim,  Po- 
!  poff,  Rosenbach  in  lead  palsy;  and  that  Fuchs,  Goldschei- 

I  der  and  Moxter,  Giese  and  Pagenstecher,  Ballet  and  Dutil 

have  found  these  cellular  changes  in  polyneuritis.  Much 
evidence,  therefore,  is  in  favor  of  the  view  that  poisons 
have  a  very  decided  effect  on  the  motor  cells  of  the  anterior 
horns. 

Marinesco^^  describes  a  case  of  polyneuritis  in  which 


Marinesco:   Revue  Neurologique,  1896,  p.  129. 


380  CHAS.  K.  MILLS  AND  WM.  G.  SPILLER. 

the  nerves  were  found  greatly  altered;  the  anterior  and 
posterior  roots  seemed  to  be  intact,  but  changes  were 
found  within  the  cell  body  very  much  Hke  those  in  the  case 
we  report.  He  speaks  of  a  resemblance  of  these  cellular 
changes  to  those  which  occur  when  a  nerve  is  cut,  and 
states  that  he  is  the  first  to  call  attention  to  this.  Figure 
17  of  his  paper  would  represent  very  well  one  of  the  cells 
of  the  anterior  horns  in  our  own  case.  He  calls  attention 
to  the  fact  that  Striimpell  and  Raymond  have  believed 
that  a  toxic  agent  may  act  at  the  same  time  on  the  nerv- 
ous centres  and  on  the  peripheral  nerves.  He  believes 
that  he  can  make  a  distinction  between  the  secondary 
changes  in  a  nerve  cell,  as  seen  when  its  fibre  is  cut,  and 
primary  changes,  such  as  occur  after  compression  of  the 
abdominal  aorta.  In  the  latter  the  destruction  of  the 
chromophilic  elements  begins  at  the  periphery  of  the  cell, 
the  perinuclear  layer  is  intact,  and  the  nucleus  is  central, 
while  in  later  stages  the  trophoplasm  (the  achromatic  por- 
tion) of  the  cell  presents  large  spaces  resulting  from  its 
partial  destruction. 

Marinesco  regards  this  degeneration  of  the  tropho- 
plasm as  an  early  lesion  in  all  acute  primary  affections  of 
the  spinal  cord,  and  has  observed  it  in  two  cases  of  Lan- 
dry's paralysis.  Whenever  the  trophoplasm  is  altered,  the 
lesion  is  irreparable,  for  there  is  no  regeneration  of  nerve 
cells  as  shown  by  the  work  of  Stroebe." 

The  question,  therefore,  as  to  the  primary  or  secondary 
involvement  of  the  cell  of  origin  of  the  peripheral  neuron 
is  one  of  some  importance.  Restoration  of  function  is  not 
uncommonly  noted  when  the  lesion  begins  in  the  axis  cyl- 
inder and  the  cell  is  altered  secondarily,  but  according  to 
Dejerine,*®  not  a  single  case  of  diffuse  myelitis  or  of  polio- 
myeUtis  with  restoration  ad  integrum  has  been  reported. 

Disease  of  the  cell  of  origin  of  the  motor  nerve  fibre 


"Stroebe:    Centralblatt  t.   allgemeine   P.itholosie  und  patholo- 
gische  Anatomic,  vol.  vi.,  1895. 

"Dejcrine:    La  Medecine  Moderne,  Dec.  21,  1895. 


ON  LANDRY'S  PARALYSIS.  381 

has  been  found  by  other  investigators  in  neuritis.  Dejerine 
and  Theohari^^  have  found  it  in  neuritis  of  the  seventh 
ner\^e,  and  SoukhanofP^  recently  in  polyneuritis.  Other 
cases  are  on  record. 

Schaffer^^  has  studied  the  cells  in  the  anterior  horns 
in  several  cases  of  tabes  in  which  trophic  lesions  were  ob- 
served, and  has  found  that  the  cellular  changes  are  the 
same  whether  there  is  amyotrophy,  osteopathy  or  arthro- 
pathy. In  the  early  stages  the  chromophilic  elements 
about  the  nucleus  are  broken  up  into  granules,  and  only 
when  the  cell  body  is  affected,  in  toto,  are  the  nucleus  and 
nucleolus  altered.  The  dendrites  are  involved  later  than 
the  cell  body,  and  may  be  found  relatively  intact  when  the 
cell  body  is  seriously  altered.  The  partially  degenerated 
cells  are  more  numerous  than  the  totally  degenerated. 
Schaffer  concludes  from  his  studies  of  cellular  lesions  from 
toxic,  infectious  and  trophic  causes,  as  well  as  from  direct 
disturbance  of  nutrition,  that  the  Nissl  stain  does  not 
show  specific  changes  in  any  case,  and  that  in  every  form 
of  cellular  disease  the  lesion  is  chromatolysis,  which  in  its 
essential  features  is  always  the  same.  This  chromatolysis 
Schaffer  does  not  regard  as  a  lesion  banale  in  the  sense 
used  by  Dejerine  and  Thomas,  but  looks  upon  it  as  an 
index  of  the  cell's  vitality. 

Mourek  and  Hess,*^  after  performing  a  number  of  ex- 
periments in  poisoning  rabbits,  concluded  that  in  all  the 
cases  the  chromatolysis  was  the  same,  and  that  the  Nissl 
elements  presented  no  characteristic  alterations  for  the 
different  poisons.      The  investigations  of  Van  Gieson,'* 


"  Dejerine  and  Theohari :    Comptes  rendus  de  la  Soci^t^  de  Bi- 
ologie,  Dec.  4,  1897. 

'*Soukhanoff:   Abstract  in  Revue  Neurologique,  No.  2,  1898. 

"Schaffer:   Monatsschrift  f.  Psychiatric  und  Neurologic,  vol.  iii.. 
No.  I. 

"Mourek  and  Hess:   Revue  Neurologique,  1897,  p.  667, 

"Van  Gieson:    Medical  Record,  April  9,  1898,  p.  526.     Ewingr 
Idem. 


382  CHAS.  K.  MILLS  AND  WM.  G.  SPILLER. 

and  more  recently  those  of  Ewing,  show  us  that  the  im- 
portance of  chromatolysis  is  not  held  to  be  equally  great 
by  all  histologists. 

The  early  changes  which  Schaffer  has  found  in  the 
spinal  cells  of  tabetic  patients  are  about  the  same  as  those 
observed  by  us  in  the  case  of  Landry's  paralysis,  and  like 
those  noted  in  cases  reported  as  polyneuritis.  SchaflFer 
believes  that  the  tabetic  changes  are  primarily  in  the  cell 
body,  but  we  must  confess  that  we  are  not  convinced  of 
the  correctness  of  this  view,  and  it  is  possible  that  such 
cellular  alterations  in  tabes  are  secondary  to  neuritis.  In 
this  sense  Dejerine'*  would  still  be  right  in  that  he  .believes 
the  muscular  atrophy  of  tabes  is  due  to  neuritis.  SchafTer 
found  that  normal  cells  were  mingled  with  diseased  ones. 
This  could  be  explained  by  the  fact  that  usually  in  neuritis 
some  of  the  ner\-e  fibres  are  intact,  and  secondary  changes 
in  the  cells  are  only  found  in  those  belonging  to  the  al- 
tered fibres;  it  could,  however,  be  used  to  explain  the  par- 
tial involvement  of  nerve  fibres  if  the  cellular  changes  are 
regarded  as  primary,  Schaffer  believes  that  the  partial 
degeneration  of  a  nerve  cell  causes  degeneration  at  the 
periphery  of  the  neuron,  in  the  terminal  ramifications  of 
the  fibre,  and  as  the  cellular  changes  increase  the  degen- 
eration of  the  fibre  creeps  upward.  May  it  not  be  equally 
true  that  the  lesion  is  primarily  in  the  nerve  termination, or 
simultaneously  in  the  nerve  termination  and  in  the  cell 
body?  May  it  not  be  true  that  the  peripheral  lesion  leads 
to  partial  degeneration  of  the  cell  body?  It  may  be  that 
the  portion  of  the  neuron  furthest  from  the  nucleus,  as 
Erb  and  Striimpell  believe,  is  the  portion  most  susceptible 
to  toxic  agents.  We  acknowledge  the  force  of  all  that 
Schaffer  says,  but  we  cannot  regard  his  arguments  as  final. 
It  seems  to  us  that  the  question  as  to  the  primary  or  sec- 
ondary involvement  of  the  motor  cells  in  tabes  and  poly- 
neuritis is  still  open. 

"Dejerine:    Sur  I'Atrophie  Musculaire  des  Ataxiques. 


ON  LANDRTS  PARALYSIS.  383 

Berger**  has  found  the  cells  of  the  anterior  horns  much 
degenerated  in  cases  of  dementia  paralytica,  and  among 
other  changes  he  describes  conditions  very  similar  to  those 
seen  by  us  in  our  case  of  Landry's  paralysis.  He  ascribes 
the  muscular  atrophy,  seen  at  times  in  general  paralysis, 
to  these  cellular  lesions. 

While  cellular  lesions  have  been  noted  in  a  number  of 

cases  of  polyneuritis,  they  do  not  always  occur.    In  at  least 

two  cases  reported  in  the  literature  they  were  absent; 

these  are  the  case  of  SoukhanofP^  and  the  one  of  Dejerine 

^nd  Thomas.'^    In  the  latter  very  notable  lesions  of  the 

cutaneous  and  muscular  nerves  were  observed,  but  the 

Spinal  cells  examined  by  the  method  of  Nissl  were  normal. 

^^jerine  and  Thomas  think  that  it  is  possible  that  the 

^'^e  cells  had  been  altered,  but  had  recovered,  inasmuch 

the  neuritis  had  improved.    They  think  also  that  chro- 

.^^olysis  of  the  cells,  observed  in  intoxications  and  infec- 

^j^^^,  is  interesting  cytologically,  but  has  little  real  im- 

"  ^^^nce,  and  may  not  cause  any  symptoms. 

The  changes  in  the  cells  of  the  anterior  horns  which 
"pallet  and  Lebon  have  found  in  myelitis  produced  in  the 
coxAs  of  rabbits  by  the  injection  of  cultures  of  the  pneumo- 
coccus  and  the  staphylococcus  (Ballet,  1.  c.  434)  consist  in 
destruction  of  the  chromophilic  elements,  and  no  mention 
is  made  of  the  peripheral  zone  of  degeneration  in  the  cell 
seen    in    compression    of    the    abdominal    aorta.       In 
Ballet  and  Lebon's  experiments  the  roots  and  peripheral 
nerves  were  intact,  or  only  slightly  altered.    The  cells  must 
have  been  primarily  altered,  and  the  changes  were  not  un- 
like those  observed  after  section  of  the  nerve  fibres. 

Ballet  and  Dutil,'®  in  a  paper  read  at  the  recent  con- 


"Berger:    Monatsschrift  f.  Psychiatrie  und  Neurologie,  vol.  iii., 
No.  I. 

"Soukhanoff:   Archiv  de  Neurologic,  1896,  vol.  i.,  p.  177. 

"Dejerine  and  Thomas:    Comptes  rendus  de  la  Soci^t^  de  Hi- 
-ologie,  1897. 

"Ballet  and  Dutil:   Monatsschrift  f.  Psychiatrie  und  Neurologie, 
tol.  ii.,  No.  5,  p.  397. 


384  CHAS.  K.  MILLS  AND  WM.  G.  SPILLER. 

gress  in  Moscow,  stated  that  difEerent  poisons  affect  the 
cells  differently,  but  that  the  early  changes  caused  by  com- 
pression of  the  abdominal  aorta  are  much  like  the  sec- 
ondary cellular  changes  caused  by  cutting  a  peripheral 
nerve,  and  that,  while  the  distinction  of  primary  and  sec- 
ondary cellular  changes  is  proper,  under  certain  circum- 
stances, it  is  impossible. 

It  seems  most  probable  that  the  nucleus  is  a  very  im- 
portant part  of  the  cell,  and  that  on  the  normal  condition 
of  this  the  health  of  the  entire  neuron  depends,  but  it  is 
not  unreasonable  to  believe  that  the  axis  cylinder  is,  to 
some  extent,  perhaps  only  a  limited  extent,  independent 
of  the  cell  body.  It  is  very  difficult  to  believe  that  the 
whole  trophic  function  of  an  axis  cylinder,  extending,  for 
example,  from  the  lumbar  region  to  the  foot,  can  reside 
in  a  body  so  small  as  the  nucleus.  It  has  been  thought 
that  the  medullary  sheath  is  for  the  purposes  of  insulation 
and  protection  to  the  neuraxon,  and  that  its  interruption 
at  the  nodes  of  Ranvier  is  for  the  purpose  of  affording  nu- 
tritious fluids  an  entrance  to  the  axis  cylinder.  This  seems 
to  be  a  reasonable  supposition. 

The  swelling  of  a  few  of  the  axis  cylinders  of  the  pos- 
terior roots  in  our  case,  as  shown  by  the  carmine  stain,  is 
interesting.  The  method  of  Marchi  shows  many  black 
dots  in  both  the  anterior  and  the  posterior  roots. 
Changes  in  the  posterior  roots,  after  amputation,  have 
been  observed  by  a  number  of  writers,  and,  therefore,  we 
should  not  be  surprised  to  observe  this  in  polyneuritis. 
Fleming**  has  noticed  very  decided  changes  in  the  cells 
of  the  spinal  ganglia  after  section  of  the  sciatic  nerve,  and 
the  degeneration  of  these  cells  was  noticed  at  a  much 
earlier  period  than  that  of  the  multipolar  cells  in  the  cord, 
beginning  as  early  as  the  fourth  day,  and  certainly  by  the 
seventh.     Redlich,  as  well  as  Darkschewitsch  (cited  by 

■  Fleming:  The  Edinburgh  Medical  Journal,  New  Series,  vol.  t. 


ON  LANDRY'S  PARALYSIS,  385 

Flatau),  found  degeneration  of  the  posterior  roots  after 
amputation,  indicating  that  the  process  had  extended 
even  beyond  the  spinal  ganglia. 

Flatau*^  was  able  to  observe  degeneration  of  the  pos- 
terior roots  after  recent  amputation  in  man  when  he  em- 
ployed the  method  of  Marchi. 

Lugaro**  found  that  the  cells  of  the  spinal  ganglia  be- 
longing to  the  sciatic  nerve  were  much  altered  when  this 
nerve  in  the  dog  was  cut,  but  that  no  distinct  changes  in 
the  ganglia  were  present  when  the  posterior  roots  or  the 
posterior  columns  of  the  cord  were  cut.     Lugaro  con- 
cluded that  the  cells  of  the  spinal  ganglion  are  altered  in 
lesions  of  their  peripheral  branches,  but  not  in  lesions  of 
^lieir  central.    From  these  observations  the  central  branch 
of  the  peripheral  sensory  neuron  would  seem  to  be  a  less 
^'tal  portion  of  the  cell  than  the  peripheral  branch. 

V^an  Gehuchten*^  has  observed  the  "reaction  at  dis- 

^^ce"  in  the  cells  of  the  spinal  ganglion  after  division  of 

-  ^  Peripheral  nerve.    Schaffer,*^  however,  was  unable  to 

^  ^ny  important  change  in  these  cells  in  tabes  when  he 

^*^^\oyed  the  method  of  Nissl,  although  he  found  the  pos- 

\^etAor  roots  greatly  degenerated. 

It  would  seem  from  these  various  statements  that  the 
'Veaction  at  distance"  does  not  occur  in  the  spinal  gan- 
glion cell  when  its  central  process  is  cut  or  diseased,  and 
does  occur  after  lesion  of  the  peripheral  process. 

Nissl  stated  that  most  of  the  cells  in  the  nucleus  of  the 
seventh  nerve  recover  after  division  of  this  nerve.  Mari- 
nesco  found  that  after  he  had  divided  the  hypoglossal 
nerve  in  rabbits  the  nuclei  in  the  cells  of  this  nerve  were 
only  a  little  eccentric  on  the  twenty-fourth  day  after  the 
operation.     It  would  seem,  therefore,  that  the  return  of 


*  Flatau:    Deutsche  med.  Wochenschrift,  No.  18,  1897,  p.  278. 

*  Lugaro  (cited  by  Flatau):    Fortschritte  der  Medicin,  1897,  No. 
15. 

*Van  Gehuchten:  Journal  de  Neurologie  et  d'Hypnologie.  1897, 
p.  27a  \  ^ 

Schaffcr:   Neurologisches  Centralblatt,  No.  i,  i8q8. 


386  CHAS.  K.  MILLS  AND  WM.  G.  SPILLER. 

the  nucleus  to  a  central  position  within  the  cell  is  an  early 
sign  of  cellular  regeneration.  In  some  cells  he  found  the 
reparative  process  perinuclear,  i,  e..  in  the  part  which  is 
first  altered  after  division  of  a  nerve  fibre,  but  this  was 
not  seen  in  all  the  cells.  Marinesco's"  experiments  cannot 
be  used  to  determine  the  condition  of  the  cells  when  peri- 
pheral reunion  of  the  cut  ends  of  the  nerve  fibre  is  pre- 
vented. Van  Gehuchten*"  also  has  studied  the  cellular  re- 
generation with  similar  results  after  experimental  division 
of  the  nerve. 

We  have  the  testimony  of  a  number  of  writers  that 
"reaction  at  distance"  occurs  in  both  sensory  and  motor 
neurons.  In  addition  to  the  quotations  already  made,  we 
may  state  that  Sano**  found  chromatolysis  of  the  cells  of 
the  column  of  Clarke  after  amputation  of  the  lower  limb, 
which  he  explained  as  "reaction  at  distance"  from  injury 
by  meningitis  to  the  nerve  processes  of  these  cells.  He 
also  found  this  reaction  in  the  motor  cells  of  the  cord. 
Barker*''  gives  the  same  explanation  for  the  chromatolysis 
which  he  found  in  cells  of  Clarke's  column  In  two  cases 
of  epidemic  cerebrospinal  meningitis.  The  direct  cere- 
bellar tract  was  injured.  The  changes  in  the  motor  cells 
he  explains  as  the  result  of  compression  of  their  axis  cylin- 
ders by  the  meningeal  inflammation. 

This,  however,  is  not  the  only  explanation  which  could 
be  offered  for  the  chromatolysis  in  the  cells  of  Clarke's 
column  in  such  cases.  Marinesco*'  has  found  such  changes 
in  these  cells  in  general  paralysis  and  in  tabes,  diseases  in 
which  degeneration  of  the  posterior  roots  is  common,  and 
he  regarded  these  as  secondary,  and  like  those  seen  in  poly- 


**Marinesco:    Comptes  rendus  de  la  Soci^te  de  Biotogie,  i8g6. 
p.  930. 

"Van  Gehuchten:   Journal  de  Neurologie  et  d'Hypnologie,  i8g7r 
p.  279. 

"Sano:  Journal  de  Neurologie  et  d'Hypnologie,  1897. 

"Barker:    Brit.  Med.  Jour.  1897,  vol.  ii.,  p.  1,839. 
Revue  Neurologique,  1896,  p.  633. 


ON  LANDRY'S  PARALYSIS.  387 

neuritis.  Van  Gehuchten*®  also  has  found  changes  in  the 
acoustic  nucleus  of  the  oblongata  after  division  of  the 
eighth  nerve,  i.  e.,  in  the  cell  body  of  the  second  neuron 
after  injury  of  the  peripheral  neuron.  The  chromatolysis 
in  the  cells  of  the  column  of  Clarke  may,  therefore,  be  the 
result  of  injury  of  posterior  root  fibres. 

Barker^^  acknowledges  the  possibility  of  the  correct- 
ness of  this  explanation.  He  states  that  in  his  cases  of 
epidemic  cerebrospinal  meningitis  he  found  two  distinct 
types  of  cellular  change.  In  the  first  the  disintegration 
of  the  Nissl  bodies  was  especially  marked  in  the  dendrites 
and  along  the  periphery  of  the  cell,  but  th^se  changes  were 
slight,  owing,  he  thinks,  to  the  fact  that  cerebrospinal 
meningitis  is  an  affection  not  associated  with  a  severe  tox- 
ccmia.  In  the  second  type  the  changes  in  the  chromo- 
philic  elements  were  those  described  as  "reaction  at  dis- 
tance," i.  e.,  they  were  chiefly  in  the  centre  of  the  cell  and 
the  nucleus  was  displaced.  The  first  type  Barker  believes 
is  the  result  of  the  direct  action  of  the  poison  upon  the 
cell  body,  and  the  second  is  due  to  injury  of  the  axis  cylin- 
der. 

He  does  not  believe  that  the  involvement  of  the  pos- 
terior roots  in  his  cases  was  sufficient  to  cut  off  enough 
of  the  sensory  impulses  to  account  for  the  changes  found 
in  almost  every  one  of  the  cells  of  Clarke's  column.  This 
is  a  forcible  argument,  but  we  cannot  forget  the  experi- 
ments of  Babinski  and  Charrin,  referred  to  above,  which 
have  shown  that  there  may  be  a  total  loss  of  function  of  a 
nerve  fibre  without  detectable  lesions. 

It  is  not  extraordinary,  therefore,  that  degeneration 
of  the  posterior  roots  should  occur  from  polyneuritis.  The 
involvement  of  the  posterior  roots  and  posterior  columns 
in  the  disease  has  been  noted  by  a  number  of  observers,  and 


•Van  Gehuchten:    Centralblatt  f.  Nervenheilkunde  und  Psychia- 
tric, Beiheft,  October,  1897,  p.  15. 

••Barker:   The  Johns  Hopkins  Hospital  Bulletin,  February,  1898, 
p.  33. 


388  CHAS.  K.  MILLS  AND  WM.  G.  SPILLER. 

Redlich''*  mentions  such  cases  in  his  critical  digest  on  dis- 
eases of  the  posterior  columns  of  the  cord.  Pal  and  Red- 
lich  do  not  believe  that  the  degeneration  of  the  posterior 
roots  is  secondary  to  the  neuritis.  As  Redlich  expresses  it, 
it  is  presumable  that  the  poison  acts  on  the  entire  sensory 
neuron  at  the  same  time.  The  possibility  of  this  must,  of 
course,  be  considered,  but  the  observation  of  Flatau 
quoted  above  would  indicate  that  the  involvement  of  the 
posterior  roots  in  polyneuritis  may  be  secondary;  for  no 
other  interpretation  could  well  be  given  of  his  findings  in 
these  roots  after  amputation. 

We  do  not  always  find  the  relations  existing  between 
disease  of  the  motor  cells,  of  the  roots  and  of  the  peripheral 
nerves  that  we  should  expect.  Thus,  Gombault  noted  that 
the  anterior  roots  were  normal  in  a  case  of  amyotrophic 
lateral  sclerosis,  although  many  of  the  motor  cells  had 
disappeared.  Dreschfeld  found  marked  lesions  in  the  an- 
terior cells  of  the  cord  while  the  intramuscular  fibres  were 
normal,  and  the  ner\'es  only  slightly  altered.  Oppenheim 
reported  similar  conditions.  V.  Monakow,  Zunker,  CEller, 
Kronthal  and  Darkschewitsch  (cited  by  Babinski'^)  have 
noted  this  want  of  correspondence  in  the  intensity  of  the 
cellular  changes  and  those  of  the  nerves  and  roots,  and 
recently  Luce^*  has  reported  a  case  in  which  the  cells  of 
the  anterior  horns  were  much  degenerated,  and  the  an- 
terior roots  were  only  slightly  affected.  These  cases  would 
seem  to  indicate  that  the  nerves  enjoy  an  existence  inde- 
pendent, to  a  certain  extent,  of  the  cell  body. 

Barbacci  and  Campacci"'  foimd  that  the  nerve  cells  in 
the  rabbit  undergo  postmortem  changes  They  noticed 
that  the  chromophilic  elements  were  paler  and  more  indis- 
tinct than  normal,  and  that  they  were  changed  into  gran- 

**  Redlich:  Centratblatt  !.  allgemeine  Pathologic  und  patholo- 
gische  Anatomie,  1896. 

■Eabinski:    Traiti  de  Medecine,  vol.  vi.,  p.  650. 

"Luce;    Deutsche  Zeitschrift  i.  Nerve nheilkunde,  vol.  xii..  No.  I, 

"Barbacci  and  Campacci:  Abstract  in  Neurol Ogisches  Central- 
blatt,  1897.  P-  i>043' 


ON  LANDRY'S  PARALYSIS.  389 

iiles,  especially  about  the  nucleus,  while  the  periphery  of 
the  cell  was  intact.    In  later  stages  vacuoles  were  found. 

Changes  were  seen  also  in  the  nucleus  and  nucleolus. 

Such  findings  must,  of  course,  make  us  cautious  in  ac- 
cepting all  the  cellular  changes  which  are  described  as 
pathological,  but  they  can  hardly  destroy  the  value  of  the 
work  of  many  investigators.  We,  as  others  have  done, 
have  examined  the  spinal  cord  removed  from  persons  some 
hours  after  death,  who  had  not  suffered  from  spinal  or  peri- 
pheral nerve  lesions,  and  have  not  found  any  such  changes 
as  are  present  in  our  case  of  Landry's  paralysis. 

Held*^®  has  shown  that  the  chromophilic  elements  do 
not  exist  in  the  living  cell;  that  they  are  precipitated  by 
the  addition  of  fluids,  and  that  they  vary  in  form  with  the 
fluid  used.  He  has  likewise  demonstrated  that  vacuoles 
in  the  protoplasm  are  postmortem  changes,  and  may  be 
produced  by  the  addition  of  water. 

These  experiments  throw  light  on  the  changes  which 
occur  within  the  cell  under  the  influence  of  poisons.  If 
the  composition  of  the  cellular  protoplasm  is  chemically 
altered  by  toxjc  substances,  the  postmortem  precipitation 
must  be  different  from  that  in  normal  cells;  or,  if  the  func- 
tion of  the  cell  is  destroyed  by  the  cutting  of  its  axis  cylin- 
der, the  composition  of  the  cellular  protoplasm  is  most 
probably  changed,  and  the  precipitation  must  also  be  dif- 
ferent. It  matters  little  whether  or  not  the  Nissl  elements 
are  postmortem  formations,  as  they  always  present  the 
same  appearance  in  normal  cells;  they  afford,  when  altered, 
an  index  of  the  diseased  condition  of  the  cell. 

Some  quite  recent  experiments  by  Goldscheider  and 
Flatau*^®  have  shown  that  great  alteration  of  the  chromo- 
philic elements  may  exist  without  disturbance  of  function, 
and  in  a  case  of  pneumonia  Dejerine  found  the  spinal  cells 
swollen  and  without  chromophilic  elements,  and  the  cellu- 


"Held:    Archiv  f.  Anatomic  und  Entwickelungsgeschichte,  1895. 
p.  396. 

•*  Goldscheider  and  Flatau:   Fortschrittc  der  Medicin,  No.  7,  1897. 


390  CHAS.  K.  MILLS  AND  WM.  G.  SPILLER. 

lar  processes  altered.  The  patient  had  had  no  motor  or 
sensory  symptoms.  This  case  Dejerine"^  brings  forward 
in  support  of  his  views  regarding  the  unimportance  of 
chromatolysis. 

Ballet  and  Dutil"*  likewise  have  stated  that  the  paraly- 
sis caused  by  compression  of  the  abdominal  aorta  may  dis- 
appear and  motion  be  perfectly  normal  at  a  time  when  the 
spinal  cells  are  still  greatly  altered. 

Our  conclusions,  therefore,  from  a  study  of  our  case 
and  of  the  literature,  are: 

1.  That  there  is  a  form  of  ascending,  flaccid  paralysis, 
with  little  disturbance  of  sensation,  with  normal  electrical 
reactions,  and  without  involvement  of  the  sphincters,  and 
that  this  is  of  rapid  course,  usually  terminating  in  death. 

2.  Other  cases  differ  from  this  type  byone  or  more 
atypical  signs,  and  transitional  forms  occur  which  make 
the  diagnosis  between  Landry's  paralysis,  polyneuritis  and 
myelitis  difficult. 

3.  It  is  possible  that  in  some  cases  no  lesions  exist; 
but  many  of  the  reports  of  such  cases  date  from  a  time 
when  the  methods  of  examination  were  very  imperfect; 
or  it  may  be  that  in  these  cases  the  lesions  are  in  an  early 
stage  of  development,  the  patient  succumbing  to  toxaemia 
before  demonstrable  changes  in  the  nervous  system  take 
place. 

4.  That  Landry's  paralysis  may  be  due  to  myelitis 
alone. 

5.  In  Landry's  paralysis  polyneuritis  may  be  present, 
but  changes  in  the  cell  bodies  of  the  anterior  horns  will 
also  usually  be  found  in  such  cases  by  Nissl's  stain,  and  it 
is  sometimes  difficult  to  say  whether  the  cellular  changes 
are  primary  or  secondary. 

6.  It  is  probable,  in  some  cases  at  least,  that  the  entire 
peripheral  motor  neuron  is  attacked  at  the  same  time  by 
the  poison  of  the  disease. 

"  Dejerine:  Comples  rendus  de  la  Societ*  de  Biologic,  1897 
"Ballet  and  Dutil:    Monatsschrift  F.  Psycbiatrie  and  Neurologic, 


/(% 


ON  LANDRY'S  PARALYSIS. 


LEGENDS. 


391 


Figure  i :    Normal  cell  from  the  hypoglossal  nucleus. 

Figure  2:    Normal  cell  from  Clarke's  column. 

Figure  3 :    Degenerated  cell  fixwn  the  hypoglossal  nucleus. 

Figure  4:    Round-cell  infiltration  in  the  oblongata. 

Figures  5  and  6:  Cells  from  the  anterior  horns  of  the 
spinal  cord,  showing  central  chromatolysis. 

Figure  7:  Nerve  fibres  from  the  external  popliteal  nerve, 
showing  tumefaction  and  disintegration  of  the  myelin. 


i: 


132,  Tabes  und  mui^tiple  Ski^rose  in  ihren  Beziehungen  zum 
Trauma.  (Tabes  and  Miiltiple  Sclerosis  in  their  Relation  to 
Trauma).  E.  Mendel  (Deutsche  med.  Wochenschr.,  p.  97,  1897). 
Mendel  comes  to  the  conclusion,  from  his  own  experience,  that 
trauma  has  not  been  clearly  shown  to  be  a  cause  of  tabes.  It  often 
does  cause  a  rapid  development  of  pre-existing  tabes,  and  in  some 
cases  tabetic  patients,  who  until  the  occurrence  of  the  trauma  had  been 
able  to  work,  have  become  unable  to  earn  their  support  after  an  acci- 
dent. It  is  probable  that  the  conditions  connected  with  the  trauma 
affect  the  disease,  especially  the  long  rest  in  bed.  It  is  a  well-known 
fact  that  tabetic  patients  have  very  imperfect  use  of  their  legs  after  a 
long  confinement  to  bed.  Hygienic  conditions  after  such  accidents 
also  play  a  part  in  the  development  of  tabetic  symptoms.  There  is  an 
important  warning  in  this  statement  against  prolonged  rest  cure  with 
confinement  to  bed  for  tabetic  patients. 

There  are  certain  cases  of  disseminated  sclerosis  which  seem  to 
result  from  trauma.  Mendel  reports  four  which  he  ascribes  to  this 
cause.  It  is  hard  to  understand  how  trauma,  which  causes  concussion 
of  the  entire  central  nervous  system,  can  affect  the  posterior  roots  or 
posterior  columns  alone,  as  it  must  do  to  produce  tabes.  In  a  certain 
number  of  cases  of  multiple  sclerosis,  disturbance  of  the  vascular 
system  seems  to  have  been  the  commencement  of  the  disease,  and  it  is 
not  difficult  to  believe  that  trauma  may  cause  changes  in  the  blood 
pressure  and  other  disturbances  of  circulation.  The  more  imperfect 
vascular  supply  of  the  white  matter  may  account  for  the  greater  fre- 
quency of  the  sclerotic  patches  in  this  part,  as  the  conditions  for  re- 
covery after  a  lesion  are  less  favorable.  There  must,  however,  be  a 
predisposition,  as  in  many  cases  disseminated  sclerosis  does  not  develop 
after  trauma.  This  predisposition  probably  consists  of  a  less  capability 
of  resistance  of  the  tissues  to  hyperaemia,  and  this  predisposition  may 
be  congenital  or  acquired,  as  from  some  infectious  disease. 

Spiller. 


I 


'  I.^i.Il; 


CASES  OF  TRIGEMINAL  SPASM;  RESECTION- 
PROBABLE  PRESENCE  OF  SENSORY  FIBRES 
IN  THE  SEVENTH  NERVE. 

Bv  JOHN    K.  MITCHELL,  M.  D., 

Philadelphia.  " 

It  will  not  be  necessary  to  state  elaborately  the  history 
of  the  patients,  a  portion  of  whose  symptoms  furnish  the 
subject  of  this  brief  paper.  It  is  the  condition  of  sensation 
following  the  operations  for  reHef,  which  is  interesting. 

Briefly,  both  patients  were  of  the  laboring  class,  both 
Irish-bom,  both  about  sixty  years  of  age.  The  first,  a 
male,  H,  M,,  had  a  typical  example  of  tic  douloureux  af- 
fecting the  supra-orbital  distribution  on  the  right  side. 
The  usual  history  of  persecution  by  tooth-drawing  was 
given.  Medical  measures,  especially  galvanization,  relieved 
him  temporarily  when  he  first  applied  at  the  Infirmary 
for  Nervous  Diseases.  The  tic  returned  in  a  few  weeks  as 
severe  as  ever,  and  operation  was  recommended,  and  por- 
tions of  the  supraorbital  and  supratrochlear  ner\'es  were 
removed  by  Dr.  W.  W.  Keen,  November  nth,  1897. 
Some  slight  difficulty  was  experienced  in  recognizing  the 
former  nerve,  on  account  of  the  haemorrhage,  and  to 
make  sure  the  supposed  trunk  was  carefully  followed 
into  the  orbit  and  resected  somewhat  further  back  than 
usual.  The  portion  removed  was  by  inadvertence  put  in 
alcohol,  which  rendered  it  impossible  to  make  any  satis- 
factory study  of  its  condition,  but  there  was  no  question 
of  its  identity.  The  patient  had  at  once  complete  relief 
from  pain,  except  for  two  or  three  slight  paroxysms  dur- 
ing the  fortnight  after.  The  dressings  were  removed  on 
the  third  day  after  operation,  and  a  hasty  examination  of 
the  condition  made.     Some  degree  of  anaesthesia  was 


I 


CASES  OF  TRIGEMINAL  SPASM. 


393 


present  for  touch  and  pain  in  the  area  usually  supplied  by 

the  ophthalmic  division  of  the  superior  maxillary  branch. 

It  was  noticed  then  that  the  loss  of  sensation  was  less 

complete  than  might  have  been  expected,  and  seemed  to 

be  absolute  only  in  an  oval  area  at  the  outer  canthus  of 

the  eyelids  and  on  the  upper,  lid.    Later,  on  the  sixth  day, 

opportunity  was  had  for  a  more  careful  study.    An  oval 

space  of  about  the  area  of  a  silver  dollar  on  the  temple,  at 

the  outer  canthus,  remained  obtuse  to  touch,  but  pressure 

or  decided  pain  was  perceivable  in  this  region.    Complete 

anaesthesia  of  the  upper  lid  persisted.     The  patient  was 

examined  again  before  his  discharge  from  the  hospital, 

"early  three  weeks  after  operation,  and  no  material  change 

from    tlie  described  condition  was  found,  except  that  the 

area  of  anaesthesia  was  a  trifle  more  sensitive. 

The  second  patient,  A.  K.,  a  married  woman,  was  ad- 
mitti^cl  from  Dr.  Weir  Mitchell's  out-service,  suffering 
with.  p)ain  and  spasm  throughout  the  supraorbital  dis- 
^"'^''^tiion,  and  to  a  less  degree  in  the  superior  maxillary 
Qivisi<^n^  especially  in  the  palpebral  and  nasal  branches. 

-C^r".  Keen  operated  on  this  patient,  March  3d,  1898, 
resecting  about  half  an  inch  of  the  supraorbital  nerve, 
draAivirjg  the  infraorbital  out  of  its  canal,  and  cutting  it  off 
also.  jjjg    former    divided    rather    further    from    the 

surf^^^  than  usual,  and  at  the  notch  presented  several 
srnB.ll     trunks.     The  face  swelled  on  the  right  side  after 
^  c:>peration,  but  otherwise  the  patient  did  well. 

T^he  excised  portions  were  teased  and  placed  in  osmic 
acid  ^t  once,  and  the  interesting  changes  found  will  be 
^^'^rtiented  on  later. 

^^11  investigating  Mrs.  K.'s  face  four  days  after  the 
^P^r^tion,  which  was  done  minutely,  on  account  of  the 
™^ings  in  the  previous  case,  we  were  astonished  to  dis- 
cov^j.  an  even  less  degree  of  loss  of  touch,  pain  and  heat 
setis^  than  was  present  in  M.'s  examination.  Indeed,  it 
^^Uld  scarcely  be  said  that  there  was  more  than  slight 
^^lay  or  impairment  of  perception  anywhere  in  the  supra- 


394 


JOHN  K.  MITCHELL. 


orbital,  nasal,  palpebral  or  labial  branches.  In  the  line 
of  the  incision  made  to  reach  the  infraorbital  foramen 
there  was  poor  touch  perception,  but  by  the  ninth  day 
after  operation,  when  Mrs.  K.  was  discharged,  there  was 
neither  slowness  nor  impairment  of  sensation  for  any  form 
of  stimulation.  The  touch  of  the  finest  filament  of  thread 
was  instantly  felt,  and  correctly  located,  everywhere  on 
the  cheek,  temple,  nose,  eyelids,  and  upper  lip.  On  April 
20th,  the  examinations  were  carefully  repeated  on  both 
patients^— five  months  after  M.'s  and  seven  weeks  after 
Mrs.  K.'s  operation.  In  the  former,  an  area  of  about  li 
by  I  inch  on  the  top  of  the  skull,  a  little  anterior  to  the 
vertex  and  slightly  to  the  right  of  the  middle  line,  was 
found  to  be  slightly  obtuse  to  pain.  The  patient  volun- 
tarily stated  that  the  upper  part  of  the  right  face  felt 
slightly  numb.  No  impairment  of  sensation  could  be  dis- 
covered, even  in  the  line  of  the  cicatrix.  Of  Mrs.  K.  the 
same  statement  could  be  made;  her  perception  of  touch, 
pain  and  heat  was  rapid  and  perfect.  There  was  absolutely 
no  lessening  of  sensibility  in  any  form  in  either  person. 

Before  discussing  possible  explanations  of  these  curious 
results,  it  may  be  well  to  say  that,  as  will  be  seen,  there  can 
be  no  doubt  that  the  nerves  were  removed,  and  the  per- 
fection of  sensation  cannot  be  attributed  to  incomplete 
removal  or  mistake  in  operation.  Perfect  relief  followed 
the  surgical  intervention,  and,  moreover,  the  nerve  tissues 
were  microscopically  identified.  But,  even  if  it  were 
possible  to  question  the  entire  destruction  of  the  involved 
nerves,  it  would  still  be  curious  that  the  restoration  of 
sensation  should  be  so  complete,  and  occur  so  soon.  It  is 
impossible  to  contend  that  regeneration  of  the  cut  nerves 
had  taken  place,  for  not  only  was  the  time  too  short,  but 
the  operations  consisted  not  merely  in  section,  but  in  the 
removal  of  considerable  lengths  of  the  nerve  trunks. 

It  is  certain  that  in  most  cases  of  neurectomy  for  tic 
douloureux  anaesthesia  in  the  distribution  of  the  resected 
nerve  follows,  but  the  present  are  not  the  only  instances 


CASES  OF  TRIGEMINAL  SPASM.  395 

n  which  an  exception  to  this  rule  has  been  noted  by  the 
jresent  writer.  In  a  case'  reported  with  Dr.  W.  W.  Keen, 
n  which  the  Gasserian  ganglion  was  removed  as  the  last 
jf  fourteen  operations,  or  attempts  at  operation,  for  per- 
iistent  tic,  very  curious  conditions  of  sensation  were  pres- 
;nt.  Before  the  final  operation  sensation  in  the  face 
seemed  in  an  anomalous  state,  but,  as  the  patient  had  had 
the  infraorbital  nerve  cut  or  removed  at  three  different 
limes,  the  third  division  of  the  fifth  resected,  the  upper 
law  t>odily  removed,  and  the  inferior  dental  canal  laid 
Dpen  and  the  nerve  removed,  the  face  was  a  tangle  of 
icars,  which  complicated  the  examination  of  sense  per- 
:eption  very  greatly.  The  unfortunate  man  was  suffering 
ihree  or  four  paroxysms  of  pain  daily.  The  whole  upper 
ight  face  was  extremely  sensitive;  to  touch  the  eye,  to 
:witch  the  eyelid,  to  open  the  mouth  widely,  would  bring 
in  a  furious  attack  of  pain  in  the  lower  jaw.  He  was  tak- 
ng  morphia  steadily,  so  that  various  circumstances  united 
to  make  it  difficult  to  judge  exactly  the  distribution  or 
ilteration  of  sensation;  but,  so  far  as  could  be  told,  the 
snly  part  of  the  face  totally  anaesthetic  to  touch  was  on 
the  right  cheek,  extending  from  near  the  middle  line  on 
the  right  of  the  nose  down  to,  and  including,  the  ala  nasi 
md  out  upon  the  cheek  about  one  and  one-haJf  inches, 
vaguely  covering  the  territory  of  the  infraorbital  nerve. 

The  rest  of  the  face  had  diminished  sensation  to  touch, 
but  thermic  sensation  was  perfect.  After  the  removal  of 
the  ganglion  the  patient's  mental  condition  was  such  for 
nine  or  ten  weeks  that  no  study  of  the  sensation  could  be 
made,  but,  when  it  became  possible,  there  was  no  absolute 
anesthesia  to  be  found,  except  between  the  margins  of 
the  wound.  Touch-sense  was  everywhere  preserved  in 
some  degree,  pain-sense  was  but  slightly  less  than  before 
the  operation.  He  had  no  spontaneous  pain  in  any  part 
after  the  operation. 


2g6  /0//Af  K.  MITCHELL. 

In  the  regions  supplied  by  the  supraorbital  nerve  sen- 
sibility to  touch  was  diminished  as  far  as  the  vertex  up- 
ward, and  forward  to  the  median  line  of  the  face  from  the 
lobe  of  the  ear  and  the  lower  border  of  the  inferior  maxilla. 
The  mucous  membrane  of  the  lips  and  cheek  on  the 
right  side,  and  the  right  side  of  *he  tongue  were  also  par- 
tially anaesthetic.  On  the  right  side  the  sense  of  taste  was 
entirely  lost.  The  ocular  and  palpebral  conjunctivae  were 
insensible  to  touch,  but  in  the  right  infraorbital  region 
immediately  about  the  scar  of  the  operation  upon  the  infra- 
orbital nerve,  there  was  a  small  area  which  was  hyperaes- 
thetic. 

When  seen  more  than  two  months  after  the  operation, 
it  was  found  that  an  area  as  large  as  a  half-dollar,  with 
its  centre  upon  the  outer  third  of  the  right  eyebrow,  cov- 
ered a  space  which  was  hyperaesthetic  to  touch,  though 
not  to  pain,  and  this  although  he  was  unable  to  move  vol- 
untarily the  muscles  above  the  brow  on  this  side.  Had 
this  patient  continued  to  have  pain  after  the  ganglion 
operation,  it  would  have  been  less  astonishing  than  to  find 
sensation  to  peripheral  stimuli  remaining.  It  the 
ganglion  itself  be  diseased,  whether  as  a  cause 
or  as  a  consequence  of  the  peripheral  nerve  trouble,  the 
removal  of  the  ganglion  will  not  affect  possible  degenera- 
tive changes  reaching  beyond  it,  and  affecting  the  tri- 
geminal sensory  tract  in  the  thalamus,  or  in  its  cortical 
terminus.  Disturbances  really  due  to  these  deep  brain 
changes  might  be  referred  to  the  surface  still,  in  a  way 
aptly  comparable  to  the  reference  of  pain  to  the  extremi- 
ties of  amputated  limbs.  But,  for  peripheral  touch  to  be 
correctly  perceived  and  locahzed  after  destruction  of  the 
ganglion,  or  after  total  ablation  of  the  nerves  leading  to 
it  from  the  stimulated  part,  makes  some  other  explanation 
than  this  necessary. 

Before  discussing  possible  explanations,  something 
must  be  said  as  to  the  nerve  supply  of  the  parts  involved. 
The  generally  accepted  cutaneous  distribution  of  the  sen- 


CASES  OF  TRIGEMINAL  SPASM. 


397 


sory  portion  of  the  fifth  gives  to  the  supraorbital  branch 
the  supply  of  the  forehead,  anterior  part  of  the  temple  and 
crown  of  the  head,  back  to  the  region  supplied  by  the  oc- 
cipital branches  of  the  second  cervical.  The  eyelids,  an- 
terior cheek,  nose  and  upper  lip  are  furnished  from  the 
second  division,  the  temples  and  the  rest  of  the  face 
proper,  except  the  under  part  of  the  chin  and  posterior 
edges  of  the  lower  jaw,  being  supplied  by  the  third  di- 
vision. 

It  may  at  once  be  said  that  maps  of  nerve  distribution 
founded  largely  upon  the  somewhat  coarse  methods  of 
the  dissection-table  are  unreliable.  Variations  are  so  fre- 
quent they  can  scarcely  be  called  anomalies.  Undescribed 
anastomoses  are  often  found  in  operating;  whole  areas 
are  observed  to  be  furnished  with  sensory  supplies  in  a 
manner  different  from  the  text-book  descriptions.  The 
present  writer  has  before  commented  upon  the  frequency, 
one  might  almost  say  the  regularity,  of  unusual  distribu- 
tion in  the  nerves  of  the  hand  and  forearm,  and  the  surgi- 
cal and  diagnostic  difficulties  arising  therefrom.  But,  ad- 
mitting every  probability  of  error  due  to  such  differences, 
no  theory  founded  on  this  will  suffice  to  account  for  such 
preservation  of  tactile  sensibility  as  was  observed  in  these 
cases.  One  anomaly  was  very  likely  present  in  the  first 
case.  The  area  described  as  anaesthetic  upon  the  first  ex- 
amination, namely,  a  region  of  oval  shape  at  the  outer 
canthus,  and  covering  a  small  part  of  the  malar  promi- 
nence, the  superciliary  ridge  and  the  temple,  is  usually 
supplied  by  the  lachrymal  branch  of  the  ophthalmic  di- 
vision. The  lachrymal  leaves  the  main  trunk  in  the  cav- 
ernous sinus,  and  should,  therefore,  not  have  been  reached 
by  the  operation,  unless  by  some  reflex  effect  upon  its 
conducting  power  caused  by  the  "shock"  to  the  ophthal- 
mic trunk.  It  is  curious  that  the  same,  or  nearly  the 
same,  area  was  found  hyperaesthetic  in  the  third  patient 
after  the  ganglion  removal. 

It  may  be  suggested  that  the  nerves  cross  the  middle 


398  JOHN  K.  MITCHELL. 

line  in  their  final  sensory  distribution,  and  that  thus  each 
nerve  supplies  both  sides  of  the  face.  This  .is  mere  sup- 
position; there  is  no  positive  evidence  of  it.  If  this  were 
at  all  a  constant  fact,  then,  after  resection,  some  loss  of 
sensation  should  be  occasionally  observed  in  correspond- 
ing territory  on  the  opposite  side  of  the  face;  but  neither 
in  the  present  cases,  nor  in  any  others,  has  this  Been  ob- 
ser\'ed,  so  far  as  is  known  to  the  writer.  If  both  sides 
are  supplied  by  each  nerve  so  thoroughly  as  such  perfect 
sense-perception  as  these  cases  have  would  imply,  why 
should  there  be  any  aniesthesia  after  operation  at  all? 
Then,  too,  in  these  instances  at  least,  the  survival  of  sen- 
sation is  too  complete.  In  the  first  there  was  no  impair- 
ment a  few  days  after  operation;  in  the  second,  very  little. 

What  secondary  or  subsidiary  sensory  supply  could 
reach  these  parts?  must,  then,  be  the  question.  The  only 
nerve,  beside  the  fifth,  in  any  way  supplying  the  surfaces 
of  the  anterior  portion  of  the  head,  other  than  the  parts 
usually  deriving  their  nerve  supplies  from  the  upper  cervi- 
cal nerves,  is  the  facial.  The  facial  has  been  suspected,  so 
to  speak,  of  containing  sensory  fibres.  It  is  not  necessary 
to  refer  to  the  loss  of  taste  occasionally  found  in  cases  of 
facial  paralysis,  as  tending  to  show  the  presence  of  sensory 
fibres,  because  this  may  be  directly  accounted  for  by  re- 
calling the  close  anatomical  relations  of  the  facial  and  the 
chorda  tympani,  which  might  well  make  them  both  sub- 
jecttoa  concomitant  lesion, not  to  mention  the  near  neigh- 
borhood of  the  nuclei  of  the  glossopharyngeal  and  the 
nerve  of  Wrisberg.  There  are  other  evidences  than  these, 
both  pathologic  and  clinical.  To  quote  some  of  them: 
Turner'  says:  "Certain  minor  connections  are  said  to  exist 
between  the  facial  nucleus  and  the  corpus  trapezoides  and 
the  sensory  trigeminal  root." 

Ramon  y  Cajal'  believes  "that  the  facial  nucleus  re- 

*  Edinburgh  Hosp.  Rep.,  vol.  iv.,  i8()6. 

'Quoted  from  Mills'  "The  Nervous  System  and  its  Diseaset," 


CASES  OF  TRIGEMINAL  SPASM.  399 

ceives  axis  cylinders  from  the  cells  of  the  substantia  gela- 
ttnosa,  which  substance  accompanies  the  descending  spinal 
root  of  the  fifth,  connection  thus  being  made  between  the 
fifth  and  seventh  nerves." 

The  facial  nucleus,  in  all  probability,  will  be  proved  to 
have  connections  with  the  thalamus;  at  present,  although 
this  has  not  been  directly  proven  anatomically,  both  clini- 
cal and  physiological  facts  point  that  way.  Lesions  of  the 
thalamus  and  of  the  posterior  part  of  the  internal  capsule 
have  been  found,  both  by  experimental  and  clinical  ob- 
servation, to  result  in  anaesthesia  of  one  side  of  the  body 
and  face;  thus  here  also  the  fifth  and  seventh  may  possibly 
be  in  close  relation. 

As  a  small  piece  of  negative  evidence,  might  be  added 
the  fact  that  the  course  of  the  central  neurons  of  the 
upper  portion  of  the  seventh  has  not  been  definitely  traced, 
and  may  be  said  to  be  as  yet  unknown.  Frankl-Hochwart 
examined,  in  Nothnagel's  clinic,  some  twenty  cases  of 
paralysis  of  the  facial;  in  eight  of  these  he  found  sensory 
or  vasomotor  disturbances.  Sensation  was  very  little  al- 
tered in  any  of  them,  and  the  disturbance  appears,  from 
the  brief  reports  of  his  observations,  to  have  consisted 
merely  in  the  slighter  grades  of  anaesthesia.  He  believes 
that  even  these  slight  changes  give  ground  for  the  as- 
sumption that  sensory  fibres  exist  in  the  facial  nerve  tn 
man,  as  it  is  well  known  they  do  in  animals. 

The  cases  here  reported  strengthen,  from  clinical  ob- 
servation, the  probability  of  this  view.  No  doubt  other 
observations  will  be  made  confirming  these.  What  would 
be  of  most  importance  would  be  to  discover  peripheral 
sensory  changes  of  decided  or  constant  character  in  cases 
of  facial  paralysis.  Could  a  series  sufficiently  large  of  cases 
of  total  paralysis  of  the  seventh  be  observed  without  any 
of  them  presenting  any  sensory  changes,  such  a  mass  of 
negative  evidence  might  be  held  to  outweigh  the  small 
positive  results;  but  till  then  the  probable  explanation  of 
such  conditions  as  these  here  reported  may  be  held  to  lie 


400 


lOHN  K.  MITCHELL. 


in  the  presence  of  sensory  fibres  in  the  seventh  nerve. 

For  the  sake  of  the  interest,  although  somewhat  be- 
side the  chief  subject  of  this  paper.  Dr.  William  G.  Spiller's 
comments  on  the  pathological  findings  in  the  nerves  re- 
moved from  the  second  case  are  added,  by  his  courtesy: 

Many,  possibly  most,  of  the  nerve  fibres  of  the  infra- 
orbital nerve,  when  separated  from  one  another  by  teas- 
ing and  stained  by  a  one  per  cent,  solution  of  osmic  acid, 
are  found  to  contain  numerous  black  balls,  approximately 
of  the  same  size.  These  are  nearly  equidistant  from  one 
another,  and  are  located  along  the  edges  of  the  fibres,  leav- 
ing, as  a  rule,  the  centres  free  from  such  accumulations. 
When  the  focus  of  the  lens  is  changed,  so  as  to  bring  other 
portions  of  the  fibres  into  view,  black  balls  are  apparently 
found  within  the  centres,  but  these  are  probably  along  the 
superficial  and  deep  portions  of  the  fibres.  The  medullary 
sheaths  are  thus  broken  into  numerous  masses  of  nearly 
equal  size,  occupying  the  normal  position  of  the  myelin 
sheaths.  It  is  exceptional  to  find  masses  of  degenerated 
myelin  of  a  size  so  large  as  is  frequently  seen  in  degenerat- 
ing fibres.  Similar  lesions  are  found  in  the  supraorbital 
branch  of  the  fifth  nerve.  Inasmuch  as  these  nerves  were 
taken  from  the  living  subject,  and  placed  immediately 
afterward  in  osmic  acid,  these  myelin  balls  cannot  be  re- 
garded as  artifacts  due  to  surgical  interference.  Such  in- 
terference causes  a  breaking  of  the  fibres  into  irregular 
masses,  but  probably  not  the  fragmentation  of  the  myelin 
into  numerous  balls. 

Sections  cut  with  the  microtome  and  stained  with  car- 
mine and  Delafield's  haematoxytin  show  more  or  less 
round  cell  infiltration  about  the  small  vessels.  The  coats 
of  the  smallest  vessels  are  not  notably  thickened,  but  one 
vessel  of  larger  size,  found  in  some  of  the  sections,  pre- 
sents a  thick  media  and  a  somewhat  proliferated  intima. 
In  some  of  the  nerve  fibres  pale  purple  bodies  are  found, 
which  resemble  the  amyloid  bodies,  and  lend  much  sup- 
port to  the  view  that  the  latter  are  degenerated  nerve 


Fig.  I.    Thickened  vessel  from  the  infraorbital  nerve. 

Fig.  II.     Infraorbital  nerve  stained  by  the  method  of  Weigert.     Ba 

myelin  are  seen  as  cliains  of  beads  about  the  axis  cylinders. 

Fig.  III.     The  medullary  sheaths  are  broken  into  numerous  balls. 


HYPERTROPHIC  NODULAR  GLIOSIS. 
By  JOSEPH  SAILER.  M.D„ 


Hypertrophic  nodular  gliosis  o!  the  brain  does  not  ap- 
pear to  have  escaped  entirely  the  notice  of  the  older  writ- 
ers, although  their  descriptions  of,  or,  rather,  their  al- 
lusions to,  this  condition  are  so  vague  and  unsatisfactory 
that  it  is  impossible  to  be  altogether  sure  of  this  fact. 
Boumeville  was  the  first  to  give  a  clear  description  of  the 
disease,  and  his  earliest  case  was  published  as  recently  as 
1880.  A  number  of  cases  have  since  been  published,  but 
only  a  few  have  been  carefully  studied,  and  it  appeared 
desirable,  therefore,  to  place  the  following  example  upon 
record: 

J.  H.,  white,  male,  was  admitted  to  the  Pennsylvania 
Traning  School  for  Feeble-Minded  Children,  on  Novem- 
ber 2d,  1888.  An  imperfect  history  was  obtained  from 
a  member  of  the  Board  of  the  Children's  Aid  Society. 
The  boy's  father  was  bom  in  Massachusetts;  he  was  a 
plumber,  and  addicted  to  the  use  of  alcohol.  His  mother 
was  bom  in  Ireland,  and  seems  to  have  had  no  neuro- 
pathic condition;  it  is  stated  that  she  died  of  cancer  of  the 
breast  at  the  age  of  50.  Nothing  is  known  of  the  grand- 
parents. The  patient  was  the  last  of  four  children;  two 
brothers  are  dead;  cause,  unknown;  one  sister  was  placed 
in  a  hospital  for  the  insane  at  the  age  of  thirteen.  The 
patient  was  born  at  full  term  after  a  normal  labor.     He 

Note. — I  desire  to  express  my  thanks  to  Dr.  Martin  W.  Barr 
and  to  Dr.  Frank  White  o(  the  Pennsylvania  Training  School  for 
Feeble-Minded  Children,  who  have  kindly  placed  the  chnic»l  history 
of  this  case  at  my  disposal.  The  microscopical  work  has  all  been 
done  at  the  Pepper  Clinical  Laboratory. 


HYPERTROPHIC  NODULAR  GUOSIS, 


403 


was  apparently  healthy  until  ten  months  old,  when  he  be- 
gan to  have  occasional  spasms,  which  occurred  more  fre- 
quently as  he  grew  older.  He  did  not  walk  until  four  years 
of  age.  His  gait  was  always  rather  slow  and  unsteady,  and 
the  power  of  coordination  poor.  He  was  able  to  say  two 
or  three  words,  but  those  were  spoken  very  indistinctly. 

The  following  notes  were  made  on  September  loth, 
1896: 

"J-  H.,  aged  fifteen,  low-grade  idiot  and  epileptic,  body 
fairly  well  nourished,  muscular  system  poorly  developed, 
cutaneous  reflexes  apparently  normal,  cremasteric  reflexes 
increased,  patellar  reflexes  exaggerated,  tactile  sensibility 
apparently  normal,  thermal  sensibility  uncertain.  The 
eyes  are  myopic;  the  pupils  react  to  light.  Hear- 
ing is  probably  good.  The  head  sphacecephalic 
but  symmetrical;  Romberg's  symptom  is  present. 
Since  admission  he  has  been  treated  for  epilepsy, 
purulent  otorrhoea  and  prolapse  of  rectum."  The  follow- 
ing notes  are  given  in  regard  to  his  general  condition: 
"He  is  totally  dependent  in  every  way,  being  unable  to 
feed  himself.  When  food  is  placed  in  his  mouth  he  makes 
little  effort  at  mastication,  so  that  it  is  necessary  to  give 
him  liquid  or  soft  diet.  He  sometimes  drinks  a  large 
amount  of  water  at  one  time,  but  it  seems  to  run  into 
the  stomach  from  gravity,  there  being  no  effort  on  his 
part  to  swallow,  and  it  does  not  seem  to  alleviate  his  thirst. 
He  was  subject  to  merycism.  There  was  often  considerable 
protrusion  of  the  rectum.  He  was  an  onanist;  the  habit 
being  apparently  more  pronounced  before  an  epileptic  at- 
tack. For  some  hours  previous  to  the  outbreak  of  a  spasm 
he  would  bark  like  a  dog.  When  taken  with  a  fit,  if  stand- 
ing, he  would  fall  instantly,  the  right  side  of  the  head 
striking  first.  During  the  seizure  the  muscles  of  the  right 
side  of  the  face  showed  quick,  spasmodic  movements;  the 
left  side  remained  in  tonic  contraction;  the  right  hand  was 
open  and  the  left  clenched,  and  the  muscles  of  the  left 
forearm  continued  spastic  for  some  time  following  the 
spasm.    After  the  spasm  he  would  laugh  in  a  silly  fashion 


f:  • 


•ij 


.1 


1 


I' 


i 


404 


JOSEPH  SAILER. 


an  hour  or  more.  Before  the  spasm  he  was  irritable  and 
restless,  but  apparently  more  intelligent  than  at  other 
times.  His  last  illness  began  in  December.  It  com- 
menced with  an  almost  constant  succession  of  spasms,  63 
occurring  in  two  hours.  They  were  general,  but,  as  a  rule, 
more  severe  on  the  right  side;  the  head  was  turned  to  the 
right;  the  left  arm  was  rigid  and  lay  in  the  bed;  the  right 
arm  was  rigid  and  elevated;  the  left  leg  twitched,  the  right 
was  rigid;  the  hands  were  flexed  at  the  wrist;  the  fingers 
fully  extended.  The  spasms  decreased  to  about  10  or  12 
per  hour,  and  in  the  course  of  24  hours  the  patient  died 
from  exhaustion." 

The  autopsy  was  performed  on  the  loth  of  December, 
1896,  about  24  hours  after  death.  The  following  notes 
were  taken: 

Body  of  boy  moderately  emaciated,  no  rigor  mortis, 
no  postmortem  lividity.  The  testicles  were  still  in  the 
inguinal  canal;  there  was  a  bruise  on  the  forehead  and  a 
deep  cut  on  the  chin,  penetrating  almost  to  the  bone. 
There  were  numerous  petechise  on  the  surface  of  the  ab- 
domen. The  meninges  of  the  spinal  cord  contained  a  con- 
siderable amount  of  fat;  they  were  not  injected,  and  there 
was  no  abnormal  collection  of  cerebrospinal  fluid.  The 
substance  of  the  cord  was  firm.  The  skull  was  slightly 
thickened;  the  dura  mater  was  firmly  adherent,  but  there 
were  no  signs  of  inflammation.  The  pia  mater  was  smooth, 
transparent,  and  stripped  easily.  In  the  cortex  of  the 
cerebral  hemispheres  were  a  number  of  sharply  circum- 
scribed areas  much  denser  than  the  normal  brain  tissue. 
These  were  pale,  slightly  protuberant,  and  the  large  ones 
slightly  depressed  in  the  centre.  When  incised,  the  sur- 
face of  the  section  was  seen  to  be  grayish  white,  firm  and 
dry.  The  nodules  appeared  to  extend  a  short  distance 
into  the  white  matter,  but  the  distinction  between  the 
medulla  and  the  cortex  was  preserved.  The  ventricles 
were  not  dilated,  but  upon  the  floor  of  the  lateral  ven- 
tricles were  a  number  of  small,  white  nodules,  a  few  mm. 


HYPERTROPHIC  NODULAR  GLIOSIS. 


405 


:r,  projecting  distinctly  above  the  surface.  The 
Willis  was  normal.  There  was  a  hemorrhage 
loor  of  the  fourth  ventricle.  The  whole  brain 
to  be  larger  than  normal.  The  abdominal  or- 
e  normal  in  arrangement.  There  were  some 
hesions  and  moderate  hypostatic  congestion  in 
s.  The  heart  was  small;  the  left  ventricle  mod- 
'pertrophied,  and  there  was  slight  sclerosis  at 
of  the  aortic  valves;  the  mitral  valve  admitted 
■;  the  aorta  was  elastic  and  smooth.  The  heart 
numerous  chicken  fat  clots.  The  surface  of  the 
I  was  covered  by  numerous  small  nodules  of 
ze,  quite  firm  in  consistency.  The  rest  of  the 
tract  showed  no  gross  morbid  changes.  The 
;  glands  were  greatly  enlarged.  Both  adrenal 
bowed  advanced  fatty  degeneration  of  the  cor- 
right  kidney  contained  a  huge  tumor-like  mass 
n.  in  diameter,  that  seemed"  to  replace  a  portion 
stance,  and  numerous  small  nodules.  The  sur- 
e  tumor  was  smooth  and  white,  and  did  not 
'  juice;  the  growth  was  sharply  circumscribed; 
ency  was  exceedingly  dense.  The  small  nodules 
ar  in  character.  The  capsule  of  the  kidney  was 
the  cortex  was  pale,  narrowed,  granular,  and 
numerous  cysts,  and  the  renal  vessels  were  in- 
he  left  kidney  contained  small  nodules,  in  all 
niilar  to  those  of  the  right,  and  the  kidney  sub- 
twed  the  same  changes.  The  liver  was  greatly 
The  left  lobe  extended  to  the  left  posterior 
le,  overlying  the  spleen;  upon  the  surface  there 
erous  whitish  discolorations.  Upon  section,  it 
to  be  normal.  The  mucous  membrane  of  the 
ras  thickened,  rugous  and  somewhat  pale.  The 
embrane  of  the  duodenum  contained  a  number 
lard  nodules.  The  rest  of  the  intestinal  tract 
al.  The  pancreas  was  soft,  and  showed  no 
The  bladder  contained  turbid  urine,  probably 


4o6  JOSEPH  SAILER. 

due  to  precipitation  of  the  urates,  for  the  mucous  mem- 
brane was  smooth.  The  thyroid  gfland  was  afiparently 
normal.  The  thymus  gland  was  present.  The  thoracic 
and  cervical  lymph  glands  were  enlarged.  The  tumors  of 
the  kidney  were  composed  of  spindle  cells,  some  with 
round  or  oval  nuclei,  and  others  with  rod-shaped  nuclei 
that  resembled  non-striated  muscular  fibres. 

Microscopically,  it  was  seen  that  the  growths  infil- 
trated the  surrounding  tissues,  and  a  number  of  the  renal 
tubules  in  the  neighborhood  exhibited  proliferation  of  the 
epithelial  cells.  The  tumors  were  therefore  diagnosed 
adenosarcomata  of  the  kidney,  although  neither  cartilage 
nor  striated  muscular  tissue  was  found.  According  to 
Birch-Hirschfeld,  these  tumors  commence  in  fetal  life,  and 
may  attain  considerable  size  in  childhood,  and  ultimately, 
if  death  does  not  occur  too  early,  give  rise  to  metastasis. 
Sections  through  the  wall  of  the  duodenum  showed  that 
the  various  layers  were  normal,  with  the  exception  of  the 
mucosa.  In  this  the  tumors  were  represented  by  masses 
staining  a  diffuse  blue  with  hasmatoxylin ;  the  central  part 
was  pale;  the  peripheral  darker.  There  was  no  distinct 
structure  to  be  found  in  these  masses,  but,  as  they  faded 
into  the  surrounding  tissue,  small,  round  cells  became 
more  distinct.  The  condition  represents  hyperplasia  of 
the  lymph  follicles,  possibly  sarcomatous  in  nature,  which 
accounts  for  the  distinct  involvement  of  the  capsule,  al- 
though the  extreme  degeneration  of  the  tissue  renders  it 
impossible  to  speak  positively.  There  was  no  evidence  of 
metastasis  in  any  other  part  of  the  body.  A  more  minute 
examination  of  the  brain  after  hardening  in  Miiller's  fluid 
showed  the  following  changes:  The  pia  stripped  readily; 
the  nodules  were  slightly  elevated,  hard,  paler  than  the 
surrounding  tissue,  and  the  surface  exhibited  slight  granu- 
lation. The  membranes  were  not  thickened  nor  con- 
gested. When  incised,  the  dense  tissue  involved  all  of 
the  cortex,  which  was  usually  increased  in  thickness, 
and  extended  a  few  millimeters  into  the  white  substance. 


HYPERTROPHIC  NODULAR  GUOSIS. 


407 


The  distinction  between  cortex  and  medtdia  was  main- 
tained, chiefly  by  the  greater  retractibility  of  the  latter. 
There  was  no  appearance  of  congestion  in  the  morbid 
tissue.  The  areas  of  gliosis  are  very  in-egular  in  shape 
and  very  unequal  in  size,  ranging  from  0.5  cm.  to  7  cm.  in 
diameter.     They  are  distributed  as  follows: 

Left  Cerebral  Hemisphere. — Convex  surface  in  the  su- 
perior frontal  convolution;  at  the  anterior  end  a  small 
nodule;  in  the  middle  a  group  of  three  small  nodules;  at 
the  posterior  end  a  large  nodule  that  extends  to  the 
median  surface.  In  the  second  frontal  convolution,  at  the 
anterior  end,  a  large  sclerotic  patch  involving  four  small 
convolutions;  just  back  of  these  is  a  smaller  mass,  and  at 
the  posterior  end  a  large  mass  that  extends  along  a  small 
annectant  gyrus,  and  involves  the  ascending  frontal  gyrus. 
In  the  third  frontal  convolution  the  operculum  is  normal; 
the  anterior  part  is  occupied  by  a  huge  sclerotic  mass,  5x7 
cm.  in  extent,  involving  a  number  of  secondary  gyri.  In 
the  ascending  frontal  convolution  there  is  only  the  nodule 
that  extends  from  the  second  frontal.  In  the  ascending 
parietal  there  is  a  small  nodule  about  the  centre,  near  the 
fissure  of  Rolando,  and  a  larger  one  near  the  longitudinal 
fissure,  and  a  still  larger  one  in  the  posterior  portion  of  the 
superior  parietal,  about  3x6  cm.  in  area.  The  supra- 
marginal  gyrus  contains  a  small  mass  in  the  anterior  limb, 
and  the  whole  of  the  angular  gyrus  appears  to  be  con- 
verted into  a  single  sclerotic  mass,  perhaps  the  largest  in 
the  brain.  The  occipital  lobe  is  composed  of  a  number  of 
nodules  of  various  sizes,  separated  by  small  areas  of  softer 
tissue,  none  of  the  convolutions  being  entirely  normal. 
In  the  first  tempero-sphenoidal  convolution  there  is  a 
small  nodule  in  the  posterior  end;  the  second  is  completely 
sclerosed  anteriorly;  in  the  third  there  is  a  small  nodular 
mass  at  the  anterior,  and  two  at  the  posterior  extremity; 
in  the  fourth  there  is  a  mass  of  gliosis,  posteriorly  extend- 
ing into  the  occipital  lobe.  The  fifth  convolution  is  ap- 
parently normal. 


4o8  JOSEPH  SAILER. 

The  Internal  Surface. — There  are  lar^e  nodules  in  the 
anterior  and  posterior  part  of  the  first  frontal  convolution, 
numerous  nodules  in  the  quadrate  lobule;  a  large  mass  in 
the  posterior  portion  of  the  cuneus,  and  a  few  nodules  on 
the  orbital  surface  of  the  frontal  lobe.  The  comu  am- 
monis  is  apparently  normal. 

Right  Cerebral  Hemi.>ipliere. — In  the  superior  frontal 
convolution  there  are  several  nodules  in  the  anterior  por- 
tion, a  large  mass  in  the  middle,  and  another  posteriorly. 
In  the  third  frontal  convolution  there  is  a  mass  in  the  an- 
terior portion.  The  operculum  is  not  involved.  There  is 
a  nodule  in  the  lower  extremity  of  the  ascending  frontal 
convolution.  In  the  superior  parietal  there  are  a  few 
nodules  posteriorly.  The  supramarginal  gyrus  is  involved 
throughout.  The  occipital  lobe  resembles  that  of  the  left 
side.  The  anterior  portions  of  the  first,  second  and  fourth 
tempero-sphenoidal  convolutions  contain  some  nodules. 
The  comu  ammonis  is  normal.  On  the  internal  surface 
there  is  a  mass  of  gliosis  in  the  posterior  part  of  the  cuneus. 
The  calloso-marginal  convolution  contains  a  few  scattered 
nodules.  There  is  a  large  mass  in  the  posterior  part  and 
another  in  the  middle  of  the  superior  frontal  convolution, 
and  a  few  small  nodules  in  the  orbital  extension  of  the 
second  frontal.  The  cerebellum,  pons  and  medulla  are 
apparently  uninvolved.  In  the  interior  of  the  brain,  areas 
of  sclerosis  large  enough  to  be  detected  with  the  naked 
eye  cannot  be  found,  excepting  the  nodules  already  de- 
scribed upon  the  surfaces  of  the  ventricles.  The  third  and 
fourth  ventricles  are  free,  and  the  basal  ganglia,  as  far  as 
examined  by  horizontal  section  through  the  brain,  are 
not  affected.  The  pyramids  and  olives  in  the  medulla 
are  quite  distinct.  The  peduncles  and  corpora  mammil- 
laria  are  of  equal  size.  The  cerebellum  is  of  normal  size 
and  consistency.     There  are  no  gross  lesions  of  the  cord. 

The  microscopical  appearances  were  as  follows:  When 
the  sclerotic  areas  were  stained  with  hiematoxylin  and 
eosin  the  following  changes  were  observed :  The  neuroglia 


HYPERTROPHIC  NODULAR  GLIOSIS. 


409 


was  composed  of  coarse  fibres,  forming  a  coarse-meshed 
reticulum,  or  else  arranged  in  bands,  or  twisted  into  a  sort 
of  spiral  form;  these  changes  were  particularly  noticeable 
either  just  beneath  the  pia  mater,  or  about  the  junction  of 
the  gray  and  white  matter;  the  neuroglia  cells  were  some- 
what smaller  than  normal,  irregular  in  outline,  and  mod- 
erately increased  in  number.  In  those  situations  where 
the  sclerosis  was  greater,  the  vessels  were  greatly  increased 
in  number;  beneath  the  pta,  however,  the  sclerotic  areas 
seemed  to  be  less  vascular  than  normal.  Nearly  all  these 
blood  vessels  were  distended  with  blood,  a  result,  I  sup- 
pose, of  the  violent  muscular  effort  occuring  during  the 
status  epilepticus.  They  appeared  to  be  much  larger  than 
normal,  and  the  walls  often  showed  proliferation  of  the 
nuclei.  The  perivascular  spaces  were  frequently  distended, 
sometimes  exceeding  in  width  the  diameter  of  the  vessels. 
Occasionally  they  were  filled  with  a  delicate  reticulum, 
although  it  could  not  be  determined  that  this  was  com- 
posed of  neuroglia  fibres.  There  was  no  accumulation  of 
round  cells  in  the  perivascular  spaces,  but  occasionally  large 
cells  could  be  seen  that  contained  granules  staining  black' 
with  osmic  acid.  These  are  probably  connective  tissue 
cells  that  have  absorbed  fatty  detritus,  perhaps  resulting 
Irom  a  degeneration  of  the  myelin  sheaths.  When  the 
vessels  were  cut  longitudinally,  it  could  be  seen  that  they 
were  moderately  tortuous,  but  they  did  not  show  any 
aneurismal  dilations.  In  sections  stained  by  Rosin's 
method  they  appeared  quite  red,  partly  due  to  the  stain- 
ing of  the  red  blood  vessels;  but  in  the  more  sclerotic 
areas  the  walls  also  appeared  to  have  taken  this  color,  and 
it  may  be  that  they  have  undergone  hyalin  degeneration, 
particularly  as  the  sections  stained  by  Van  Gieson's 
method  showed  the  same  peculiarities.  Amylaceous 
bodies  were  not  observed  in  the  cortical  lesions.  The  nerve 
cells  stained  fairly  well;  they  were  present  in  all  the  areas 
of  sclerosis,  excepting  those  few  where  the  bundles  of 
neuroglia  were  arranged  in  wavy  bands  or  spirals  and  per- 


4IO  JOSEPH  SAILER. 

meated  by  large  and  numerous  vessels.  Neither  by  car- 
mine nor  htcmatoxylin  did  they  show  any  signs  of  de- 
generation, but  they  appeared  to  be  more  irregularly 
placed  than  usual.  This  alteration  was  still  more  pro- 
nounced in  the  sections  that  had  been  stained  by  Nissl's 
method,  in  which  it  could  be  seen  that  the  apices  of  the 
pyramidal  cells  pointed  in  all  directions.  They  were  very 
numerous,  even  more  so,  apparently,  than  normal,  and 
stained  rather  deeply;  their  processes  were  slightly  tor- 
tuous, but  there  were  no  definite  nuclear  changes  and  no 
alterations  in  the  protoplasm.  In  position  they  seemed 
to  be  abnormal,  large  cells  being  found  in  the  second 
layer  as  well  as  the  third.  A  number  of  sections  were  also 
stained  by  Berkeley's  modification  of  Golgi's  method. 
The  neuroglia  cells  appeared  to  be  very  numerous,  and 
impregnated  very  distinctly.  The  pyramidal  cells  were 
only  found  in  a  few  sections,  in  which  they  seemed  to  be 
perfectly  normal.  The  method  is,  however,  so  unsatisfac- 
tory for  pathological  purposes,  that  its  only  value  in  the 
present  instance  is  to  show  that  normal  cells  exist  in  the 
sclerotic  areas.  In  some  parts  of  the  cortex  certain  pe- 
culiar bodies  were  observed  in  considerable  number,  that 
were  circular  or  pear-shaped  and  very  pale,  appearing  like 
vacuoles  in  the  midst  of  the  neuroglia  tissue.  Each  con- 
tained a  small,  faintly  staining,  round  nucleus  in  the  cen- 
tre, and  probably  represented  a  degenerated  cell;  but 
whether  they  are  derived  from  the  ganglion  or  the  neu- 
roglia cells,  it  is  quite  impossible  to  say,  A  number  of 
sections  were  stained  by  the  Weigert  or  Pal  methods.  In 
nearly  all  these  the  tangential  fibres  of  the  cortex  were 
absent.  Toward  the  white  matter  the  cortex  remained  per- 
fectly pale,  with  the  exception 'of  a  few  delicate  fibres  that 
passed  irregularly  through  it.  When  the  gliosis  invaded 
the  white  matter,  it  did  not  in  general  cause  complete 
destruction  of  the  myelin  sheaths,  but  the  distance  be- 
tween the  individual  fibres  was  considerable,  and  gave  riae 


HYPERTROPHIC  NODULAR  GLIOSIS. 


%1 

Section  through  a  sclerui.c  area  in  the  third  (rontal  cmivolulioii 
ol  the  right  side.  The  focus  is  about  4  mm.  in  diameter  and  situated 
at  the  junction  of  the  cortex  and  white  matter.  It  contains  an  ex- 
tessisre  number  of  blood  vessels,  the  neuroglia  cells  are  more  thickly 
placed  Ihan  is  normal,  and  the  neuroglia  fibres  are  coarser  and  form 
■  looiiT  meshwork.     (Hafmatoxylin  and  eosin.    Zeiss  DD;  oe.  3.) 


/OSEPU    SA/LEA*. 


r,sa 


HYPERTROPHIC  NODULAR  CUOSIS. 


413 


to  an  extremely  feathery  appearance  at  the  junction  of  the 
white  matter  and  the  cortex.  In  these  areas  the  sections 
appeared  to  be  much  paler  than  in  other  parts.  The  fibres 
of  association  could  not  be  made  out,  and  were  probably 
largely  lacking.  Where  the  sclerosis  was  most  advanced 
no  myelinated  fibres  could  be  found.  No  deeenerated 
fibres  were  found  by  Marchi's  method,  but  a  few  cells  con- 
taining black  granules  were  observed  in  the  perivascular 
spaces. 

The  nodules  upon  the  floor  of  the  lateral  ventricles 
consisted  of  almost  pure  neuroglia  tissue,  arranged  in 
bands,  or  in  whorls  twisted  about  the  centre  of  the  nodule. 
The  blood  vessels  were  greatly  increased  in  number 
throughout  the  majority  of  these  sclerotic  areas,  and  in 
the  sections  stained  by  Van  Gieson's  method,  exhibited 
the  same  changes  as  those  in  the  cortex.  In  one  of  the 
nodules  on  the  left  side,  there  were  a  number  of  peculiar, 
irregular  bodies,  that  were  usually  circular  in  shape,  al- 
though sometimes  slightly  elongated,  and  showed  a  dis- 
tinctly concentric  structure.-  They  stained  deep  blue  with 
baematoxylin,  remained  a  deep  brown  color  in  the  sections 
stained  by  Weigert's  method;  they  retained  the  stain  by 
Gram's  method,  and  with  thionin  and  acid  fuchsin  stained 
bluish  green  with  a  delicate  red  border;  they  stained  a 
deep  red  by  Van  Geison's  method,  and  bright  red  with 
gentian  violet.  They  were  not  soluble  in  alkaline  or  acid 
solutions.  I  am  inclined  to  believe,  on  account  of  their 
situation  beneath  the  ependyma  and  their  peculiar  stain- 
ing reactions,  that  they  represent  agglomerations  of  al- 
tered amyloid  material.  They  do  not,  however,  stain 
brown  with  iodine.  I  have  observed  exactly  similar  bodies 
in  an  area  of  softening  in  the  brain  of  a  child  that  died 
of  tubercular  meningitis,  and  others  somewhat  similar  in 
a  case  of  paralysis  agitans  with  marked  arterial  sclerosis. 
They  appear,  therefore,  to  indicate  degeneration  of  ner- 
vous tissue,  a  view  held  by  Stroebe  and  also  by  Dagonet, 
who  regards  them  as  a  derivative  of  cerebrin.     Beyond 


414 


JOSEPH  SAILER, 


these  nodules  the  hyperplastic  neuroglia  tissue  extends 
deeply  into  the  optic  thalamus,  showing  the  same  thick- 
ening of  the  fibres  and  coarse  meshing  that  was  found  in 
the  sclerotic  areas  of  the  cortex.  The  ependyma  covering 
the  nodules  was  considerably  wrinkled,  giving,  in  cross 
section,  a  slightly  papilomatous  appearance;  it  was  com- 
posed of  a  single  layer  of  polygonal  cells  with  deeply  stain- 
ing nuclei,  that  showed  no  evidences  of  proliferation,  such 
as  are  present  in  neoplastic  and  inflammatory  processes; 
the  appearance  bore  a  striking  resemblance  to  that  often 
seen  in  the  intima  of  sclerotic  arteries,  and  was  probably 
due  to  retraction  of  the  neuroglia  tissue.  In  the  cere- 
bellum quantitative  changes  were  distinctly  seen.  The 
cells  of  Purkinje  were  sometimes  widely  scattered,  some- 
times close  together.  They  stained  bright  red  with  eosin; 
the  nucleus  showed  a  faint  bluish  tinge,  was  irregular  in 
outline,  and  apparently  contained  very  little  chromatin. 
The  medullated  fibres  were  much  fewer  than  ordinarily 
observed,  and  none  at  all  were  found  in  the  cortical  layer. 
The  vessels  in  the  cerebellum  were  not  particularly  nu- 
merous, and  did  not  show  the  perivascular  spaces.  The 
pons  was  apparently  normal.  Along  the  edge  of  the  left 
pyramidal  tract  in  the  medulla  was  a  small  area  of  scle- 
rosis, sharply  defined  from  the  rest  of  the  tract.  The  neu- 
roglia cells  appeared  to  be  increased  in  number,  and  there 
was  the  same  reticular  arrangement  of  the  neuroglia  fibres. 
Otherwise  the  process  resembled  more  closely  a  patch  of 
insular  sclerosis.  In  the  spinal  cord  (lower  cervical  region) 
no  distinct  changes  were  noted,  excepting  on  the  left  side, 
just  outside  the  anterior  comua,  where  there  were  a  num- 
ber of  dilated  blood  vessels,  somewhat  tortuous  in  their 
course,  and  a  slight  proliferation  of  the  neuroglia  tissue, 
staining  red  with  acid  fuchsin.  Sections  stained  by  the 
Weigert,  Pal  and  Marchi  methods,  and  by  carmine,  failed 
to  show  any  trace  of  degeneration.  The  ganglion  cells  of 
the  anterior  comua  were  normal.  The  central  canal  still 
existed  as  a  microscopical  channel. 


HYPERTROPHIC  NODULAR  GUOSIS. 


415 


An  examination  of  the  literature  for  similar  cases  has 
yielded  the  following  results.  It  must  not  be  understood, 
however,  that  all  the  cases  of  which  I  give  abstracts  were 
reported  as  tuberous  gliosis.  Some  have  been  included 
under  the  title  of  hereditary  syphilitic  disease,  and  others 
have  been  described  as  cases  of  insular  sclerosis. 

The  negative  testimony  is  not  uninteresting.  Eche- 
verria,  whose  book  upon  epilepsy  appeared  in  1870,  and 
was  the  best  monograph  that  had  hitherto  been  published 
upon  the  subject  in  America,  makes  no  mention  of  any 
lesion  similar  to  this,  although  he  describes  quite  ex- 
tensively the  pathological  change  found  in  epileptic 
brains: 

Case  I. — Boumeville.  The  patient  was  a  finale  with- 
out neuropathic  heredity.  Convulsions  commenced  in  in- 
fancy, and  at  the  age  of  two  years  assumed  the  form  of 
typical  epilepsy.  She  never  learned  to  walk  nor  talk,  and 
when  she  was  admitted  to  the  hospital,  at  the  age  of 
fifteen  years,  it  was  found  that  the  right  arm  and  leg  were 
flexed  and  partially  atrophic.  The  epileptic  attacks  were 
Jacksonian  in  type,  the  spasm  commencing  in  the  right 
eye,  which  was  drawn  up  and  to  the  right;  then  rigidity 
of  the  right  arm,  followed  by  clonic  spasm  of  the  right 
arm  and  eyelids.  At  the  autopsy  the  brain  was  large  and 
slightly  asymmetrical,  the  right  peduncle  and  corpus 
mammillare  being  larger  than  the  left.  The  pyramids 
were  united  with  the  olives;  the  pia  mater  was  delicate 
and  slightly  adherent  over  the  focal  lesions.  In  the  cortex 
of  both  cerebral  hemispheres  were  numerous  rounded 
masses  of  various  sizes,  white,  opaque,  firmer  than  the 
brain  substance,  and  slightly  prominent,  with  a  shallow 
umbilication  in  the  centre  of  the  larger  ones;  the  comua 
ammonis  were  normal.  The  lungs  were  pneumonic;  the 
left  ventricle  of  the  heart  hypertrophied,  and  white  nodul- 
ar masses,  apparently  cancerous  in  structure,  were  found 
in  both  kidneys. 

Case  11. — Bourneville  and  Brissaud,     The  patient  was 


4l6  JOSEPH  SAILER. 

a  male;  two  other  children  were  healthy.  The  mother 
had  had  convulsions  during  pregnancy.  The  child  learned 
to  walk  at  the  age  of  two  years,  but  could  not  speak.  He 
had  freqiient  epileptic  attacks,  during  which  he  was  cya- 
nosed,  and  later  this  condition  became  permanent.  There 
was  a  loud  cardiac  murmur.  Death  occurred  at  the  age  of 
four  years,  apparently  from  cardiac  insufficiency..  There 
was  a  large  area  of  softening  in  the  right  frontal  lobe,  over 
which  the  pia  mater  was  adherent.  The  sclerotic  areas 
were  found  in  both  hemispheres,  but  were  more  nu- 
merous on  the  left  side.  There  was  a  congenital  lesion 
of  the  heart.  Microscopic  examination  of  the  brain  sub- 
stance showed  the  absence  of  nervous  elements  in  the 
sclerotic  tissue.  The  glia  cells  were  increased  in  number, 
but  were  somewhat  irregular  in  shape.  There  was  no 
sharp  line  of  demarkation  between  the  sclerotic  and  nor- 
mal tissue,  but  the  ganglion  cells  in  the  neighborhood 
of  the  lesions  were  granular  and  yellow;  the  blood  vessels 
were  few  but  large,  and  Brissaud,  who  made  the  examina- 
tion, declares  that  medullated  fibres  were  absent  in  the 
lesions,  but  he  used  only  the  carmine  stain. 

Case  III. — Bourneville  and  Bonnaire.  The  patient 
was  a  male,  the  tenth  of  thirteen  children,  of  whom  only 
three  others,  all  of  whom  appeared  to  be  normal,  lived 
for  any  considerable  time  after  birth.  There  was 
neuropathic  family  history.  The  child  was  appar- 
ently normal  for  the  first  five  months,  and  then  re- 
ceived a  severe  injury  to  the  head,  which  was  followed  by 
a  notable  change  in  its  disposition.  Convulsions,  during 
which  the  child  would  become  rigid  for  about  15  minutes, 
without  loss  of  consciousness,  commenced  at  the  age  of 
seven  and  a  half  months.  He  did  not  walk  until  two  years 
and  a  half  old,  could  not  talk,  recognize  his  parents  nor 
feed  himself.  He  died  at  the  age  of  five  years.  The  brain 
weighed  1,040  grms.;  the  dura  mater  was  adherent  to  the 
calvarium.  The  pia  mater  was  injected,  but  not  adherent. 
The  sclerotic  nodules  were  found  in  the  cortex  and  in  the 


HYPERTROPHIC  NODULAR  GUOSIS.  417 

corpus  striatum.  Numerous  round  tumors  were  found 
in  the  kidney,  which  proved  to  be  encephaloid  sarcoma. 
There  were  no  lesions  in  the  isthmus  or  cerebellum,  and 
the  ventricles  were  not  dilated. 

Case  IV, — Boumeville  and  Bonnaire.  The  patient 
was  a  male,  the  fourth  of  seven  children,  only  three  of 
whom  lived  beyond  the  age  of  infancy.  There  was  marked 
neuropathic  heredity,  and  both  father  and  mother  had 
had  skin  eruptions.  The  child  was  born  at  the  sixth 
month,  and  had  signs  of  scrofula.  Convulsions  were  first 
noted  in  the  sixth  week,  and  recurred  frequently.  At  the 
age  of  two  years  there  was  paresis  of  the  neck  and  arms, 
but  this  disappeared  two  years  later.  The  child  never 
could  walk  without  support,  and  there  was  a  tendency  to 
fall  forward.  It  was  an  imbecile  and  filthy  in  its  habits, 
the  only  manifestation  of  intelligence  being  the  occasional 
expression  of  pleasure.  Death  occurred  at  the  a^e  of  five 
years  in  status  epilepticus.  The  sclerotic  nodules  were 
found  in  the  cortex  and  basal  ganglia.  The  occipital 
region  of  the  brain  was  slightly  flattened.  The  kidneys 
contained  numerous  serous  cysts  and  raised  tumors,  that 
were  soft  and  white. 

Case  V. — Boumeville  and  Bonnaire.  The  patient  was 
a  male,  with  neuropathic  family  history;  two  children  were 
dead,  two  others  lived,  and  were  apparently  healthy. 
There  was  no  history  of  syphilis  or  injury.  Convulsions 
commenced  at  the  age  of  five  years  and  nine  months. 
The  sclerotic  nodules  were  found  in  the  cortex  of  the 
hemispheres  and  in  the  caudate  nuclei.  The  kidneys  con- 
tained cysts  and  some  large,  firm  tumors. 

Case  VI. — Hartdegen.  The  patient  was  a  male,  as- 
phyxiated at  birth  and  unable  to  nurse  or  to  swallow. 
The  anterior  fontanelle  was  dilated,  and  there  was  a  lum- 
bosacral spina  bifida  that  became  infected,  giving  rise  to 
a  leptomeningitis,  apparently  the  cause  of  death,  which 
occurred  at  the  age  of  forty-eight  hours.  Numerous  scle- 
rotic nodules  were  found  on  the  surface  of  the  hemispheres. 


4l8  JOSEPH  SAILER. 

which  were  firmer,  paler  and  dryer  than  the  brain  sub- 
stance. Smaller  nodules  were  found  in  the  walls  of  the 
ventricles.  The  thoracic  and  abdominal  organs  were  nor- 
mal. Microscopically,  the  sclerotic  areas  consisted  of  a 
finely  granular  tissue  containing  delicate  fibres.  The  scle- 
rotic lesions  contained  numerous  ganglion  cells  that  were 
irregular  in  shape  and  abnormal  in  position,  some  of  the 
largest  being  found  in  the  most  superficial  layer  of  the 
cortex:.  The  nodules  in  the  lateral  ventricles  consisted  of 
large  cells  with  numerous  processes,  that  were  mingled 
with  fibres  of  connective  tissue,  extending  downward  from 
the  ependyma.  He  regards  these  growths  as  glioma  gan- 
glionare  cerebri  congenilum.  The  ventricles  were  dilated. 
The  convolutions  were  normal  in  arrangement. 

Case  VII, — PoUak.  The  patient  was  a  female,  whose 
mother  had  had  severe  headache  and  attacks  of  dizziness 
during  pregnancy.  Two  other  children  were  healthy;  one 
had  died  of  epileptic  attacks.  Convulsions  occurred  four 
days  after  birth,  accompanied  by  fever  and  osdema  of  the 
scalp;  this  continued  four  days,  after  which  the  child 
seemed  paretic,  no  spontaneous  movements  being  ob- 
served excepting  a  slight  twitching  of  the  facial  muscles 
when  loud  noises  were  made.  Deglutition  was  always 
difficult,  and  the  patient  showed  a  marked  aversion  to 
liquids,  especially  water,  never  drinking,  although  she  had 
constant  polyuria.  In  spite  of  this,  she  was  well  nourished. 
As  she  grew  older,  she  manifested  pleasure  when  shown 
bright  objects  or  when  she  heard  music,  and  recognized 
her  father's  voice.  There  were  occasional  attacks  of  trem- 
bling, and  paradoxical  contraction  was  observed  in  the 
tibialis  anticus  and  quadricep  extensor.  There  was  nys- 
tagmus, divergent  strabismus  and  unequal  pupils;  the  fix- 
ing eye  was  in  extreme  myosis  and  the  other  mydriatic. 
During  the  second  dentition  muscular  atrophy  com- 
menced in  the  feet  and  hands.  In  the  fourth  year  of  her 
age  chronic  cramps  occurred  in  the  limbs;  there  were 
gnashing  of  the  teeth  and  the  signs  of  hydrocephalus,  fol- 


HYPERTROPHIC  N0DUL4R  GLIOSIS.  4x9 

lowed  by  death  in  a  few  months.  At  the  autopsy  it  was 
found  that  the  dura  mater  was  adherent,  the  pia  mater 
thickened  and  partially  adherent.  Pale,  hard  elevations 
were  observed  in  the  cerebral  hemispheres,  anterior  to  the 
ascending  parietal  convolution,  and  over  these  the  pia 
mater  was  firmly  adherent.  The  corpus  callosum  was 
thickened  and  nodular.  The  ventricles  were  rough,  and 
the  basal  ganglia  and  spinal  cord  contained  areas  of  scle- 
rosis. No  microscopical  examination  was  made.  Pollak 
calls  the  case  one  of  congenital  disseminated  sclerosis,  and 
claims  that  he  made  an  ante-mortem  di^nosis,  although 
he  appears  to  be  unfamiliar  with  the  nature  of  the  process. 
Two  years  previously  he  reported  a  living  case  with  simi- 
lar, but  less  severe,  symptoms. 

Case  VIII. — Bruckner.  There  was  no  neuropathic 
heredity,  no  history  of  injury  or  of  syphilis.  The  patient 
was  a  girl,  who  commenced  to  speak  in  her  second  year 
and  to  walk  in  her  fourth.  At  school  she  learned  to  write 
with  great  difficulty,  and  was  always  shy  and  timorous. 
She  was  never  able  to  calculate.  The  first  epileptic  at- 
tack occurred  in  her  ninth  year.  After  this  fits  recurred 
occasionally,  and  there  was  some  disturbance  of  the  gait, 
which  later  improved.  At  the  age  of  eighteen  years,  the 
patient  became  maniacal,  and  then  passed  rapidly  into  a 
state  of  apathetic  idiocy,  although  sensation,  motion  and 
the  vegetative  organs  remained  normal.  A  year  later  epi- 
leptic attacks  recommenced,  but  were  quite  infrequent. 
At  the  age  of  twenty-two  years  the  patient  died  of  phthisis. 
.\t  the  autopsy  the  brain  was  found  to  be  large  and  to 
contain  numerous  circumscribed  foci  of  hardening,  the 
larger  ones  having  depressed  centres.  They  involved 
principally  the  gray  matter,  but  also  extended  into  the 
white  substance.  Microscopically,  a  coarse  fibrous  con- 
nective tissue  was  found,  especially  just  beneath  the  pia 
mater,  where  it  assumed  the  form  of  a  band  of  wavy  fibres. 
In  places  ganglion  cells  were  observed,  included  in  a  fine- 
meshed  reticulum,  that  were  apparently  normal,  but  more 


420 


JOSEPH  SAILER. 


thickly  placed  than  usual.  The  blood  vessels  were  charac- 
terized by  wide  perivascular  lymph  spaces.  The  ventricles 
of  the  brain  were  distended,  and  from  the  ependyma  $ 
fine  fibrous  stroma  extended  inward,  containing  holes 
filled  with  large,  glassy,  round  cells,  between  which  were 
some  chalky  deposits. 

Case  IX. — Pozzi  reports  the  case  of  a  man  admitted  to 
the  hospital,  at  the  age  of  sixty-eight  years,  suffering  from 
dementia,  with  occasional  outbursts  of  maniacal  violence, 
alternating  with  states  of  melancholic  depression.  There 
was  a  history  of  epilepsy,  but  nothing  further  could  be 
ascertained  about  the  patient.  Shortly  after  admission, 
and  two  months  before  death,  the  epileptic  attacks  re- 
curred with  great  frequency,  and  death  was  apparently 
due  to  "status  epilepticus."  At  the  autopsy  the  skull 
was  thick,  the  dura  mater  partially  adherent,  the  pia  mater 
injected,  but  not  adherent,  and  there  was  some  subarach- 
noid effusion.  In  certain  regions  the  convolutions  were 
small,  hard  and  granular;  in  others  they  were  enlarged, 
hard  and  smooth,  the  enlargement  being  nodular  in  char- 
acter. Brissaud  examined  the  specimens  microscopically, 
and  reported  that  the  hypertrophic  areas  resembled  cir- 
rhosis.the  neuroglia  forming  a  dense,  non-vascular  mass, 
harder  than  the  brain  tissue.  The  ganglion  cells  were  not 
degenerated,  but  rarer  than  usual.  The  large  motor  cells 
could  not  be  found.  There  was  no  disturbance  of  the 
normal  succession  of  the  layers  of  the  cortex.  The 
atrophic  convolutions  were  similar  in  character,  excepting 
that  the  neuroglia  seemed  to  be  denser  and  the  ganglion 
cells  even  fewer.  He  also  found  certain  round  masses  in 
the  midst  of  the  neuroglia,  that  he  regarded  as  colloid 
in  nature. 

Case  X. — Simon.  The  patient  was  a  female,  with 
neuropathic  family  history.  At  the  age  of  two  and  one- 
half  years  she  was  admitted  to  the  hospital,  and  it  was 
noted  that  she  was  microcephahc  artd  showed  contractions 
of  all  four  limbs.    There  was  continual  agitation  of  the 


HYPERTROPHIC  NODULAR  GUOSIS.  431 

muscles  of  the  face  and  limbs  and  frequent  attacks  of 
epilepsy.  The  intelligence  was  almost  nothing.  The  di- 
gestive functions,  excepting  deglutition,  were  normal. 
Death  occurred  one  month  after  admission.  At  the  au- 
topsy two  sclerotic  nodules  were  found  in  each  hemi- 
sphere, just  in  front  of  the  fissure  of  Rolando.  The  con- 
volutions in  the  neighborhood  were  atrophic.  The  scle- 
rotic tissue  extended  two  or  three  millimeters  into  the 
substance  of  the  brain,  and  the  microscopical  examina- 
tion showed  proliferation  of  fibrous  tissue,  the  destruc- 
tion of  the  cells  and  of  the  myelin  sheaths.  There  were 
secondary  alterations  in  the  pyramidal  columns  of  the 
cord. 

Case  XI. — Schule.  The  sex  of  the  patient  is  not 
given,  and  there  is  no  family  history.  The  epileptic  at- 
tacks commenced  at  the  age  of  three  years.  The  patient 
was  not  a  total  idiot,  and  learned  something  at  school. 
There  was  right-sided  facial  atrophy,  the  gait  was  normal, 
Romberg's  sign  was  present,  the  speech  was  slow,  and  the 
hearing  of  the  left  ear  imperfect.  Death  occurred  in 
status  epilepticus,  at  the  a^e  of  sixteen  years.  The  brain 
weighed  1,390  grams.  The  dura  was  adherent  to  the  skull 
and  the  pia  mater  over  the  projecting  sclerotic  mass  in 
the  frontal  region.  The  brain  otherwise  exhibited  typical 
nodular  sclerosis. 

Case  XII. — Buchholz  describes  the  specimen  from  a 
case.  The  brain  contained  some  nodules  upon  the  surface 
of  the  convolutions  and  some  cysts  in  the  brain  substance. 
There  was  round-cell  infiltration  around  the  vessels,  as  if 
the  processes  were  inflammatory  in  nature.  Some  of  the 
nodules  were  composed  of  true  connective  tissue,  with 
spindle-shaped  nuclei,  and  a  similar  tissue  was  found  in 
the  cysts.  It  is  stated  that  some  of  the  fibrous  bands 
represented  degenerated  vessels. 

Case  XIII, — Thibal  reported  another  case  from  the 
service  of  Boumevilfe,  but  I  have  been  unable  to  obtain 
the  original  paper. 


422  JOSEPH  SAILER. 

Cases  XIV.,  XV.,  XVI.— Buchholz  reports  three 
doubtful  .cases.  Two  of  the  patients  were  epileptic  males; 
.  in  the  brains  of  both  of  whom  increase  of  the  neuroglia 
cells  and  hyperplasia  of  the  neuroglia  tissues  were  found, 
and  also  degeneration  of  the  ganglion  cells.  The  changes 
were  principally  found  in  the  cortex,  but  sometimes  af- 
fected the  white  substance,  and  occasionally  led  to  cavity 
formation,  in  which  case  compound  granular  cells  were 
usually  present.  One  of  the  brains  weighed  1,575  grams. 
The  third  patient  was  a  paranoiac  woman,  who  had  been 
married;  her  brain  presented  similar  changes. 

Cases  XVII.  to  XXII.— Wilmarth.  Six  cases  are 
mentioned  as  having  been  found  in  the  brains  of  epileptics 
and  idiots  at  the  Training  School  for  Feeble-Minded  Chil- 
dren. In  some,  the  situation  of  the  sclerotic  nodules  in 
the  motor  region  explained  the  symptoms.  The  descrip- 
tions are  very  meagre  and  unsatisfactory. 

Case  XXIII. — Henoch..  The  patient  was  included  in 
a  series  of  doubtful  cases  of  cerebral  syphilis.  The  child 
was  admitted  to  the  hospital  at  the  age  of  two  years,  and 
presented  a  peculiar  alternation  of  slyness  and  stupidity. 
There  was  spina  ventosa,  but  no  disturbance  of  motility. 
Death  occurred  from  diphtheria.  At  the  autopsy  a  num- 
ber of  rough  tumors,  about  the  size  of  cherries,  were  found 
in  the  substance  of  the  brain  and  cerebellum.  A  similar 
growth  was  also  found  in  the  upper  portion  of  the  left 
kidney.  There  was  some  periostitis  upon  the  surface  of 
the  tibia,  and  the  tumors  were  declared  by  a  pathologist 
to  be  gummata. 

Case  XXIV. — Berdez.  The  patient  was  a  male,  with- 
out neuropathic  family  history.  Other  children  in  the 
family  were  perfectly  healthy.  At  the  age  of  four  months 
convulsive  attacks  occurred,  in  which  the  child  became 
slightly  rigid,  and  there  were  movements  of  the  eyes,  fol- 
lowed by  periods  of  loss  of  consciousness.  Later,  these 
became  more  typically  epileptic.  The  child  never  talked 
nor  gave  any  signs  of  intelligence,  and  could  not  walk. 


HYPERTROPHIC  N'ODULASt  GLIOSIS. 


423 


At  the  age  of  two  years,  when  admitted  to  the  hospital, 
the  head  was  found  to  measure  fifty-two  centimeters  in 
circumference.  The  pupils  were  normal;  there  were  no 
muscular  atrophies  nor  choreic  movements  of  the  extremi- 
ties. A  diagnosis  of  hydrocephalus  was  made,  and  crani- 
otomy performed,  which  resulted  in  death.  The  brain 
was  large,  and  presented  the  typical  appearance  of  tu- 
berous sclerosis,  the  nodules  being  found  in  both  hemi- 
spheres, and  one  in  each  of  the  caudate  nuclei.  The  ven- 
tricles were  not  distended,  and  their  surface  was  smooth. 
The  central  canal  of  the  cord  was  dilated.  In  the  sclerotic 
areas  the  nerve  cells  and  fibres  were  absent.  In  the  neigh- 
borhood of  the  lesion  they  still  existed,  but  appeared  nor- 
mal. Many  of  the  cells  were  surrounded  by  large  peri- 
cellular spaces.  The  lymphatic  spaces  were  also  distended, 
and  the  vessels  were  fewer  than  normal.  The  neuroglia 
appeared  hyperplastic. 

Case  XXV. — Boumeville.  The  antecedents  of  the 
patient  were  distinctly  neuropathic.  Both  the  father  and 
mother  had  had  syphilis,  and  the  latter  had  had  numerous 
miscarriages.  The  first  signs  of  mental  deficiency  were 
observed  at  the  age  of  three  months.  At  the  age  of  thirty- 
three  months  a  few  words  were  spoken,  and  the  patient 
made  an  effort  to  walk.  Epileptic  attacks  commenced  at 
the  age  of  eight  months,  but  soon  ceased,  and  did  not 
recur  until  the  child  was  three  years  old.  Death  occurred 
at  the  age  of  eleven  years.  The  pia  mater  was  adherent 
to  the  cortex  over  the  sclerotic  nodules.  These  consisted 
of  dense  masses  of  neuroglia  tissue,  without  nervous  ele- 
ments, although  the  neuroglia  cells  sometimes  presented 
peculiar  elongations,  and  contained  fewer  blood  vessels 
than  the  normal  tissue. 

Case  XXVI. — ^Tedeschi.  The  patient,  a  woman,  lived 
to  the  age  of  twenty-eight  years,  and  was  married.  She 
suffered  from  chronic  epilepsy,  and  died  from  tuberculosis. 
The  brain  presented  the  characteristics  of  the  disease. 
It  was  enlarged  and  firm,  and  about  twenty  nodules  were 


424 


JOSEPH  SAILER. 


distributed  upon  the  surface  ot  the  hemispheres.  Upon 
section  of  the  sclerotic  nodules,  they  were  found  to  con- 
sist of  a  gray  peripheral  zone,  a  pale,  white,  median  zone, 
and  an  intensely  red  centre.  Beneath  the  ependyma  were 
a  number  of  hard  swellings,  about  the  size  of  millet  seeds. 
The  sclerotic  areas  contained  a  few  faintly  staining  vari- 
cose fibres.  The  neuroglia  cells  possessed  threadlike  pro- 
cesses, and  formed  a  thick  network,  and  some  of  them  re- 
sembled ganglion  cells,  having  large,  pale  nuclei  and 
some  branching  processes.  There  was  hyperplasia  of  the 
blood  vessels,  but  no  round-celled  infiltration.  The  masses 
in  the  floor  of  the  ventricles  were  composed  of  cells  with 
long,  delicate  processes,  that  formed  a  network  permeated 
by  normal  vessels.  The  ganglion  cells  of  the  thickened 
gyri  were  vacuolated,  and  sometimes  the  nucleus  was  de- 
formed and  near  the  periphery.  In  the  other  areas  large 
cells,  fifty-four  microns  in  diameter,  with  large,  pale  nu- 
clei, degenerated  protoplasm,  and  branching  processes 
were  found,  which  Tedeschi  holds  to  be  ganglion  cells 
similar  to  those  found  in  glioma. 

Case  XXVII. — Spiller.  There  was  no  family  history. 
The  patient  was  an  imbecile,  and  was  epileptic;  during  his 
fits  he  would  fall,  striking  the  right  parietal  region  of  the 
head.  The  history  is  extremely  meagre.  The  are  is  not 
given.  At  the  autopsy  it  was  noted  that  both  feet  were 
in  the  equino-varus  position.  There  were  no  contractures 
and  only  slight  evidences  of  rachitis.  The  dura  was  not 
adherent.  The  brain  was  slightly  oedematous,  and  con- 
tained a  sclerotic  area,  about  the  size  of  a  dollar,  in  the 
right  frontal  lobe.  The  cortex  was  narrowed.  A  similar 
area  was  found  in  the  right  parietal  lobe.  The  other 
organs  were  normal. 

Case  XXVIII. — ^Jiirgens.  The  family  history  was 
negative.  Three  weeks  before  delivery  the  mother  had  a 
slight  fall.  At  the  age  of  three  months  the  child  had  a 
convulsion.  This  was  repeated  two  weeks  later.  The 
child  appeared,  however,  to  have  normal  intelligence.  Six 
weeks  later  general  convulsions  recommenced,  and  con- 


HYPERTROPHIC  NODULAR  GUOSIS. 


425 


tinued,  with  brief  intervals,  for  several  days.  There  was 
then  paralysis  of  the  right  arm.  The  convulsions  were  re- 
peated weekly,  and  were  often  associated  with  movements 
of  the  eyes,  and  preceded  by  a  cry.  The  head  was  large, 
41  cm.,  in  circumference;  the  fontanelles  were  prominent 
and  fluctuating.  There  was  no  disturbance  of  the  reflexes 
and  no  contractures.  Death  occurred  at  the  age  of  six 
months.  At  the  autopsy  the  skull  showed  rachitic  thick- 
ening; the  dura  mater  was  distended,  but  otherwise  nor- 
mal; the  arachnoid  and  pia  were  thin  and  transparent; 
the  convolutions  were  flattened,  and  many  contained 
round,  sharply  circumscribed  areas  of  a  grayish  white  color 
and  almost  cartilaginous  consistency.  The  upper  surface 
of  the  lateral  ventricles  was  rough,  exhibiting  here  and 
there  slight  elevations,  some  almost  as  large  as  a  cherry. 
The  ependyma  was  thickened;  sclerotic  masses  were  also 
found  in  the  basal  ganglia.  The  spinal  cord  was  normal, 
excepting  the  lower  part  of  the  lumbar  region,  which  was 
slightly  hardened.  At  the  apex  of  the  left  ventricle  there 
was  a  hard,  spindle-form  intumescence.  Similar  but 
smaller  foci  were  scattered  throughout  the  substance  of 
the  left  ventricle,  usually  just  beneath  the  pericardium. 
The  mesenteric  glands  were  enlarged:  the  kidneys  con- 
tained cysts.  Microscopical  examination  of  the  myocar- 
dial lesions  showed  sclerotic  muscular  fibres  and  areolar 
fibrous  connective  tissue,  in  the  meshes  of  which  were 
small,  round  or  oval  cysts  resembling  coccidia.  Similar 
bodies  were  also  found  in  the  sclerotic  areas  in  the  brain. 
An  emulsion  of  brain  substance  injected  into  three  rab- 
bits caused  the  death  of  two  in  two  days  without  lesions, 
and  of  the  third  in  eight  days  with  typical  parasitic  myo- 
carditis. Three  rabbits  were  also  inoculated  in  the  eye, 
and  one,  at  the  time  the  paper  was  written,  exhibited 
cerebrospinal  symptoms. 

Of  these  cases,  the  four  reported  by  Buchholz  and  that 
of  Henoch,  should  possibly  be  excluded  as  of  some  other 
nature.  ji 


^26  JOSEPH  SAILER. 

In  addition  to  these  cases,  similar  pathological  con- 
ditions are  more  or  less  deBnitely  alluded  to  by  other 
writers.  Rokitansky  speaks  of  the  partial  indurations  ol 
the  brain,  which  are  g«ierally  distinguished  for  the  great 
degrees  of  hardness  which  they  attain,  and  known  as  a 
callous  state  or  cicatrix  of  the  brain.  These  infiltrutiona, 
which  he  appears  to  regard  as  cancerous,  sometimes  ren- 
der the  diseased  portion  of  the  brain  tough  and  firm,  as 
if  it  were  composed  of  fibrous  tissue.  According  to 
Bouraeville,  Hayem,  Hoffmann  and  D'Espine  have  re- 
ferred to  cases  that  may  also  be  similar.  Barlow  and 
Bury  also  speak  as  if  they  had  seen  a  number  of  examples^ 
but  give  no  details. 

The  common  features  of  all  these  cases  are,  clinically, 
the  existence  of  epilepsy  with  a  greater  or  less  impairment 
of  the  intelligence,  and,  pathologically,  of  a  hyperplasia 
of  the  neuroglia,  with  the  formation  of  tumorlike  masses, 
and  some  destruction  of  the  ganglion  cells  and  nerve 
fibres.  Hyperplasia  of  the  neuroglia,  without  the  forma- 
'    tion  of  nodules,  has  also  been  described  in  epilepsy. 

Chaslin  examined  three  brains  from  epileptics,  and 
found  thickening  and  diffuse  sclerosis  of  the  cortex,  that 
was  due  to  a  hyperplasia  of  the  neurogliar  cells  and  an 
increase  of  their  fibres,  which,  he  believes,  may  traverse 
the  protoplasm  of  the  cells,  or  be  independent  of  them. 
The  neuroglia  seemed  to  invade,  and,  to  a  certain  extent, 
to  replace  the  surrounding  structures,  the  most  super- 
ficial layer  of  the  cortex  being  chiefly  affected.  Often 
the  nuclei  of  the  neurogliar  cells  stained  poorly,  and  their 
protoplasm  showed  a  slight  projection  in  one  part.  The 
ganglion  cells  were  rare  and  irregularly  arranged,  and 
their  protoplasmic  processes  altered.  The  vessels  were 
usually  normal,  excepting  in  the  sclerotic  parts,  where 
they  were  reduced  in  number  and  had  thickened  walls. 
The  degree  to  which  the  process  was  advanced  varied  in 
different  regions.  Bleuler  examined  twenty-six  brains 
obtained  from  chronic  epileptics  and  idiots,  in  all  of  which 


HYPERTROPHIC  NODULAR  GUOSIS.  437 

the  neuroglia  wae  increased  between  the  tanf^ential  tibres 
of  the  cortex  and  the  pia  mater.  This  change  was  diffuse, 
but  not  uniform,  in  all  parts  of  the  brain,  and  its  extent 
appeared  to  correspond  more  closely  to  the  degree  of 
idiocy  than  to  the  duration  of  the  disease.  The  pia  was 
not  adherent.  In  fifty-four  brains  taken  from  patients  not 
epileptic,  there  were  slight  indications  of  the  sclerosis 
in  fifteen  (idiots,  paranoiacs,  paralytics  and  senile  de- 
ments), but  even  in  these  cases  the  appearance  was  not  the 
same;  the  fibres  were  not  parallel  and  were  more  loosely 
arranged.  Schultze  found  hyperplasia  of  the  neuroglia 
in  a  case  of  porencephaly,  probably  congenital  in  nature. 
Corpcwa  amylacea  and  compound  granular  cells  were  also 
found  in  the  lesions,  and  there  were  warty  prominences 
upon  the  floors  of  the  ventricles.  Pierrot  has  observed 
sclerosis  in  senile  brains,  affecting  the  deepest  and  most 
superficial  layers  of  the  cortex. 

Various  theories  have  been  held  regarding  the  nature 
of  gUosis.  Brissaud,  in  discussing  the  case  which  he  re- 
ported with  Boumeville,  speaks  of  it  as  a  chronic  inflam- 
matory process  of  slow  development,  with  its  chief  seat 
in  the  gray  matter.  In  the  following  year,  in  discussing 
the  case  of  Pozzi,  he  stated  that  the  only  distinction  be- 
tween the  hypertrophic  and  atrophic  forms  is  that  the 
former  represents  an  earlier  stage,  and  the  latter  a  later 
stage  of  the  process;  that  is,  hypertrophic  sclerosis  repre- 
sents hyperplasia  of  the  neuroglia  cells  and  fibres,  atrophic 
sclerosis  their  subsequent  contraction. 

Hartdegen,  however,  whose  patient  died  two  days 
after  birth,  pointed  out  that  the  process  must  be  congeni- 
tal; but,  as  in  his  case  there  was  no  defect  in  the  arrange- 
ment of  the  convolutions,  he  held  that  it  must  have  com- 
menced after  the  seventh  month  of  fcetal  life,  before  which 
time  the  convolutions  are  not  fully  formed.  Pollak  is  satis- 
fied to  call  it  disseminated  sclerosis,  which  he  believes  may 
affect  the  fcetus  in  utero,  developing  slowly  or  rapidly 
after  birth.    Furstner  and  Stiihlinger  had  a  theory  of  their 


428  JOSEPH  SAILER. 

own  that  to-day  sounds  somewhat  absurd.  They  believed 
that  the  lymphocytes  passed  through  the  blood  vessels 
and  collected  outside  the  adventitia,  where  they  were  con- 
verted into  neuroglia  cells,  and  that  their  gradual  accumu- 
lation produced  the  sclerotic  change.  After  this,  pres- 
sure, or  other  cause,  may  produce  softening  in  the  centre 
of  these  areas;  a  process,  they  remark,  and  not  unjustly, 
very  similar  to  that  which  occurs  in  syringomyelia.  They 
even  claim  to  have  observed  these  lymphocytes  in  the 
process  of  transformation.  It  should  be  noted  that  their 
specimens,  all  of  which  were  from  adults,  showed,  distinct 
signs  of  inflammatory  reaction.  Chaslin,  in  1889,  be- 
lieved that  the  sclerosis  that  occurs  in  epilepsy  is  due  to  a 
hyperplasia  of  the  neuroglia,  and  proposed  to  call  it  neu- 
roglia sclerosis.  He  points  out  that  the  neuroglia  forms 
bundles  of  coarse  fibres;  an  observation  that  had  already 
been  made  by  Buchholz,  who  explained  it  by  supposing 
that  the  neuroglia  cells  were  converted  into  fibres.  In  a 
paper  published  two  years  later  he  stated  that  he  did  not 
believe  that  the  gliosis  cerebri  is  due  to  an  old  inflamma- 
tory lesion,  especially  as  the  hyperplasia  takes  place  at 
some  distance  from  the  blood  vessels,  and  is  most  intense 
in  the  superficial  layer,  and  nevertheless  the  pia  is  not 
adherent.  He  suggests  three  hypotheses:  I.  Arrest  of 
development  of  the  nerve  cells  and  fibres.  2.  Only  partial 
development  of  the  nerve  tissue,  3.  Primary  development 
of  the  neuroglia  and  atrophy  of  the  nerve  tissue  by  com- 
pression. He  preferred  the  last,  particularly  as  he  regards 
the  process  as  congenital,  and  as,  in  the  regions  where  it 
was  advanced,  the  capillaries  are  compressed.  He  con- 
cluded that:  I.  The  fibres  in  the  cerebral  cortex  in  sclerosis 
are  developed  from  the  neuroglia.  2.  This  process  is  found 
in  epilepsy,  is  due  to  some  congenital  defect,  and  should  be 
called  gliosis.  3.  In  many  conditions  in  which  it  occurs 
several  causes  are  active. 

Fere  appears  to  include  sclerose  tubereuse  among  the 
chronic  forms  of  encephalitis,  although  he  admits  that 


HYPERTROPHIC  NODULAR  GLIOSIS.  429 

Chaslin  has  demonstrated  that  it  is  due  to  proliferation 
of  the  neurogUa  tissue  and  is  peculiar  to  the  nervous  sys- 
tem. 

Birch-Hirschleld  has  suggested  the  possibility  that 
the  primary  lesion  is  an  atrophy  of  the  nervous 
elements  with  consecutive  proUferation  of  the  neu- 
roglia tissues.  He  is  skeptical  regarding  the  in- 
flammatory nature  of  the  process.  Ziegler  also 
rejects  the  inflammatory  theory,  and  holds  to  that  of 
congenital  defect;  although  he  states  that  the  form  known 
as  ependymal  sclerosis,  that  is,  the  thickening  of  the  sub- 
ependymal neuroglia  and  its  projection  into  the  ventricle, 
a  condition  commonly  present  in  gliosis  cerebri,  is  usually 
associated  with  degenerative  or  inflammatory  conditions. 
Thibal  alone  seems  to  consider  nodular  gliosis  as  a  distinct 
disease,  believing  that  there  is  a  rapid  hyperplasia  of  the 
neuroglia  tissues,  which  presses  upon  the  nervous  ele- 
ments and  causes  atrophy.  A  totally  different  view  is 
taken  by  the  English  authors  Barlow  and  Bury.  They 
do  not  speak  of  tuberous  sclerosis  at  all,  but  describe, 
among  the  changes  occurring  in  the  brain  as  a  result  of 
hereditary  syphilis,  conditions  which  are  identical  with 
it.  The  most  striking  and  important  lesions  are  found  in 
the  cortex.  The  sclerosis  occurs  in  small  masses,  or  may 
involve  entire  convolutions,  with  or  without  increase  of 
their  bulk.  Sometimes  there  is  a  certain  amount  of 
atrophy,  some  of  the  convolutions  being  narrow,  of  car- 
tilaginous consistency,  and  brownish  pink  in  color.  The 
white  substance  may  be  involved  also,  but  ordinarily  the 
change  is  entirely  cortical.  Microscopically  there  is  found 
extensive  overgrowth  of  the  neuroglia  and  disappearance 
of  the  nerve  cells;  occasionally  themembranesareadherent, 
and  arterial  changes  are  frequent,  although  not  constant. 
Gowers,  who  appears  to  have  devoted  very  little  attention 
to  this  particular  condition,  adopts  this  view  without 
hesitation.  Henoch,  although  not  suggesting  any  other 
etiology,  does  not  believe  that  the  cases  are  demonstrably 


430 


JOSEPH  SAILER. 


syphilitic,  an  opinion  with  which  most  pathologists  will 
agree.  Barlow  and  Bury  do  not  describe  any  cases,  (ail 
to  mention  whether  syphilitic  antecedents  usually  are  pres- 
ent, or  if  unquestionable  syphilitic  lesions  are  to  be  found 
in  other  parts  of  the  body. 

Examination  of  the  recorded  cases  with  reference  to 
the  etiology  gives  very  unsatisfactory  results.  In  the  great 
majority  it  is  not  discussed.  Of  all  the  twenty-seven  cases 
the  sex  is  given  in  seventeen,  six  female  and  eleven 
males;  the  presence  or  absence  of  neuropathic  heredity  is 
mentioned  in  nine  cases,  and  may  be  inferred  in  a  tenth; 
it  was  present  in  six.  Traumatism  occurred  in  one  case, 
and  appeared  to  bear  some  etiological  relation  to  the  con- 
dition, Syphilis  of  the  parents  is  mentioned  in  one  case, 
and  it  may  have  existed  in  another.  In  a  number  of  others 
it  was  apparently  excluded  on  account  of  the  existence 
of  other  healthy  children  in  the  family,  both  older  and 
younger.  It  is  interesting  to  note  the  condition  of  the 
kidneys.  This  has  been  recorded  in  only  eight  cases;  in 
a  number  of  the  others  they  were  certainly  not  examined, 
and  in  the  rest  no  mention  is  made  of  either  the  presence 
or  absence  of  changes.  Of  these  eight  cases,  tumors  of  the 
kidneys,  essentially  similar  in  their  gross  appearance, were 
found  in  Ave,  and  the  kidneys  of  a  sixth  case  contained 
cysts.  In  one  case  congenital  lesions  of  the  heart  were 
present.  In  a  case  of  .Von  Recklinghausen,  which  may 
possibly  belong  to  this  condition,  multiple  myomata  of 
the  heart  were  found.  The  discovery  of  a  coccidial  parasite 
by  Jurgens  is  of  great  interest;  but,  although  it  is  ap- 
parently pathogenic  for  rabbits,  it  cannot  be  accepted  as 
the  cause  of  the  brain  lesions  without  further  confirma- 
tion. Unfortunately,  these  cases  appear  to  be  so  rare  that 
this  is  not  likely  soon  to  be  forthcoming.  The  congenital 
character  of  some  of  the  .cases  and  the  entire  absence  of 
any  bodies  resembling  coccidia  from  the  lesions  justify,  for 
the  present,  a  certain  degree  of  conservative  skepticism. 
An  examination  of  the  lesions,  with  particular  refer- 


HYPERTROPHIC  NODULAR  GUOSIS. 


431 


ence  to  the  nature  of  the  process,  shows  that  the  following 
features  are  more  or  less  constant  in  all  of  the  cases:  The 
thickening  of  the  neuroglia  fibres  and  their  arrangement 
either  in  wavy  lines  or  in  coarse  mesh  work.  Freund  de- 
scribes it  as  a  hyperplasia  of  the  neuroglia,  with  increase 
of  the  cells,  and  atrophy  and  partial  or  total  disappear- 
ance of  the  nervous  elements.  The  neuroglia  forms  a 
coarse-meshed  network,  or  bundles  that  may  subsequently 
retract.  This  is  found  not  only  in  the  forms  of  sclerosis 
that  appear  to  be  idiopathic,  but  also  as  a  chang-e  secon- 
dary to  destructive  injuries  and  infectious  diseases,  such  as 
syphilis.  Tedeschi  and  I  have  both  found  it  as  a  result  of 
experimental  injury.  Koppen  has  found  it  in  a  number  of 
cases  that  were  usually  of  syphilitic  nature.  In  one  the 
lesions  were  found  in  the  occipital  lobes,  limited  particu- 
larly to  the  cortex,  and  consisted  of  small  areas  somewhat 
lighter  and  denser  than  the  ordinary  tissue.  These  were 
of  two  kinds — those  containing  granular  cells  and  fibrous 
connective  tissue,  and  showing  traces  of  nervous  tissue, 
and  those  consisting  of  proliferated  neuroglia,  in  which  the 
gliacellswere  increased  in  number,  and  their  fibres  formed  a 
wide-meshed  network ;  in  these  areas  there  was  an  excessive 
number  of  blood  vessels,  and  the  ganglion  cells  and  nerve 
fibres  had  disappeared.  In  a  brain  with  microgyri,  prob- 
ably a  case  of  atrophic  sclerosis,  the  neuroglia  in  some  situ- 
ations was  arranged  in  irregular  fibrous  masses,  sometimes 
in  wavy,  sometimes  in  spiral  form.  There  was  no  network, 
and  neither  glia  cells  nor  ner\e  fibres  could  be  found.  In 
the  subependymal  tissue  similar  changes  were  present. 
Weygandt  also  observed  a  coarse  reticulum  in  the  neu- 
roglia in  the  neighborhood  of  a  gumma  of  the  brain,  and 
in  some  of  the  neighboring  convolutions  the  cortex  con- 
tained an  excess  of  glia  cells.  I  have  observed  similar 
changes  in  the  cortex  of  a  brain  from  a  habitual  criminal, 
which,  excepting  an  apparent  thinness  of  the  gray  mat- 
ter, exhibited  no  gross  lesions. 

The  pyramidal  cells  are  usually  entirely  absent  in  the 


432 


JOSEPH  SAILER. 


most  sclerotic  foci;  in  other  situations  they  are  present, 
often  apparently  increased  in  number,  and  staining  well, 
but  they  are  atypical  in  arrangement,  and  show  tortuosity 
of  their  protoplasmic  processes,  as  occurred  in  my  own 
case  and  in  those  of  Hartdegen  and  Bruckner.  The  same 
condition  has  been  described  by  Koster  as  occurring  in 
the  brain  of  an  idiot  who  died  at  the  age  of  twenty-six, 
and  whose  brain  presented  no  gross  lesions;  by  Bourne- 
ville  and  PiUiet,  in  a  case  of  diffuse  sclerosis  of  the  brain 
and  cord,  and  by  Chaslin  in  his  three  epileptic  brains.  The 
pericellular  spaces  are  occasionally  distended.  This,  ac- 
cording to  De  Quervain,  is  not  an  antemortem  condition, 
even  although  round  cells  are  sometimes  found  in  this 
space.  Koster,  however,  looks  upon  it  as  a  morbid  lesion, 
having  sometimes  found  two  ganglion  cells  in  one  di- 
lated space.  It  is  certainly  an  artefact  in  many  cases,  how- 
ever, and  I  do  not  personally  believe  that  much  weight 
can  be  attached  to  it.  More  important  is  the  dilation  of 
the  perivascular  spaces.  Jendrassik  and  Marie  were  the 
first  to  call  special  attention  to  this.  In  their  case  this 
space  was  sometimes  five  or  six  times  as  wide  as  the 
vessel  it  surrounded,  and  was  entirely  occupied  by  a  large- 
meshed  reticular  tissue,  with  cells  at  the  intersections  of 
the  fibres  that  were  not  unlike  neurogliar  cells.  The  fibres 
either  ceased  at  the  inner  surface  of  the  lymphatic  sheath, 
or  they  extended  into  the  adventitia.  The  medullated 
nerve  fibres  stopped  at  the  edge  of  the  space  as  if  cut  off, 
and  the  vessels  were  tortuous  and  apparentlv  more  nu- 
merous than  normal,  both  changes  probably  due  to  the  re- 
traction of  the  tissue.  Muhr  has  described  similar  changes 
in  a  case  of  hemiatrophy  of  the  brain.  This  distension  of 
the  perivascular  lymph  spaces  seems  to  confirm  Striim- 
pell's  theory  of  lymphatic  obstruction. 

The  degree  of  vascularity  has  been  variously  described. 
Bourneville  and  Pilliet,  and  Tedeschi  have  found  the  blood 
vessels  to  be  numerous,  while  Chaslin  and  Bourneville  and 
Brissaud  have  stated  that  they  are  few,  or  absent  from  the 


HYPERTROPHIC  NODULAR  GUOSIS. 


433 


sclerotic  areas.     Buchholz  regards  some  of  the  fibrous 
tissue  in  his  case  as  representing  degenerated  blood  ves- 
sels.     In  my  case  both  conditions  were  present.     Where 
the   sclerosis  was  slight,  the  blood  vessels  did  not  seem 
to  be  increased  in  number.     Where  it  was  marked,  par- 
ticularly in  those  areas  found  in  the  deepest  layers  of  the 
cortege,  they  were  distinctly  more  numerous.     In  fact,  it 
sometimes  appeared  as  if  an  agiomatous  alteration  had 
taken  place.    In  the  subependymal  nodules,  on  the  other 
hand ,  where  the  changes  were  by  far  the  most  gronounced,   ' 
the    blood  vessels  were  entirely  absent.     It  seems  easy  to 
understand  how  these  variations  occur.    The  proliferated 
neuroglia  tissue  must  exert  more  or  less  pressure  upon  the 
surrounding  tissue.     In  certain  areas  this  pressure  causes 
obstruction,  with  secondary  dilatation  of  the  blood  vessels, 
^"^^^      perhaps,    the    approximation    of    certain    adjacent 
•"^Tiches.     That  an  actual  vascular  proliferation   takes 
^  ^«  it  is  impossible  to  deny,  but  there  seems  to  be  no 
*  ^^  reason  to  believe  that  it  does,  unless  we  accept  the 
vftcsriry  of  Birch-Hirschfeld  that  there  is  a  primary  atrophy 
o^  the  true  nervous  elements  and  secondary  proliferation 
ol  the  other  tissues  to  take  their  place;  but  this  theory 
appears  to  be  disproved  by  the  frequently  reported  pres- 
ence of  pyramidal  cells  and  nerve  fibres  in  those  areas 
where  the  sclerosis  has  not  reached  an  extreme  degree. 
The  ultimate  disappearance  of  the  blood  vessels  is  prob- 
ably due  to  their  total  obliteration  by  pressure.    Compar- 
iiif  two  neighboring  nodules  I  saw  numerous  vessels  in 
one,  while  in  the  other,  in  which  the  neuroglia  fibres  were 
coarser  and  the  process  appeared  to  be  more  advanced, 
they  were  totally  absent,     Perhaps  the  peculiar  bodies 
found  in  the  sclerotic  areas  beneath  the  ependyma  of  the 
lateral  ventricles  are  more  significant  of  the  destruction 
o(  nerve  tissue.     Pozzi  describes  them,  and  calls  them 
colloid,  and  they  are  probably  the  same  as  the  round, 
glassy  bodies  that  Bruckner  mentions.     Dagonet  has  de- 
scribed what  are  evidently  the  same  things,  and  calls  them 


434  JOSEPH  SAILER. 

hyaloid.  He  believes  that  they  are  derived  from  cere- 
brin.  Stroebe  found  them  in  the  cords  of  rabbits,  in  which 
partial  or  total  section  had  been  made,  and  from  their  re- 
lation to  the  nerve  fibres  is  convinced  that  they  are  the 
products  of  the  degeneration  of  the  myelin  sheaths  and  the 
axis  cylinders.  They  have  been  frequently  described  in 
degenerative  processes,  and  I  have  observed  them  in  arr 
area  of  softening  in  the  brain  of  an  infant  that  died  of  tu- 
bercular meningitis,  and  in  the  sclerotic  areas  in  the  cor- 
tex of  the  brain  of  a  criminal.  The  peculiar  pale,  pear- 
shaped  bodies  found  in  the  cortex  are  more  difficult  to 
explain.  Bourneville,  Tedeschi  and  De  Ouervain  have 
found  similar  bodies  and  considered  them  as  degenerated 
cells,  either  neuroglia  or  ganglion,  an  opinion  with  which 
I  agree.  If  we  consider  them  to  be  neuroglia  cells,  they 
suffice  to  explain  the  disappearance  of  these  from  the  areas 
where  the  gliosis  is  most  pronounced.  In  all  the  positive 
cases  endarteritis  and  perivascular  round-cell  infiltration 
appear  to  have  been  absent. 

It  does  not  appear  from  this  analysis  that  there  is  any 
ground  for  the  assumption  of  either  an  inflammatory  or 
syphilitic  etiology.  Either  process  can  produce  hyper- 
plasia of  the  neuroglia  tissue,  but  the  absence  of  the  round 
cells  and  proliferation  of  the  true  connective  tissue,  and 
the  infrequency  of  pial  adhesions  are  sufficient  to  exclude 
the  former.  Syphilis  produces  such  a  variety  of  lesions  that 
it  is  difficult  to  state  positively  that  it  could  not  cause 
nodular  gliosis.  Von  Bechterew,  however,  holds  that 
syphilis  of  the  nervous  system  is  a  disease  of  specific  na- 
ture, caused  directly  by  luetic  infection,  and  not  a  condi- 
tion which  may  develop  as  a  result  of  preexisting  syphilis. 
In  the  case  of  disseminated  syphilitic  sclerosis  that  he  re- 
ports, the  focal  lesions  appear  to  have  been  due  to  pro- 
liferation of  the  perivascular  connective  tissue,  and  not  to 
hyperplasia  of  the  neuroglia,  and  there  was  extensive  en- 
darteritis. The  inclusion  of  pure  gliosis  among  the  syphi- 
litic conditions  by  Barlow  and  Bury  seems  wholly  without 


HYPERTROPHIC  NODULAR  GLIOSIS.  435 

warrant.    The  clinical  histories  are  also  negative;  the  fact 
that  the  parents  of  one  child  were  certainly  syphilitic  is 
offset  by  the  fact  that  in  several  cases  we  can  be  reasonably 
certain  that  they  were  not.    The  case  of  Henoch,  in  all 
likelihood,  does  not  belong  to  this  group;  for  in  none  of 
the  others  do  the  nodules  bear  the  slightest  resemblance 
to  gummata.    We  are  then  forced  to  fall  back  upon  some 
theory  of  the  idiopathic  proliferation  of  the  neuroglia. 
In  this  connection  it  is  interesting  to  note  the  considerable 
number  of  congenital  defects  that  have  been  reported  as 
occurring  in  these  cases.     In  eight  cases  in  which  com- 
plete autopsies  were  made,  tumors  or  cysts  of  the  kidneys 
of  considerable  size  were  found  in  six.    Unfortunately,  sat- 
isfactory diagnoses  have  not  been  made  in  any  of  these 
cases  with  the  exception  of  my  own,  although  Boumeville 
speaks  of  one  of  his  specimens  as  being  cancerous,  and 
Henoch  of  the  nodules  in  his  case  as  g^mmata.    As  the 
microscopic  description  of  two  of  them  at  least  agrees 
closely  with  the  condition  I  observed,  I  think  it  not  unlike- 
ly they  were  tumors  similar  to  mine,  that  is,  adenosarco- 
mata  of  a  distinctly  congenital  type.    In  no  case  except  my 
own,  as  far  as  I  am  aware,  were  nodules  found  in  any  other 
part  of  the  body.    It  seems  to  me  therefore  reasonable  to 
conclude  that  hypertrophic  tuberous  gliosis  is  akin  to 
tumor  formation,  and  represents  a  growth  peculiar  to  late 
foetal  existence  in  view  of  observations  of  Binswager  and 
Hartdegen.    It  is  closely  allied  to  atrophic  sclerosis,  a  con- 
dition most  carefully  described  by  Jendrassik  and  Marie, 
and  to  sclerosis  with  cavity  formation.    These  varieties  are 
not  sharply  separated,  but  any  two,  or  all  three,  may  co- 
exist in  the  same  brain.    Bourneville  has  reported  one  case 
and  Fiirstner  and  Stiihlinger  two,  in  which  cavities  were 
found  in  sclerotic  nodules,  and  in  nearly  all  cases  of  the 
hypertrophic  form  some  of  the  convolutions  were  atrophic* 
The  symptoms  of  this  disease  are  exceedingly  various. 
The  essential  ones  are  epilepsy,  commencing  in  some  form 
or  other  in  early  infancy,  associated  with  a  greater  or  less 


i 


436  JOSEPH  SAILER. 

degree  of  idiocy.  Richardiere  holds  that  in  the  hyper- 
trophic form  the  convulsions  are  more  frequent  and  se- 
vere, and  the  idiocy  more  profound,  than  in  the  atrophic 
form,  but  this  is  doubtful.  It  is  said  of  Schule's  case  that 
she  learned  to  read  and  write,  although  she  was  always 
unable  to  reckon;  and  Bruckner's  patient  learned  to  write 
a  little.  Tedeschi's  subject  was  a  married  woman  of  28. 
Pozzi's,  an  old  man  of  63,  who  had  been  able  to  keep  out 
of  an  asylum  for  that  many  years.  My  own  case  exhibited 
remarkable  skill  in  untying  knots,  no  matter  how  compli- 
cated. The  epilepsy  also  may  be  reduced  to  transient 
attacks  of  rigidity,  as  in  Pollak's  patient,  or  completely 
absent  for  long  periods,  as  in  Bruckner's  case.  The  epi- 
leptic attacks,  as  far  as  one  can  gather  from  the  often 
meagre  reports,  are  sometimes  Jacksonian  in  type,  some- 
times more  general.  The  other  symptoms,  such  as  nys- 
tagmus, muscular  atrophies,  facial  atrophy,  are  too  infre- 
quent to  be  seriously  considered  in  making  a  diagnosis; 
difficulty  of  deglutition  has  been  noted  in  Simon's  and 
Pollak's  cases,  and  in  my  own.  The  value  of  symptoms 
indicating  focal  lesions  is  doubtful.  When  the  very  con- 
siderable microscopic  alteration  of  the  cortex  and  the 
fact  that  the  lesions  are  often  found  in  the  motor  and 
visual  regions  are  considered,  it  must  be  admitted  that 
corresponding  functional  disturbances  cannot  exist.  This 
is  not  improbable,  in  view  of  the  frequent  presence  of  the 
ganglion  cells  in  the  sclerotic  areas  of  the  cortex.  Boume- 
ville  holds  the  clinical  diagnosis  to  be  exceedingly  difficult. 
Freund,  that  it  is  impossible,  claiming  that  the  disease 
cannot  be  diflferentiated  from  diffuse  atrophic  sclerosis,  or 
meningo-encephalitis;  but  Simon  confidently  describes  the 
clinical  course,  and  reports  a  number  of  living  cases,  as 
does  also  Richardiere,  although  the  latter  admits  the  un- 
certainty of  his  diagnoses.  Bruckner,  in  his  own  case, 
ascribes  the  idiocy  to  the  involvement  of  the  frontal  lobes, 
and  the  epilepsy  to  the  lesions  in  the  motor  region;  but 
Simon's  patient  had  no  lesions  in  the  frontal  lobes,  and 


HYPERTROPHIC  NODULAR  GLIOSIS. 


437 


was  nevertheless  an  idiot,  although  it  must  be  admitted 
that  a  certain  degree  of  microcephaly  might  account  for 
this.  It  is  not  unlikely,  however,  that  the  process,  even 
in  the  hypertrophic  nodular  variety,  is  tolerably  diffuse; 
for  I  have  observed  slight  changes  in  portions  of  the  cor- 
tex that  are  apparently  normal.  In  my  own  case,  the 
greater  extent  of  the  process  on  the  left  side  may  have 
been  associated  with  the  invariable  tendency  to  fall  to  the 
right.  Unfortunately,  no  accurate  record  of  the  condition 
of  the  eyes  was  kept,  otherwise  it  is  not  impossible  that 
the  symmetrical  lesions  in  the  cuneus  might  have  been 
suspected. 

The  following  conclusions  seem  to  be  warranted: 

1.  There  is  a  morbid  process  characterized  by  a  hyper- 
plasia of  the  neuroglia  cells  and  fibres  that  leads  to  gradual 
atrophy  of  the  nerve  fibres  and  the  ganglion  cells,  and  is 
associated  with  perivascular  changes  of  doubtful  nature. 

2.  The  first  manifestations  occur  in  early  life,  often  a 
few  weeks  after  birth,  and  anomalies  or  congenital  tumors 
are  sometimes  found  in  the  same  cases. 

3.  All  cases  of  this  disease  are  epileptics,  and  many  of 
them  idiots. 

4.  The  cause  is  unknown,  but  the  disease  probably 
commences  before  birth  and  after  the  seventh  month  of 
foetal  Existence,  and  is  of  the  same  nature  as  gliomatosis. 

Scarpatetti  (Archiv  fiir  Psychiatric,  vol.  30,  No.  2,  p. 
537)  has  recently  reported  an  additional  case  of  this  na- 
ture. The  father  of  the  patient  was  unknown;  the  mother 
had  always  been  sickly.  The  child  had  visited  school  in 
her  youth  and  had  learned  something.  In  later  life  she 
had  been  at  service,  and  had  had  three  illegitimate  chil- 
dren. The  first  is  still  living,  the  second  died  of  hydro- 
cephalus, the  third  she  strangled.  The  investigation 
instituted  by  the  court  developed  that  she  had  suffered 
for  years  with  occasional  attacks  of  epilepsy.  She  was 
small,  undeveloped  and  stupid.  Her  head  had  a  circum- 
ference of  58  cm.  There  was  a  dermoid  cyst  on  the  left 
side  of  the  nose;  the  ears  were  especially  small,  and  there 


1 1 


^'•1 

w 


If 


438  JOSEPH  SAILER. 

was  torus  palatinus.  The  patient  was  industrious,  but  ap- 
peared to  take  no  interest  in  anything  but  her  manual 
work.  At  the  age  of  20  sh^  was  attacked  with  fever, 
diarrhoea,  pains  in  the  legs,  and  paraplegia,  dying  on  the 
third  day  of  the  attack.  At  the  autopsy  the  skull  was 
found  to  be  thick  and  solid,  the  dura  slightly  adherent.  In 
the  substance  of  the  brain  were  four  hard,  tumorlike  masses, 
between  the  first  and  second  frontal  lobes.  Many  of  the 
convolutions  were  pale  and  of  the  consistency  of  cartilage. 
The  larger  swellings  were  depressed  in  the  centre,  and 
over  them  the  pia  mater  was  adherent.  Numerous  small,, 
hard  nodules  were  found  in  the  ependyma  of  the  ventricles. 
The  cerebellum,  basal  ganglia  and  spinal  cord  were  nor- 
mal; the  kidneys  contained  a  number  of  small,  hard,  cir- 
cumscribed nodes,  consisting  chiefly  of  involuntary  muscle 
fibres.  Microscopically,  no  degenerated  fibres  were  found 
in  the  sclerotic  areas.  The  pyramidal  cells  were  either 
slightly  swollen  or  atrophic.  They  were  much  altered  in 
shape,  and  their  position  was  irregular.  The  tangential 
fibres  had  disappeared,  and  at  the  periphery  of  the  cortex 
nothing  was  left  excepting  a  coarse  neuroglia  tissue.  The 
other  regions  in  the  brain  were  normal.  The  blood  ves- 
sels exhibited  marked  hyalin  degeneration,  and  were  in 
part  obliterated.  In  the  sclerotic  areas  they  were  more 
numerous  than  normal.  The  author  calls  attention  to  the 
presence  of  other  signs  of  degeneration,  but  is  rather  in- 
clined to  believe  that  the  disease  is  the  result  of  hereditarv 
syphilis,  and,  on  account  of  the  normal  position  of  the 
chief  sulci,  he  is  inclined  to  believe  that  it  developed  late 
foetal  life.  He  admits,  however,  that  it  probably  is  only 
an  exaggeration  of  the  condition  usually  found  in  epileptic 
brains. 

Scarpatetti  refers  to  an  additional  case,  that,  on  ac- 
count of  its  misleading  title,  escaped  my  attention,  and  has 
not  been  included  in  the  literature.  The  changes  were  ap- 
parently slight.  (Koch:  "Ein  Fall  von  Idiotie  in  Folge  von 
Application  der  Zunge."  Neurologisches  Centralblatt, 
1887.) 


HYPERTROPHIC  NODULAR  GLIOSIS. 


439 


No. 


I 
2 

3 
4 
5 
6 

7 
S 

9 

10 

II 

12 

13 
14 
15 
i6 

17 
i8 

19 

20 
21 
22 

23 

24 

25 
26 

27 
28 

29 

30 


Name. 


• 

a 

OS 

Sex. 

ropath 
realty. 

00 

< 

?2 

1 

el 


fiourneville 

Bourneville  &  Brissaud 
Boumeville  &  Bonnaire 
Bourneville  &  Bonnaire 
Bourneville  &  Bonnaire 

Hartdegen 

Pollak 

Bruckner 

Pocci 

Simon 

Schule 

Bucholz 

Thibal 

Bucholz 

Bucholz 

Bucholz 

Wilmarth 

Wilmarth 

Wilmarth 

Wilmarth 

Wilmarth 

Wilmarth 

Henoch 

Bcrdez 

Bourneville 

Tedeschi 

Spiller 

Jurgens 

Sailer 

Scarpatetti 


15 

4 

5 

2  days 
3 

22 

68 

2yi 


2 

4 
II 

28 

6mos. 
IS 

20 


f. 

m. 
m. 
m. 
m. 
m. 
f. 
f. 

m. 
f. 


m. 
m. 
m. 

f. 


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0 


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LITERATURE. 


S 

p 

& 


Bio 

8° 


z 

I 


Barlow  &  Bury:  Tuke's  Dictionary  of  Psycholgical  Medicine^ 
London,  1892,  p.  1261. 

Von  Bechterew:  Arch,  fur  Psychiatric,  vol.  xxviii..  No.  3,  1896. 

Berdez:  Ziegler's  Beitrage,  vol.  xvii.,  p.  648. 

Binswanger:  Virchow's  Archiv,  102,  1886. 

Birch-Hirschfeld:  Lehrbuch  der  pathologischen  Anatomic,  vol. 
ii.,  Leipsic,  1894. 

Bleuler:   Munch,  med.  Woch.,  Aug.  15,  1895. 

Bourneville:   Arch,  de  Neurologic,  iSk),  p.  91. 

Bourneville:   Progres  Medical,  1896,  No.  9. 

Bourneville  et  Bonnaire:  Bull,  de  la  Soc.  Anat.  de  Paris,  Feb.^ 
1881. 

Bourneville  et  Bonnaire:  Bull,  de  lo  Soc.  Anat.  de  Paris,  July, 
1881. 

Bourneville  et  Bonnaire:    Progres  M6dicale,  1881,  p.  1007. 

Boumeville  et  Brissaud:    Arch,  de  Neurologic,  1880,  p.  397. 

Bourneville  et  Pillet:  Recherches  sur  TEpilepsie,  I'Hysterie  ct 
"Idiotic  par  Boumeville  et  Bricon,  Paris,  1885. 


1 


i 

.  ri 


440 


JOSEPH  SAILER. 


Bruckner:   Arch,  fiir  Psychiatric,  vol.  xii.,  No.  3,  1882. 

Buchholz:   Arch,  fiir  Psychiatric,  vol.  xix.,  1888,  p.  591. 

Buchholz:    Neurologisches  Centralblatt,  1890,  p.  036. 

Chaslin:   Semaine  Medicale,  1889. 

Chaslin:   Arch,  de  Medicine  Experinientale,  vol.  iii.,  1891. 

Dagonet:   Systeme  Nerveux  Central,  Paris,  1897. 

De  Quervain:  Virchow's  Archiv,  133,  1893. 

Echeverria:    Epilepsy,  New  York,  1870. 

Fere:  Traite  Elementaire  d' Anatomic  Medicale,  Systeme  Ner- 
veuse,  Paris,  1891. 

Freund:    Infantile  Cerebrallahmungen,  Vienna,  1897. 

Fiirstner  und  Stiihlinger:    Arch,  fiir  Psychiatric,  vol.  xviL,  1896. 

Gowers:    Diseases  of  the  Nervous  System,  Philadelphia,  1896. 

Hartdegcn:    Arch,  fiir  Psychiatric,  vol.  xi.,  1881,  p.  117. 

Henoch:    Kinderkrankheiten,  Berlin,  1893. 

Jendrassik  et  Marie:  Arch,  de  Physiologic  Normale  et  Patholo- 
gique,  1895. 

Jiirgens:    Berl.  klin.  Woch.,  April  4,  1898. 

Koppen:  Arch,  fiir  Psychiatric,  vol.  xxviii.,  No.  3,  1896. 

Koster:    Neurologisches  Centralblatt,  1889,  p.  292. 

Muhr:   Arch,  fiir  Psychiatric,  1876,  p.  733. 

Pierret:    Bride.  These  de  Lyon,  1888  (quoted  by  Fer6). 

Pollack:    Arch,  fiir  Psychiatric,  1881-2. 

Pollak:   Deutsches  Arch,  fiir  klin.  Med.,  vol.  xxiv.,  1879,  P-  407- 

Poszi:    L'Encephale,  1883,  p.  157. 

Richardiere:    These  de  Paris,  1896. 

Rokitansky:    Manual  of  Pathological  Anatomy,  London,  1850. 

Sailer:  Proceedings  of  the  Pathological  Society  of  Philadelphia, 
vol.  i.,  No.  3. 

Schule:    Klinische  Psychiatric,  3d  edition,  1886. 

Schulze:    Festschrift,  Heidelberg,  1886. 

Stroebe:    Ziegler's  Beitrage,  vol.  xv. 

Simon:    Rev.  Mens,  des  Maladies  de  L'Enfance,  Dec.  1883. 

Spiller:  Reports  of  the  Philadelphia  Pathological  Society,  1896-7. 
•  Striimpell:   Arch,  fiir  Psychiatric,  vol.  ix.,  p.  268. 

Tedeschi:  Revista  Sperimentale  di  Freniatria  e  di  Med.  Legal,  voL 
XX.,  1894,  p.  332. 

Tedeschi:    Ziegler's  Beitrage,  vol.  xxi..  No.  i,  1897. 

Thibal:    These  de  Paris,  1888  (quoted  by  Chaslin). 

Weygandt:    Arch,  fiir  Psychiatric,  vol.  xxviii.,  No.  2,  1896. 

Wilmarth:    Alienist  and  Neurologist,  1890. 

Ziegler:    Lehrbuch  der  pathologischen  Anatomic,  vol.   ii.,  Jena, 

1895. 


A  CASE  OF  SEROUS  (ALCOHOLIC)  MENINGITIS 
SIMULATING  BRAIN  TUMOR.* 

4 

By  THEODORE    DILLER,  M.  D., 

Neurologist  to  the  Allegheny  General  Hospital ;   Visiting  Physician  to  the  Insane 

Department  ol  St.  Francisi  Hospital,  Pittsburg. 

The  case  of  serous  meningitis  to  be  related  was  mis- 
taken by  me  for  one  of  brain  tumor.  The  symptoms  pre- 
sented by  it  were  so  strikingly  like  those  produced  by  an 
intracranial  neoplasm,  that  I  am  led  to  hope  that  a  brief 
account  of  the  case  may  be  of  some  value. 

Mr.  X.,  aged  33,  formerly  a  strong,  vigorous  man,  was 
seen  by  me  on  March  5th,  1898.  For  many  months  he  had 
been  indulging  in  large  amounts  of  alcoholic  drinks. 

He  had  been,  for  many  years,  subject  to  tick  headaches  and 
vomiting  attacks.  For  two  or  three  months  back  these  head- 
aches had  become  very  much  more  severe  in  character  and 
longer  in  duration,  and  largely  localized  in  the  frontal  region. 
The  patient  had  latterly  spoken  of  them  as  head  pains  rather 
than  headaches.  They  sometimes  lasted  two  or  three  days  at 
a  time,  and  were  constantly  growing  more  and  more  severe. 

During  the  previous  six  months  vomiting  spells  had  grown 
more  frequent.  They  occurred  at  any  time  in  the  day,  and,  in- 
deed, they  often  came  upon  him  in  the  night.  They  were  ac- 
companied by  little  or  no  nausea,  and  occurred  whether  the 
stomach  was  full  or  empty.  Since  the  increase  in  the  fre- 
quency of  the  vomiting  attacks  he  had  constantly  grown 
thinner. 

For  about  five  months  his  eyesight  had  been  steadily  fail- 
ing. Three  months  ago  it  was  noted  that  he  staggered  In  walk- 
ing, and  as  time  went  on  this  became  more  and  more  apparent. 
For  two  months  past  he  had  complained  of  pains  in  the  thighs 
and  legs,  chiefly  in  the  latter,  and  of  burning  in  the  soles  of 
the  feet. 

On  February  23d,  1898,  ten  days  before  I  saw  him,  he  was 
seized,  for  the  first  time,  with  a  convulsion.    It  was  general  in 

^  Presented  at  the  annual  meeting  of  the  American  Neurological 
Association,  held  in  New  York,  May  26th,  27th  and  28tli,  1898. 


^42  THEODORE  DILLER. 

.character,  accompanied  by  unconsciousness,  and  lasted  only 
a  few  minutes.  An  hour  later  he  had  a  similar  convulsion,  and 
a  third  about  an  hour  after  this.  For  two  weeks  preceding 
these  convulsions  the  headaches  had  been  especially  agoniz- 
ing. 

Since  the  convulsions  he  had  become  possessed  of  many 
fleeting  delusions  with  reeard  to  time,  place  and  persons,  some 
of  which  were  of  a  painful  character.  His  memory  was  de- 
fective, and  he  was  in  a  condition  of  more  or  less  semi-stupor. 

This  was  his  mental  condition  when  I  first  saw  him.  In 
conducting  my  examination  I  had  little  difficulty  in  getting 
him  to  do  as  I  wished.     But  after  I  left  he  remarked  that  he 

guessed  that  B was  trying  to  act  "smart,"  being  under  the 

impression  that  I  was  the  local  confectioner,  with  whom  he 
was  well  acquainted. 

He  staggered  in  walking,  and  his  gait  was  one  of  weak- 
ness. He  was  considerably  emaciated;  his  muscles  were  flabby. 
There  was  a  good  deal  of  tenderness  to  pressure  in  the  legs 
and  feet,  and  a  moderate  amount  in  the  thighs.  Both  knee- 
jerks  were  much  diminished.  No  ocular  palsies  were  present 
The  pupils  reacted  to  light  and  in  accommodation.  He  was 
imable  to  distinguish  various  coins,  or  the  large  letters  of  news- 
papyers.  There  were  no  cranial  nerve  palsies.  The  urine  showed 
no  albumin  or  sugar.  His  temperature,  from  the  time  I  saw 
him  up  to  his  death,  varied  between  99  and  100.  Double  optic 
neuritis  was  present. 

The  patient  gradually  sank  into  coma,  and  died  six  days 
later  while  in  that  condition. 

The  autopsy  failed  to  reveal  a  brain  tumor,  but  disclosed 
g^eat  dilatation  of  the  pial  vessels,  with  a  large  amount  of  clear, 
colorless  fluid  beneath  the  pia.  There  was  intense  congestion 
of  the  pia  in  several  spots.  But  little  more  than  the  usual 
amount  of  fluids  was  found  in  the  ventricles. 

To  briefly  recapitulate.  The  patient  had  been  ailing 
and  going  steadily  downward  for  six  months,  presenting 
during  this  time  the  following  symptoms:  Severe  head- 
aches; frequent  vomiting  attacks;  failing  vision,  due  to 
optic  neuritis;  weak,  ataxic  gait;  loss  of  knee-jerks;  tender- 
ness in  the  legs  and  burning  in  the  feet,  and,  finally,  gen- 
eral convulsions  followed  by  marked  mental  changes. 

It  seemed  quite  plain  that  the  man  was  suffering  from 
multiple  neuritis,  due  to  alcoholism.  The  ataxic  gait, 
weakness,  wasting  and  tenderness  of  the  legs  and  burn- 
ing of  the  feet,  with  diminished  knee-jerks,  were  explained 


A  CASE  OF  SEROUS  MENINGITIS. 


443 


very  reasonably  by  this  diagnosis.    There  remained,  how- 
ever, the  headaches,  vomiting,  optic  neuritis*  convulsions 
and  mental  symptoms  to  be  accounted  for.    These  seemed 
to  me  to  indicate  the  presence  of  a  brain  tumor,  although 
1  recognized  the  fact  that  the  mental  symptoms  were  very 
like  those  seen  in  alcoholic  multiple  neuritis.     Indeed,  I 
was  uncertain  how  much  these  symptoms  should  be  at- 
tributed to  the  supposed  brain  tumor,  and  how  much  to 
alcoholism. 

While  nearly  all  the  cardinal  general  symptoms  result- 
ing from  brain  tumor  were  present  in  this  case,  there  were 
two  features  which  should,  perhaps,  have  led  one  to  recog- 
nize the  real  situation,  viz.,  the  historv  of  alcoholism  and 
the  presence  of  multiple  neuritis.    The  diagnosis  of  brain 
tumor  and  multiple  neuritis  assumed  a  coincidence  which 
would  have  been  unnecessary,  had  the  true  condition  been 
recognized. 

Acute  serous  alcoholic  meningitis,  as  described,  for 
example,  by,  Dana,*  could  not  easily  be  mistaken  for  a 
brain  tumor,  but  it  is  in  chronic  cases  of  this  disease  that 
there  is,  as  has  been  so  well  pointed  out  by  Quincke^  fre- 
quently a  great  liability  of  this  mistake  being  made.  Op- 
penheim,'  indeed,  calls  attention  to  the  striking  resem- 
blance of  the  symptoms  produced  by  chronic  serous 
meningitis  and  those  produced  by  brain  tumor,  and  fur- 
ther says  that  in  most  cases  of  the  first-named  disease  the 
diagnosis  of  brain  tumor,  has  been  made.  In  this  latter 
statement  of  Oppenheim  I  find  a  measure  of  personal  com- 
fort. 


^Medical  Record,  vol.  Hi.,  p.  8oi,  et  seq. 

'  Sammlung  klinischer  Vortrage,  1893,  No.  67,  p.  655. 

*  Berliner  klin.  Wochenschrift,  Nos.  49  and  50. 


NEW  PATHS  IN  PSYCHIATRY.^ 

(INAUGURAL  ADDRESS)  By  FREDERICK  PETERSON,  M.D. 

President  of  the  New  York  Neurological  Society. 

■ 

Eighty  years  ago  a  medical  student  engaged  in  the 
commonplace  work  of  walking  the  London  hospitals,  with 
a  young  mind  open  to  thrilling  impressions,  came  unex- 
pectedly upon  a  new  domain,  not  a  domain  of  medicine,  ex- 
cept as  that  is  related  to  and  bounded  by  the  vast  domains 
of  human  knowledge,  but  a  ''wide  expanse*'  of  fancy  and 
imagination,  the  discovery  of  which  led  him  to  exclaim; 

"  Then  felt  I  like  some  watcher  of  the  skies 

When  a  new  planet  swims  into  his  ken; 
Or  like  stout  Cortez  when  with  eagle  eyes 

He  stared  at  the  Pacific — and  all  his  men 
Looked  at  each  other  with  a  wild  surmise — 

Silent,  upon  a  peak  in  Darien." 

Thus  we,  the  voyagers  of  a  later  day,  in  an  older  period 
of  the  world's  history,  with  our  several  conquests  of  the 
secrets  of  Nature  behind  us,  stand  upon  the  threshold  of 
unexplored  regions,  and  may  well  regard  each  other  "with 
a  wild  surmise." 

A  writer  in  a  recent  number  of  the  Revue  ScientiHque 
describes  Psychiatry  as  the  new 'Prometheus  which  shall 
wrest  from  Nature  the  secrets  of  thought. 

All  over  this  earth,  in  a  hundred  clinics  and  in  a  hun- 
dred laboratories,  patient  investigation  is  being  carried 
on.  Man  is  studying  the  biological  unit  of  himself.  What 
a  problem  that  unit  is!  What  an  array  of  specialists  is  en- 
gaged in  the  work!  There  are  the  anatomist,  the  com- 
parative anatomist,  the  histologist,  the  comparative  his- 
tologist,  the  cytologist,  the  comparative  cytologist,  the 


*  Read  before  the  New  York  Neurological  Society,  May  3,  1898. 


NEIV  PATHS  IN  PSYCHIATRY. 


445 


physiologist,  the  comparative  physiologist,  the  chemist, 
the  embryologist,  the  ethnologist,  the  pathologist,  and 
many  more,  who  busy  themselves  with  the  body.  There 
arc  the  psychologist,  the  comparative  psychologist,  the 
psychiatrist,  the  criminologist,  the  philologist,  the 
pedagogue,  and  the  innumerable  others,  whose  labors  are 
with  the  mind  of  man.  Almost  every  one  of  these  par- 
ticular fields  of  work  is  subdivided  into  still  other  special- 
ties, so  that  it  requires  even  now  a  singularly  broad  and 
all-embracing  mind  to  collect,  digest  and  build  up  the 
facts  already  accumulated  into  some  structure  of  great 
truth  or  general  principle. 

We  who  are  students  of  the  phenomena  presented  by 
the  normal  and  by  the  disordered  nervous  system,  while 
we  realize  the  enormous  progress  made  in  our  province 
during  the  last  twenty  years,  in  localization  of  functions, 
in  the  pathogeny  of  nervous  diseases,  in  discoveries  like 
that  of  the  causation  of  cretinism  and  myxoedema,  in  the 
understanding  of  the  minute  structures  and  relations  of 
centres  and  tracts,  in  the  investigation  of  the  laws  of 
heredity,  in  the  study  of  degeneracy  and  its  stigmata,  in 
the  knowledge  of  the  development  of  the  mind  from  in- 
fancy to  adult  life,  in  the  realms  of  hypnotism,  hysteria, 
aphasia,  and  the  like,  while  we  realize  all  this,  we  still  feel 
that  we  stand  but  in  the  half-light  of  discovery,  and  that  \ 

there  extend  far  out  before  us  innumerable  pathways  lead-  j 

ing  into  unknown  regions,  wherein  shines  the  dim  and 
fitful  light  of  new  truths  to  be  attained : 


Thus  spake  another  English  medical  poet,^  who  sixty 
years  ago  practised  medicine  in  Zurich,  and  busied  himself 
with  translating  "Grainger  on  the  Spinal  Cord"  into  Ger- 
man. 

'Thomas  L.  Beddoes,  author  of  Death's  Jest-Book. 


"As,  in  one  eye, 
Light,  from  unnumbered  worlds  and  furthest  planets 
Of  the  star-crowded  universe,  is  gathered  .. 

Into  one  rav."  if 


ill 


446  FREDERICK  PETERSON. 

One  of  the  most  bewildering,  intricate  and  mysterious 
of  these  pathways  is  that  of  physiological  and  pathological 
chemistry.  But  the  explorers  who  follow  this  trail  must 
need  be  **invincible  athletes"  if  they  shall  penetrate  far 
into  the  labyrinth  of  disturbed  chemical  metabolism  in  the 
numerous  tissues  of  the  body,  and  bring  us  practical  facts 
in  regard  to  the  disordered  functions,  auto-intoxications, 
etc.,  produced  thereby. 

The  roads  of  normal  and  pathological  histology  and 
cytology  are  more  worn  and  better  followed,  but  their 
many  travelers  are  still  remote  from  any  final  bourne. 

It  is  not  the  happy  privilege  of  many  of  us  to  be  able 
to  enter  upon  researches  of  these  great  proportions.  Time, 
strength  and  means  are  not  adequate  for  all  of  us  to  study 
the  body  and  mind  of  man  as  a  biological  unit.  The  great- 
est discoveries,  the  most  far-reaching  results,  must  be  at- 
tained by  aggregations  of  specialists  trained  in  many  de- 
partments. These  are  now  and  then  fortuitously  associ- 
ated in  contributions  scattered  in  different  periodicals  or 
monographs  in  many  tongues.  But  far  more  satisfactory 
will  be  their  work  in  so  promising  an  aggregation  as  has 
recently  been  established  in  this  city  by  the  Commission 
in  Lunacy  of  the  State  of  New  York,  under  the  manage- 
ment and  inspiration  of  Van  Gieson,  and  in  the  well- 
equipped  private  laboratories  of  one  or  two  of  the  members 
of  this  society,  and  in  the  several  combined  laboratories  of 
foreign  psychiatric  clinics. 

Yet,  though  some  of  these  paths  may  not  be  open  to 
us  all,  there  is  at  least  one  of  the  roadways  leading  into 
the  realms  of  the  mind  which  any  one  of  us  rnay  follow.  It 
lies  in  the  direction  of  the  better  clinical  examination  of 
our  cases  from  the  standpoint  of  psychology. 

The  neurologist  may  gamer  a  vast  number  of  extreme- 
ly valuable  data  by  the  application  of  some  of  the  prin- 
ciples and  apparatus  of  the  new  physiological  and  experi- 
mental psychology  to  the  investigation  of  his  cases  of 
organic  brain  disease.    These  patients  have  rarely,  if  ever, 


NEIV  PATHS  IN  PSYCHIATRY. 


447 


been  carefully  studied  in  relation  to  their  mental  phe- 
nomena. We  are  only  beginning  to  appreciate,  for  in- 
stance, the  utility  of  the  psychological  examination  in 
lesions  of  the  frontal  lobes.  But  I  believe  it  to  be  of  the 
greatest  importance  to  study  the  quality,  intensity  and 
tone  of  sensations,  the  contents,  distinctness,  energy  and 
emotional  character  of  ideas,  the  evolution,  durability  and 
associations  of  ideas,  the  disorders  of  the  affective  life  in 
the  way  of  depression,  exaltation,  irritability,  apathy  and 
mutability,  the  disorders  of  the  idea-association  in  the  way 
of  memory,  attention,  accelerated  or  retarded  flow,  co- 
herence and  ethical  feeling,  and,  finally,  the  disorders  of 
the  judgment  associations  in  the  way  of  falsification  or  de- 
fect, in  all  of  our  cases  of  organic  cerebral  disease,  in  tu- 
mors, hemorrhage,  softening,  multiple  sclerosis  or  other 
lesions,  and  even  in  diseases  of  the  cerebellum.  We  can- 
not yet  tell  what  lacunae  may  not  be  thereby  discovered 
in  the  psychic  unity  of  the  affected  individual.  Our  studies 
of  aphasia  have  been  remarkably  deficient  as  regards  their 
psychic  side. 

In  the  investigation  of  the  functional  disorders  of  the 
brain  also,  there  are  fine  conquests  to  be  made  by  means 
of  recent  psychological  methods. 

While  the  neurologist  has  much  to  gain  by  following 
the  psychological  path  in  the  study  of  neurological  cases, 
far  more  vast  is  the  expanse  that  opens  out  to  physicians 
in  reformatories,  prisons,  institutions  for  idiots  and  asylums 
for  the  insane,  if  they  will  travel  the  new  road,  under  the 
new  guidance,  in  the  dawn  of  the  new  day! 

When  I  look  back  upon  three  years  spent  in  asylum 
work  without  light  or  guide,  it  seems  to  me  that,  aside 
from  some  practical  gain  in  methods  of  management  of 
patients  and  a  certain  familiarity  with  types  of  insanity  ac- 
quired, I  traversed  a  somewhat  barren  waste.  It  would 
be  an  inestimable  privilege  to  live  again  throup*h  such  op- 
portunities, to  be  awake  and  not  asleep,  no  longer  be- 
numbed by  the  slumbrous  psychiatric  dissertations  of  that 
day. 


M 


i: 


!;• 


'•S 

'W 


i!.^ 


448  FREDERICK  PETERSON, 

Doubtless  these  new  psychological  theories  will  have 
their  period,  and  give  place,  in  turn,  to  other  and  better 
ones,  but  there  is  a  pleasant  fascination  in  regarding  men- 
tal phenomena  by  scientific  method,  a  certain  charm  in 
sifting  the  psychical  processes  down  to  stimulus,  sensa- 
tion, idea-association,  movement ;  in  which  series  the  emo- 
tions have  a  place  only  as  attributes  or  properties  of  sen- 
sation and  idea,  while  voluntary  action  is  merely  the  re- 
sult of  a  play  or  battle  of  motives  in  the  idea-association 
(Ziehen).  With  some  such  scheme  of  investigation  before 
us,  it  becomes  a  delight  to  study  the  disorders  of  sensation, 
the  disorders  of  the  memory-pictures  or  ideas,  the  disturb- 
ances of  the  idea-association>,  the  derangement  of  the 
judgment-associations,  the  influences  of  these  various  dis- 
orders upon  the  movements,  action  or  conduct,  the  affec- 
tions of  the  emotional  tone  of  sensations  and  ideas,  and, 
finally,  the  whole  character  of  the  individual  as  made  up 
of  the  sum  of  the  specific  ethical  feelings  that  are  associ- 
ated with  his  more  complicated  ideas. 

But  this  is  not  the  occasion,  nor  is  there  time,  to  give 
more  than  a  passing  glance  at  the  rich  region  that  lies 
with  limitless  horizon  before  every  physician  who  has  to 
do  with  morbid  minds  in  his  private  practice,  or  in  special 
institutions,  if  he  but  follow  the  new  paths. 

Ever  since  I  observed  the  splendid  facilities  for  study 
in  some  of  the  foreign  psychiatric  clinics,  it  has  seemed 
to  me  a  misfortune  that  not  one  of  our  large  cities  on  this 
side  of  the  water  is  provided  with  such  a  centre  for  psy- 
chological investigation.     The  psychological  laboratories 
attached  to  some  of  our  universities,  dealing,  as  they  do, 
with  the  normal  mind,  can  never  hope  to  accomplish  as 
much  in  the  way  of  new  discoveries  as  similar  foundations 
associated  with  clinics  for  nervous  diseases  or  asylums  for 
the  insane,  where  is  gathered  together  an  abundant  mor- 
bid material  upon  which  to  draw  for  the  solution  of  many 
a  psychic  riddle.    For  it  is  true  that  most  of  our  knowledge 
of  normal  functions  of  the  human  body,  physiological  or 


NEW  PATHS  IN  PSYCHIATRY. 


449 


\ 


/ 


j^j^chological,  has  been  gained  by  the  physician  through 
^^^^tigations  conducted  when  these  functions  were  per- 
^^^d  or  destroyed  by  disease. 

Surely  this  great  city,  blessed  with  so  many  hospitals, 
charities  and  institutions  of  learning,  possessed  of  so  many 
citizens  eager  to  employ  their  large  wealth  for  benevolent 
purposes  and  for  human  progress,  might  well  lead  the 
cities  of  the  New  World  in  the  establishment  of  a  psycho- 
pathic hospital,  a  psychiatric  clinic,  fully  equipped  with 
all  adjuncts  for  clinical,  chemical,  psychological  and  patho- 
logical investigation.  A  psychopathic  hospital  would  ac- 
complish great  practical  good.  It  would  be  a  boon  to  the 
many  insane  now  gathered  daily  into  a  pavilion  at  one  of 
our  hospitals  merely  for  distribution  to  various  asylums. 
•  In  such  a  hospital  many  cases  could  be  treated  and  cured, 
thus  avoiding  transfer  and  commitment  to  asylums.  Medi- 
cal students  and  special  students  of  psychiatry  would  profit 
from  the  convenience  of  access  to  the  psychiatric  clinics, 
and  the  young  graduate  would  enter  upon  practice  with 
some  definite  knowledge  of  insanity  and  its  treatment. 
But  the  greatest  value  of  the  proposed  special  hospital 
would  undoubtedly  be  the  opportunities  afforded  for  those 
aggregate  studies  by  many  specialists,  whicli  are  destined 
one  day  to  discover  the  origin  and  cure  of  many  of  the 
psychoses,  and  incidentally  to  unravel  some  of  the  mys- 
teries of  mind. 


Clinical  ®asje0» 

A  CASE  OF  UNIVERSAL  MUSCULAR  ATROPHY. 

By  H.  a.  hare,  M.D., 

Professor  of  Therapeutics  in  the  Jefferson  Medical  Collesfc. 

The  patient  that  I  show  you  has  the  following  history: 

Mrs.  E.  K.,  aged  45,  married,  a  housekeeper,  was  admitted 
to  the  Jefferson  Hospital,  March  ist,  1898.  She  was  born  in 
Dublin,  Ireland. 

Family  History: — Her  father  died  at  the  age  of  fifty  of 
unknown  cause.  Her  mother  is  living,  is  in  good  health,  and 
is  sixty-three  years  old.  She  had  two  brothers,  both  of  whom 
died  in  infancy  from  unknown  causes,  but  she  had  no  sisters. 
There  is  no  history  of  any  hereditary  disease. 

Personal  History: — She  contracted  measles  and  whoop- 
ing-cough when  a  child,  and  had  a  severe  attack  of  mumps 
seven  years  agx>,  which  she  contracted  from  her  children.  She 
had  malaria  in  1882,  but  has  never  been  seriously  ill  until  her 
present  trouble  developed.  In  1872  she  was  married,  and  has 
had  ten  children,  all  of  whom  are  living  and  well,  except  one, 
which  died  of  croup  when  five  years  of  age.  She  has  had  no 
miscarriages  or  uterine  trouble. 

Present  Illness: — Her  last  child  was  born  in  July,  1893. 
For  about  one  month  previous  to  its  birth  she  suffered  with  a 
great  deal  of  pain  in  the  lower  extremities,  especially  in  the 
knees  and  feet,  and  the  feet  became  swollen  and  dropsical. 
After  confinement  these  symptoms  disappeared,  and  she  had 
no  further  trouble  until  three  years  ago,  when  the  condition 
gradually  returned,  the  lower  limbs,  especially  the  knees  and 
feet,  becoming  painful  and  the  feet  being  swollen.  This  con- 
dition persisted,  but  did  not  become  serious  until  one  year 
ago,  when  she  was  obliged  to  take  to  her  bed,  to  which  she 
has  been  confined  ever  since.  During  the  last  year  her  hips, 
shoulders,  elbows  and  hands  have  been  implicated,  and  she 
has  gradually  lost  the  use  of  the  joints,  the  tendons  becoming 
contracted  and  the  joints  deformed.  The  deformity  is  particu- 
larly marked  in  the  hands,  the  right  especially  presenting  the 
typical  "seal-fin"  hand  appearance.  She  has  lost  a  great  deal 
of  weight  during  the  past  year,  and  is  weak  and  emaciated. 
She  is  unable  to  walk,  and  attributes  this  more  to  weakness 
than  to  deformity.     The  knees  are  sharply  flexed,  and  she  is 


Read  before  the  Philadelphia  Neurological  Society,  March  28th,  1898. 


Universal    Muscular   Atrupliy. 


UNIVERSAL  MUSCULAR  ATROPHY. 


451 


rt  able  to  straighten  the  limbs.  The  toes  are  sore  and  tender 
touch.  For  the  last  six  months  she  has  had  an  intermJltent 
iginal  discharge,  dark  in  color,  ajid  of  an  offensive  odor,  not 
rge  in  amount,  but  the  gynjecologist  reports  no  serious 
erine  lesion.  The  menopause  l>egan  in  the  summer  of  1896. 
nail  bed  sores  are  present  over  the  sacrum,  apex  of  left 
apul ,  and  on  the  left  elbow.  Her  appetite  is  good,  and  her 
>wels  are  regular.  Th«  examination  of  the  eyes  shows  that 
e  color  fields  are  reversed,and  the  visual  fields  greatly  con- 
acted.    The  urinary  examination  is  negative. 

Asyou  will  seefrotnan  examination  of  the  patient's  ILmb!! 
id  trunk,  ^e  is  the  subject  of  universal  muscular  wasting 
a  rather  unusual  type.  You  will  also  notice  that  an  ex- 
ninatton  of  her  eyes  reveals  reversal  of  her  color  fields 
id  marked  limitation  of  her  fields  of  vision,  and  her  facies 
distinctly  hysterical.  While  at  first  glance  the  seal-fin 
mds  and  the  bent  limbs  remind  one  of  the  posture  of  a 
:rson  suffering  from  arthritis  deformans,  a  careful  ex- 
nination  of  the  joints  shows  that  there  is  no  marked 
sease  of  their  surfaces  nor  the  development  of  exostoses 
eking  the  joints.  On  the  contrary,  the  deformities  are 
liefly  due  to  muscular  contractures.  The  difficulty  in  ex- 
^nding  her  limbs  depends  upon  the  condition  of  contract- 
re  in  the  muscles  of  the  arms  and  thighs.  Quiet,  con- 
ant  extension  of  a  limb,  kept  up  until  the  muscles  are 
red,  causes  stretching  of  these  muscles,  so  that  both  the 
ms  and  legs  can  be  almost  completely  straightened  out. 

I  bring  this  case  before  you,  not  only  in  wder  to  ex- 
;bit  it,  but  with  the  hope  that  the  members  present  vnll 
cpress  their,  views  as  to  the  correct  diagnosis  to  be 
ached. 

When  I  first  saw  her  I  concluded  that  it  was  a  case  of 
leumatoid  arthritis,  with  secondary  muscular  wastirig, 
}mplicated  with  distinct  hysterical  manifestations,  which 
ight  be  in  part  responsible  for  the  muscular  contractures, 
id  this  diagnosis  I  am  still  inclined  to  adhere  to.  The 
,ct  that  the  muscles  of  the  trunk  are  as  much  wasted  as 
lose  of  the  extremities  is,  however,  an  interesting  fact  to 
e  considered. 


:ases  of  ophthalmoplegia. 

epartment  oE  Prof.  B.  Sachs  at  the  New  York  Polyclinic.) 

OF  FUNCTIONAL  (HYSTERICAL)  OPHTHAL- 
LEGIA      REPORTED  BY  B.  SACHS,  M.  D. 

uia]  ophthalmoplegia  is  sufficiently  rare  to  war- 
i  report.  The  patient — F.  S. — ^was  kindly  re- 
le  by  Prof.  Marple,  to  whom  I  am  indebted  for 
>hthalmoscopic  examination,  and  for  the  charts 
al  fields. 

:ient  (Fig.  i)  is  51  years  or  age;  for  many  years 
1  a  heavy  drinker  of  beer;  also  gives  an  uncertain 
irevious  specific  infection.  He  has  been  married 
past  27  years;  his  first  wife,  who  is  said  to  have 
Kular  palsy,  died  from  a  paralytic  stroke  about 
i  ago.  Six  years  ago  he  married  his  second  wife, 
t  led  a  regular  life;  attended  to  his  business  as  a 
er;  at  one  time  he  weighed  300  pounds;  now 
<  pounds.  He  was  in  good  health  until  January 
.  On  that  day  he  attended  the  funeral  of  a 
hile  standing  on  the  sidewalk,  waiting  for  the 
t  carried  out,  he  noticed  a  flash  of  light  before 
:gan  to  see  double,  felt  slightly  dizzy,  and  could 
to  the  light.  At  no  time  did  he  Ipse  consdous- 
was  badly  frightened;  knew  that  he  had  the 
3le  from  which  his  first  wife  suffered,  and  of 
died.  Some  friends  assisted  him  to  his  home; 
tval  he  found  that  both  eyelids  drooped;  the 
ia  was  intense,  and  this  symptom  has  been  the 
^sing  one  ever  since.  At  the  time  of  my  first 
>n  (March  5th,  1898),  the  following  record  was 
luble  ptosis;  when  asked  to  look  up  makes  a 
mavailing  effort;  slowly  raises  the  entire  head. 


FUNCTIONAL  OPHTHALMOPLEGIA.  453 

but  does  not  use  the  frontales  muscles,  as  patients  with 
ptosis  ordinarily  do.  After  repeated  commands,  manages 
to  raise  the  eyelids  a  little,  but  does  not  do  so  again, 
though  requested  to  do  so  frequently,  during  the  course 
of  a  long  examination.  On  lifting  the  eyelids  with  the 
fingers,  it  is  seen  that  the  axes  converge  slightly.  Conju- 
gate movement  of  the  eyes  to  the  left  is  imperfect;  to  the 
right  the  movement  is  performed  easily.  Upward  and 
downward  movements  of  both  eyes  are  slightly  limited 
and  done  in  a  jerky  manner.  Testing  the  eyes  singly,  it 
is  noticed  that  the  1.  rectus  extemus  moves  the  eye  around 
about  half  its  normal  distance.  All  other  movements  are 
performed  more  satisfactorily;  but  the  movements  are 
jerky,  and  at  times  succeed  very  much  better  than  at 
others;  muscles  appear  to  be  easily  fatigued.  The  pupils 
are  slightly  irregular  in  contour;  they  react,  though  feebly, 
to  light,  but  contract  promptly  during  accommodation. 
Dr.  Marple  reported  that  there  are  no  fundus  changes. 
There  is  some  apparent  contraction  of  the  visual  fields. 
He  has  no*  central  color  scotoma,  and  his  visual  fields  for 
color  show  no  marked  peculiarity.  He  has  some  choroidal 
changes,  such  as  are  usual  in  myopes;  he  also  has  some 
astigmatism. 

Left  vision  is  20/40;  with  — iD.  cyl.  ax.  90=20/30. 
Left  vision  is  20/40;  with  — iD.  cyl.  ax.  90=20/30". 
A  complete  examination  of  the  patient  did  not  reveal 
any  palsy  in  any  other  part  of  the  body;  the  reflexes  were 
normal,  and  there  was  no  ataxia.  Gait  and  station  were 
normal.  The  head  was  held  in  a  rigid  position,  with  a 
slight  curve  to  the  right,  from  an  evident  desire  to  avoid 
the  light.  The  only  other  sym.ptom  was  a  complete  left 
hemianalgesia,  with  the  exception  of  the  left  cornea,  which 
was  sensitive  to  touch;  in  every  other  part  of  the  left  half 
of  the  body,  including  the  left  nostril  and  the  left  half  of 
the  tongue,  severe  pricks  with  a  pin  were  not  felt.  Touch, 
temperature  and  muscular  sensations  were  normal  in  both 
halves.    In  the  further  progress  of  the  case  (to  May  ist. 


Fig.  I  (Casei). 


456  B,  SACHS. 

noticed  that  his  face  was  contracted  and  pulled  toward  the 
left  side.  This  continued  for  about  a  minute,  and  then  he 
dropped  to  the  floor,  and  became  unconscious  with  an  at- 
tack of  convulsions.  After  the  attack  of  convulsions  he 
fell  asleep;  slept  for  one  hour,  and  awoke  apparently  well, 
with  the  exception  of  the  condition  present  in  his  eyes. 
Previous  to  this  attack  he  admits  having  suffered 
from  headache,  dizziness  and  palpitation,  which  at  times 
were  quite  severe.  Denies  all  excesses  in  alcoholism,  syphilis 
and  tobacco.  Never  had  rheumatism.  Family  history 
negative.  Status  praesens:  Heart  is  hypertrophied;  pulse, 
128  to  140;  irregular  at  times.  No  murmur  can  be  de- 
tected, although  carefully  looked  for  and  examined  by 
several  gentlemen  besides  myself. 

The  eyes  present  the  following  conditions: 

Patient's  vision  is  very  good.  There  is  a  ptosis  of  the 
left  eyelid.  This  Hd  cannot  be  raised  beyond  the  pupil 
when  the  eye  is  looking  straight  forward.  The  right  lid  is 
raised  only  incompletely.  The  movements  of  the  eye- 
balls are  very  much  restricted.  Diplopia  is  present  when 
looking  either  upward  or  downward,  the  objects  looked  at 
showing  one  image  above  the  other. 

The  following  muscles  are  affected  in  each  eye: 

Left  Eye:  External  rectus,  slight;  internal  rectus, 
slight;  inferior  rectus,  slight;  superior  rectus,  jnarked. 

Right  Eye:  Internal  rectus,  slight;  superior  rectus, 
slight;  external  rectus,  very  slight. 

The  discs  and  retina  in  both  eyes  appear  normal.  The 
field  of  vision  and  color  sense  are  also  normal.  Pupils 
respond  to  light  and  accommodation.  The  patient  be- 
lieves that  during  all  this  time  the  condition  above  ob- 
served has  never  grown  any  worse,  nor,  on  the  other  hand 
has  any  improvement  been  noticed. 

The  patient  otherwise  presents  no  nervous  symptoms. 
He  still  suffers  from  headache  and  dizziness  and  occasional 
palpitation. 

In  regard  to  the  diagnosis  in  this  case,  it  was  necessary 
at  first  to  determine  whether  the  lesion  had  only  involved 


FUNCTIONAL  OPHTHALMOPLEGIA.  457 

of  the  oculomotor  nerve,  or  actually  the  nerve 

St  the  involvement  of  the  nerve,  in  other  words, 
ral  neuritis,  was,  in  the  first  place,  the  escape  of 
sic  muscles  of  both  eyes  in  a  bilateral  affection; 
ripheral  neuritis  is  usually  unilateral;  3rd,  other 

close  proximity  to  the  third  would  usually  suf- 

same  time. 

cclusion  we  must,  therefore,  believe  that  the 
!  involved  the  nuclei.  As  arguments  against  a 
uclear  ophthalmoplegia,  we  record  the  rapid  on- 
he  absence  of  any  progression  in  the  symptoms 
I  further  invasion  of  the  nuclei.  An  acute  nuclear 
ludden  onset  is  more  probable. 
;ard  to  the  nature  of  the  lesion,  we  must  differen- 
veen  one  of  the  following  conditions:  1st,  hem- 
ad,  an  inflammatory  condition  which  is  charac- 
i  polioencephalitis  superior;  3d,  embolism. 
emorrhage  had  occurred  in  this  area,  the  symp- 
lld  have  been  much  more  severe  and  extensive. 
;ard  to  polioencephalitis  superior,  we  are  inclined 
e  that  from  the  very  sudden  onset  and  the  ab- 
any  constitutional  symptoms,  together  with  the 
ly  improvement  or  progression  in  the  symptoms, 

a  morbid  process  did  not  exist, 
le  other  hand,  the  condition  of  this  boy's  heart, 
with  the  sudden  onset  and  the  peculiar  irregular 
ent  of  the  nuclei  on  both  sides,  points  to  the  in- 
it  of  one  of  the  arterial  branches  of  the  basilar 
The  nature  of  the  lesion  in  an  individual  of  this 

denies  any  excess  in  alcoholism  or  tobacco,  and 
egative  syphilitic  history,  must  necessarily  be  an 

lave,  therefore,  in  this  patient  a  very  unusual 
nctive  case  of  an  incomplete,  bilateral,  external 
loplegia  of  sudden  onset,  due  to  an  embolus  hav- 
lodged  in  one  of  the  branches  of  the  basilar  ar- 


A  CASE  OF  MYXGEDEMA  TREATED  WITH  THY- 
ROID  EXTRACT  AND  WITH  THYROCOLLOID. 

Reported  from  the  Clinic  of  Prof.  M.  Allen  Starr,  College  of  Phj- 

sicians  and  Surgeons,  New  York. 

By  R.  H.  CUNNINGHAM,  M.  D., 

Clinical  Assistant   in    Neurology,  Vanderbilt   Clinic,    Demonstrator   of  Physiology, 

V  olumbia    University,  New  York. 


In  the  British  Medical  Journal,  March  21st,  1896,  R. 
Hutchison,  in  a  preliminary  note,  claims  that  the  active 
material  of  the  thyroid  gland  consists  of  the  colloid  matter. 
In  later  papers^  he  gives  further  data  regarding  the  chem- 
istry of  the  colloid,  and  also  reports  two  cases  of  myxoe- 
dema  that  were  treated  with  that  substance.     Since  the 
publication  of  his  papers  I  have  administered  the  colloid 
to  a  number  of  thyroidectomized  dogs,  but  it  has  not 
been  my  good  fortune  until  within  the  past  few  months 
to  be  able  to  test  the  activity  of  that  substance  upon  a 
patient  with  myxoedema,  or,  rather,  upon  a  patient  in 
which  the  symptoms  of  myxoedema  had  very  nearly  disap- 
peared.   As  the  results  are  interesting  from  a  therapeutical 
point  of  view,  and  as  they  apparently  corroborate  certain 
facts  regarding  the  toxicity  of  the  thyroid  material,  which 
have  been  described  by  me  elsewhere,^  a  moderately  de- 
tailed summary  of  the  history  and  of  the  progress  of  this 
patient  during  the  treatment  may  prove  of  interest   to 
those  who  have  so  often  remarked  the  occurrence  of  toxic 
symptoms  after  the  ingestion  of  thyroid  extract  or  of  dried 
thyroid  glands. 

The  patient,  J.  G.,  an  Englishman  from  Bolton,  aet. 
34  years,  came  under  my  immediate  supervision  on  Feb- 
ruary 2 1st,  1898,  in  the  Neurological  Department  of  Pro- 

*  Hutchison,  R.:  Brit.  Med.  Journ.,  January  23d,  1897;  Joum.  of 
Physiol.,  XX.,  p.  474,  1896. 

'  Cunningham,  R.  H. :  Joum.  of  Exp.  Med.,  iii.,  1898. 


A  CASE  OF  MYXOEDEMA.  459 

fessor  Starr,  at  the  Vanderbilt  Clinic.  From  November 
22d,  1897,  to  February  21st,  1898,  he  had  been  under  the 
care  of  Dr.  Norrie,  clinical  assistant  in  that  department, 
who  had  treated  him  very  successfully  with  small  doses 
of  the  powdered  dessicated  thyroid  of  Parke,  Davis  &  Co. 
Thus,  the  following  summarized  history  of  the  patient 
is  from  the  records  of  the  Vanderbilt  Clinic: 

November  22d,  1897. — ^J.  G.,  34  years  of  age,  brick- 
layer by  trade;  chancre  in  1886,  which  was  followed  by  no 
secondary  symptoms,  although  he  received  only  local 
treatment  for  it. 

He  thinks  his  present  trouble  began  in  1895,  ^^  which 
time  he  began  to  have  pains  in  his  back  and  arms.  His 
arms  and  legs  gradually  became  weaker,  and  when  he 
worked  he  would  become  fatigued  very  quickly.  In  March, 
1897,  he  had  to  stop  work,  owing  to  increasing"  weakness. 
He  noticed  then  that  his  hair  was  growing  thinner.  Dur- 
ing the  past  two  years  his  appearance  has  altered  so  much 
that  his  old  friends  fail  to  recognize  him.  He  suflfers  all 
the  time  from  the  cold,  and  very  often  has  frontal  head- 
ache. For  one  year  his  gums  have  been  very  sore  and 
bleed  easily.  He  weighed  formerly  about  145  pounds;  he 
weighs  now  165  pounds.  His  appetite  is  fair  and  his  bowels 
are  regular.  His  voice  has  become  hoarse  and  his  speech 
slow. 

His  hair  is  thin  and  dry.  The  cheeks  are  flushed,  and 
the  skin  of  the  face  is  firm,  that  of  the  arms  and  legs  very 
firm.  The  characteristic  myxcedematous  appearance  of 
the  patient  is  well  shown  by  the  accompanying  photograph 
taken  by  Dr.  Norrie.    (Fig.  i.) 

Temperature  of  the  mouth,  98.5^  F.;  pulse,  60  beats 
per  minute.    Urine  contains  no  albumin  nor  sugar. 

Treatment. — From  November  22d  to  November  26th, 

he  took  one  five-grain  capsule  of  thyroid  (P.,  D.  &  Co.) 

every  night.    He  lost  six  pounds  after  taking  §ye  capsules. 

November  26th  — Diarrhoea.    Thyroid  continued,  and 

a  mixture  o^  bismuth,  opium  and  chalk  prescribed.    De- 


k>  R.  H.  CUNNINGHAM. 

mber  ist — No  diarrhoea;  two  capsules  per  dav.  Decem- 
;r  loth — Weight,  147  pounds.  The  change  for  the  bet- 
r  in  the  patient's  appearance  is  marked.  Skin  mcMst  and 
irspires  freely.  December  loth  to  February  i6th,  1898 — ■ 
ne  capsule  per  day  has  been  taken  during  this  time. 
'^eight,  143  pounds.  Capsules  discontinued,  February 
)th — Weight,  146  pounds.  One  capsule  per  day.  Feb- 
lary  21st  — Weight,  145  pounds;  pulse,  84;  temperature, 
J.S*^  F.;  occasional  headaches  and  tightness  about  the 
;ad.  He  feels  almost  strong  enough  to  go  to  work.  His 
lir  has  returned.  His  appearance  has  remarkably  altered 
ir  the  better.  (Fig.  2.)  Capsules  of  dried  thyroid  dis- 
>ntinued  and  .05  gram  of  thyroid-colloid  (A*)  ordered  to 
;  taken,  t.  i.  d.,  between  meals. 

February  28th — Weight,  146  pounds;  pulse,  72;  tem- 
srature,  95.5°  F.;  dose  of  colloid  (A)  increased  to  .1  t.  i. 
,  (i  gram  of  colloid  is  equivalent  to  i  gram  of  raw  thy- 
)id,  according  to  Hutchinson). 

March  nth — Weight  (shortly  after  his  dinner),  146! 
Dunds;  pulse,  72;  temperature,  98.5^  F.;  ordered  .725 
ram  of  colloid  (A)  t.  i.  d. 

March  25th  — Weight,  142  pounds,  after  discarding 
is  overcoat;  pulse,  74;  temperature,  98.5°  F.  Since  the 
3th  has  been  working  hard  every  day  as  a  bricklayer.  He 
as  had  no  disagreeable  symptoms,  and  has  voluntarily 
:marked  that  these  new  capsules  don't  seem  to  affect  his 
ead,  like  those  he  took  at  first,  in  November,  1897.  Col- 
lid  (A)  discontinued. 

March  28th. — Weight,  142  pounds;  pulse,  78;  tem- 
erature,  98.5°  F.;  ordered  colloid  (B"),  i  gram  t.  i.  d. 


*  The  colloid  A  was  prepared  from  raw  sheeps'  thyroid  glands  that 
id  been  removed  from  the  animals  about  one  hour  before  by  the 
■lowing  process:  The  glands  were  finely  ground  and  mixed  with  ■ 
rge  volume  of  .r  per  cent,  caustic  soda,  and  the  mixture  constantly 
irred  for  one  hour.  The  mixture  waa  filtered  through  muslin  and 
le  filtrate  precipitated   by   adding  acetic   acid.     This   precipitate,   or 


A  CASE  OF  MYXOEDEMA.  46 1 

March  31st  — ^Weight,  140  pounds  shortly  after  dinner; 
pulse,  105;  temperature,  98.5°  F.  He  says  that  during 
the  past  two  days  he  has  had  headache  and  pains  in  his 
back  and  arms.    Colloid  (B)  discontinued. 

April  i8th — Weight,  145  pounds;  pulse,  74;  tempera- 
ture, 98.5°  F.  Has  been  working  steadily  and  feels  in  ex- 
cellent health.  Ordered  .8  gram  of  coUpid  (A)  t.  i.  d. 
(equals  24  grams  of  raw  thyroid  per  day). 

April  25th — ^Weight,  144  pounds;  pulse,  76;  tempera- 
ture, 98.5°  F.  No  disagreeable  symptoms  have  been  no- 
ticed, and  the  patient  says  he  feels  like  a  new  man.  Since 
the  above  date  I  have  not  seen  him,  as  he  is  working  out 
of  town. 

Remarks: — Owing  to  the  fact  that  the  administration 
of  the  colloid  was  begun  at  a  time  when,  practically,  all 
of  the  signs  of  myxoedema  had  nearly  disappeared  from 
the  previous  use  of  dried  thyroid,  its  action  in  the  preced- 
ing case  by  no  means  strikingly  demonstrates  that  it  is 
the  active  substance  of  the  thyroid  gland.  It  certainly 
appears  to  be  active  enough  in  preventing  a  recurrence 
of  the  symptoms  of  myxoedema,  and  the  progressive  im- 
provement in  the  patient's  condition  seems  to  continue 
from  its  use.  A  more  definite  test  of  its  activity  would 
have  been,  of  course,  to  begin  the  treatment  with  the  puri- 
fied colloid;  but,  judging  from  its  beneficial  action  in  the 
cases  of  Hutchinson  that  were  treated  at  the  outset  with 
the  colloid,  I  think  it  highly  probable  that,  had  the  above 
mentioned  man  been  put  upon  the  colloid  in  the  begin- 
ning, the  result  would  have  been  the  same. 

Besides  the  very  favorable  result  effected  by  the  treat- 


colloid,  was  collected  on  filters  and  redissolved  in  dilute  caustic  soda 
solution.     This  alkaline  solution   was  then   brought  to   the  boiling 

?oint,  and  then  reprecipitated  by  adding  a  few  drops  of  acetic  acid, 
'his  precipitate  was  then  collected,  spread  on  glass  plates,  and  quickly 
dried  in  a  strong  current  of  air,  and  finally  pulverized.  After  the 
first  extraction  a  large  volume  of  dilute  caustic  soda  solution  was 
again  added  to  the  thyroid  material,  and  the  maceration  allowed  to 
continue  for  eighteen  hours.  From  this  mixture  colloid  B  was  ob- 
tained by  the  method  employed  to  obtain  colloid  A. 


462  R.  H.  CUNNINGHAM. 

merit,  the  further  very  interesting  feature  in  the  case  con- 
sists of  the  non-appearance  of  any  symptoms  of  the  thy- 
roid intoxication  while  he  was  taking  comparatively  co- 
lossal amounts  of  the  colloid  (A),  the  colloid  that  is  re- 
moved from  the  fresh  glands  before  any  evident  post- 
mortem chemical  alteration  of  its  constituents  has  oc- 
curred. Although  it  is  conceivable  that  the  chemical 
manifestations,  the  acidification,  etc.,  which  were  em- 
ployed to  extract  this  substance  from  the  fresh  raw  glands 
might  have  produced  more  or  less  chemical  change  in  the 
structure  of  the  colloid,  and  so  have  altered  its  physiologi- 
cal action,  no  evident  change  seems  to  have  occurred. 

Colloid  (A),  even  in  doses  equivalent  to  24  grams  of 
raw  thyroid,  did  not  produce  headache,  restlessness,  trem- 
or, heightened  temperature,  and  acceleration  of  the  pulse 
rate;  or,  in  other  words,  the  various  symptoms  of  the 
thyroid  intoxication.  But  comparatively  very  small  doses 
of  colloid  (B),  which  was  extracted  from  the  same  thyroid 
material  as  colloid  A  during  a  period  of  eighteen  hours, 
very  promptly  sent  the  pulse  rate  up  to  105,  and  also  pro- 
duced other  symptoms  of  a  mild  thyroid  intoxication. 
Practically  similar,  though  more  marked,  effects  were  no- 
ticed by  Hutchinson  in  his  cases  of  myxoedema  to  whom 
very  small  doses  of  the  eighteen-hour  colloid  were  given. 
Evidently,  then,  colloid  B  contains  something  that  colloid 
A  does  not  contain,  and,  as  I  have  previously  pointed 
out,*  this  something  must  develop  as  the  result  of  chemical 
changes  taking  place  in  some  one  or  other  constituent  of 
the  thyroid  during  the  long  period  of  its  maceration.  Con- 
sequently, the  results  described  in  this  report  fully  accord 
with  those  that  I  have  described  elsewhere,  and  this  ob- 
servation evidently  further  substantiates  the  conclusion 
reached  in  my  article  on  experimental  thyroidism  that  the 
symptoms  of  induced  thyroidism  are  manifestations  of  an 
intoxication  resulting  from  the  ingestion  of  thyroid  ma- 


*  Cunningham,  1.  c 


I 


A   CASE  OF  MYXOEDEMA.  463 

il  that  has  undergone  more  or  less  chemical  alteration 
ome  one  or  more  of  its  compounds.    Whether  or  not 

change  consists  of  a  reversion  of  some  of  the  less  per- 
\y  formed  colloid  back  to  the  form  in  which  it  is  taken 
a  the  blood,  according  to  one  of  the  early  theories  of 

thyroid  function,  I  am  not  prepared  at  present  to 
e  definitely,  for  the  chemistry  of  the  thyroid  gland,  as 
ndeot  from  the  generous  profusion  of  various  pure  (?) 
ve  principles,  supposedly  existing  in  the  thyroid  gland, 
:in  too  indefinite  for  one  to  venture  a  decided  opinion. 


Suppurative  inflammation  limited  to  the  loose  tissue  surrounding 
lura  mater  of  the  spinal  cord,  is  exceedingly  rare.  Cases  thus  far 
rted  have  nearly  all  been  secondary  to  caries  of  the  vertebrie, 
Tiatism,  bed-sores,  accumulations  of  pus  in  other  parts  of  the  body, 
cute  infectious  diseases. 

The  case  reported  by  the  above  authors  was  that  of  a  young  man 
>,  who,  after  being  exposed  to  wet,  was  taken  with  pain  and  rigid- 
n  the  back  and  severe  cramps  in  the  lower  extremities.     He  was 

by  the  reporters  on  entrance  into  the  hospital  three  days  after 
3nsct,  when  he  had  a  temperature  of  40.4  deg.,  an  elevated  pulse, 
marked  signs  of  some  spinal  affection.  There  was  a  rigidity  of  the 
e,  but  no  opisthotonos  and  no  spasms;  the  extremities  were  not 
lyied,  although  he  could  not  stand  or  raise  himself  in  bed.     The 

were  still  the  seats  of  very  painful  muscular  cramps;  there  was 
it  exaggeration  of  the  knee-jerks,  normal  sensation,  distension  of 
abdomen,  constipation  and  retention  of  urine.  Treatment  was 
out  effect.  The  patient's  general  condition  rapidly  became  worse, 
he  died  17  days  after  admission  to  the  hospital,  the  pain  and  rigid- 
if  the  back  resisting  to  the  last.  The  muscular  spasm  disappeared, 
there  was  no  paraplegia. 

At  the  post-mortem  examination  the  brain  and  its  meninges  were 
id  to  be  normal,  and  the  thoracic  and  abdominal   organs  showed 

existence  of  general  infection.  On  incising  the  back  muscles  pre- 
tory  to  removing  the  spinal  cord,  pus  oozed  from  the  interverte- 

spaces,  and  on  removing  the  arches,  the  entire  cord  from  its.  third 
icai   nerves  to  the  cauda  equina  was  found  to  be  bathed  in  pus. 

dura  was  somewhat  thickened,  but  its  inner  surface  as  well  as  the 
bI  pia  mater  was  found  to  be  simply  congested,  with  here  and 
t  small  traces  of  pus.  The  spinal  cord  itself  was  absolutely  normal, 
ere  also  the  nerve  roots.  Patrick. 


Critical  Si^pest 


ON    MULTIPLE    SCLEROSIS,  WITH    ESPECIAL 
REFERENCE  TO  ITS  CLINICAL  SYMPTOMS, 
ITS  ETIOLOGY  AND  PATHOLOGY. 
By  B.  SACHS,  M.D. 
[^Concluded.) 
ETIOLOGY. 
Opinions  have  varied  much  regarding  the  cause  or 
causes  of  multiple  sclerosis.    At  the  very  outset,  it  will  be 
well  to  enter  a  protest  against  the  supposition  that  the 
disease,  occurring  at  widely  different  periods  of  life,  should 
or  could  be  due  to  one  cause  only.  But,  strangely  enough, 
whenever  any  data  are  collected  in  favor  of  proving  the  ex- 
istence of  some  special  etiological  factor,  that  speciaj  fac- 
tor, in  the  minds  of  many,  becomes  the  sole  cause  of  the 
disease.     The  study  of  the  subject  has  led  the  present 
writer  to  the  belief  that  there  are  several  and  equally  im- 
portant causes  which  may  give  rise  to  multiple  sclerosis, 
Charcot  and  his  immediate  followers  recognized  the  im- 
portance of  exposure  to  cold  and  wet.     In  recent  years 
little  evidence  has  been  brought  forward — if  we  except  a 
contribution  by  Krafft-Ebing — to  substantiate  this  doc- 
trine; but  ive  may  well  concede  that  occasionally  it  is  the 
refrigeration  process,  and  not  a  mere  wetting,  which  may 
be  the  cause  of  the  disease.    The  same  school  attributed 
multiple  sclerosis  to  traumatism  and  emotional  depression. 
Mendel  has  adduced  further  proof  that  the  disease  is  at 
times  due  to  traumatism,  basing  his  views  upon  four  cases 
of  his  own  and  a  collection  of  24  others  taken  from  litera- 


CRITICAL  DIGEST.  465 

ture.  It  will  be  remembered  that  of  late  years  several  au- 
thors have  also  contended  for  the  traumatic  origin  of 
tabes.  Mendel  concedes  that  there  must  be  an  acquired 
or  congenital  predisposition  to  the  disease,  without  which 
the  injury  would  not  have  led  to  the  development  of  this 
widespread  morbid  process. 

Of  the  value  of  emotional  origin  I  have  seen  several 
illustrations,  one  being  the  case  of  a  young  girl  of  18,  who 
developed  typical  multiple  sclerosis  after  the  death  of  a 
parent,  and  the  other,  a  boy  of  12,  who  was  seriously 
frightened  by  a  fire  occurring  near  his  dwelling,  and  with- 
in a  few  weeks  developed  the  typical  symptoms  of  the 
disease. 

The  earliest  writers  have  recognized  that  disseminated 
sclerosis,  in  contradistinction  to  paralysis  agitans,  is  a 
disease  of  early  life,  the  majority  of  cases  occurring  before 
the  age  of  30,  and  some  of  them  before  the  age  of  puberty. 
During  the  past  ten  years  much  has  been  made  of  the  oc- 
currence of  the  disease  in  children;  but,  as  we  have  seen 
in  the  preceding  section  of  this  paper,  the  majority  of 
cases  should  be  looked  upon  with  some  reserve,  though 
I  am  not  inclined  to  deny  that  the  disease  does  occur, 
however  rare  it  may  be.  Women  were  supposed  to  be 
subject  to  the  disease  more  frequently  than  men.  In  39 
cases  collected  by  Berlin,  26  were  women  and  13  men. 
Such  differences  mav  have  been  accidental,  for  later  sta- 
tistics  have  shown  a  very  different  relationship  between 
the  sexes.  In  Nolda's  collection  of  36  cases,  occurring  in 
early  life,  16  were  boys  and  10  girls.  In  Krafft-Ebing's 
collection  there  were  58  males  and  42  females.  In  Red- 
lich's  experience  the  number  was  almost  equally  divided 
between  men  and  women — 12  males  and  11  females.  In 
Stieglitz's  statistics  there  were  17  males  and  17  females, 
the  sex  of  one  case  not  being  mentioned.  In  the  15  cases 
seen  by  myself  the  ordinary  division  has  been  entirely 
reversed,  for  of  these,  10  were  males  and  only  5  females. 
Such  smaller  statistics  are  subject,  however,  to  accidental 


466  B.  SACHS, 

variations,  and  it  would  not  be  fair  to  infer  from  them 
that  the  disease  shows  any  distinct  preference  for  sex. 

Of  late  years  the  occurrence  of  multiple  sclerosis  after 
infectious  diseases  in  early  life  has  led  to  the  theory  of  its 
infectious  origin.  As  long  ago  as  1878,  Ley  den  insisted 
upK>n  the  importance  of  preceding  infectious  diseases. 
Other  authors  referred  to  its  occurrence  after  typhoid 
fever  (Ebstein,  Kahler,  Pick,  Westphal  and  others);  after 
cholera  (Joffroy);  after  smallpox  (Charcot);  but  Marie 
has  been  the  warmest  advocate  of  the  theory  of  the  in- 
fectious origin  of  multiple  sclerosis,  and  he  contended 
more  particularly  that  the  primary  change  was  to  be 
looked  for  in  disease  of  the  blood  vessels.  According  to 
Redlich,  who  has  gone  over  this  part  of  the  subject  very 
thoroughly,  up  to  the  year  of  1897  cases  in  support  of 
this  view  were  cited  by  Schoenfeld  (after  diphtheria),  by 
Massolongo  (after  influenza),  by  Rolland  (after  phleg- 
monous angina),  by  Williamson  (after  rheumatism),  by 
Torti  and  Angelini  (after  malaria).  Redlich  cites  a  case  of 
polyneuritis,  in  a  boy  of  17,  coming  on  after  a  sore  throat. 
The  clinical  symptoms  in  this  case  gradually  passed^  into 
those  of  multiple  sclerosis.  Henschen  refers  to  a  case  of 
a  girl  of  14,  who  developed  the  symptoms  of  multiple 
neuritis  after  diphtheria,  death  ensuing  after  three  months. 
At  the  autopsy  he  found  multiple  sclerosis  and  degenera- 
tion in  the  peripheral  nerves.  This  case  appears  to  us  to 
need  careful  interpretation,  for  it  is,  at  least,  questionable 
whether  or  not  multiple  sclerosis  existed  for  some  time 
before  the  diphtheria.  The  rapid  development  and  early 
death  make  the  case  an  entirely  exceptional  one,* 


'While  this  digest  was  passing  through  the  press  an  article  by 
Jiirgens  has  reached  the  writer.  In  this  communication  (Berliner 
kl.  Wochenschrift,  April  4,  1898)  the  author  reports  upon  the  case 
of  a  child,  six  months  old,  that  had  had  convulsions  at  the  age  of 
three  months;  repeated  convulsions  with  paralysis  of  right  arm.  Child 
died  in  convulsions.  Whatever  else  the  case  may  have  been  (instru- 
mental delivery,  etc.!)  it  was  surely  not  a  case  of  multiple  sclerosis. 
The  brain  contained  '^sclerotic  patches,"  in  which  protozoa  were  found 
similar  to  those  found  in  patches  in  the  heart  The  finding  is  of 
interest.    A  pity  it  is  that  it  has  no  bearing  upon  multiple  sclerosis. 


CRITICAL  DIGEST.  467 

Among  more  recent  authors,  Oppenheim,  Leyden, 
Goldscheider  and  Sachs  have  favored  the  occasional  in- 
fectious origin  of  the  disease,  but  do  not  feel  warranted 
in  supposing  this  etiological  factor  to  be  far  more  im- 
portant than  many  others.  Marie's  views  have  been  op- 
posed more  particularly  by  Redlich  and  Kraflft-Ebing. 
In  the  15  cases  observed  by  the  present  writer  only  2 
came  on  after  infectious  diseases,  and  in  both  of  these 
so  long  after  such  a  disease  that  a  direct  relation,  as  of 
cause  and  effect,  could  not  be  established.  It  is  well  to 
bear  in  mind,  however,  that  if  infectious  diseases  were 
the  chief  cause  of  multiple  sclerosis,  the  vast  majority  of 
cases  should  come  on  before  the  age  of  15,  and  such  is  not 
the  case. 

Oppenheim  has  directed  attention  to  the  large  num- 
ber of  cases  of  multiple  sclerosis  in  which  chronic  metallic 
poisoning  seemed  to  play  a  rather  important  part,  basing 
his  views  upon  the  frequent  occurrence  of  multiple  scle- 
rosis in  those  who  work  in  factories  in  which  toxic  chemi- 
cal substances  are  used — such  as  lead,  tin,  aniline  dyes,  and 
the  like.  It  was  Oppenheim,  too,  who  referred  to  the 
importance  of  a  puerperal  condition  as  a  predisposing 
cause. 

It  may  be  asserted  with  some  degree  of  assurance 
that  syphilis  is  not  an  important  etiological  factor,  al- 
though Jacobson,  Moncorvo  and  Filatow  have  cited  cases 
in  which  hereditary  syphilis  was  present,  and  some  others 
(Michaelow  and  Schuster)  have  referred  to  acquired  syphi- 
lis; but  Redlich  is  correct  in  issuing  a  caution,  which  the 
present  writer  has  also  uttered,  that  multiple  sclerosis 
and  multiple  cerebro-spinal  syphilis  have  so  many  symp- 
toms in  common  that  the  differential  diagnosis  is  not  eas- 
ily established.  Whether  or  not  the  disease  be  distinctly 
hereditary  is  still  in  doubt,  although  Eichhorst  has  pub- 
lished two  cases  in  which  the  disease  occurred  in  mother 
and  child.  Its  occurrence  as  a  family  disease  has  been 
noted  by  Friedreich  and  Erb  (according  to  Krafft-Ebing 


B.SACHS. 

::  .      cilich),  and  Totzke  has  mentioned  the  occurrence 

:    -!e   lisease  in  two  members  of  the  same  family.     But 

:::-     -lestion  naturally  arises,  since  these  cases  were  not 

-,:•  -iGjitiated,  whether  they  may  not  have  been  cases  of 

:ere*  Li  tary  spastic  paralysis. 

TTie  latest  contribution  to  this  subject  has  been  made 
:y  Blumenreich  and  Jacoby,  who  report  on  29  cases  of 
multiple  sclerosis — 23  in  males  and  6  in  females — and  in 
these  cases  the  infectious  diseases,  intoxications  and  trau- 
matism have  been  the  chief  etiological  factors.  They  are 
of  the  opinion  that  the  original  cause  may  have  preceded 
the  outbreak  of  the  disease  for  many  years,  and  that  the 
disease  may  even  be  of  congenital  origin.  It  is  somewhat 
surprising  to  find  that  alcoholic  and  sexual  excesses  are 
not  cited  as  occasional  etiological  factors  of  some  im- 
portance; for,  in  the  present  writer's  experience,  two  cases 
seemed  to  be  the  result  of  previous  alcoholic  excess,  and  in 
three  now  under  observation  no  other  factor  except  pro- 
longed sexual  excesses  can  be  found.  In  these  three 
cases,  moreover,  the  clinical  symptoms  are  so  typical  that 
there  can  be  no  doubt  of  the  existence  of  multiple  scle- 
rosis. 

A  little  reflection  regarding  the  etiology  of  multiple 
sclerosis  necessarily  leads  to  the  conclusion  that  many 
different  causes  may  be  at  work  resulting  in  the  develop- 
ment of  the  disease,  provided  there  be  a  predisposition 
to  the  disease.  I  cannot  agree  with  Redlich  in  refuting 
Striimpell's  theory  of  the  endogenous  character  of  mul- 
tiple sclerosis,  and  am  inclined  to  think  that  for  a  large 
number  of  cases,  particularly  for  those  occurring  early  in 
life,  some  slight  defect  in  the  original  development  of 
the  central  nervous  system  must  be  held  responsible  for 
the  outbreak  of  the  disease,  and  that  the  other  etiological 
factors  so  frequently  referred  to  are  to  be  regarded  as 
the  exciting  causes.  If  we  adopt  this  view,  the  usual  re- 
semblance between  the  cases  of  multiple  sclerosis  develop- 
ing early  in  life,  and  the  various  forms  of  hereditary  and 


CRITICAL  DIGEST,  469 

family  affections  observed  at  that  period,  can  be  inter- 
preted more  readily. 

I  have  also  had  occasion  to  observe  several  cases  in 
which  a  distinct  neurasthenic  condition,  due  to  overwork, 
preceded  the  development  of  the  symptoms  of  multiple 
sclerosis.  According  to  Eddinger's  theory,*  the  develop- 
ment of  a  sclerosis  following  upon  functional  exhaustion 
does  not  appear  to  be  at  all  anomalous.  And,  finally,  I 
may  refer  to  the  fact  that  in  one  patient  of  mine,  a  music 
teacher,  a  functional  tremor  first  appeared  in  the  right 
hand;  this  was  followed  by  a  distinct  intention  tremor, 
and  from  this  stage  the  symptoms  passed  into  those  of  a 
typical  paralysis  agitans.  Altogether,  the  relation  of.  func- 
tional to  organic  nervous  diseases  would  appear  to  need 
further  attention,  for  the  same  sequence  of  events  has 
no  doubt  been  observed  by  others,  and  it  is  not  to  be 
supposed  that  the  diagnosis  of  a  preceding  functional 
condition  was  erroneously  made.  Some  of  the  mooted 
points  regarding  the  etiology  of  multiple  sclerosis  acquire 
additional  interest,  if  we  consider  them  in  connection  with 
a  discussion  of  the  morbid  anatomy  and  pathogenesis  of 
the  disease^ 

PATHOLOGICAL  ANATOMY  AND   PATHOGENESIS. 

The  irregular  sclerotic  patches  (plaques)  occurring  in 
different  parts  of  the  central  nervous  system  constitute 
the  chief  anatomical  feature  of  the  disease.  These 
^'plaques"  represent  the  terminal  condition  of  a  morbid 
process  often  lasting  through  a  period  of  years;  but  a  study 
of  "late  stages"  has  helped  us  as  little  toward  an  under- 
standing  of  the  morbid  anatomy  of  multiple  sclerosis,  as 
has  been  the  case  in  regard  to  poliomyelitis.  The  process 
can  be  understood  only,  if  studied  in  its  earliest  stages. 
Such  studies  have  been  made  by  Ribbert,  Cramer,  Bikeles, 
Taylor  and  Goldscheider. 

With  some  slight  exception,  the  general  agreement 
has  been  reached  that  the  blood  vessels  play  an  important 

*This  theory  appears  to  have  received  experimental  proof:  c.f., 
Report  of  the  Congress  f.  innere  Med.,  Wiesbaden,  1898. 


470 


B,  SACHS. 


part  in  the  initial  stages  of  the  disease.  Goldscheider  de- 
scribes the  conditions  as  presented  by  a  patch  in  the  cervi- 
cal  portion  of  the  spinal  cord.  The  blood  vessels  are  di- 
lated, and  the  adventitia  is  infiltrated  with  small  cells  and 
with  considerable  detritus.  In  the  vicinity  of  these  blood 
vessels  the  nerve  fibres  are  swollen,  the  sheath  and  the 
axis-cylinder  participating  in  the  swelling.  The  medullary 
sheath  suffers  more  than  the  axis-cylinder;  at  least,  every 
cross-section  exhibits  a  number  of  naked  and  well-pre- 
served axis-cylinders.  Goldscheider  supposes  that  the  en- 
larged nerve  fibres  crowd  against  each  other,  causing  the 
disintegration  and  absorption  of  the  myelin  of  some  fibres^ 
thus  leaving  room  for  other  fibres  to  persist  in  their  en- 
larged (swollen)  condition.  The  changes  thus  far  de- 
scribed are  not  unlike  those  occurring  in  an  ordinary 
acute  myelitis. 

Taylor  is  of  the  opinion  that  we  are  not  warranted  in 
connecting  the  vascular  changes  directly  with  the  scle- 
rotic process,  for  the  patches  are  not  always  related  to  the 
diseased  vessels,  and  in  many  plaques  the  blood  vessels  are 
entirely  normal,  and  other  portions  of  the  vascular  sys- 
tem show  no  tendency  to  disease.. 

As  early  as  1863  Rindfleisch  maintained  the  importance 
of  disease  of  the  blood  vessels.  According  to  him,  each 
plaque  contained  in  its  centre  a  blood  vessel  with  changed 
walls,  denoting  a  condition  of  chronic  inflammation.  Borst 
found  marked  changes  in  almost  every  blood  vessel 
(hyaline  degeneration,  narrowing,  thickening  of  the  walls^ 
etc.).  He  also  found  a  condition  of  hyperlymphosis  and 
lymphstasis,  which  he  supposed  caused  a  destruction  of 
the  medullary  sheaths;  but  his  views  lack  support.  Red- 
lich  found  changes  in  the  larger  blood  vessels,  and  even 
in  the  capillaries;  the  neuroglia  tissue  is  easily  affected 
in  the  immediate  vicinity  of  the  blood  vessels,  leading  at 
times  to  a  perivascular  sclerosis.  Ribbert  found  in  two 
blood  vessels  thrombi  consisting  of  leucocytes.  A  plug- 
ging of  blood  vessels  was  also  noticed  byRedlich;  but  these 


CRITICAL  DIGEST.  47 1 

findings  appear  to  us  to  have  no  especial  significance,  ex- 
cept that  they  prove  that  the  vascular  system  is  diseased 
in  some  instances.  It  is  to  be  inferred,  from  other  reports, 
that  the  blood  vessels  often  remain  entirely  normal.  The 
impartial  inference  necessarily  to  be  drawn  is  that,  while 
the  blood  vessel  may  be  the  starting  point  of  the  morbid 
process  in  some  cases,  it  need  not  be  so  in  all,  and  we 
shall  find,  as  we  proceed  in  this  discussion,  that  the  ter- 
minal findings  are  the  only  ones  that  are  entirely  similar 
in  all  cases,  but  that  there  is  a  difference  of  opinion  as  to 
the  intermediate  stages  by  which  this  terminal  condition 
is  reached.  Thus,  in  Goldscheider's  case  the  nerve  fibres 
were  the  structures  particularly  affected;  while  in  Rib- 
bert's  case  the  neuroglia  cells  were  chiefly  affected,  and 
there  was  no  swelling  of  the  nerve  fibres. 

If  the  nerve  fibre  becomes  involved,  it  is  no  doubt  true, 
as  was  recognized  by  the  earliest  investigators  (Rind- 
fleisch,  Charcot,  Leyden,  Schultze)  that  the  medullary 
sheath  is  easily  destroyed,  >yhile  the  axis-cylinder  remains 
normal.  Popoff  alone  contends  that  the  axis-cylinder  is 
also  destroyed,  but  that  it  is  regenerated.  This  tnay 
occur  at  rare  intervals;  it  is  much  more  rational  to  assume 
that  the  axis-cylinder  is  not  destroyed,  and  the  preserva- 
tion of  normal  axis-cylinders  in  a  mass,  exhibiting  any 
number  of  disintegrating  medullary  sheaths,  argues  in 
favor  of  this  view.  The  preservation  of  the  axis-cylinder 
is  responsible  for  the  lack  of  secondary  degeneration  in 
multiple  sclerosis.  Buss  has  recorded  an  ascending  degen- 
eration of  the  columns  of  GoU,  and  of  the  direct  cerebellar 
tract  from  the  eighth  cervical  segment  into  the  medulla 
oblongata.  These  observations  are  quite  unique,  and 
need  further  corroboration. 

It  has  been  assumed  by  Redlich  and  others  that  the  fine 
fibrils  which  Popoff  took  to  be  regenerated  axis-cylinders 
are  part  of  the  proliferating  neuroglia  tissues.  It  is  also 
significant  that  Weigert,  wTiose  opinion  is  of  the  highest 
value  in  this  matter,  insists  that  the  proliferation  of  neu- 


472  B.  SACHS, 

roglia  tissue  is  more  marked  in  multiple  sclerosis  than  in 
any  other  disease.  This  statement  militates  against  the 
view  of  Lapinsky,  that  the  fine  fibrils  discovered  in  the 
plaques  are  connective  tissue  formations  issuing  from  the 
medullary  sheaths,  and  are  not  neuroglia  fibres.  Recent  in- 
vestigations, utilizing  Weigert's  neuroglia  stain,  have  sat- 
isfied Redlich  that  the  proliferating  interstitial  tissue  con- 
sists of  neuroglia  fibres  of  varying  sizes.  Huber  concedes 
that  there  are  slight  changes  in  the  neuroglia,  but  that 
these  consist  chiefly  of  lacunae,  due  to  the  loss  of  nerve 
fibres,  and  of  the  presence  of  detritus  and  granular  cells. 
According  to  Huber,  the  process  is  of  parenchymatous 
origin,  the  changes  in  the  neuroglia  and  in  the  blood  ves- 
sels being  secondary.  Adamkiewicz  has  also  advocated 
the  theory  of  the  primary  affection  of  nerve  fibres. 

If  the  neuroglia  be  affected,  primarily  or  secondarily, 
its  cells,  as  well  as  its  fibres,  undergo  proliferation.  Red- 
lich, who  has  studied  this  tissue  carefully,  maintains  that 
the  neuroglia  changes  may  be  exhibited  in  various  ways: 
I.  The  increase  is  largely  due  to  the  increase  of  neuroglia 
fibres,  which  gradually  form  a  network  of  fibres,  in  which 
only  slightly  altered  nerve  fibres  will  be  found.  As  these 
neuroglia  fibres  grow  broader  and  broader,  the  network 
becomes  denser.  2.  In  some  patches  the  network  is  not 
so  dense,  the  neuroglia  cells  and  their  processes  being  the 
most  pronounced  features,  while  the  nerve  fibres  have 
dropped  out.  This  appearance  is  entirely  similar  to  the 
account  given  by  Huber,  to  which  we  have  referred  above. 

Fuerstner  is  of  the  opinion  that  the  neuroglia  cells 
are  developed  from  leucocytes,  thus  bridging  over  the 
chasm  between  those  who  maintain  that  the  disease  is  a 
parenchymatous  aflfection  and  those  who  believe  it  to  be 
of  vascular  origin.  The  actual  participation  of  the  neu- 
roglia tissue  has  acquired  greater  interest,  in  view  of 
Struempeirs  recent  theory  that  the  disease  is  due  to  a 
primary  proliferation  of  the  neuroglia,  that  multiple  scle- 
rosis is  practically  a  multiple  gliosis,  and  that  it  belongs 


CRITICAL  DICEST.  473  j 


to  the  order  of  endogenous  affections  which  are  excited 
by  accidental  causes,  such  as  injuries  and  infectious  dis- 
eases. Ziegler  appears  to  have  entertained  a  similar  view 
(Redlich). 

To  complete  the  record  of  histological  changes,  we 
may  add  that  Gowers  referred  to  the  involvement  of  the 
ganglion  cells  in  the  earlier  stages  of  the  disease;  while 
Taylor  states  very  positively  that  the  ganglion  cells  do 
not  become  affected  until  the  late  stages  of  the  disease 
have  been,  reached.  He  draws  this  inference  from  the 
conditions  as  observed  in  three  cases  of  his  own.  The 
changes  as  described  by  Taylor  are:  Considerable  pigmen- 
tation, filling  up  the  entire  cell  body,  which  is  unusual  in 
healthy  young  individuals;  the  nuclei  are  generally  want- 
ing; the  nerve  processes  are  well  preserved;  a  diminution 
of  cells.  Koeppen  found  the  ganglion  cells  normal.  Ober- 
steiner  allowed  that  "the  ganglion  cells  ....  may 
exhibit  changes  similar  to  those  found  in  myelitis." 
(Quoted  after  Taylor.) 

The  patches  of  disseminated  sclerosis  present  a  bluish- 
gray  appearance,  and  are  sometimes  slightly  elevated; 
at  other  times  the  parts  in  which  they  occur  appear 
shrunken  and  contracted.  The  question  has  arisen  whether 
there  is  any  rule  governing  the  distribution  of  the  plaques. 
By  some  it  was  supposed  that  the  brain  or  the  spinal  cord 
may  be  affected  singly.    Charcot  supported  the  view  of  a 
spinal  form  of  multiple  sclerosis.     Erb  accepted  this  on 
clinical  grounds  only.    Charcot,  Struempell,  Erb  and  many 
other  writers  considered  that  the  white  substance  of  the 
brain  and  spinal  cord  was  the  favored  site;  that  the  gray 
matter  was  rarely  involved.     Charcot  believed  that  the 
cortex  of  the  brain  and  cerebellum  is  rarely  affected,  and 
it  cannot  be  denied  that  in  this  form  the  statement  is  true 
enough.    Basing  his  conclusions  upon  three  cases,  Taylor 
finds:  i.  White  and  gray  are  affected  without. distinction. 
2.  There  is  no  especially  favored  site  for  the  development 
of  the  sclerotic  foci.    3.  The  cortex  of  the  cerebrum  and 


474 


B,  SACHS. 


of  the  cerebellum  is  not  exempt.  The  points  i  and  2 
cannot  be  accepted  unconditionally,  as  such  statements 
must  rest  upon  the  examination  of  a  larger  number  of 
cases.  Charcot  believed  that  the  auditory,  the  olfactory 
and  the  optic  nerves  are  the  only  cranial  nerves  affected; 
others  (Cruveilhier,  Skoda,  Taylor)  have  found  all,  or  al- 
most all,  involved.  It  is  well  known  that  the  motor  and 
sensory  roots  of  the  spinal  nerves  are  often  diseased,  and 
Tavlor  has  demonstrated  the  occurrence  of  a  marked  de- 
generation  of  the  nerve  fibres  in  the  cauda  equina. 

The  sclerotic  patches  may  occur  anywhere,  but  there 
can  be  little  doubt  that  they  do  occur  most  frequently  in 
the  dorsal  half  of  the  pons,  of  the  medulla  oblongata 
(whence  the  occurrence  of  "bulbar  forms"),  in  the  white 
strands  near  the  periphery  of  the  cord  and  in  the  gray 
matter  near  the  central  canal.  Obersteiner  believes  that 
the  patches  are  lessened  in  number  as  we  approach  the 
lumbar  portion  of  the  cord.  Leyden  and  Goldscheider  de- 
scribe a  condition  of  diffuse  sclerosis,  or  of  a  diffuse 
chronic  myelitis,  due  to  the  confluence  of  numerous  foci 
in  the  spinal  cord.  These  authors  also  describe  a  purely 
spinal  form  of  multiple  sclerosis,  which  is  the  representa- 
tive of  the  old-time  chronic  myelitis. 

The  sclerotic  patches  appear,  on  macroscopical  exam- 
ination, to  be  sharply  differentiated  from  the  surround- 
ing healthy  tissue,  but,  microscopically,  the  transition  is 
a  gradual  one.  Taylor  has  shown,  however,  that  the  di- 
vision between  healthy  and  diseased  tissue  may  be  strictly 
defined,  and  the  same  is  true  in  Goldscheider's  case.  (See 
Fig.  2  of  his  article.) 

The  pathogenesis  of  multiple  sclerosis  is  still  obscure. 
There  are  theories  enough,  but  none  that  explains  satis- 
factorily all  the  cases.  In  all  probability  there  is  no  sinele 
mode  of  origin. 

Charcot  believed  that  the  disease  was  due  to  an  in- 
terstitial inflammation,  with  a  special  proliferation  of  the 
neuroglia,  the  destruction  of  the  parenchyma  being  sec* 


CRITICAL  DIGEST.  475 

ondar}'  to  this.  Charcot  ascribed  some  importance  to  the 
blood  vessels,  and  regarded  them  as  a  source  of  irritation, 
thus  following,  in  the  main,  Rindfleisch's  teachings.  But 
the  part  played  by  the  blood  vessels  did  not  attain  to  its 
present  dignity  imtil  Marie  published  his  views  regarding 
the  infectious  origin  of  disseminated  sclerosis,  for  he  sup- 
posed that  the  exciting  agents  were  carried  through  and 
along  the  blood  vessels.  Ribbert  also  favored  the  theory 
that  the  plaques  were  due  to  some  noxious  substances 
conveyed  by  the  blood,  and  setting  up  circumscribed  in- 
flammatory lesions  in  different  parts  of  the  central  nervous 
system.  Mendel  explained  the  traumatic  etiology  of  some 
cases  through  the  agency  of  blood  vessels.  Fuerstner 
brought  the  blood  vessels  into  play  by  making  them 
primarily  responsible  for  nutritive  disturbances  in  the 
nerve  cells  and  fibres.  Goldscheider  savs:  "I  believe  I  shall 
describe  the  nature  of  the  morbid  process  most  correctly 
by  assuming  the  existence  of  a  perivascular  inflammation 
which  injures  the  neighboring  nerve  structures,  causing 
more  especially  a  disintegration  of  the  medullary  sheath, 
but  allowing  the  axis-cylinder  to  escape.  Later  on,  in 
the  course  of  the  disease,  a  reactive  interstitial  prolifera- 
tion is  established."  He  regards  multiple  sclerosis  as  a 
form  of  disseminated  myelitis.  Koeppen,  Huber  and  Tay- 
lor do  not  attach  so  much  importance  to  the  blood  vessels, 
and  Redlich  is  not  convinced  that  the  disease  is  always  of 
inflammatory  origin. 

The  vascular  theory  has  been  opposed  by  others. 
Adamkiewicz  regards  the  disease  as  a  parenchymatous  de- 
generation. Weigert  is  inclined  to  the  belief  that  the 
neuroglia  changes  are  secondary  to  the  affections  of  the 
parenchyma,  and  Striimpell,  as  we  have  seen,  is  inclined 
to  regard  the  disease  as  being  due,  primarily,  to  a  peculiar 
defective  (?)  development  of  the  neuroglia,  which  is  made 
evident  in  later  years  by  especial  exciting  causes. 

We  hope  soon  to  be  able  to  shed  some  further  light 
upon  this  controversy  by  researches  of  our  own,  but  an 


476  H-  SACHS. 

Impartial  review  of  the  results  published  by  other  authors 
leads  to  the  conclusion  that  there  is  some  truth  in  several 
of  the  views  advanced.  We  believe  that  the  vascular 
theory  holds  good,  particularly  for  the  cases  developed 
after  infectious  diseases,  after  injuries,  etc.;  and,  according 
to  the  intensity  of  the  toxic  agent,  the  nerve  fibres  or 
the  neuroglia  may  be  attacked  first.  This  is  in  agreement 
with  views  expressed  by  Redlich.  Congenital  anomalies 
(Ziegler,  Struempell)  may  make  the  central  nervous  sys- 
tem an  easier  prey  for  the  various  toxic  agencies  and  other 
injuries.  But  there  still  remains  a  considerable  number  of 
cases  which  cannot  be  explained  on  the  supposition  of  an 
inflammatory,  toxic  or  traumatic  origin,  nor  as  the  re- 
sult of  congenital  anomalies.  These  would  seem  to  de- 
pend rather  upon  functional  exhaustion,  and  such  ex- 
haustion might  affect  primarily  the  nerve  elements  of  the 
central  nervous  system.  For  such  cases  the  assumption 
of  a  parenchymatous  affection  would  be  most  plausible. 
In  spite  of  the  numerous  contributions  to  this  subject, 
further  investigation,  impartially  conducted,  will  be  bene- 
ficial. Above  all,  there  is  need  of  careful  inquiries  into  the 
earliest  histological  changes  in  disseminated  sclerosis. 

BTBLIOGRAPHY.' 

Adamkiewicz:     Die   degtnerativen    Erkrankungen    des    Rucken- 
markcs.     1S88. 

Amcschot  (Forme  frustel:    Neurol,  Centralbl.,  1895,  p.  732. 

Bass:    Das  Geskhtsfeld,  etc.     Stuttgart,  i8g6. 

Babinski:    Etude  ana  to  mique,  etc.    These  de  Paris,  iSgj. 

Bechterew:    On   Specific   Disseminated  Sclerosis,  etc.     Archiv  i 
P.'iychiatrie,  vol.  xxviii.,  1896. 

Berlin:    Deutpches  Archiv  f.  Win.  Med,,  1874. 
ikfles:    Obersleiner  Arbeiten,  Vienna,   iSgs.  3d  part. 
lumenreich  &  Jacoby:    Deutsche  med.  Wochenschrift,  1897,  No. 

orsi:  Ziegler's  Beilrage  zur  path.  Anat.,  vol.  xxi..  i8g7  (Hyper- 


ristowe:   Med.  Times  and  Gazette,  1897. 

iT  full  reference  lists  consult  articles  by  Redlich  and  Stieglitz. 


r 


CRITICAL  DIGEST.  477 

Brans:    Ncurolog.  Ccntralb!.,  iSgo.  p.  520  ^Relation  to  Mt^ds). 

Buzzard:    British  Med.  JoumaL  l^05. 

Buss:    Deutsches  Archiv.  i.  klia,  Med.,  vo!.  xlv.,  1;^ 

Charcot:  Gazette  Mcdicalc,  Jan.  S.  i^T^S^  Progres  Medical,  1879^ 
(Formes  fnistes.) 

Charcot:  Cliniqae  des  Maladies  du  Sy5t>:me  Xerveux,  1S92,  pi 
J99,  vol.  L 

Critical  Digest:    Brain.  1890,  p.  3^ 

Danitsch:  Xeurolog.  Centrs'.b'...  lijyo. 

Dejerine:    Revue  de  Med.,  iSm. 

Dreschfeld:    .Med.  Times  and  U-^zette.  1878.  vol.  i..  p.  14a 

Eichhorst:   Virchow's  Archiv.  vol.  xcvi..  1S96.  ^^Hereditary  form.) 

Fromaan:  Untcrsuchungen  ubcr  die  Gei^ssveranderungen,  187& 
(Quoted  by  Rediich.) 

Freund:    Archiv  f.  Psychiatrie,  1801,  vol.  xxii.,  p.  317. 

Fiirstner:  Xeurolog.  CentralbL,  1895,  p.  615.  Archiv.  f.  Psychiatric, 

vol.  XXX.,    p.  I. 

Goldscheider:   Zeiischrift  f.  klin.  Med.,  vol.  xxx,  p.  417- 

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NEW  YORK  NEUROLOGICAL  SOCIETY. 
Stated  Meeting,  May  3d,  1898. 
Frederick   Peterson,  M.  D.,  President. 

ADDRESS  OF  THE  RETIRING  PRESIDENT. 

Dr.  B.  Sachs,  in  retiring  from  the  presidency  of  the 
society,  stated  that  during  the  past  two  years  the  papers 
and  discussions  had  covered  a  very  wide  range,  and  that 
greater  attention  had  been  paid  to  psychiatry  and  to  the 
presentation  of  clinical  cases  than  formerly. 

ADDRESS  OF  THE  PRESIDENT-ELECT—  NEW  PATHS  IN 

PSYCHIATRY. 

Dr.  Frederick  Peterson,  on  assuming  office,  delivered 
an  address,  entitled  "New  Paths  in  Psychiatry."  (  See  page 
444) 

SUTURE  OF  MEDIAN  NERVE. 

Dr.  B.  Farquhar  Curtis  presented  a  young  woman  who, 
last  September,  received  a  small  punctured  wound  of  the 
right  wrist.  Following  that  there  was  anaesthesia  of  the 
forefinger  and,  to  a  less  extent,  of  the  thumb  and  middle 
finger,  but  without  any  marked  paralysis.  The  area  of 
anaesthesia  was  not  quite  typical  of  that  observed  after 
complete  division  of  the  median  nerve,  because  the  ulnar 
side  of  the  middle  finger  was  not  involved.  The  operation 
had  been  done  a  week  ago,  and,  on  exposing  the  nerve,  it 
had  been  found  that  it  had  been  completely  divided,  in 
spite  of  the  atypical  area  of  anaesthesia.  On  cutting  off 
the  bulbous  ends  an  interval  of  about  one  inch  was  left 
between  the  ends  of  the  nerves.  Both  ends  were  forciblv 
stretched,  and  apposed,  and  the  hand  kept  in  a  flexed  po- 
sition by  a  suitable  splint.  Two  or  three  catgut  sutures 
were  passed,  not  merely  through  the  sheath,  but  through 


48o  NEW  YORK  NEUROLOGICAL  SOCIETY. 

the  nerve  itself.  Instead  of  cutting  away  the  bulbous  ends 
entirely,  the  fibrous  part  of  the  sheath  was  preserved  and 
used  as  a  sort  of  flap  for  the  reinforcement  of  the  suture. 
The  anaesthesia  had  been  so  complete  before  the  operation 
that  she  had  repeatedly  burned  the  ends  of  the  fingers. 

TRAUMATIC  ULNAR  NEURITIS— TRANSPLANTATION  OF 

THE  NERVE. 

Dr.  Curtis  also  presented  a  woman,  twenty-eight  years 
of  age,  who  had  been  doing  a  good  deal  of  writing  with 
a  pen.  In  childhood  she  had  received  a  fracture  of  both 
condyles  of  the  right  elbow.  As  a  result  of  this,  the  ulnar 
nerve  lay  upon  an  exposed  surface,  instead  of  in  the  groove. 
For  two  or  three  years  there  had  been  increasing  numbness 
and  pain.  Dr.  Dana  had  seen  the  case,  and  made  a  diag- 
nosis of  neuritis.  Dr.  Curtis  exposed  the  nerve  by  a  curved 
incision  and  flap.  The  nerve  was  found  to  be  thickened 
tor  a  distance  of  about  an  inch  and  a  half,  and  to  about 
twice  its  normal  diameter.  On  incision  through  the  sheath 
there  seemed  to  be  a  general  increase  of  the  fibrous  tissue 
of  the  nerve.  The  nerve  was  split  and  stretched  gently,  and 
then  removed  from  its  exposed  situation  to  a  more  pro- 
tected part,  i.  e.,  to  the  front  of  the  elbow.  The  result  has 
been  surprisingly  satisfactory,  so  that  she  has  been  enabled 
to  resume  her  long  hours  of  writing  without  discomfort. 
The  speaker  said  that  there  had  been  some  cases  reported 
of  dislocation  of  the  ulnar  nerve,  in  which  the  nerve  had 
been  restored  to  its  proper  groove  by  operation.  There 
had  been  no  material  change  in  the  general  appearance  of 
the  hand,  except  perhaps  that  it  was  a  little  more  plump. 

DISCUSSION. 

Dr.  Sachs  said,  regarding  the  maintenance  of  sensation  in 
the  ulnar  half  of  the  hand  in  the  first  case,  that  the  areas  of 
sensation  pertaining  to  the  two  nerves  are  so  irregular  that 
one  can  not  predict  with  any  certainty  as  to  the  result  in  any 
given  case.  The  result  in  both  cases  presented  was  certainly 
very  good. 

TREPHINING  FOR  EPILEPSY. 

Dr.  B.  F.  Curtis  then  exhibited  a  recent  case  of  tre- 
phining for  epilepsy,  with  a  view  to  illustrating 
the  technique  of  the  general  operation  of  craniotomy  with 
a  bone  flap.    The  patient,  an  Italian,  twenty-five  years  of 


NEW  YORK  NEUROLOGICAL  SOCIETY.  48 1 

age,  had  had  epilepsy  quite  severely,  but  the  details  of  the 
previous  history  were  not  in  his  possession  at  present. 
There  were  no  localizing  symptoms,  but  there  was  a  scar 
on  the  right  side  of  the  head,  and,  at  Dr.  Hammond's  sug- 
gestion,  an   exploratory   operation   was   performed   last 
March.  As  there  was  no  definite  localization,  a  large  open- 
ing was  required.     This  was  made  by  the  osteoplastic 
method,  using  the  wire  saw.     Four  small  trephine  open- 
ings were  rapidly  made,  and  then  a  flat  director  of  Ger- 
man silver  was  passed  between  the  skull  and  the  dura  from 
one  opening  to  the  other.     Through  this  an  eyed-probe 
armed  with  a  string  could  be  passed.    The  string  served 
to  carry  the  wire  saw.    The  latter  is  nothing  but  a  piece 
of  piano-wire  having  a  screw  thread  cut  upon  it.    It  is  op- 
erated like  a  chain  saw,  and  cuts  very  rapidly.     The  ad- 
vantage over  the  electric  saw  was  that  it  eliminated  the 
uncertainties  connected  with  the  use  of  a  battery.    The 
disadvantage  of  having  to  put  a  guard  underneath  was  one 
which  is  shared  by  all  the  other  methods  of  this  nature. 
As  the  saws  were  very  cheap,  a  new  one  could  be  used  for 
each  case.    The  saw  was  used  on  the  three  sides,  and  the 
remainder  of  the  flap  broken  away.    Fully  one  third  of  the 
brain  was  exposed  in  this  way.    It  seemed  to  him  much 
easier  to  make  these  large  openings  and  work  through 
them  than  through  the  smaller  trephine  apertures.    The 
cut  with  the  saw  is  made  obliquely,  so  that  immediately 
afterward  the  bone  can  be  replaced  and  will  rest  firmly 
in  place.    In  this  case  some  atrophy  of  the  cortex  and  of 
the  underlying  parts  was  found. 

Dr.  Curtis  then  reported  two  other  cases  which  had 
been  operated  upon  previously,  and  which  had  failed  to 
present  themselves  at  this  meeting  for  inspection.  The 
first  case  was  that  of  a  married  woman,  thirty  years  of 
age,  who,  as  a  result  of  a  fall,  had  severely  injured  her  right 
arm.  She  did  not  have  any  epileptic  fits,  however,  until 
six  years  before  coming  under  Dr.  Dana's  observation. 
Shortly  before  that  time  they  had  become  very  frequent 
and  severe.  In  other  respects  she  appeared  to  be  healthy. 
The  attacks  always  began  in  the  left  foot  and  spread  up 
the  leg;  then  they  attacked  the  arm  and  spread  to  the 
body.  She  frequently  had  a  complete,  general  and  typical 
epileptic  attack,  with  loss  of  consciousness.  There  was 
no  paralysis  and  no  optic  neuritis.  She  would  have  as  many 
as  a  dozen  attacks  in  one  night.    The  speaker  said  that  at 


482  NEIV  YORK  NEUROLOGICAL  SOCIETY, 

the  operation  he  had  made  an  opening,  two  inches  in  di- 
ameter, over  the  fissure  of  Rolando.  On  testing  the  cen- 
tres with  a  strong  current  of  electricity  an  intense  general 
convulsion  had  been  provoked.  This  began  in  the  left 
leg,  and  the  pulse  becoming  very  feeble,  the  wound  was 
closed  temporarily.  It  was  worthy  of  note  that  the  fits 
continued,  notwithstanding  the  relief  of  pressure_afforded 
by  the  removal  of  the  bone.  A  week  after  this  operation 
the  wound  was  reopened,  and  a  flap  of  dura  was  turned 
back.  The  vessels  surrounding  the  motor  centres  were 
ligated,  and  then  the  cortex  on  both  sides  of  the  fissure 
of  Rolando  and  the  region  of  the  arm  and  leg  centres  was 
excised.  Some  adhesions  to  the  pia  mater  were  encoun- 
tered and  separated.  There  was  some  rise  of  temperature, 
but  no  other  sign  of  inflammation  after  the  operation. 
The  patient  was  completely  paralyzed  in  the  left  arm  and 
leg,  and  had  a  few  fits  in  the  first  week,  and  her  whole 
demeanor  underwent  a  marked  change.  After  a  time  the 
mental  depression  passed  off,  and  when  she  left_the  hos- 
pital she  was  in  good  spirits.  She  took  the  bromides  during 
her  stay  in  the  hospital,  but  discontinued  them  afterward. 
Motion  in  the  arm  and  leg  began  six  weeks  after  opera- 
tion, and  in  six  months  she  had  complete  power  in  both 
extremities.  Eighteen  months  after  operation  he  had  ex- 
amined her.  She  had  gained  twenty  or  thirty  pounds  in 
weight,  and  had  entirely  recovered  the  use  of  the  hand 
and  leg.  She  no  longer  had  fits,  and  was  in  the  best  of 
health,  her  former  cheerfulness  and  mental  activity  hav- 
ing been  restored.  Slight  headache  and  indisposition  to 
meet  people  at  certain  times  were  the  only  remnants  of 
the  old  trouble.  There  was  a  considerable  depression  of 
the  scalp  over  the  aperture. 

The  second  case  was  one  of  hemorrhagic  cyst  of  the 
brain,  with  epilepsy,  in  which  recovery  follow^ed  the  op- 
eration of  trephining.  The  patient  was  a  Russian  bOy, 
thirteen  years  of  age,  who  was  admitted  to  the  Post-Grad- 
uate  Hospital  on  June  nth,  1896.  Fourteen  months  pre- 
viously he  had  had  a  cerebral  hemorrhage,  with  left  hemi- 
plegia, and  for  about  a  year  he  had  suffered  from  epileptic 
fits.  There  was  no  special  localization, but  he  was  guided  to 
the  situation  by  the  limited  paralysis  on  the  opposite  side 
of  the  body.  In  this  case  the  operation  was  about  the 
same  as  in  the  other  case.  The  aperture  was  made  about 
two  inches  in  diameter  over  the  motor  region.    The  dura 


NEW  YORK  NEUROLOGICAL   SOCIETY.  483 

was  opened,  and  when  the  circulation  became  feeble,  the 
brain  appeared  unusually  blanched  and  soft.  Further  ex- 
ploration revealed  a  cystic  cavity  immediately  underneath 
the  cortex.  Here  the  cortical  substance  of  the  brain  was 
very  much  thickened  by  fibrous  tissue.  The  cavity  ex- 
tended backward  into  the  posterior  lobe,  and  forward  for 
three  or  four  inches.  The  cyst  contained  clear  serum,  but 
there  was  no  tension  in  the  cyst.  The  cyst  was  closed  by 
catgut  sutures,  as  the  brain  tissue  was  quite  fibrous  and 
permitted  such  a  method  to  be  used.  The  operation  was 
done  on  July  4th.  On  October  25th  there  were  seven  con* 
vulsions  in  twenty-four  hours.  On  the  following  day  a 
large  aspirating  needle  was  plunged  into  the.  cyst,  and  five 
or  six  grammes  removed.  He  remained  free  from  con- 
vulsions until  February  i8th,  1897,  when  it  became  neces- 
sary to  repeat  the  aspiration.  Up  to  last  January  he  had 
remained  free  from  convulsions  under  the  use  of  the  bro- 
mides. 

DISCUSSION. 

Dr.  W.  M.  Leszynsky  said  that  he  had  seen  this  boy  about 
one  week  ago.  Although  before  operation  the  bromides  had 
had  absolutely  no  effect,  since  the  last  aspiration  of  the  cyst 
the  boy  had  been  comparatively  well.  He  had  been  taking 
thirty  grains  of  bromide,  three  times  a  day,  and  now  had  only 
an  occasional  slight  attack,  limited  to  the  paralyzed  side — 
about  one  in  three  weeks — and  his  mental  condition  had  im- 
proved. He  had  reported  the  case  to  the  American  Neuro- 
logical Association  last  year.  Even  in  such  apparently  hopeless 
cases  some  benefit  seemed  to  follow  surgical  interference.  He 
had  suggested  an  exploratory  operation,  in  view  of  the  limited 
character  of  the  paralysis. 

Dr.  C.  L.  Dana  said  he  desired  to  emphasize  the  remark- 
able success  achieved  in  the  case  which  had  been  under  his 
observation,  and  which  was  one  of  true,  classical  Jacksonian 
epilepsy,  without  any  discoverable  gross  lesion  of  the  brain. 
Dr.  Collins  and  he  had  made  a  microscopical  examination  of 
the  excised  part,  and  had  found  marked  degenerative  changes 
in  the  cells.  Dr.  Collins  had  published  in  "Brain"  the  results 
of  this  study.  Dr.  Dana  said  he  had  no  doubt  that  the  case,  if 
left  alone,  would  have  developed  into  one  of  ordinary  epilepsy. 

Dr.  Sachs  said  that  one  great  obstacle  to  the  successful 
performance  of  these  operations  had  always  been  the  difficulty 
of  obtaining  a  suitable  saw.  The  instrument  just  exhibited 
seemed  to  be  a  great  improvement  on  former  instruments. 
Most  of  the  neurologists  and  surgeons  seemed  now  agreed 
upon  the  advisability  of  using  a  large  flap.    He  thought  a  care- 


484  NEW  YORK  NEUROLOGICAL  SOCIBTY. 

ful  record  should  be  made  of  every  case  of  this  kind  in  which 
a  good  result  had  been  obtained,  because  the  whole  subject 
of  the  surgical  treatment  of  epilepsy  had  lately  received  an- 
other serious  blow  from  Bergmann.  Certainly,  a  sufficient 
number  of  cases  had  been  relieved  by  operation  to  warrant  a 
selection  of  such  cases  as  seemed  suitable  for  operation,  par- 
ticularly those  in  which  the  interval  between  the  development 
of  the  epilepsy  and  the  operation  was  not  very  long.  The  fact 
that  in  the  case  just  reported  the  interval  had  been  six  years 
made  the  good  result  all  the  more  remarkable. 

Dr.  J.  Arthur  Booth  said  that  it  was  common  for  cases  to 
go  without  attacks  for  two  or  three  years  under  the  bromide 
treatment,  and  without  surgical  interference;  hence,  these 
cases  should  not  be  considered  as  cured  until  at  least  four  or 
five  years  had  elapsed. 

Dr.  Peterson  also  thought  it  extremely  important  that  care- 
ful records  o*  these  cases  should  be  kept  for  a  lone  time  after 
operation.  At  least  four  years  should  elapse  without  an  at- 
tack before  a  case  should  be  considered  as  cured. 

Dr.  Curtis  said  he  had  not  intended  to  bring  up  the  cen- 
tral subject  of  the  surgical  treatment  of  epilepsy  at  this  time. 
He  thought  the  surgeon  should  be  willing  to  operate  upon  a 
good  many  of  these  cases,  but  two  classes  should  be  carefully 
distinguished,  viz.,  (i)  cases  like  the  ones  just  reported,  in 
which  there  is  localization  of  the  epilepsy,  and  (2)  cases  like 
that  of  the  Italian  just  presented,  whose  future  is  hopeless,  and 
whose  history  is  vague.  For  the  sake  of  the  few  who  might 
be  benefited  it  seemed  to  him  justifiable  to  operate.  The  op- 
eration certainly  causes  a  temporary  amelioration  of  the  symp- 
toms, and  this  repays  the  patient  for  the  slight  risk  incurred 
by  submitting  to  the  operation.  In  cases  requiring  an  ex- 
tensive and  dangerous  operation  the  probable  benefit  is  cor- 
respondingly great.  He  was  not  enthusiastic  about  this  kind 
of  work,  and  did  not  speak  of  the  cases  reported  as  "cured," 
but  it  was  certainly  worth  while  to  place  them  on  record.  At 
present  an  exploratory  operation  seemed  to  him  justifiable 
and  desirable. 


PHILADELPHIA  NEUROLOGICAL  SOCIETY. 

March  28th,  1898. 
The  President,  Dr.  F.  X.  Dercum,  in  the  chair. 

Dr.  James  J.  Putnam,  of  Harvard  University,  read  a 
paper  on 

THE  NATURE  AND  SYMPTOMS  OF  THE  POST-TRAU- 
MATIC NEUROSES,  BASED  ON  PERSONAL  OBSERVA- 
TIONS.    (To  be  published  in  this  journal.) 

DISCUSSION. 

Dr.  Charles  K.  Mills  said  that  the  society  was  certainly  un- 
der great  obligations  to  Dr.  Putnam  for  the  manner  in  which 
this  subject  had  been  presented.  He  had  brought  before  us,  in  a 
manner  somewhat  diflFerent  from  that  in  which  the  subject  is 
usually  treated,  the  importance  of  the  psychical  element  in  the 
production  of  the  condition  present  in  post-traumatic  neuroses. 
All  who  have  had  much  experience  with  these  cases  ap- 
preciate the  importance  of  this  element. 

The  points  that  he  had  made  with  reference  to  the  social 
condition  of  the  sufferers  from  these  injuries  were  novel  and 
of  interest.  They  had  not  been  brought  forward  in  the  same 
way  in  the  discussion  of  these  cases,  although  Dr.  Putnam 
may,  perhaps,  have  laid  almost  too  much  stress,  relatively, 
upon  the  psychical  or  moral  element. 

Dr.  John  K.  Mitchell  was  glad  to  be  able  to  reinforce  from 
a  recent  observation  the  statement  of  Dr.  Putnam  as  to  the 
frequency  with  which  these  cases  are  seen  in  certain  classes. 
The  difficulty  of  treatment  is  also  increased  by  this  very  ele- 
ment of  want  of  energy.  As  has  been  said,  traumatic  neuroses 
are  more  apt  to  occur,  and  are  more  apt  to  be  unsatisfactory 
in  treatment  and  result,  in  what  we  may  refer  to  as  the  lower 
middle  and  lower  classes.  He  had  a  patient  of  this  kind  who 
had  given  him  a  great  deal  of  trouble,  and,  while  her  physical 
condition  had  become  normal,  she  had  no  reserve  of  energy  to 
enable  her  to  recover  from  the  neurosis.  He  thought  that 
this  want  of  energy  is  partly  a  congenital  condition.  Atten- 
tion had  not  been  before  so  forcibly  called  to  this  matter,  but 
it  is  of  interest  both  as  regards  causation  and  treatment. 

Dr.  F.  X.  Dercum  said  that  his  experience  differed  in  es- 


486  PHILADELPHIA  NEUROLOGICAL  SOCIETY. 

sential  points  from  that  of  Dr.  Putnam.  In  the  first  place,  by 
far  the  larger  number  of  cases  present  evidences,  marked  or 
slight,  of  some  physical  injury — ^most  frequently  to  the  muscu- 
lar and  fibrous  structures  (ligaments,  muscular  insertions, 
fasciae)  of  the  back,  neck,  other  portions  of  the  trunk,  limbs, 
etc.;  furthermore,  cases  in  which  the  traumatic  neuroses  are 
associated  with  gross  physical  injury  to  the  skull,  bones  or 
joints  are  not  by  any  means  infrequent.  Secondly,  when  ner- 
vous symptoms  are  present  in  these  cases  they  always  assume 
a  definite  and  well-defined  syndrome,  either  that  of  neuras- 
thenia or  that  of  hysteria;  sometimes  the  stigmata  of  both  con- 
ditions are  present.  Thirdly,  in  Dr.  Dercum's  experience,  the 
statement  made  by  Dr.  Putnam  with  regard  to  the  social  con- 
dition of  persons  presenting  the  traumatic  neuroses  is  not 
borne  out.  Traumatic  neurasthenia  and  traumatic  hysteria 
occur  just  as  frequently,  if  not  more  frequently,  in  the  upper 
social  classes  as  in  the  lower.  It  is  merely  that  the  poor  and 
less  well-to-do  seek  redress  by  litigation  more  frequently  than 
the  rich.  The  illustration  used  by  Dr.  Putnam  of  the  com- 
parative immunity  enjoyed  by  football  players  is  not  valid. 
First,  because  football  players  are  a  trained  bodv  of  picked 
athletes,  and,  most  important  of  all,  because  the  injuries  from 
which  they  suffer  are  not  accompanied  by  the  element  of  shock, 
especially  psychic  shock. 

Dr.  Spiller  hoped  that  Dr.  Putnam  would  not  think  he 
did  not  appreciate  the  value  of  the  paper  if  he  took,  to  some 
extent,  the  opposite  side.  He  thought  that  there  is  consider- 
able danger  of  considering  certain  organic  diseases  as  func- 
tional, especially  as  the  number  of  cases  of  true  traumatic 
neuroses  is  so  large.  He  spoke  of  a  case  which  he  had  re- 
cently seen,  in  which  the  diagnosis  of  a  spinal  cord  lesion  could 
be  excluded  almost  with  certaintv.  A  man  had  received  a 
very  severe  blow  in  the  lumbar  region,  and  afterward  was  very 
weak  in  the  lower  extremities,  especially  in  one  limb.  One 
might  have^said  that  concussion  of  the  spine  existed  in  this 
case,  but  this  cortld  be  excluded  after  careful  examination. 
No  vesical  or  rectal  disturbances,  no  diminution  of  the  re- 
flexes and  no  alteration  of  sensation,  even  in  the  perineal 
region,  were  noted.  A  large  area  of  ecchymosis  and  an  ab- 
scess were  found  in  the  lumbar  region.  With  proper  treat- 
ment the  man  was  cured  within  a  few  weeks.  Another  patient 
had  been  seen  with  Dr.  C.  M.  Edwards.  He  had  received  a 
severe  blow  on  the  head,  and  had  had  at  first  the  signs  of  con- 
cussion of  the  brain.  After  some  weeks  he  had  entirely  re- 
covered, except  that  he  had  lost  the  senses  of  smell  and  taste. 
It  is  not  impossible  that  these  symptoms  were  the  result  of 
contre-coup.  We  have  reason  to  believe  that  the  centres  for 
smell  are  situated  at  the  base  of  the  cerebrum,  and  it  mav  be 


ta 


PHILADELPHIA  NEUROLOGICAL  SOCIETY.  487 

that  those  for  taste  are  near  the  same  region,  although  we 
know  little  positively  in  regard  to  the  latter. 

Observations  on  the  lower  animals  show  that  organic 
changes  do  occur  after  concussion  of  the  spine  without  fracture 
(Schmaus,  Bickeles,  Kirchgasser),  and  a  number  of  such  cases 
occurring  in  man  has  been  collected  by  Wagner  (Beitrage  zur 
klin.  Chir.,  vol.  xvi.) 

Dr.  Spiller  said  that  Dr.  Willard  and  he  had  reported  a 
case  in  which  fracture  of  the  spinal  column  had  occurred. 
They  had  stated  very  distinctly  that  the  fracture  could  not  be 
ignored,  and  they  had  not  attempted  to  separate  the  lesions 
resulting  from  such  a  condition  from  those  due  to  the  con- 
cussion. They  had  desired  to  call  attention  to  the  fact  that 
where  vertebral  fracture  exists,  some  of  the  symptoms  are 
due  to  concussion.  This  view  seemed  to  them  tenable,  inas- 
much as  very  intense  lesions,  even  rupture  of  the  spinal  mem- 
branes and  cord,  have  been  observed  in  cases  in  which  no 
fracture  had  existed. 

Reference  was  made  to  the  extraordinary  paper  by  Erb,  in 
which  poliomyelitis  seemed  to  be  the  result  of  trauma.  We 
are  beginning  to  realize  that  trauma  may  play  a  very  important 
part  in  the  development  of  organic  nervous  diseases. 

Dr.  J.  J.  Putnam  stated  that  in  preparing  this  paper  al- 
most all  the  points  that  the  gentlemen  had  brought  forward 
were  in  his  mind,  but  he  did  not  have  time  to  discuss  them. 
He  certainly  agreed  with  Dr.  Dercum,  that  persons  of  the  cul- 
tivated classes  do  have  these  conditions.  They  suffer  from 
the  shock  in  the  beginning,  and,  it  may  be,  pretty  severely,  but 
differences  are  seen  later.  The  tendency  of  the  disease  among 
them  is  more  often  toward  the  neurasthenic  than  toward  the 
hysterical  type,  and  there  is  a  greater  tendency  to  improve- 
ment, on  the  whole,  at  least  among  the  lighter  cases. 

With  regard  to  what  Dr.  Spiller  had  said,  he  fully  agreed 
that  these  accidents  are  sometimes  productive  of  actual  lesions. 
Possibly,  slight  lesions  are  of  very  frequent  occurrence,  but 
he  did  not  think  that  they  play  an  active  part  in  causing  the 
symptoms  of  traumatic  hysterias  and  neurasthenias.  He  had 
a  series  of  cases,  which  he  did  not  have  time  to  bring  up,  in 
which  chronic  spinal  symptoms  had  followed  these  injuries. 
One  was  that  of  a  lady,  28  years  of  age,  who  was  thrown  from 
a  wagon,  striking  her  head  and  face.  The  arms  and  legs  felt 
powerless  for  a  short  time,  and  then,  substantially  but  not  fully, 
recovered.  He  saw  her  fifteen  weeks  later.  The  movements 
of  the  feet  and  legs  were  impaired,  and  there  was  slight  im- 
pairment of  coordination  of  both  legs  and  arms,  and  some 
impairment  of  sensibility,  yet  there  was  no  fracture  nor  even 
stiffness  of  the  vertebral  column.  He  had  seen  several  well- 
marked  cases  of  this  class  which  corresponded  with  those  re- 
ported by  Erb. 


488  PHILADELPHIA  NEUROLOGICAL  SOCIETY, 

In  presenting  a  subject  like  this,  one  has  to  emphasize  the 
points  that  he  wishes  to  enforce,  and  his  object  was  to  bring 
out  strongly  the  fact  that  certain  psychical  factors  do  play  a 
more  important  part  than  has  generally  been  ascribed  to  them^ 
and  to  suggest  the  lines  on  which  this  subject  should  be 
studied. 


Dr.  H.  A.  Hare  exhibited 

A  CASE  OF  UNIVERSAL  MUSCULAR  ATROPHY. 

(See  page  450.) 


Dr.  Dercum  presented 

A  CASE  OF  SYRINGOMYELIA  OF  THE  LUMBAR  CORD. 

As  is  well  known,  syringomyelia  affects,  in  by  far  the 
greater  number  of  cases,  especially  the  cervical  portion  of 
the  cord.  In  the  patient  exhibited  by  Dr.  Dercum  the  lum- 
bar portion  of  the  cord  w^as  evidently  involved,  while  the 
cervical  portion  was  apparently  free.  The  case  was  also  in- 
teresting because  of  the  presence  of  trophic  ulcerations 
on  one  of  the  toes,  and  in  this  respect  it  resembled  another 
case  of  syringomyelia  of  the  lumbar  cord  presented  by 
him  to  the  society  a  year  or  two  ago.  The  case  is  as 
follows: 

The  patient  was  a  male,  aged  26  years,  a  clerk,  and  a 
native  of  Roumania,  He  had  had  the  ordinary 
diseases  of  childhood,  which  presented  nothing  peculiar. 
Some  ten  or  twelve  years  ago  he  had  suffered  severely 
from  conjunctivitis.  He  had  also  had  several  severe  at- 
tacks of  supraorbital  neuralgia.  He  had  no  illness  of  mo- 
ment until  two  years  ago,  when  he  noticed  a  burning  on 
the  anterior  surface  of  the  left  thigh,  and  several  weeks 
afterward  a  sensation  of  heaviness  in  the  left  knee.  For 
some  time  subsequently  he  experienced  occasional  shoot- 
ing pains,  extending  from  the  left  knee  to  the  foot,  and 
during  these  paroxysms  the  foot  would  jerk.  About  a 
year  later  similar  symptoms  made  their  appearance  in  the 
right  leg,  save  that  no  sensation  of  burning  was  felt  here. 
These  symptoms  had  persisted  with  increasing  severity, 
and  had  continued  to  be  most  pronounced  in  the  left  leg. 
He  had  suffered  also  greatly  from  constipation  and  in- 
digestion.   Three  months  ago  he  noticed  loss  of  sensation 


PHILADELPHIA  NEUROLOGICAL  SOCIETY,  489 

in  the  left  leg,  below  the  upper  third  of  the  thigh.     No 
history  of  syphilis  was  obtained. 

The  station  of  the  patient  at  the  time  of  his  presen- 
tation was  somewhat  ataxic.  The  gait  was  both  ataxic 
and  spastic.  The  left  leg  was  more  spastic  than  the  right. 
The  knee-jerks  were  phis,  and  ankle-clonus  was  present. 
Complete  loss  of  the  temperature  sense  and  of  the  pain 
sense  was  found  in  the  left  thigh,  left  leg  and  left  foot. 
Tactile  sense,  on  the  other  hand,  was  everywhere  well  pre- 
served. No  thermal  loss  or  analgesia  existed  in  the  right 
leg  or  elsewhere.  The  patient,  in  addition,  complained  of 
soreness  and  pain,  which  he  referred  to  the  lower  portion 
of  the  back,  and  which  he  stated  extended  down  the  hips 
and  thighs.  The  right  knee  seemed  to  be  distinctly  larger 
than  the  left,  and  suggested,  possibly,  a  beginning  arthro- 
pathy. On  the  middle  toe  of  the  left  foot  an  ulceration 
was  seen  at  the  base  of  the  nail.  This  ulceration  was  per- 
fectly painless.  The  patient  stated  that  it  seemed  to  be 
in  process  of  healing,  as  the  sore  was  smaller  than  it  had 
been. 


135,  II  bagno  d'aria  caldo  comk  mezzo  terapeutico  d'alcuni 
PAROSSiSMi  EPii^ETTici  (The  Hot  Air  Bath  as  a  Means  of  Treat- 
ing Epilepsy).     C.   Cabitto   (Revista  Sperimentale  di  Freniatria, 

23.  1897,  p.  52). 

In  a  previous  article  on  the  toxicity  of  the  sweat  of  epileptics,  the 
author  showed  that  the  sweat  of  epileptics  during  the  paroxysm  ex- 
erted a  toxic  and  convulsive  effect  when  injected  into  animals,  es- 
pecially rabbits.  He,  therefore,  concluded  that  the  retention  of  the 
sweat  tended  to  confirm  the  theory  of  auto-intoxication  in  the  genesis 
of  epileptic  seizures.  The  author  reports  four  cases  in  full,  where 
the  hot-air  bath  was  successfully  used,  and  states  that  in  other  cases 
he  has  had  equally  good  results.  The  length  of  time  that  the  patient 
remains  in  the  bath  is  about  one  half-hour.  The  fi-equency  of  the 
bath  depends  upon  the  frequency  of  the  convulsions. 

The  author  concludes  as  follows: 

"The  hot-air  bath  has  proven,  in  my  cases,  an  excellent  means  to 
prevent  and  interrupt  the  epileptic  seizures.  There  is  hope,  when 
other  observations  come  to  confirm  these  results,  that  such  a  method, 
united  with  lavage  and  antiseptic  treatment  of  the  digestive  tract,  not 
excluding  other  means  for  stimulating  the  secretions,  will  in  many 
cases  of  general  epilepsy  prove  a  logical  and  useful  method  of  treat- 
ment, or,  at  least,  a  less  objectionable  one  than  the  bromide  treat- 
ment Krauss. 


iVith  Ihe  Assittmxtt  of  the  Following  CoUdboratort: 

ChasXewis  Ai.LKN,M.D.,Wash.,D.C.R.  K.  Macalester,  M.D.,  N.Y. 
J.  S.  Christison,  M.D.,  Chicago,  111.  J.  K.  Mitchell.  M.D.,  Phila.,  Pa 
A.  Freemak,  M.D.,  New  York.  M.  Patrick,  M.D..  Chicago.  Ill 

S.  E.  jELLiyFE,  M,D.,  New  York.  Joseph  Sailer,  M.D.,  Phila..  Pa. 
Wm.C.Kraoss,M.D.,  Buffalo,  N.Y.  Hehry  L.  Shively.  M.D..  N.Y. 
W.  M,  Leszyhskv,  M.D.,  New  York.  A.  Sterne,  M.D.,  Indianapolit- 

ANATOMY. 


This  is  a  beautifully  concise  statement  of  the  present  status  ol 
the  neuroglia  question,  with  a  few  suggestions  based  on  a  new  method 
of  examination.  This  method  is  to  swell  the  section  of  nervous  tis- 
sue by  brief  immersion  in  a  hot  concentrated  solution  of  caustic  potash 
and  then  to  allow  it  to  dry,  which  optically  obliterates  cells  and  their 
processes  and  brings  into  clear  relief  the  neurogliar  mesh-work.  The 
.method  attains,  indeed,  the  same  abject  as  a  differential  stain,  snch 
as  that  of  Weigert;  that  is,  it  brings  out  strongly  certain  tissue  elements 
to  the  exclusion  of  others.  The  author  does  not  state  that  such  a 
method  has  its  draw-backs  as  well  as  advantages.  In  the  present 
instance  the  former  are  serious,  for  with  cells  and  cell  processes  ex- 
eluded  from  vision,  the  question  of  the  connection  of  neuroglia  fibres 
with  gita  cells,  could  scarcely  be  determined.  His  investigations, 
however,  are  valuable  especially  as  he  has  employed  his  method  in 
connection  with  the  Golgi  stain.    He  concludes; — 

1.  The  sustentacular  apparatus  of  the  nervous  system  consists 
of  an  interlacing  net  work  of  fibrils,  in  the  meshes  of  which  lie  cells 
both  neurogliar  and  nervous. 

2.  These  fibrils  show  no  evidence  of  being  direct  processes  of 
cells,  and  do  not  appear  to  branch. 

3.  The  sponge-like  reticulum  thus  formed  is  to  be  regarded  as 
the  peripheral  portion  of  the  lymphatic  gjrstem,  consisting  of  lymph- 
atic spaces  and  channels. 

4.  The  fibrils  form  a  complete  basket-work  for  each  element  in 
lie  nervous  tissue,  including  the  blood  vessels. 

5.  The  fibrils  consist  of  a  highly  refractile  substance  (refractive 
ndex  about  1.5)  with  a  considerable  degree  of  elasticity,  as  is  shown 
)y  their  curvature  on  release. 

6.  Chemically  the  fibrils  appear  to  be  composed  of  a  substance 
vhich  is  neither  neurokeratin  nor  elastin.  Patrick. 

;37,  Studies  on  the  Neuroglia.    F.  W,  Eurich  (Brain,  20,  1897. 

p.  114). 

The  author,  in  a  short  note,  discusses  the  neuroglia  tissue  from 
1  comparative  point  of  view,  in  the  light  of  the  newer  Weigert  dis- 
:overies.     He  shows  briefly  some  of  the  stages  in  the  development 


PERISCOPE.  491 

■ 

of  this  tissue  through  the  lower  forms  and  discusses  some  of  the  I 

theories  of  its  functions.  He  believes  that  Bevan  Lewis'  "scavenger 
cell"  is  but  a  form  characterising  the  neuroglia  cell  in  one  period  of 
its  life  history,  and  that  in  any  proliferating  process  this  earlier  stage 
must  be  returned  to,  before  fibrillation,  as  the  final  result  can  be  at- 
tained. VOGEL, 

138.  A  Contribution  to  thk  Study  of  Human  Neurogwa.     W. 
Taylor  (Jour,  of  Exp.  Med.,  2,  1897,  p.  611). 

On  a  basis  of  two  cases  of  cerebral  tumor  the  author,  using  Mai- 
lory's  modification  for  staining  the  neuroglia,  comes  to  the  opinion 
that  the  term  connective  tissue  should  be  dropped  when  discussing 
sclerosis  of  the  nervous  system,  and  that  the  term  "glio-sarcoma 
should  also  be  relegated  to  oblivion.  Neuroglia  cells  show  a  succes- 
sive type  of  differentiation,  first  possessing  no  processes,  later  with 
processes, •  and  finally  these  processes  developing  into  true  fibrils; 
thus  he  adopts  Weigert's  view.  In  the  tumors  under  discussion  both 
the  latter  stages  were  evident.  In  contradistinction  to  Weigert's 
statements,  the  author  is  not  prepared  to  accept  that  a  glioma  is  char- 
acterized by  an  increase  of  glia  cells,  while  a  gliosis  consists  of  an 
increase  of  fibres.  He  further  adds  that  no  distinctive  features  separate 
gliomata  and  sarcomata.  Jelliffb. 

139.  Notes  on  Granui.es.      A.  Hill  (Brain,  20,  1897,  p.  125). 

In  using  his  chrome  silver  method,  the  author  believes  he  has 
found  a  new  type  of  cell  in  the  cerebellum.  These  he  first  described 
as  "  granules  with  centripetal  axis-cylinder  processes."  They  re- 
semble Golgi  cells  in  an  embryonic  condition,  but  retaining  their 
shape  in  the  adult,  he  believes  them  to  be  a  type  distinct  from  the 
Golgi  cells  of  the  cerebellum.  These  cells  were  found  near  the  sum- 
rait  of  the  folia  and  only  in  the  deeper  stratum  of  the  granular  layer. 
In  diameter  they  range  from  10-15  mikra.  (in  the  rat),  about  the 
same  as  the  ordinary  cerebellar  granule  cells.  Their  axis  cylinders 
run  parallel  with  the  fibres  of  the  arbor  vitae,  often  traversing  the 
granular  layer  for  some  distance  before  joining  the  fibres.  These 
are  usually  destitute  of  collaterals.  Most  of  the  cells  are  carrot-shaped, 
semi-fusiform.  The  centripetal  axis  cylinder  process  distinguishes 
them  from  the  granules.  The  author  has  found  these  cells  in  the  cat 
and  in  the  rat.  Jelliffb. 

140.  Structure  of  the  Spinal  Ganglia  of  Mammals  W.  Flem- 
ming  (Arch.  f.N  Psychiatrie,  29,  1897,  p.  969). 

Flemming  confirms  in  the  main  the  observations  made  by  Len- 
hossek  upon  the  structure  of  the  cells  of  the  spinal  ganglia.  By  his 
method  of  progressive  staining  with  hematoxylin  he  maintains,  in 
opposition  to  Lenhossek,  the  fibrillary  structure  of  the  achromatic 
substances  of  the  cells.  These  fibrillated  structures  are  more  or  less 
longitudinally  arranged  at  the  sites  of  the  origin  of  the  dendrites  and, 
in  the  main  body  of  the  cell,  are  more  reticulated.  It  is,  he  believes, 
characteristic  that  this  reticulum  is  more  marked  in  the  cells  of  the 
spinal  ganglia  than  in  the  cells  of  the  anterior  horns  or  of  the  cortex. 

Jelliffe. 

141.  Der  Zellenbau  der  Grosshirnrinde  des  Affen  (Macacus 
Cynomolgus)  The  Cells  of  the  Cortex  pf  the  Monkey  (Macacus 
Cynomolgus).  M.  Schlapp  (Arch.  f.  Psychiatrie,  30,  1898,  p.  583). 
The  author  here  presents  a  careful  and  valuable  contribution  to 

our  knowledge  of  the  comparative  cytology  of  the  vertebrate  brain. 
The  investigation  is  made  by  the  Nissl  methods  and  this  investigator^s 
classification  of  the  cell  types  is  followed  by  the  author:    In  the  brain 


492  PERISCOPE, 

of  the  monkey  it  would  appear  that  there  are  three  fairly  well  differ- 
entiated areas,  each  with  its  distinctive  grouping  of  cell  elements. 
The  region  occupied  by  the  first  type  comprises  the  frontal  convolu- 
tions and  is  bounded  behind  by  the  precentral  convolutions.  Its  cell 
distribution  resembles  in  some  particulars  that  of  the  motor  region 
type  of  man  consisting  of  five  layers: 

1.  The  layer  of  tangential  fibres  with  irregular  cell  groupings. 

2.  Layer  of  the  small  polymorphous  cells. 

3.  Layer  of  small  pyramidal  cells,  with  small  oval  and  round  cells 
between,  most  of  the  cells  being  found  in  the  para  pygnomorphic 
condition. 

4.  Layer  of  large  and  giant  pyramidal  cells  which  are  usually  in 
the  pygnomorph  condition. 

5.  Layer  of  polymorphous  or  spindle  cells. 

The  area  of  the  second  type  occupies  the  region  just  posterior 
to  that  of  the  first  type,  and  constitutes  the  greater  part  of  the  cortex, 
leaving  but  a  small  area,  homologous  with  the  general  occipital 
region  for  the  third  type. 

This  area  is  characterized  by  a  seven-layered  arrangement  of  cells. 
The  first  and  second  layers  are  similar  to  those  found  in  the  area 
of  the  first  type.  The  third  layer  is  also,  in  the  main,  similar;  added 
to  it  are  a  number  of  cells  for  which  B.  Lewis  has  introduced  the 
name  "globose  cells." 

The  fourth  layer  is  the  same  as  the  outer  half  of  the  corresponding 
layer  for  the  first  type,  while  the  inner  half  is  made  up  of  new  type 
cells,  constituting  the  fifth  layer.  These  cells  are  the  "granule  cells" 
— corresponding  to  the  4th  layer  of  Hammarberg's  sensory  type.  The 
sixth  layer  contains  pygnomorph  pyramidal  cells,  similar  to  those 
found  in  the  inner  parts  of  the  fourth  layer  of  the  first  type,  and 
the  seventh  layer  is  composed  of  the  polymorphous  cells. 

The  area  of  the  third  layer  is  the  smallest,  yet,  perhaps,  the  most 
characteristic.  It  occupies  the  general  region  of  the  occipital  lobes, 
and  its  cells  appear  to  be  arranged  in  eight  more  or  less  regular  layers. 
These,  briefly  stated,  are: 

I  St,  2d,  and  3d  layers  as  in  the  first  type. 

4th  layer,  reproduction  cells,  in  "granule"  cells. 

5th  layer,  projection  cells,  apygnomorph  pyramid  cells. 

6th  layer,  "granule"  cells. 

7th  layer,  projection  cells. 

8th  layer,  polymorphous  cells. 

The  paper  is  well  illustrated;  and  the  character,  and  sizes,  and 
variations  of  the  various  cells  carefully  elucidated.  Jelliffe. 

PHYSIOLOGY. 

142.  A  Study  of  the  Temperature  Sense.     J.  F.  Crawford  (Psy- 
chological Rev.,  5,  1898,  p.  6z). 

In  a  preliminary  report  of  experiments  upon  six  subjects,  the 
author  comes  to  a  conclusion  the  opposite  of  Goldscheider's,  as  he 
finds  continuous  sensitive  regions,  and  within  a  fairly  sensitive 
region  he  could  not  find  a  spot  that  was  non-sensitive.  These  sensi- 
tive regions  are  of  various  size  and  indefinite  limits,  and  within  them 
are  often  found  smaller  regions  of  greater  intensity,  but  never  in  the 
form  of  groups  of  spots. 

Three  of  his  subjects  .gave  thirty  sittings,  and  three  gave  eight 
sittings.  He  used  two  pairs  of  brass  cylinders,  one  pair  being  V$  mm. 
across  at  the  ends,  and  the  other  pair  being  considerably  less.  Sharper 
points  produce  the  sensation  of  pricking  or  burning.  The  cylinders 
were  partly  covered  with  cork  and  immersed  in  hot  and  cold  water 
of  known  temperatures. 


PERISCOPE,  493 

Slight  changes  of  temperature  are  insignificant,  especially  with  cold, 
a  difference  of  5  deg.,  making  no  practical  difference  in  the  reactions. 
From  o  deg.  up  to  23  deg.  or  24  deg.  there  are  cold  reactions,  intense 
below  6  deg.  or  8  deg.,  and  growing  less  marked  up  to  15  deg.  At 
22  deg.  hot  reactions  begin  to  come  in  but  are  not  marked  until  40 
deg.  or  42  deg.  are  reached.  At  between  49  deg.  and  54  deg.  the  heat 
passes  over  into  pain  which  arises  from  all  points  of  the  skin  alike. 
The  range  of  cold  reactions  is  much  greater  than  that  of  hot. 

The  relation  between  "hot"  and  "cold"  seems  to  be  one  of  mutual 
independence.  They  are  neither  coincident  nor  complementary,  but 
seem  to  overlap  without  law.     The  personal  factor  was  prominent. 

ClIRISTISON. 

143.  La  tosstcito  del  Sudork  nkgu  p:pit.ettici  (The  Toxicity  of  the 
Sweat  of  Epileptics).  Cabitto  (Revista  Sperimentale  di  Freniatria, 
23,  1897,  p.  36). 

Dr.  Clemente  Cabitto  experimented  with  the  perspiration  of  epi- 
leptics upon  rabbits  and  came  to  the  following  conclusions: 

I.  The  sweat  of  epileptics  in  the  prodromal  period  of  the  attack 
injected  into  the  circulation  of  rabbits  provoked  a  decisive  toxic  action 
and  a  very  strong  convulsive  attack. 

II.  The  toxic  and  convulsive  power  of  the  sweat  increases  as  the 
attack  advances,  and  decreases  in  the  period  after  the  paroxysm  rela- 
tively with  the  duration  of  the  post  epileptic  state. 

III.  The  attacks  preceding  the  day  of  experimentation  do  not 
exert  any  influence  over  the  toxicity  of  the  sweat. 

IV.  The  action  of  the  sweat  of  epileptics  some  time  before  the 
•    attack  does  not  differ  from  that  of  a  healthy  subject.  Krauss. 

144.  IvE  SENS  DE  I/ORIENTATION.  (The  Senee  of  Position).  P. 
Bonnier  (Revue  Scientifique,  1898,  p.  108). 

In  a  short  and  interesting  article  the  author  discusses  the  general 
problem  of  the  sense  of  position.  To  the  ampullx  of  the  semi-circular 
canals  he  attaches  much  importance,  in  that  there  is  a  memory  sense 
connected  with  the  displacement  of  their  contents.  Vc)(;ki.. 

145.  La  SENSIBIUTP:  musculaire  des  yeux  (Muscular  Sensibility 
of  the  Eyes).  B.  Bourdon  (Revue  Philosophique,  22,  1S97,  No.  10). 

In  the  estimation  of  space  this  muscular  sense  is  of  value,  and  the 
!  results    of   previous   investigations    having   given    such    contradiclory 

j  results,  the  author  was  led  to  perform  some  experiments. 

The  results  of  these  experiments  would  be  contrary  to  the  hypo- 
1  thesis  that  our  conception  of  space  is  due  to  muscular  sensibility  of 

the  oculomotorius.     The  movements  of  the  eyes  are.   therefore,   not 
controlled   by   muscular   sensibility,    but    by   the    retinal    impressions. 
Muscular  sensibility  of  the  oculomotorius  could  be  markedly  diniin 
ished,  yet  visual  space  perception  suffer  no  loss.  Jklliffk. 

PATHOLOGY. 

146.  DEGENERATIONEN  DER  VoRDERHORNZEIJ.KN  DKS  RirCKHNMARKS 

BEi  Dementia  Paralytica       (Degenerations  of  the  (ells  of  the 

Anterior  Horns  of  the  Spinal  (\)rd  in  1  ementia  Paralytica).     H. 

j  Berger  (Monatsschrift  f.  Psychiatric  u.  Neurologic,  3,  i8<j«S,  p.  i ). 

I  Berger  has  examined  the  cells  of  the  anterior  horns  of  the  cord 

[  in  twelve  cases   of  dementia   paralytica.      lie   has    found    pigmentary 

degeneration,    karyolysis,    destruction    of    the    dendrites,    tumefaction 

of  the  cells,  chromatolysis.  vacuolation,  changes  in  the  nucleus  and 


494  PERISCOPE. 

nucleolus,  etc.  The  division  of  the  nucleus  of  the  nerve  cell  into  two 
parts,  reported  by  him,  each  with  a  nucleolus,  without  division  of  the 
cell  body,  is  worthy  of  special  note.  Berger  regards  this  as  an  in- 
complete regeneration  of  the  nerve  cell.  He  has  observed  changes 
in  both  horns  of  the  cord  in  man  after  destruction  of  one  pyramidal 
tract,  but  he  was  unable  to  find  that  lesions  of  this  tract  in  the  dog 
and  cat,  or  of  a  posterior  root  in  the  dog,  had  any  effect  on  the 
anterior  cells  of  the  cord.  He  explains  the  muscular  atrophy  seen 
in  dementia  paralytica  by  the  cellular  changes  which  he  has  observed, 
and  states  that  such  cellular  alteration  occurs  in  the  anterior  horns 
of  the  cord  in  83  per  cent,  of  all  cases  of  general  paralysis,  and  is 
most  frequent  in  the  lumbar  region.  He  believes  that  the  disease 
of  the  anterior  cells  is  primary;  that  it  is,  to  a  certain  extent,  inde- 
pendent of  degeneration  of  the  white  columns;  and  that  there  is  no 
constant  relation  between  the  degree  of  these  cellular  changes  in 
the  cord  and  the  degeneration  in  the  brain. 

Spiller- 

147.  Thk   Morbid   Anatomy  of   a  Cask  of  Hereditary  Ataxia. 
A.  Meyer  (Brain,  20,  1897,  p.  276). 

The  author  had  an  opportunity  to  study  a  case  already  reported 
by  Dr.  Sanger  Brown.    The  following  general  statements  are  offered: 

1.  There  is  no  circumscribed  cerebellar  lesion,  nor  does  the  cortex 
show  a  marked  decrease  of  the  number  of  the  Purkinje  cells. 

2.  Parts  of  the  spinal  cord  and  medulla  which  are  known  to  have 
relations  with  the  cerebellum  were  found  affected. 

3.  The  spinal  cord,  as  a  whole,  shows  increase  of  the  superficial 
neuroglia,  and  a  remarkably  large  number  of  corpora  amylacea,  similai 
to  what  is  seen  in  very  old  people,  in  paralysis  agitans,  etc. 

Jelliffe. 

148.  Fait  rei^atik  .\  i^' etude  de  i*a  pathogenie  des  arthropathies 

ET  DES  FRACTURES  SPONTANEES  CHEZ  I<ES  TABETIQUES   (The  Path- 

ogney  of  Arthropathies  and  Spontaneous  Fractures  in  Tabetics). 
A.  Pitres  et  G.  Carriere  (Archives  Cliniques  de  Bordeaux,  5,  1896, 

p.   483). 

The  authors  give  the  clinical  history  and  pathological 
findings  in  a  case  of  tabes  in  a  man  of  58,  in  whom  the 
disease  had  existed  since  his  twenty  -  sixth  year.  At  38, 
there  was  spontaneous  fracture  of  the  right  tenth  rib;  at 
42,  arthropathy  of  the  left  knee.  The  autopsy  and  microscop- 
ical examination  showed  the  usual  sclerosis  of  the  posterior  columns, 
no  change  in  the  antero-lateral  columns  or  the  cells  of  the  anterior 
horns;  advanced  atrophy  of  the  posterior  roots,  the  anterior  roots 
normal;  diffuse  alterations  in  the  ulnar,  intercostal  and  nerves  of  the 
lower  extremities,  especially  marked  in  the  nerves  of  the  left  knee- 
joint,  and  the  tenth  right  intercostal — supplying  the  fractured  rib. 
They  then  discuss  the  two  theories  proposed  to  account  for  arthro- 
pathies and  spontaneous  fractures. 

The  one  theory  makes  the  trophic  disturbance  of  the  bones  and 
joints  dependent  upon  atrophy  of  the  cells  of  the  anterior  horn;  the 
other  refers  it  to  degeneration  of  the  peripheral  nerves,  especially  of 
those  supplying  the  diseased  part.  Collecting  all  available  observa- 
tions, they  find  that  in  only  four  cases  alterations  in  the  cells  of  the 
anterior  horn  are  reported,  and  these  cases  were  studied  before  the 
development  of  our  present  technique. 

On  the  other  hand,  between  1882  and  1896,  seventeen  cases  have 
been  examined,  and  in  none  of  these  was  found  alteration  of  the  cells 
of  the  anterior  horns.    In  eleven  of  these  cases  the  peripheral  nerves 


r 


PERISCOPE,  495 

were  examined,  and  in  each  /ase  there  was  nerve  degeneration  more 
or  less  widely  distributed,  but  most  marked  in  the  nerves  supplying 
the  affected  bones  or  joints.  The  authors  regard  the  number  of  ob- 
servations as  yet  too  few  to  speak  with  positiveness,  but  think  the 
weight  of  evidence  so  far  in  favor  of  the  neuritic,  rather  than  of  the 
myelopathic  theory.  Allen. 

149.  ITkbkr  Nkrvknzkllknverandhrunoen  des  Vorderhorns  bei 
Tabes  (Concerning  Changes  in  the  Cells  of  the  Anterior  Horns 
in  Tabes).  Karl  SchafFer  (Monatsschrift  f.  Psychiatric  u.  Neu- 
rologic, 3,  1898,  p.  64). 

Schaffer  attempts  to  prove  that  the  cells  of  the  anterior  horns 
of  the  spinal  cord  are  much  altered  in  cases  of  tabes  with  trophic 
lesions,  and  that  these  cellular  changes  are  the  cause  of  the  tabetic 
amyotrophy,  osteopathy  and  arthropathy.  In  all  instances  of  tabes 
with  trophic  lesions  reported  in  the  literature  by  other  writers  in 
which  the  peripheral  nerves  have  been  examined,  these  nerves  have 
been  found  degenerated,  and  central  lesions,  apart  from  those  in 
Leyden's  case,  have  not  been  positively  observed.  Schaffer,  however, 
two  years  ago  published  a  case  of  tabetic  amyotrophy  and  arthro- 
pathy of  one  lower  limb,  in  which  the  cells  of  the  anterior  horns 
of  the  lumbar  cord  presented  marked  chromatolysis.  In  the  present 
paper  he  reports  the  results  of  an  examination  of  four  new  cases  of 
tabes,  only  one  of  which  was  without  trophic  lesions.  The  changes 
in  the  cells  of  the  anterior  horns  were  the  same  whether  amyotrophy, 
osteopathy  or  arthropathy  existed,  and  were  present  in  all  cases  with 
trophic  disturbances.  They  were  more  advanced  in  cases  with  osteo- 
pathy and  arthropathy  than  where  amyotrophy  existed  alone.  Central 
chromatolysis  (destruction  of  the  chromophilic  elements  about  the 
nucleus)  was  almost  invariably  the  earliest  cellular  lesion  in  these 
cases  of  tabes,  and  the  disintegration  extended  peripherally.  The 
edge  of  the  nucleus  appeared  folded,  the  nucleus  was  eccentric,  was 
stained  a  pale  blue  (normally  it  is  unstained),  and  its  shape  was  ir- 
regular. Later  the  nucleus  was  indistinct,  the  shape  of  the  nucleolus 
was  much  altered,  and  the  cell  lost  its  processes.  The  nucleus  and 
nucleolus  exhibited  degenerative  changes  only  when  the  entire  cell 
was  altered. 

Shaffer  says  that  the  Nissl  method,  as  far  as  his  experience  in 
cellular  pathology  goes  (infectious,  toxic,  trophic  and  nutritive 
changes),  does  not  show  specific  staining  in  any  case.  The  lesion  is 
always  chromatolysis,  which,  in  its  essential  features,  is  always  the 
same.  This  is  a  very  different  opinion  from  the  one  he  formerly  held. 
In  tabes,  however,  vacuoles  in  the  cells  are  not  numerous,  and  this 
infrequency  is  due  to  the  chronicity  of  the  process,  for  vacuoles  indi- 
cate an  acute  process. 

The  location  of  the  cellular  lesions  in  the  cases  of  tabes  corre- 
sponded to  the  centres  of  the  parts  involved  in  the  trophic  lesions, 
and  in  the  one  instance  in  which  the  latter  were  not  observed  distinct 
cellular  changes  were  absent.  He  was  unable,  however,  to  find  dis- 
tinct groups  of  degenerated  cells,  as  diseased  cells  were  mingled  with 
normal  ones. 

In  chronic  processes,  according  to  Schaffer,  only  a  portion  of 
the  cell  body  is  at  first  affected  ("partial  degeneration"),  and  a  de- 
crease in  the  cell's  vitality  is  caused  in  this  way,  which  manifests  itself 
first  at  the  periphery  of  the  neuron,  i.  e.,  in  the  end  ramifications.  As 
this  "partial  degeneration"  increases,  more  central  portions  of  the 
neuron  are  involved,  and  the  alteration  of  the  nerve  gradually  creeps 
upward  toward  the  cell  body.  Chromatolisis  must  be  regarded  as  a 
pathological  process,  and  as  the  result  of  disturbed  cellular  nutrition; 
it  is,  therefore,  an  indication  of  the  disturbed  function,  inasmuch  as 
the  latter  depends  on  the  cell's  impaired  vitality. 


496 


PERISCOPE. 


The  tabetic  atrophy  is  due  to  disease  of  the  cells  of  the  anterior 
horns,  and  the  latter,  in  turn,  is  due  to  the  loss  of  irritation  trans- 
mitted through  the  posterior  roots,  to  a  feeble  resisting  power  of 
these  motor  cells,  and  to  the  influences  of  the  postsyphilitic  toxin. 
The  tabetic  muscular  atrophy  resembles  that  of  spinal  muscular 
atrophy,  and  this  fact  SchafTer  regards  as  an  argument  in  favor  of 
the  spinal  nature  of  the  tabetic  atrophy.  The  wasting  which  occurs 
in  tabes  should  be  looked  upon  as  a  complication,  and  not  as  an 
essential  part  of  the  disease;  the  correctness  of  this  view  is  shown 
by  the  comparative  rarity  of  the  atrophy  and  the  late  appearance  of 
the  trophic  lesions. 

Spiller. 

150.  Das  Verhat.ten  der  Spinalganglienzeixen  bet  T.\bes  auf 
Grund  Nisst/s  Farbung  CThe  Cells  of  the  Spinal  Ganglia  in 
Tabes,  as  Shown  by  the  Nissl  Stain).  K.  Schaffer  Neurolog- 
isches  Centralblatt,  t7,  i8q8,  p.  2). 

The  author  follows  Lenhossck  in  his  classical  description  of  the 
spinal  ganglion  cells,  and  reports  upon  three  cases  of  Tabes,  one  of 
which  was  examined  in  the  early  stages  of  the  disease.  By  means  of 
the  Ni<;sl  methods  of  staining  he  was  unable  to  find  any  grave  cyto- 
lofficpl  vnrinti<->ns  from  the  norm  established  by  Lenhossek.  In 
two  of  his  cases  the  degeneration  was  marked  in  the  posterior  roots, 
yet  the  cells  of  the  sjanglia  were  practically  normal,  though  he 
notes  a  quantitative  diflference  in  the  amount  of  the  coloration  of  the 
chromophilic  substances,  these  appearing  paler  in  the  cells  of  the 
cases  showinc:  the  stronger  grade  of  degeneration.  His  results  were. 
therefore.  ne<rativc,  and  are  distinctlv  in  contrast  with  those  of  Mari- 
ncsco.  Tie  furthermore  concludes  from  these  cases  that  the  central 
lesion  of  tabes  is  probably  not  to  be  found  in  the  spinal  ganglia. 

Jelliffe. 

15 1.  Die  embryonalen  F.\sersysteme  in  den  Hinterstrancbn 
UNI)  ihrk  Degeneration  bei  der  Tabes  dorsaus  (The  Em- 
bryonal Fibre  Svstems  in  the  Posterior  Columns  and  their  De- 
generation in  Tabes).     Trepinski    (Archiv  f.  Psychiatric.  30,  1898. 

r».    54). 

The  author  here  presents,  firstlv.  a  careful  study  of  the  spinal 
rnrd  of  the  newlv  born  child,  in  which  he  believes  he  finds  that  four 
methods  of  development  may  be  present,  i.  e..  the  development  of  the 
posterior  columns,  from  an  embryological  point  of  view,  proceeds 
along  four  different  lines.  Some  of  these  embryonal  fibre  systems 
are  morphologically  quite  distinct,  while  others  overlap  one  another, 
both  with  reference  to  their  position  in  the  cord  and  to  the  time  of 
their  development.  In  accordance  with  this  presention,  he  then  dis- 
cusses four  cases  of  tabes,  in  each  of  which  a  diflFerent  type  of  de- 
crcnerative  lesion  can  be  demonstrated,  corresponding,  he  believes, 
with  the  four  embryonal  fibre  systems  demonstrated  in  his  preceding 
discussion.  He  states  that,  bearing  these  facts  in  mind,  it  is  readily 
imderstood  whv  such  a  variation  in  intensity  and  extension  in  the 
pathological  nirtures  may  be  present.  He  would  further  erect  at  least 
four  types  of  the  disease,  according  to  which  of  the  embryonal  fibre 
systems  is  most  involved.  Mixed  types  are  naturally  to  be  expected. 
The  paper  is  well  illustrated  and  suggestive.  Jelliffe. 

152.  Acute  Degeneration  of  the  Nervous  System  in  Diphtheria. 
J.  J.  Thomas  (Boston  Med.  and  Surg.  Jour.,  38,  1898,  pp.  76,  97, 
123). 

In  this  series  of  articles  an  important  contribution  is  made  to  the 
pathology  of  diphtheria  which   posseses  an   additional  interest  from 


r 


PERISCOPE.  497 

its  relation  to  the  clinical  question  of  death  from  cardiac  failure,  which 
is  such  a  frequent  termination  of  the  disease.  The  early  administration 
of  antitoxin  would  appear  to  be  a  nractical  therapeutic  corallery  from 
the  constant  defeneration  of  the  pneumogastric  nerve  observed.  The 
writer's  conclusions  are  based  upon  a  series  of  twenty-five  carefully- 
recorded  cases,  with  autopsy  and  microscopical  examination,  from  the 
pathological  laboratory  of  the  Boston  City  Hospital.  The  specimens 
were  treated  by  Marchi's  method.  Other  sections  were  stained  by 
hematoxylin  and  eosin,  and  in  some  of  the  cases  with  eosin  and 
Unna's  alkaline  methylene-blue  stain. 

The  chief  change  of  the  nervous  system  in  diphtheria  is  an  acute 
degenerative  process,  chiefly  parenchymatous,  most  marked  in  the  peri- 
pheral nerves,  affecting  both  the  motor  and  sensory  nerves.  The  mye- 
lin sheath  is  affected  first  and  later  also  the  axis  cylinder,  generally 
without  infiltration  or  much  multiplication  of  the  nuclei.  In  this  the 
results  correspond  pretty  closely  with  those  of  other  investigators, 
both  clinical  and  experimental,  as  Prinz.  Martin  and  Crocq,  as  well  as 
earlier  observers,  such  as  Mendel.  Leyden  and  others.  Nor  do  these  re- 
sults stand  at  marked  variance  with  those  of  authors  who  have  found 
changes  in  the  central  nervous  system,  though  hemorrhages  and  mye- 
litis were  not  found;  yet  dilatation  of  the  capillaries  was  observed,  and 
the  more  marked  changes  certainly  seem  possible. though  probably  rare. 
The  most  marked  change  found  in  the  central  nervous  system,  and  that 
in  the  brain,  as  vvell  as  the  cord,  was  the  presence  of  fat  here,  showing 
that  the  effect  of  the  toxic  substances  upon  the  nerve  structures  is  not 
confined  to  the  peripheral  nerves.  These  degenerations  were  diffuse; 
but.  if  anythins?-.  more  marked  in  the  posterior  columns  of  the  cord, 
as  has  been  noted  also  by  Bikeles-  a  fact  difficult  of  interpretation, 
unless  we  assume  a  less  power  of  resistance  to  injurious  influences  of 
these  nerves  fibres  than  is  found  in  others.  Indications  of  the  exist- 
ence of  such  a  fact  are  not  wanting,  as  shown  bv  the  large  number  of 
diseases  in  which  degenerative  nrocesscs  have  been  observed  in  this 
region,  as  for  example  in  pernicious  anaemia,  pellagra,  leprosy  and 
others.  Perhaps  this  affection  of  the  posterior  columns  may  account, 
as  Bikeles  <;uggests,  for  the  ataxia  so  often  observed  in  diphtheritic 
paralysis.  That  the  cranial  nerves  do  not  always  escape  the  process 
affecting  the  nervous  system  so  widely  is  also  certain,  as  shown  by 
the  marked  degeneration  of  the  fifth  nerve  found  in  one  case.  These 
results  agree  with  those  of  Martin,  in  that  the  posterior  nerve  roots 
were  found  fully  as  much  affected  as  the  anterior  ones.  In  regard  to 
the  condition  of  the  nerve  cells  one  is  not  warranted  in  drawing  any 
very  definite  conclusions  from  the  results  obtained  by  means  of  the 
stains  used,  but  certainly  there  was  no  myelitis  present.  It  seems  quite 
probable,  however,  that  some  of  the  nerve  cells  would  show  changes, 
at  least  in  their  finer  structure,  where  the  nerve  processes  have  suffered 
so  widely. 

The  processes  found  in  the  specimens  of  heart  muscle  examined 
correspond  closely  to  those  previously  reported  by  others.  There  was 
a  parenchymatous  degeneration  of  the  muscle  fibres,  shown  by  loss  of 
the  striations,  vacuolization  and  fatty  degeneration.  An  increase  of 
the  muscle  nuclei  was  not  present  though  the  nuclei  were  quite  numer- 
ous: but  this  is  due  to  the  fact  that  the  hearts  examined  were  from 
children  in  whom,  from  the  small  size  of  the  fibres,  the  nuclei  appear 
to  be  more  numerous.  The  nuclei  showed  no  marked  degenerative 
changes.  The  dilatation  of  the  vessels  was  marked,  and  also  the  in- 
filtration, both  in  the  myocardium  and  in  the  interstitial  tissue.  This 
infiltration  consisted  mostly  of  small,  round  lymphoid  cells,  with  a 
few  larger  cells,  the  nature  of  which  could  not  be  accurately  determined 
because  of  the  methods  of  hardening  used — formol.  and  Miiller's  fluid. 
Certainly,  leucocytes  played  no  important  part  in  the  process.     The 


498 


PERISCOPE. 


most  constant  change  was  the  interstitial  process.  The  fact  that  changes 
were  found,  more  or  less  marked,  in  all  the  pneuraogastric  nerves  ex- 
amined, seems  to  point  to  considerable  influence  upon  the  mode  of 
death  in  the  cases  of  sudden  death.  In  what  way  does  the  poison  act? 
It  seems  most  probable  that  in  such  cases  it  acts  through  the  nerve 
structures,  interfering  with  their  normal  function,  and  that  this  may 
occur  before  degenerative  processes  have  proceeded  far  does  not  lessen 
in  any  way  the  importance  of  their  occurrence,  but  would  rather  lead 
us  to  place  greater  weight  upon  slight  changes,  where  other  obvious 
causes  of  death,  as  markedly  degenerated  heart  muscle,  do  not  exist. 
The  variability  of  the  amount  of  changes,  both  in  the  heart  muscle 
and  in  the  nerves,  may  point  to  a  varying:  cause  for  these  cases  of  sud- 
den death;  but  the  argument  of  the  disturbance  of  the  functions  of  the 
nerve  seems  strongest. 

To  sum  up,  the  changes  in  the  nervous  system  produced  bv  diph- 
theria are:  (i)  a  marked  parenchymatous  degeneration  of  the  peripheral 
nerves,  sometimes  accompanied  by  an  interstitial  process,  and  hyper- 
a^mia  and  hemorrhages;  (2)  acute,  diffuse,  parenchymatous  degener- 
ation of  the  nerve  fibres  of  the  cord  and  brain;  (3)  no  changes,  or  but 
slight  ones,  in  the  nerve  cells;  (4)  acute,  parenchymatous  and  inter- 
stitial changes  in  the  muscles,  especially  the  heart  muscle;  (5)  occasion- 
al hyperaemia,  or  infiltration,  or  hemorrhage  in  the  brain  or  cord,  in 
rare  cases  severe  enough  to  produce  permanent  troubles,  such  as  the 
cases  of  multiple  sclerosis  or  of  hemiplegia  which  have  been  observed. 
Finally,  the  probability  that  the  cases  of  sudden  death  from  heart  failure 
in  diphtheria  during  the  disease,  or  convalescence,  are  due  to  the  effects 
of  toxic  substances  produced  in  the  disease  upon  the  nerve  structures 
of  the  heart.  Shively. 

CLINICAL  NEUROLOGY. 

153.  Tabes  avkc  conskrvation  des  reflexes  rotuuens  (Tabes 
with  Preserved  Patellar  Reflexes).  MM.  Achard  and  Levi  (La 
Med.  Moderne,  9,  1898,  p.  176). 

A  typical  case  of  tabes,  except  for  the  preservation  of  the  knee- 
jerks,  is  reported,  with  the  autopsy.  There  was  sclerosis  of  the  pos- 
terior columns,  most  marked  in  the  sacral  and  cervical  regions.  The 
cornu-commissural  zone,  the  comma-shaped  columns  of  Schultze,  and 
the  other  "descending  areas"  were  well  preserved.  At  the  junction 
of  the  lumbar  and  dorsal  segments  Westphal's  zone  of  entry  of  the 
posterior  roots  ("Wurzel-Eintritt")  was  observed  to  be  intact.  Nu- 
merous cases  have  now  been  reported  of  various  forms  of  disorder 
of  the  spinal  cord,  in  which  it  might  be  expected  that  the  knee-jerk 
would  be  lost,  but  in  which  it  has  persisted,  and  wherever  careful  post- 
mortem investigation  has  been  made  this  zone  has  been  found  in- 
tact. Lehmann,  Kraus,  Westphal,  Minor,  Pick  and  others  have  ob- 
served this  persistence  of  the  reflex  in  cases  of  tabes  and  "combined 
disease,"  and  accounted  for  the  fact  by  the  integrity  of  this  area  in 
the  cord.  Mitchell. 

154.  Tabes  Dorsalis  und  Wanderniere  (Tabes  Dorsalis  and  Float- 
ing Kidneys).  A.  Habel  (Centralblatt  fur  Innere  Medicine,  18, 
1897,  p.  t6i). 

Attention  is  called  to  the  fact  that  in  cases  of  tabes  a  large  propor- 
tion of  wandering  kidneys  was  observed.  Thus  in  the  Zurich  Clinic 
some  14  per  cent,  of  all  the  cases  of  tabes  presented  this  anomaly,  and 
in  the  case  of  the  women  some  25  per  cent,  were  noted.  The  propor- 
tion observed  in  the  general  medical  clinic  at  the  same  institution  for 
the  same  time  being  i  per  cent.  The  author  believes  it  not  improbable 
that  some  sort  of  causative  or  predisposing  condition  may  exist  in 
this  disease  or  in  this  anomaly.  Jelliffe. 


PERISCOPE,  499 

155.  Arthropathius  TABE5TIQUES  (Tabetic  Arthropathies).  M.  Hirtz 
(La  Med.  Moderne,  9,  1898,  p.  48). 

The  author  reports  a  case  presenting  a  joint  lesion  of  tabes  in 
the  unusual  situation  of  the  metatarso-phalangeal  articulations.  Radi- 
ographs were  shown,  demonstrating  the  condition  excellently. 

Mitchell. 

156.  Des  troubles  du  gout  et  de  l'odorat  daNvS  le  tabes. 
(Disturbances  of  Taste  and  Smell  in  Tabes).  M.  Klippel  (Ar- 
chiv.  de  Neurologie,  3,  1897,  p.  257). 

The  author  shows  that  disturbances  in  taste  and  smell  are  by 
no  means  as  infrequent  as  a  search  of  neurological  literature  would 
lead  one  to  suppose,  and,  moreover,  that  such  affections  are  of  much 
value,  in  that  they  may  be  found  among  the  earlier  symptoms  of  this 
disease.  The  symptoms  noted  are  various  and  often  difhcult  of  exact 
observation.  They  consist  in  paraesthetic  sensations  in  the  nose,  loss 
of  smell  and  taste,  disturbances  in  the  ordinary  sensibility,  perversion 
of  smell  and  taste,  and  in  some  cases  taste  or  smell  crises  may  be 
observed,  those  in  the  nose  being  associated  constantly  with  prickling, 
and  culminating  in  violent  and  repeated  sneezing.  In  the  severer 
grades  of  these  sensory  disturbances  accompanying  involvement  of 
other  cranial  nerves  is  often  observed.  In  one  case  reported  by  the 
writer  an  autopsy  was  performed,  and  microscopical  examination  of 
the  olfactory,  glossopharyngeal  and  trigeminus  nerves  and  their  cor- 
responding ganglia  showed  marked  degenerative  changes,  thus  ac- 
counting for  the  symptoms.  Jelliffe. 

157.  On  Periodic  Vomiting  in  Tabes  ;  Gastric  Crises.  P. 
Ostankow  (Oboszrenie  psichiatrie  (Russian),  1897,  Nos.  7  and 
8;  Neurol.  Centralblatt). 

The  author  reports  upon  two  cases  of  gastric  crises.  In  the  first 
case  the  gastric  symptoms  lasted  for  many  weeks,  with  intervals  of 
freedom  of  from  three  to  four  days  at  a  time.  In  the  second  case  the 
crises  were  shorter,  but  were  almost  uninterrupted.  In  both  of  the  cases 
there  was  a  prodromal  period,  characterized  by  a  loss  of  sleep,,  re- 
tention of  the  urine,  restlessness  and  anorexia.  In  the  first  case  dur- 
ing the  crises  the  pulse  was  increased  in  frequency;  in  the  second 
there  was  arhythmia  and  interrupted  variation  in  tension.  Cerium 
oxalate  in  doses  of  from  .05  to  .15  gm.  (i  to  3  grs.)  t.i.  d.  gave  re- 
lief  in   both   cases.  Vogel. 

158.  Note  sur  la  retour  de  la  sensibility  testiculaire  dans  la 
"tabf^"  (Note  on  the  Return  of  the  Sensibility  of  the  Testicle 
in  Tabes).  E.  Bitot  et  J.  Sabrazes  (Revue  de  Med.,  17,  1897,  p. 
156). 

Pitre  first  noticed  that  analgesia  of  the  testicle  was  a  nearly  con- 
stant sign  in  tabes,  occurring  in  as  many  as  75  per  cent,  of  the  cases. 
The  authors  hold  that  this  analgesia  is  of  interest  in  that  it  does  not 
seem  to  follow  the  same  rules  as  other  sensory  changes  in  tabes,  relative 
its  constancy  after  once  having  been  established.  They  report  three 
cases  in  which  the  sensibility  returned,  and  in  two  of  them  there  was 
a  well-marked  gain  in  the  sexual  vigor  of  the  patients.       Jelliffe. 

159.  On  the  Early  and  Little  Known  Symptoms  of  Tabes. 
W.  Bechterew  (Revue  de  Psych.  (Russian),  1897,  No.  8;  Rev. 
Neurologique). 

The  author  calls  attention  to  the  preservation  of  the  reflexes, 
cutaneous  abdominal  and  epigastric,  coincident  with  th''  loss  of  the 


s 


500  PERISCOPE. 

tendon  reflexes  in  the  initial  stages  of  tabes.  He  also  speaks  of  the 
analgesia  of  the  popliteal  nerve  in  the  popliteal  fossa  as  a  sign  more 
frequent  and  more  constant  than  Biernacki's  analgesia  of  the  ulnar 
nerve  or  Sarbo's  analgesia  of  the  peroneal.  Vogel. 

160.  A  Case  of  Psukdo-Tabks  folt^owino  Diphtheritic  Infection 

IN  THE  Penis.    J.  W.  Courtney  (Atlantic  Medical  Week,  9,  1898^ 

p.  ZZ)- 

The  author  cites  an  interesting  case  in  which  there  was  a  typical 
diphtheritic  ulcer  on  the  penis  of  a  man  of  47  years  of  age.  Similar 
ulcers  were  found  upon  the  ring  finger  of  the  right  hand.  About  a 
month  after  healing  the  patient  noted  a  loss  of  power  in  his  limbs  as 
he  arose,  and  also  a  numbness  in  the  left  heel.  Later  his  gait  became 
unsteady,  and  he  had  beginning  paralysis  of  accommodation.  At  the 
time  of  examination  the  patient  had  an  extreme  ataxic  gait,  marked 
Romberg,  pupils  equal  and  normal.  No  cranial  nerve  palsy,  right  hand 
weak,  incoordination.  Lower  extremities  weak  and  atrophied  muscles, 
knee  jerks  absent,  no  ankle  clonus,  no  loss  of  sensation  and  no  marked 
electrical  disturbances. 

On  tonic  treatment  the  patient  gradually  improved,  and  the  pro- 
gnosis seemed  favorable  for  a  complete  recovery.  Vogel. 

THERAPY. 

161.  L*fel*ONGATlON  VRAIE  DE  I*A  MOPXT^E   EPINIERE  ET  SON  APPLICA- 
TION   AU    TRAITEMENT    DE  T/ATAXIE  LOCOMOTRICE  ;    RECHERCHES 

experimentai.es  ETTHivRAPEUTiQUES  (Loconiotor  Ataxia  Treated 
by  Stretching  in  the  Sitting  Position.  MM.  Gilles  de  la  Tourette 
et  A.  Chipault  (Gaz.  Hebd.  de  Med.  et  Chir.,  2,  1897,  p.  401). 

The  authors  reported  some  observations  upon  tiie  topo- 
graphical anatomy  of  the  spinal  cord  which  convinced  them  that  ii 
was  possible  for  certain  well-defined  manoeuvres  to  make  decided 
elongation  of  the  cord,  and  that  these  could  not  practically  be  done 
by  suspension;  but  by  passive  flexion  of  the  body  with  the  patient 
seated  with  the  legs  extended,  there  could  be  an  elongation  of  about 
one  centimetre,  the  stretching  affecting  the  posterior  portion  of  the 
column  to  the  level  of  the  first  lumbar  pair  of  nerves. 

With  an  apparatus  constructed  for  the  purpose,  they  have  experi- 
mented on  ten  healthy  individuals,  who  were  competent  to  render  a 
report  of  their  sensations,  and  upon  47  ataxics,  all  of  whom  were  in 
the  second  stage  of  the  disease.  Only  ten  of  the  patients  treated  did 
not  seem  to  receive  any  benefit;  22  were  much  improved,  and  15  were 
benefited.  Mitchell. 

162.  LE    TRAITEMENT  DE  L*ATAXIE  LOCOMOTRICE    PAR    L' IvL<^NGATlON 

VRAIE  DE  LA  MOELLE  ivPiNii$RE  (Treatment  of  Locomotor  Ataxia 
by  True  Stretching  of  the  Spinal  Cord).  M.  Gilles  de  la  Tourette 
(Gazette  des  Hopitaux,  70,  1897,  p.  1,368. 

The  good  results  of  this  therapeutic  method,  which  have  already 
been  presented  to  the  Academy  by  M.  Chipault  have  been  confirmed 
by  further  experience.  In  collaboration  with  M.  Gasue  a  large  num- 
ber of  tabetics  were  observed  at  the  Salpetriere,  upon  whom  the 
treatment  was  regularly  carried  out  for  a  sufficiently  long  period  to 
test  the  method.  Seventeen  cases  out  of  twenty-one  were  considerably 
benefited,  especially  as  regards  pain,  genito-urinary  symptoms  (ex- 
cepting incontinence,  which  was  little  affected)  and  incoordination. 
This  percentage  will  doubtless  appear  large,  but  ft  should  be  remem- 
bered that  not  all  the  cases  of  tabes  were  indiscriminately  submitted 


PERISCOPE.  501 

to  the  stretching  treatment.  This  treatment  ought  to  be  refused  to 
greatly  debilitated  subjects,  to  those  in  whom  the  disease  is  pursuing 
a  very  mild  course,  in  arthritic  cases  and  to  cases  in  whom  laryngeal 
crises  occur.  It  should,  moreover,  be  determined  beforehand  that 
the  vertebral  column  is  neither  too  flexible  nor  too  rigid;  a  sensation 
of  numbness  felt  in  the  feet  during  the  application  of  treatment  is 
the  best  proof  that  elongation  is  actually  produced  and  that  the  ap- 
paratus has  been  properly  applied.  Shively. 

163.  TrAITEMBNT  DB  L* ataxia  DBS  TAB^TIQUBS  PAR  hA,  M^HODB  D9 

REEDUCATION— MifeTHODB  DB  Frknkbi,  (Treatment  of  Tabetic 
Ataxia  by  Reeducation  (Method  of  Frenkel).  Maurice  Faure 
(Presse  Medical,  5,  1897,  p.  352). 

The  author  records  the  results  of  the  application  of  systematic 
coordinated  exercises  upon  13  cases  in  the  service  of  Prof.  Raymond 
at  the  Salpetriere.  In  all,  the  application  of  FrenkeFs  method  was  co- 
incident with  an  improvement  of  the  ataxia,  the  more  pronounced 
the  more  severe  the  condition  had  been.  He  describes  the  move- 
ments employed  and  discusses  the  general  principles  to  be  observed. 
The  seances  should  be  short  in  the  beginning  of  the  treatment;  later 
they  may  be  longer,  though  it  is  advisable  to  allow  a  brief  rest  every 
ten  minutes.  It  is  important  that  some  one  with  sufficient  authority 
and  intelligence  should  be  present  to  control  the  movements  of  the 
patient.  No  movements  should  be  employed  that  require  strengths 
the  idea  being  to  develop  dexterity,  and  it  must  be  remembered  that 
the  extreme  laxity  of  the  muscles  does  not  limit  the  movements  of  the 
joints,  as  in  a  normal  person,  and  that  the  bones  are  frequently 
fragile.  Altogether,  40  cases  have  been  reported  by  various  authors,, 
with  40  successes.  The  object  of  this  method  is  to  improve  the  ataxia. 
It  is  of  no  value  against  the  other  symptoms,  and  should  be  used 
only  in  those  cases  in  which  coordination  is  pronounced.  The  contra- 
indications are  rapidly  developing  ataxia,  grave  general  symptoms, 
either  trophic  or  visceral,  particularly  if  there  is  any  cachexia,  amau- 
rosis or  psychical  disturbance,  accompanied  by  paralysis,  although 
true  paralysis  must  not  be  confounded  with  the  apparent  forms  re- 
sulting from  extreme  ataxia;  cases  accompanied  with  hyperae  sthesia,. 
in  which  fatigue  appears  rapidly,  and,  finally,  the  presence  of  ar- 
thropathies or  fractures.  The  most  favorable  cases  are  those  in  which 
the  ataxia  develops  rapidly  at  first,  or  those  in  which  it  is  almost  the 
only  symptom.  The  results  will,  of  course,  be  better  if  the  patient 
is  young,  energetic  and  intelligent.  In  the  beginning  the  benefit  is 
usually  very  pronounced.  This  is  due  largely  to  suggestion.  Later 
improvement  is  more  gradual,  and,  finally,  there  comes  a  time  when 
the  patient  is  not  further  benefited,  and  treatment  should  be  sus- 
pended. Sailer. 

164.  Traitement  de  l'ataxie  dans  i*e  tabes  dorsalis  par  i,e  re- 
feucATiON  DBS  MOUVEMENT  (Mcthode  de  Frenkel).  Hirsch- 
berg  (Archiv.  de  Neurologic,  2,  1896,  p.  337). 

The  author  presents  his  results  with  Frenkel's  methods  on  nine 
cases  treated,  going  greatly  into  detail  as  to  the  precise  series  of  move- 
ments practised.  As  k  rule,  he  began  with  30-minute  exercises,  and 
extended  them  to  an  hour,  rarely  exceeding  that  limit,  and  always 
ceasing  the  moment  that  muscle  tire  became  evident.  In  all  of  his 
cases  there  was  some  improvement,  though  three  of  them  had  grave 
ataxia,  whereas  the  others  had  but  the  early  symptoms.  The  im- 
provement was  evident,  not  only  with  the  walking,  but  also  with  the 
feeling  of  the  patient,  and  the  author  believes  that  this  method  is  of 
service  in  all  stages  of  tabes,  and  is,  perhaps,  contraindicated  only 
when  the  disease  is  progressing  rapidly.  Vogel. 


f^ooU  §l«xitjeitrs. 


The  Genesis  and  Dissoi^ution  of  the  Facui^ty  of  Speech.  A 
Clinical  and  Psychological  Study  of  Aphasia,  by  Joseph  Collins, 
M.  D.,  Professor  of  Diseases  of  the  Mind  and  Nervous  System 
in  the  New  York  Post-Graduate  Medical  School,  etc.  Awarded 
the  Alvarenga  Prize  of  the  College  of  Physicians  of  Philadelphia, 
1897.    New  York:   The  MacMillan  Company,  1898. 

A  book  that  has  received  a  prize  is  like  a  painting  marked,  "  Hors 
concours."  You  are  told  thereby  that  the  artist  has  done  good  work, 
and  that  there  must  be  merit  in  his  production.  If  you  cannot  see  it, 
the  fault  is  with  your  powers  of  observation  and  not  with  the  painting^-* 
In  this  instance  we  are  ready  to  endorse  the  verdict  of  the  jury.  Dr. 
Collins'  essay  on  aphasia  was  altogether  worth]r  of  the  prize,  for  it 
is  characterized  by  an  intelligent  grasp  of  the  subject,  by  much  origin- 
ality of  thought,  and  by  a  critical  spirit  which  has  enabled  the  author 
to  give  a  just  estimate  of  contending  theories.  He  has  laid  down 
his  monograph  on  the  broadest  lines,  including  under  aphasia  "the 
total  inability,  or  partial  disability,  of  an  individual  to  make  outward 
expression  of  thoughts,  feelings,  or  other  states  of  consciousness, 
whether  such  disability  result  from  interference  with  the  formation 
of  the  mental  content,  or  in  the  emission  of  it" 

The  subject  is  subdivided  (in  the  introductor^r  chapter)  into: 
I.  True  Aphasia — aphasia  of  apperception,  due  to  lesion  of  the  speech 
region;  2.  Sensory  Aphasia;  3.  Motor  Aphasia;  4.  Compound  Aphasia. 
The  distinction  between  true  aphasia  and  motor  and  sensory  aphasia 
is  not  ''posited"  (to  use  one  of  the  author's  many  pet  words)  very 
clearly,  nor  is  it  maintained  throughout  the  book;  and,  surely,  motor 
aphasia  is  due  to  a  lesion  of  the  centre  itself,  as  well  as  to  a  lesion  of 
the  "motor  pathways  over  which  motor  impulses  travel  in  passing  to 
the  peripheral  speech  musculature." 

In  the  chapter  on  the  history  of  aphasia  (an  unusually  well 
written  chapter)  the  author  gives  an  excellent  and  interesting  account 
of  the  writings  of  previous  authors.  We  have  no  fault  to  find  with 
his  estimate  of  the  relative  importance  of  the  contributions  by  various 
standard  writers,  but  regret  that  he  did  not  enter  more  fully  into  the 
analysis  of  the  essays  by  Hughlings  Jackson,  which,  to  our  thinking, 
have  been  the  most  enduring  contributions  to  the  psychology  of 
aphasia.  To  be  sure,  the  author  states  that  "three  great  names  .  .  . 
stand  out  above  those  of  all  others  (aside  from  Broca  and  Wernicke), 
namelv,  Trousseau,  Hughlings' Jackson  and  Kussmaul." 

Chapters  3  and  4  are  devoted  to  the  genesis  and  functions  of 
speech  and  to  the  conception  of  aphasia.  In  the  latter  the  author 
defines  his  position  in  accord  with  those  who  believe  speech  to  be 
the  function  not  of  any  one  or  two  centres,  but  of  the  zone  of  language 
in  which  the  special  centres  and  the  association  tracts  connecting 
them  are  situated.  It  is  a  relief  to  know  that  the  speech  area  is 
gondola-shaped.  We  had  thought  it  resembled  a  slipper,  but  gon- 
dola it  is.  Flechsig's  recent  publications  have  formed  an  important 
support  for  the  author's  conception  of  aphasia.  He  has 
accepted  the  professor's  theories  in  toto,  and  we  fear  that  he  has 
not  read  them  with  the  same  "criticalness"  which  he  has  applied  to 
the  writings  of  others.    Collins  does  not  believe  in  a  special  graphic 


BOOK  REVIEIVS.  503 

Tnotor  centre,  and  his  arguments  on  this  point  are  convincing.    Wc 
<annot  approve  entirely,  however,  of  his  objections  to  the  form  of 
subcortical  motor  aphasia,  and  think  Proust- Lichtheim's  test  is  more 
satisfactory  than  the  author  seems  willing  to  believe. 

The  chapters  on  sensory  and  subcortical  sensory  aphasia  contain 
•comprehensive  statements  of  the  questions  involved.  The  clinical 
and  patholo^cal  data  furnished  by  the  writer  help  to  make  these 
•chapters  particularly  valuable.  We  cannot  refer  in  detail  to  the  many 
interesting  points  discussed,  but  may  note  in  passing  that  reference  is 
made  to  the  case  of  Freund,  which  shows  "that  the  peripheral  auditory 
neuron  can  be  normal  for  the  conduction  of  ordinary  sounds,  and 
<]iseased  for  the  conduction  of  sounds  haying  highly  differentiated 
•significance." 

In  the  chapter  on  total  aphasia  the  author  has  shown  the  results 
of  his  own  clinical  experience.  Many  other  writers  have  erred  in 
defining  their  cases  always  as  belonging  to  the  type  either  of  motor 
or  of  sensory  aphasia,  and  in  not  allowing  that  the  two  may  be  com- 
l>ined.  During  the  period  of  convalescence  these  mixed  or  "total" 
aphasias  are  most  puzzling. 

Of  the  remaining  chapters  of  the  book  it  need  only  be  said  that 
Collins  has  done  ample  justice  to  the  consideration  of  the  etiology, 
the  morbid  anatomy  and  the  treatment  of  aphasia,  but  the  reader 
must  remain  impressed  with  the  fact  that  in  nine  cases  out  of  ten 
the  aphasia  is  only  one  of  a  series  of  symptoms.  In  the  chapter  on 
treatment,  pedagogic  methods  are  properly  extolled. 

The  attentive  reader  will  lay  down  this  book  impressed  by  its 
matter  and  its  style.  As  we  have  said  above,  there  is  much  originality 
in  the  former,  and  we  cannot  help  saying  that  there  is  still  more  in 
the  latter.  Few  medical  men  of  our  day  wield  as  facile  a  pen,  but 
there  is  danger  in  this  ease  of  diction — the  danger  that  the  reader's 
•attention  will  be  arrested  first  by  the  style,  and  lastly  by  the 
contents.  Collins  has  a  special  fondness  for  archaic  terms  and  for 
new  (composite)  terms.  Where  is  the  "word  coining^'  centre  that 
luirbors  "awakement,"  "paronymization"  (shades  of  Wilder!),  "dex- 
trality."  "  hostilely,"  "ideate/*  "  materies  of  storage,"  "undislodg- 
able?"  There  is  every  reason  to  believe  that  the  editor  of  the  next 
Century  Dictionary  will  have  a  serious  task  before  him.  But.  to  be 
original  is  meritorious,  and  many  of  us  will  ascribe  our  "awakement" 
on  the  subject  of  aphasia  to  the  materies"  of  Collins'  splendid  mono- 
Srraph.  B.  Sachs. 


A  TsxT-BooK  OF  THB  PRACTICE  OP  MEDICINE.  By  James  M. 
Anders,  M.D.,  Ph.D.,  LL.D.,  Professor  of  Practice  of  Medicine 
and  of  Clinical  Medicine  in  the  Medico-Chirurgical  College  of 
Philadelphia.    W.  B.  Saunders.    Philadelphia,  18^. 

Dr.  Anders  has  written  quite  a  large  and  presentable  work  on 
the  practice  of  medicine.  In  it  about  200  pages  are  devoted  to  the 
•diseases  of  the  nervous  system.  In  a  practice  of  medicine  one  does 
not  expect  to  find  an  extensive  treatment  of  any  one  i>articttlar  field, 
and  hence  the  chapters  on  nervous  diseases  will  be  of  little  service  to 
the  neurologist,  but  to  the  beginning  student  of  neurology  we  be- 
lieve the  chapters  in  question  will  be  of  a  great  deal  of  service.  The 
style  is  good,  the  information,  for  the  most  part,  accurate,  and  there 
18  one  feature  commendable  from  the  pedagogic  point  of  view.  This 
consists  in  the  large  number  of  tables  of  diflFerential  diagnosis, 
specially  valuable  for  the  beginner,  though  the  specialist  realizes  their 
inadequacy.  Vogel. 


504 


BOOK  REVIEWS. 


Thb  Psychoi/x;y  of  Suggestion.  A  Research  into  the  Sub- 
conscious Nature  of  Man  and  Society.  By  Boris  Sidis,. 
M.A.,  Ph.D.    Appleton  and  Company.     i8g%. 

So  much  has  been  written  upon  the  general  allied  subjects  of 
hypnotism,  unconscious  cerebration  and  suggestion,  which  for  the 
most  part  serves  the  purpose  of  mental  obfuscation,  that  it  is  a  re- 
lief to  read  a  book  in  which  an  endeavor  has  been  made  to  state  the 
problems  in  a  clear  and  comprehensive  manner.  This,  we  believe,  the 
present  volume  does  in  the  main.  In  three  parts  Suggestibility," 
The  Self  and  "Society"  are  treated.  The  opening  chapters  arc  the 
best.  Here  the  author,  from  observation  and  a  series  of  experi- 
ments, formulates  a  number  of  laws  with  reference  to  what  he  terms- 
normal  and  abnormal  suggestibility.  "Normal  suggestibility,"  he 
states,  as  one  of  these  laws,  "varies  as  indirect  suggestion  and  in- 
versely as  direct  suggestion."  Its  opposite,  the  law  of  "abnormal 
suggestibility."  While  these  laws  look  attractive,  and  the  small  series 
of  experiments  quoted  would  point  to  their  general  application,  we 
cannot  help  but  feel  that  the  author  has  very  indistinctly  differentiated 
what  he  means  by  direct  and  indirect  suggestion,  and  certainly  we 
are  not  prepared  to  accept  his  dicta  on  the  evidence  here  presented. 
In  our  opinion,  Baldwin's  presentation  of  much  the  same  subject  is 
far  more  reasonable  and  scientific,  from  the  psychological  point  of 
view,  and  his  conclusions  would  be  far  from  those  expressed  in  this 
volume. 

The  author's  point  of  view  is  well  illustrated  in  his  enconium  of 
Gurney's  classification  of  the  hypnotic  phenomena,  which  he  desig- 
nates as  the  most  philosophical,  and  hence  the  best.  Thus,  he  would 
ally  himself  rather  with  those  working  purely  in  the  field  of  the 
Psychical  Research  Society,  commendable  though  their  workers  may 
be  in  many  respects,  with  their  fallacious  evidence  derived  from  the 
so-called  "law  of  probabilities,"  rather  than  with  the  more  conserva- 
tive ,  and,  we  believe,  more  careful  "physiological  psychologists." 

In  Part  2,  "The  Self,"  we  find  most  of  the  familiar  anecdotes  which 
are  repeated  from  book  to  book,  each  author  using  them  as  illustra- 
tions of  his  own  point  of  view,  though"  often  the  points  of  view  are 
diametrically  opposed.  Psychical  phenomena  seem  to  be  more  than 
usually  elastic  from  an  interpretative  point  of  view. 

The  author  apparently  adopts  Binet's  exposition  of  the  "double 
personality,"  and  cites  many  of  the  threadbare  examples,  and  adds 
an  interesting  one  of  his  own. 

In  Part  3  "Society"  is  dealt  with,  and  the  familiar  caption  of  the 
"suggestibility  of  the  mob"  is  treated.  The  facts  brought  together  are 
extremely  interesting,  but  we  do  not  think  that  the  analysis  of  the 
conditions  is  thorough  nor  satisfactory.  Impressionists  are  rarely 
scientists,  and  a  general,  hazy  delineation  of  a  large  movement, 
termed  mania  or  epidemic  for  descriptive  effect,  which  involves  a  great 
many  factors,  is  not  a  careful  presentation  of  the  principles  of  social 
movements. 

Considered  as  a  whole,  the  work  is  instructive  and  suggestive: 
it  is  a  little  too  anecdotal  in  character,  a  feature  of  all  the  works  of 
this  kind,  and  somewhat  hastily  constructed,  but  well  worth  the  read- 
ing. VOGEL. 

The  Procbedings  of  the  American  MEmco-PsYCHoix)GiCAi,  As- 
sociation. Fifty-third  Annual  Meeting  held  in  Baltimore,  May 
iith-i4th,  1897. 

The  present  volume,  like  most  of  the  preceding  numbers,  is  made 
up  in  the  main  from  reprints  of  articles  which  have  appeared  in  the 
"American  Journal  of  Insanity."  The  wide  scope  and  the  high 
character  of  the  work  are  an  evidence  of  the  activity  of  the  society 
and  the  scientific  interests  of  its  members.  Jelltffe. 


Trional 


The  cModem  Hypnotic 


As  the  result  of  numerous  and  thorough  trials  in  private  and  hospital  practice 
by  leading  authorities  in  America  and  in  Europe,  Trional  has  earned  the  title  of 
the  mosi  perfect  .of  modern  hypnotics.  It  is  not  a  narcotic,  but  produces  normal, 
i^Q&eshing  sleep,  promptly,  safely,  and  agreeably, 

Without  Sequels  or  Habituation. 

Trional  is  indicated  in  all  forms  of  sleeplessness,  especially  simple  agrypnia,  the 
inBomnia  of  neurastlienia,  and  of  mental  diseases. 


^perazine- Bayer,  Samatose,  SiilfonaU Bayer,  Pbenacetine-Bayer,  Tannigen, 

Lyeetol,  ProtsLr^al,  lodotbyrine,  Aristol,  Burophen,  Salophen,  FerrO' 

Somatoso,  I^aotoSomatose,  Tannopine,  and  l/osopban. 

f rite  for  pan.p^J.ts  fo  Schicffelin   &  Co.,   NcW   Yofk, 

Sole  Agents  for  Products  of 
Farbenfabriken  l>orm*  Friedr*  Bayer  &  Co*,  Elberfeld,  Germany^ 


T^rotargoL** 


A.  Nexv  Organic  Silver  Compound. 

PROTARGOL  is  a    combination   of  silver  with  a   proteid  base,    possessing 
marked    bactericidal    properties,   but   perfectly  unirritating.      It  is   readily 
soluble  in  water,  undecornposed  by  secretions  from  wounds  and  mucous 
surfaces,  and  penetrates  deeply  into  the  tissues. 

In  view  of  these  advantages  it  has  been  found  of  especial  value  in  the  treat- 
ment of  the  various  forms  of  acute  and  chronic  urethritis,  in  which  it  rapidly 
destroys  the  organisms,  arrests  the  discharge,  and  effects  a  cure.  Protargol  is 
regarded  by  Professor  Neisser  as  the  best,  safest,  and  most  rapid  remedy  in  the 
treatment  of  gonorrhoea. 

As  an  antiseptic  in  the  treatment  of  wounds,  especially  if  suppurating, 
Protargol  is  also  of  service,  as  well  as  in  various  conditions  in  which  the  silver 
compounds  have  been  found  useful. 

Piperazine-Bayer,  Samatose,,  Snlfonal-Bayer,  Phenacetine-Sayer,  Tannigen, 
Lycetal,  Salophen,  Iad.othyrine,  Aristol,  J^uropben,  Trional,  Perro-Somatose, 

l^ctaSatnatoae,  Tannopine,  and  I^osopban. 

Write  for  pamphieis  to  ScUeffeUn  &  Co.,  New  York, 

Sate  Agents  for  Products  of 
Farbenfabriken  T^orm.  Friedr.  Bayer  &  Co..  Etberfetd,  Germany. 


«     « 


VOL.    XXV. 


July,  1898. 


No.  7. 


THE 

Journal 


OF 


Nervous  and  Mental  Disease 


AMERICAN  NEUROLOGICAL  ASSOCIATION. 

Twenty-fourth  Annual  Meeting,  held  at  The  New  York 
Academy  of  Medicine,  New  York,  May  26th,  27th  and 
28th,  1898. 

The  President,  Dr.  Graeme  M.  Hammond,  in  the  chair. 
PRESIDENTS  ADDRESS.^ 

Gentlemen:  Before  proceeding  to  say  the  few  words 
which  will  constitute  my  address  to  you,  I  desire  to  ex- 
press my  warmest  thanks  for  the  honor  you  have  conferred 
upon  me  in  choosing  me  your  President  for  this  year.  Ap- 
preciating, as  I  do,  that  the  Presidency  of  the  American 
Neurological  Association  is  the  highest  honor  the  neu- 
rologists of  this  country  can  bestow,  I  cannot  but  feel 
gratified  and  complimented  that  in  your  eyes  I  am  con- 
sidered worthy  of  it. 

I  will  not  detain  you  with  many  words.  Even  were 
I  disposed  to  do  so,  the  unprecedented  number  of  papers 
on  the  programme,  more  than  have  ever  been  presented 
in  the  history  of  this  association,  compels  me  to  leave  un- 
said the  words  I  had  originally  intended  should  be  your 
greeting. 

I  cannot  refrain,  however,  from  calling  your  attention 
to  certain  matters  which  seem  to  warrant  your  earnest 
consideration. 

One  of  the  charter  members  of  this  association,  one 
who  was  for  many  years  your  faithful  secretary  and  treas- 
urer, and  whose  constant  adherence  and  earnest  endeavors 


'Read  at  the  twenty-fourth  annual  meeting  of  the  American  Neu- 
rological Association,  May,  1898. 


5C)6  GRAEME  M.  HAMMOND. 

have  tended  to  place  this  association  on  the  sound  scien- 
tific foundation  on  which  it  stands  to-day,  has  passed 
away.  I  refer  to  Dr.  E.  C.  Seguin,  who,  as  a  pure  scientist, 
helped  in  no  inconsiderable  way  to  advance  the  knowledge 
of  neurology  in  America.  The  history  of  American  neu- 
rology cannot  be  written  without  the  name  of  Dr.  Seguin 
on  the  title-page.  It  must  be  a  consolation  to  you  all 
to  remember  that  you  recognized  his  years  of  service  as 
an  American  neurologist  by  electing  him  to  honorary 
membership  in  the  association,  the  greatest  honor  the  as- 
sociation can  confer,  an  honor  which  you  may  know  grati- 
fied him  in  his  last  days,  and  made  him  feel  that  his  life- 
work  was  appreciated  by  those  who  were  capable  of  un- 
derstanding him  and  his  works.  It  will  give  me  pleasure, 
at  the  proper  time,  to  appoint  a  committee  to  draft  suit- 
able resolutions,  expressing  our  sorrow  and  regret  at  the 
loss  of  a  most  valued  member,  to  whom  neurological  science 
was  deeply  indebted. 

Almost  from  our  beginning  we  have  had  classes  of 
membership  known  as  associate  and  honorary  members. 
In  the  beginning  we  were  weak,  certainly  as  a  national 
body,  if  as  nothing  else.  The  possession  of  associate  and 
honorary  members  of  foreigners  who  had  achieved  great- 
ness in  neurology  seemed  to  make  us  more  important,  and 
to  reflect  some  of  their  greatness  upon  us;  thus,  by  re- 
flection, making  us  seem  greater  as  an  association  than 
we  really  were.  Many  of  these  were  elected,  not  only 
w^ithout  solicitation  on  their  part,  but  sometimes  without 
even  their  consent.  In  the  great  majority  of  instances 
they  have  never  taken  the  slightest  notice  of  their  election. 
They  neither  add,  except  in  the  most  rare  instances,  to  the 
scientific  work  of  our  association,  nor  do  thev  bv  their 
names  attract  new  members. 

This  association  of  American  neurologists  is  to-day 
capable  by  its  works  of  maintaining  a  prestige  in  the 
neurological  world  without  depending  upon  the  names 
of  those  who  neither,  apparently,  desire  to  be  affiliated 


i 


PRESIDENTS  ADDRESS.  507 

with  us,  nor  show  a  just  feeling  of  reciprocity  by  electing 
American  neurologists  to  membership  in  their  societies. 
This  association  should  be  what  its  name  stands  for  —  an 
association  of  American  neurologists.  It  is  so  actually. 
It  has  never  received  either  aid,  encouragement  or  con- 
tributions, except  reprints,  from  its  foreign  members. 
They  do  not  want  us.  We  do  not  need  them.  I  would, 
therefore,  recommend  such  legislative  action  by  the  as- 
sociation as  either  to  abolish  associate  membership,  or,  if 
that  seems  inexpedient,  to  prevent  the  addition  of  new 
members  to  that  rank. 

It  is  the  same  in  regard  to  honorary  membership.  It 
seems  to  me  as  if  hoijorary  membership  should  be  con- 
ferred only  upon  members  of  the  association,  who.  either 
by  long  years  of  faithful  service,  or  by  their  scientific  repu- 
tation, have  achieved  the  right  to  the  distinction  and 
honor  of  being  elected  to  honorary  membership  in  this 
association. 

I  do  not  mean,  for  a  moment,  to  imply  that  we  are 
not  honored  by  our  honorary  membership  as  it  stands 
to-day.  The  fact  that  one  is  elected  to  honorary  mem- 
bership is  a  sufficient  warrant  of  distinction  in  itself. 
Neither  do  I  desire  to  be  considered  narrow-minded  in 
arguing  for  this  policy  of  exclusion,  but  I  would  prefer 
to  see  this  association  American,  and  American  only.  I 
now  declare  the  scientific  session  open. 


Note. — By  the  unanimous  vote  of  the  Association  the  following 
distinguished  physicians  were  elected  Honorary  Members: 

Sir  William  R.  Gowers,  of  London,  England. 
Dr.  Byrom  Bramwell,  of  Edinburgh,  Scotland. 
Prof.  H.  Nothnagel,  of  Vienna,  Austria. 


©riflitial  ^vticUs. 


ON  MYOTONIA.^ 

By  GEORGE  W.  JACOBY,  M.  D. 

The  disease,  first  known  through  the  description  of 
the  Silesian  physician,  Dr.  Thomsen,  and  since  then  called 
after  him,  is  an  affection  scientifically  so  remarkable  and 
interesting  that  I  may  be  pardoned  for  again  bringing 
this  subject  before  you.  Nor  would  I  do  so  now,  were  it 
simply  for  the  purpose  of  recording  another  case  of  Thom- 
sen's  disease  (myotonia  congenita);  for,  while  the  affec- 
tion must  be  one  of  infrequent  occurrence,  scarcely  more 
than  so  cases  having  been  published,  yet  all  of  these 
cases  resemble  each  other  to  such  an  extent,  that  one 
typical  case  may  fittingly  be  looked  upon  as  a  paradigm 
of  the  rest. 

The  subject  must,  however,  to-day  be  looked  upon 
from  a  broader  point  of  view  than  that  of  mere  casuistics. 

The  history  and  literature  of  Thomsen's  disease  up  to 
1886  will  be  found  in  Erb's  monograph,  that  from  1886 
to  1889  in  his  article  in  the  Deutsches  Archiv,  and  that 
from  1889  to  1894  in  the  article  by  Suesskand,  published 
in  the  Zeitschrift  fiir  klinische  Medizin,  vol.  xxv.  The 
only  case  of  unusual  interest  published  since  then  is  the 
one  with  autopsy  by  Dejerine  and  Sottas,  and  to  this  I 
shall  have  occasion  to  refer  again. 

Our  knowledge  of  this  affection  is  now  so  well  de- 
fined that  the  term  Thomsen's  disease,  or  myotonia  con- 
genita, embraces  a  clearly  circumscribed  clinical  entity, 


*  Read  before  the  American  Neurological  Association,  May  27th, 
1898. 


ON  MYOTONIA.  509 

and  constitutes  a  picture  to  which  nothing  can  possibly 
be  added;  nevertheless,  it  seems  to  me  that  the  time  has 
come  when  we  must  limit  this  name  to  the  actually  con- 
genital cases,  and  not  expand  it  to  include  the  acquired 
ones,  or,  possibly,  even  such  as  have  the  myotonic 
disorder  and  myotonic  reaction,  but  in  other  respects 
differ  to  a  greater  or  less  extent  from  cases  of  Thomsen's 
disease.  In  view  of  the  cases  which  I  herewith  publish,  I 
think  it  proper  to  assign  all  such  cases  to  the  one  clinical 
category  of  myotonia,  and  to  then  subdivide  this  class 
into  various  groups. 

If  we  analyze  the  well-known  picture  of  the  disease,  we 
find  it  made  up  of  the  following  components: 

1.  The  Etiology.  Here  the  most  imi>ortant  factor  is, 
beyond  a  doubt,  heredity,  either  as  a  direct  transfer  from 
the  ascendant,  or  only  indirectly  by  inherited  disposition; 
atavistically,  as  in  Weichmann's  case,  or  where  collateral 
branches  are  affected,  as  in  the  cases  of  Knud  Pontop- 
pidan  and  Bernhardt;  or  the  disease  may  occur  as  a  fam- 
ily type,  without  direct  heredity. 

2.  The  myotonic  disorder  of  movement;  i.  e.,  the  occur- 
rence of  tension,  stiffness  and  tonic  spasm  in  the  voluntary 
muscles  at  the  beginning  of  intended  movements. 

3.  The  myotonic  reaction,  which  is  made  up  of  normal 
mechanical,  faradic  and  galvanic  excitability  of  the  motor 
nerves,  and  an  increased  mechanical,  faradic  and  galvanic 
excitability  of  the  muscles.  Here  with  the  galvanic  cur- 
rent only  closure  contractions  are  obtainable,  and  these 
are  as  strong  with  the  anode  as  with  the  kathode;  the 
contractions  are  always  slow,  tonic  and  prolonged. 

In  many  muscles  strong  faradic  currents  produce  ir- 
regular undulating  contractions  and  stabile  galvanic  cur- 
rents, rhythmical  contraction  waves  which  follow  one 
upon  the  other. 

3.  Hypertrophy  of  the  muscles. 

4.  Absence  of  all  symptoms  pointing  to  gross  involvement 
of  the  nervous  system. 


5IO 


GEORGE  If.  JACOBY. 


Of  the  published  cases  of  myotonia  congenita,  the 
large  majority  correspond  absolutely  to  these  require- 
ments. Cases  which  show  symptoms  of  organic  disease 
of  the  central  nervous  system,  with  myotonic  disorder,  but 
without  myotonic  reaction,  such  as  Dana's,  can  at  once 
be  excluded  from  the  group  of  myotonias.  A  large  mi- 
nority, however,  show  certain  smaller  deviations  from  thn 
typical  picture.  Aside  from  variations  in  intensity  and 
extensity  of  the  disease,  all  or  only  some  muscles  being 
severely  or  slightly  affected,  the  most  frequent  deviation 
consists  in  the  affection  being  neither  hereditary  nor  con- 
genital. Such  cases  have  been  described  by  Seligmiiller. 
Peters,  Weichmann,  Rieder,  Vigoroux,  G.  Fischer.  Erb 
and  Suesskand. 

The  following  historj'  is  that  of  a  typical  acquired  case: 

Case  I. — W.  J,  G.,  of  Wheeling,  W.  \'a..  was  referred  to 
me  by  Dr.  J.  Schwimi  of  that  city,  with  the  diagnosis  Tliom- 
sen's  disease,  and  was  presented  at  the  New  York  Neurological 
Society  on  Nov.  2d,  1897,  as  a  typical  case  of  this  disease. 

Patient  is  28  years  of  age,  was  born  in  Ireland,  and  came 
to  the  United  States  in  1884.  He  is  a  railroad  brakeman  by 
occupation. 

Family  History.— His  grandparents  lived  to  an  old  age. 

His  father  died  at  the  age  of  70,  cause  unknown;  his  mother 

■-  'iving  and  well  at  the  age  of  69.    She  had  nine  children,  of 

ich  two  are  dead.    The  others,  five  sisters  and  one  brother, 

healthy. 

The  patient  himself  was  rather  delicate  up  to  his  14th  year; 
crwise,  with  the  exception  of  an  attack  of  measles,  and  one 
whooping  cough,  he  was  perfectly  well.  He  never  noticed 
■  difference  between  himself  and  his  schoolmates  in  regard 
physical  strength,  and  was  able  to  participate  in  all  out-of- 
*r  sports  and  games.  Psychically,  he  says  he  was  rather 
id,  and  perhaps  slightly  backward.  At  the  age  of  18  he  had 
attack  of  typhoid  fever  without  complications,  which  kept 
I  in  the  house  for  five  weeks.  When  he  went  out  for  the 
t  time,  he  experienced  a  severe  painless  cramp  in  the  calves 
t)Oth  legs,  more  marked  on  the  -ight  side.  Tliis  cramp 
ed  about  two  minutes.  During  the  next  two  weeks  it  re- 
red  several  times  each  day.  and  his  legs  felt  somewhat  weak, 
then  complained  of  feeble  sexual  powers  with  frequent 
turnal  emissions,  but  was  well  and  gained  rapidly  tn  weight 


ON  MYOTONIA,  5 1  r 

and  strength.  During  this  time  his  muscles  increased  in  size, 
so  that  tlhey  seemed  to  him  unusually  large,  and  now  that  he 
is  questioned,  he  thinks  he  was  somewhat  stiff  during  all  this 
time. 

About  two  years  after  this  attack  of  typhoid,  he  began  to 
complain  of  stiffness  of  his  legs,  especially  noticeable  when 
climbing  a  ladder,  or  stepping  into  a  car.  He  also  noticed  that 
after  a  prolonged  rest  the  stiffness  in  his  muscles  was  always 
decidedly  increased,  aad  that  after  the  first  few  moments  the 
stiffness  gradually  disappeared  and  he  again  had  full  use  of 
his  Hmbs.  At  first  only  the  muscles  of  his  legs  were  affected, 
and  these  slightly,  then  gradually  nearly  all  of  the  voluntary 
muscles  became  involved. 

During  the  time  of  this  progression,  and  before  his  arms 
were  seriously  affected,  his  legs  became  so  bad  that  in  1893, 
when  he  jumped  from  a  car,  the  muscles  would  cramp  up  so 
that  he  w'ould  fall;  then  he  could  get  up  only  by  using  his 
hands  as  a  support.  If  in  walking  or  running  he  stubbed  his 
toe,  his  leg  would  stiffen  so  that  he  could  not  lift  his  foot  from 
the  ground.  It  would,  as  he  expresses  it,  "stick  to  the  earth," 
and  then  he  would  fall.  Since  a  year  he  has  complained  of  a 
similar  condition  of  stiffness  in  his  hands,  so  that  when  turning 
the  wheel  of  the  car  brake,  it  would  require  a  long  time  before 
he  could  loosen  his  grip  and  straighten  his  fingers.  This  was 
accompanied  by  a  feeling  of  tension  and  stiffness  in  the  arm; 
also  when  his  arm  was  forcil)ly  extended  he  could  not  bend 
it  again  until  the  spasm  ceased. 

Recently  the  neck  muscles,  the  face  muscles  and  tongue 
have  become  affected,  though  not  to  so  marked  a  degree.  He 
also  feels  a  *'stiffness"  w^hen  he  closes  his  eyes,  and  at  times 
he  feels  his  right  eye  "catch"  when  he  turns  his  eye  outward. 
He  has  no  pains  and  feels  perfectly  well.  The  trouble  is  worse 
at  certain  times  than  at  others;  some  days  he  seems  all  right, 
but  he  does  not  think  that  the  weather  has  any  influence  upon 
his  condition.  He  has  often  wondered  at  the  fact  that  though 
his  muscles  seemed  to  increase  a  great  deal  in  size,  his  strength 
was  not  correspondingly  great,  in  fact,  he  thinks  he  has  be- 
come weaker. 

Status. — Medium  height.  Panniculus  adiposus  poorly  de- 
veloped, in  contrast  to  the  muscular  development  w-hich  is 
extreme,  giving  the  man  the  appearance  of  an  athlete.  Though 
all  the  muscles  show  an  exceedingly  strong  development,  the 
muscles  of  the  legs,  forearms  and  arms  are  especially  large. 
The  calves,  when  contracted,  measure  42  cm.  in  circumfer- 
ence at  their  largest  part. 

The  accompanyine  photograph  gives  a  good  illustration 
of  their  appearance.  The  gross  power  of  the  muscles  is  feeble 
in  comparison  to  their  size.    Aside  from  the  muscular  disorder, 


512  GEORGE  W.  JACOBY. 

no  symptom  of  disease  of  any  organ  can  be  discovered.  Sen- 
sory disturbances  are  absent;  the  superficial  reflexes  are  nor- 
mal. Triceps  ami  Achilles  tendon  reflexes  are  not  obtainable. 
The  knee-jerk  is  very  well  marked,  in  the  beginning  even 
exaggerated,  but  becomes  exhausted  after  repeated  blows, 
so  that  at  the  end  of  a  prolonged  examination  it  is  no  more 


Fig.  I. 

obtainable,  reappearing,  however,  in  its  increased  state  after  a 
rest  cf  half  an  hour  or  more. 

Very  pronounced  is  the  myotonic  disorder  of  all  the  mus- 
cles. When  the  lids  are  firmly  pressed  together,  they  cannot 
be  opened  at  once,  although  he  makes  great  effort  to  do  so. 
Only  after  a  time  is  he  able  to  Open  his  eyes.    The  spasm  in 


ON  MYOTONIA.  513 

these,  as  well  as  in  all  other  muscles,  lasts  from  15  to  25 
seconds. 

The  internus  of  the  right  eye  seems  somewhat  affected, 
inasmuch  as  the  eyeball  cannot  at  times  be  brought  to  the 
inner  canthus  or  at  times  having  been  brought  to  that  position, 
cannot  promptly  be  returned  to  its  normal  position  of  rest. 

The  pupils  react  promptly  to  light  and  accommodation, 
the  visual  field  is  not  restricted  and  the  fundus  is  normal. 

This  condition  of  spasm  is  present  in  the  tongue  and  in  the 
muscles  of  mastication. 

In  the  tongue,  however,  we  find  that  the  spasm  occurs  only 
when  the  intrinsic  muscles  are  exerted,  but  that  the  genio- 
glossus  is  free,  inasmuch  as  no  spasm  occurs  in  protrusion  of 
the  tongue.  So  also  the  disorder  of  the  masticator^'  muscles 
is  limited  to  the  masseters,  while  the  pterygoids  (lateral  move- 
ments) are  free.  The  masseters  stand  out  hard  and  rigid  like 
bars  of  iron,  when  the  teeth  are  forcibly  closed.  The  spasm, 
contraction  and  after-duration,  is  also  present  in  the  muscles 
of  the  face,  but  it  is  not  so  marked  as  elsewhere. 

In  the  movements  of  the  arms,  hands,  and  legs,  this  myo- 
tonic disorder  is  most  apparent.  This  is  particularly  notice- 
able in  the  hands  when  any  object  is  tightly  grasped,  and  in 
the  legs  in  going  up  stairs  or  in  jumping  from  a  low  stool. 

The  thorax  muscles  are  implicated  with  excessive  move- 
ments ;  thus  when  he  expands  his  chest  to  its  maximum  capac- 
ity, he  is  not  at  once  able  to  empty  it,  but  must  allow  several 
seconds  to  elapse.  The  muscles  when  uncontracted  convey 
no  different  sensation  to  the  examiner's  hand  than  does  a 
normal  muscle. 

Mechanical  Excitability. — The  mechanical  excitability  of 
the  trunks  of  the  motor  nerves  (n.  facialis,  plexus  brachialis,  n. 
ulnaris,  n.  peroneus)  is  not  increased. 

Mechanical  Excitation  of  the  Muscles. — All  the  muscles 
showed  the  formation  of  the  marked  lasting  furrows,  upon 
excitation  with  the  percussion  hammer.  When  stronger  blows 
were  employed,  an  idiomuscular  mound  was  formed  in  certain 
muscles  (biceps,  pectoralis)  which  remained  so  long  and  was 
of  such  consistency,  that  it  could  be  distinctly  palpated  and 
manipulated.  The  total  contractions  of  the  muscles  showed 
no  after-duration,  were  very  marked  upon  the  first  blow,  then 
with  each  succeeding  blow  grew  less  and  less,  until  finally  they 
could  no  longer  be  obtained.  Even  when  they  were  thus  lost, 
the  local  and  fibrillar  contractions  were  obtainable  to  their 
maximum  extent. 

The  electrical  examination  showed  normal  faradic  and  gal- 
vanic excitability  of  the  motor  nerves.  The  muscles  with  me- 
dium faradic  currents  showed  slow,  lazy,  lasting  contractions 
{20  to  25  seconds).  Single  opening  shocks,  no  matter  how 
strong,  produced  only  short  quick  contractions. 


514  GEORGE  IV.  JACOBY. 

The  muscles  showed  certain  quantitative  and  qualitative 
changes  to  the  galvanic  current.  In  nearly  all  of  the  muscles 
a  contraction  could  be  obtained  with  less  current  than  is  norm- 
ally the  case;  for  instance, in  the  triceps  a  Ka.  C.  C.  is  produced 
with  \  !M.  A.  of  current.  An  C.  C.  is  obtained  with  about  the 
same  amount  of  current  as  Ka.  C.  C,  or  in  some  muscles  with 
a  very  little  more.  Even  with  minimum  currents  the  An.  C.  C. 
shows  a  certain  amount  of  slowness;  as  soon  as  the  current  is 
increased,  both  contractions,  Ka.  C.  C.  and  AN.  C.  C.  show 
marked  slowness,  tonicity  and  after-duration. 

In  this  patient  I  was  also,  after  various  attempts,  able,  dur- 
ing the  passage  of  a  strong  steady  galvanic  current,  to  obtain 
the  peculiar  rhythmical  contraction  waves  as  described  byErb; 
a  large  flat  electrode  being  fastened  to  the  back  of  the  shoulder, 
the  other  electrode  placed  in  the  palm  of  the  hand  or  upon  the 
flexors  of  the  forearm,  and  the  current  of  at  least  20  M.  A. 
closed.  The  primary  result  is  a  lasting  tonic  contraction  of  all 
the  muscles  of  the  arm.  Then  after  about  half  a  minute,  slow 
wavy  contractions  set  up  and  pass  from  the  Ka.  to  the  An,  one 
wave  following  another  at  inter\'als  of  i  to  2  seconds.  In  the 
lower  extremities  I  was  also  able  to  obtain  these  waves,  but 
could  not  satisfy  myself  of  their  direction  from  the  Ka.  to  the 
An.  These  waves  were  not  always  demonstrable.  Their 
production  always  required  strong  currents  and  a  great  deal 
of  manipulation  of  current  and  electrodes. 

Examination  of  the  blood  showed  nothing  abnormal.  Hse- 
moglobin,  80  per  cent.;  red  blood  corpuscles,  4.360,000;  white 
blood  corpuscles,  7,450. 

For  purposes  of  microscopical  examination  two  pieces  of 
muscle  were  excised  from  the  left  quadriceps,  and  one  piece 
from  the  left  biceps.  These  pieces  were  kindly  prepared  for 
me  by  Dr.  F.  Schwyzer. 

Immediately  after  excision  each  piece  of  muscle,  in  order 
so  far  as  possible  to  prevent  permanent  shortening,  was  fully 
extended  and  thus  fixed  by  means  of  a  skewer,  both  ends  of 
which  were  pointed.  Each  end  of  the  muscle  piece  was  slipped 
over  the  corresponding  end  of  the  skewer,  and  thus  extended, 
the  pieces  were  placed  for  hardening  in  a  mixture  consisting 
of  formalin  i  part  to  4  parts  of  physiological  salt  solution; 
they  were  then  transferred  to-  alcohol,  finally  embedded  in 
celloidin,  cut  and  stained.  When  the  pieces  were  transferred 
from  the  formalin  to  the  alcohol,  it  was  noted  that  one  of  them 
had  torn  away  from  its  fastenings  and  was  very  much  con- 
tracted, while  the  others  remained  fastened  and  extended. 
This  accident,  as  will  be  seen  later,  proved  to  be  rather  fortun- 
ate. The  specimens  were  stained  with  iron  haematoxylin  (nu- 
clear stains),  and  after  preparation  were  compared  with  speci- 
mens taken  from  normal  muscle  and  with  others  from  mvo- 
tonia  congenita. 


ON  MYOTONIA.  515 

A  careful  examination  of  all  the  specimens  showed  that  we 
had  two  distinct  pictures  before  us,  both  of  the  transverse  as 
well  as  of  the  longitudinal  sections. 

In  the  one  transverse  picture(Fig'.II.)  we  found muFcle fibres 
more  or  less  polygonal  in  shape,  the  nuclei  in  a  few  of  the 
fibres  somewhat  increased  in  number,  and  the  interstitial  tissue 
also  somewhat  augmented.  The  diameters  of  the  fibres  in  these 
sections  were  as  follows:  In  100  fibres,  the  smallest  fibre  meas- 


Transverse  section  of  extended  muscle.     (Oc.  4.,  Obj-  A.  Zeiss.) 

ured 60  microns;  the  largest,  100  microns.    Of  these  100  fibres, 
go  per  cent,  measured  less  than  90  microns,  and  only  10  per 

cent,  were  found  to  measure  between  go  and  100.  j? 

In  the  second  series  (¥>(•.  III.)  of  transverse  pictures  we  'S 

find  the  single  fibres  mostly  with  rounded  edges,  the  nuclei  .] 

and  interstitial  tissue  decidedly  increased,  and  almost  all  of  g 

the  fibres  very  much  larger  than  in  the  other  specimens,  Meas-  ji 


5l6  GEORGE  W.  SACOBY. 

urements  here,  again  of  lOO  fibres,  showed  the  smallest  to 
measure  75  microns;  the  largest,  195  microns  in  diameter. 
33  per  cent,  measured  between  75  and  100;  60  per  cent  be- 
tween 100  and  150  microns,  and  71  per  cent,  between  150  and 
19s  microns.  The  longitudinal  sections  again  revealed  the 
same  variations  in  different  sections,  some  showing  the  same 
characteristics  as  those  of  the  second  series  of  transverse  sec- 
tions, others  not. 

In  addition  it  was  seen  that  in  the  one  set  all  the  muscle 


Fig.  III. 
Transverse  section  of  no n -extended  muscle.     (Oc.  4.,  Ob).  A.  Zeiss). 

fibres  were  parallel,  straight,  with  linear  contours,  while  in  the 
other  there  was  no  such  regularity;  the  fibres  not  being 
straight  and  parallel,  but  convoluted.  Furthermore,  the  trans- 
verse striation  was  here  indistinct  and  delicate,  the  entire  fibre 
being  more  homogeneous,  and  in  some  of  the  fibres  only  a 
longitudinal  striation  being  discernable. 

In  short,  our  two  sets  of  specimens  show  sections  which 
in  the  one  set  closely  approximate  those  from  normal  muscle, 


ON  MYOTONIA. 


517 


while  in  the  second  they  correspond  fully  to  what  has  hereto- 
fore been  looked  upon  as  characteristic  of  Thomsen's  disease. 
Inasmuch  as  all  the  specimens  were  taken  from  the  same 
individual,  at  the  same  time,  and  treated  in  precisely  the  same 
manner,  this  difference  must  be  due  to  the  accidental  breaking 
away  from  its  fastenings  of  the  one  piece  of  muscle ;  in  other 
words,  that  piece  of  muscle  which  was  allowed  to  contract  to 
its  limit  showed  the  characteristic  changes  of  Thomsen's  di- 
sease, while  the  other  not  entirely  contracted  pieces  gave  sec- 
tions which  appeared  almost  like  normal  muscle.  To  this  we 
shall  refer  again. 

This  case  is  as  typical  a  case  of  Thomsen's  disease  as 
can  well  be  found.  The  myotonic  disorder,  the  myotonic 
reaction,  the  hypertrophy  of  the  muscles,  with  their  dis- 
proportionate weakness,  all  make  the  diagnosis  unmis- 
takable. Yet  the  absence  of  heredity,  and  especially  the 
occurrence  of  the  affection  after  an  attack  of  typhoid 
fever  at  the  age  of  18,  render  it  imperative  to  make  use 
of  some  other  designation  than  that  of  myotonia  con- 
genita. 

The  hypertrophy  of  the  muscles  coming  on,  as  it  did,  at 
the  same  time  as  the  myotonic  disorder,  and  not  having 
preceded  it,  shows  the  entire  symptom  complex  to  have 
been  an  acquired  one.  There  is  not  the  slightest  ground 
for  the  assumption  that  any  symptom  of  the  disease  ex- 
isted prior  to  the  attack  of  typhoid. 

The  result  of  the  microscopical  examination  of  the 
muscles  is  also  of  great  interest,  and  it  must  cast  a  doubt 
upon  the  changes  thus  far  described  by  myself  and  others 
as  being  pathognomonic  of  Thomsen's  disease. 

Another  acquired  case,  but  one  which  deviates  very 
much  from  the  congenital  type,  is  the  following. 
I  will  curtail  the  history  as  much  as  possible. 

D.  L.,  male,  40  years  of  age,  pianist  by  occupation,  con- 
sulted me  first  about  eight  years  ago.  The  family  history  is 
unimportant.  Patient  himself  was  perfectly  well  until  his  26th 
year,  when  he  met  with  an  accident,  slipping  and  falling.  He 
at  that  time  fell  for\\'ard  and  struck  flat  upon  his  palms,  over- 
extending  both  hands.     This  was  followed  by  considerable 


^1 


^4 


■m 


5l8  GEORGE  IV.  JACOBY. 

pain  and  some  swelling  in  both  wrist  joints,  but  in  about  lo 
days  he  had  apparently  entirely  recovered,  so  that  he  again 
began  to  practice  upon  the  piano,  and,  as  was  his  custom, 
played  frooi  6  to  lo  hours  daily.  He  then,  after  several  days 
of  such  practicing,  overstretched  his  right  hand;  this  was  im- 
mediately followed  by  a  painless  abductor  cramp  of  the  hand 
muscles,  so  tliat  he  could  not  bring  his  fingers  together  until 
he  rubbed  and  warmed  them,  when  the  cramp  passed  away. 

In  the  course  of  the  following  six  months  such  cramps 
occurred  whenever  he  forcibly  stretched  his  fingers,  i.  e.,  ab- 
ducted them,  the  left  hand  becoming  similarly  affected.  He 
gave  up  piano  playing,  but  without  beneficial  result,  for  the 
trouble  grew  constantly  worse.  Soon  the  cramps  affected 
other  muscular  groups,  finally  involving  all  the  muscles  of 
the  upper  extremities,  and  occurring  upon  any  forced  move- 
ment. 

The  spasm  is  especially  noticeable  when  he  attempts  to 
grasp  any  object  tightly;  then  his  hand  clings  to  the  grasped 
object,  so  that  he  cannot  for  the  time  being  relinquish  it 

He  is  worse  in  winter  than  in  summer;  cold  water  increases 
the  liability  to  spasm,  and  he,  therefore,  always  washes  his 
hands  in  warm  water.  He  has  never  complained  of  his  legs 
troubling  him. 

Examination  showed  patient  to  be  of  strong  and  healthy 
appearance.  With  the  exception  of  the  muscular  ones,  no  dis- 
orders of  any  kind  are  discoverable.  Tlie  muscles  of  his 
arms,  shoulders  and  neck  are  almost  athletic  in  their  develop- 
ment; the  legs  also  are  unusually  large,  but  do  not  attract 
attention  in  the  same  measure  as  do  his  arms.  The  patellar 
tendon  reflexes  are  exaggerated;  the  mechanical  excitability 
of  the  muscles  of  both  thighs  is  remarkably  increased,  a  slight 
blow  producing  a  quick  contraction  of  the  entire  irritated 
muscle;  tonicity  is  not  present.  Electrical  reactions  are  nor- 
mal. 

The  arms,  in  comparison  to  their  development,  are  very 
w^eak;  extension  and  flexion  of  the  forearm  ui>on  the  upper 
arm  qan  very  easily  be  prevented  by  comparatively  slight  op- 
position. A  dynamometer,  which  under  pressure  by  the  av- 
erage man  indicates  150  for  the  left  and  200  for  the  right 
hand,  registers  only  60  and  80,  respectively,  upon  maximum 
pressure  by  the  patient.  Myotonic  motor  disorder  is  found 
to  exist  in  all  the  muscles  of  the  hands,  arms  and  shoulders. 
In  these  same  muscles,  as  well  as  the  chest  and  neck  muscles, 
the  myotonic  reaction  to  mechanical  and  electrical  excitation 
was  plainly  demonstrable.  The  nerves  (plexus  brachialis,  n. 
accessorius  and  n.  ulnaris)  show  normal  reactions  to  both 
forms  of  excitation.  Rhythmical  contraction  waves  were  never 
obtainable 


ON  MYOTONIA. 


5»9 


months  ago  I  sought  an  opportunity  of  again  ex- 
Iiis  patient;  he  was  then  in  a  condition  similar  to 
described,  but  it  was  evident  that  the  disease  had 
".e  progress,      his  entire  upper  body,  with  the  ex- 

ihe  abdominal  and  facial  muscles,  shows  the  myo- 
rders.    So  long  as  patient  is  careful  to  use  his  hands 

only  for  ordinary'  movements,  he  has  no  trouble  of 

but  every  sudden,  violent  exertion,  or  any  occu- 
:essitating  a  quick  maximum  contraction  of  any  of 

muscles  cr  muscular  groups,  as  well  as  sudden  ex- 
cold,  brings  on  a  spasm  which  is  myotonic  in  char- 

lyotonic  reaction  is  present  at  all  times, 

gs,  with  the  exception  of  increased  knee-jerks  and 

[ability   of   the   muscles   to   mechanical    excitation, 

iisorder. 

ithstanding  that  this  case  differs  materially  from 
al  picture  of  Thomsen's  disease,  in  coming  on 
ry  and  overstrain  in  a  man  of  26,  who  had  pre- 
een  in  good  health,  and  in  affecting  only  -the 
t  of  the  body,  and  leaving  the  abdomen  and.  legs 
ree,  it  must,  nevertheless,  be  classed  as  a  case 


I  . 


her  or  not  it  may  be  looked  upon  as  a  variety 
len's  disease  is  a  question  which  is  of  no  import, 
aside  from  its  acquisition,  not  any  more  atypical 
case  of  Martius  and  Hansemann,  which  Erb  con- 
iuch  a  variety,  notwithstanding  that  the  disorder 
only  temporarily  under  the  influence  of  cold,  was 
>  the  upper  extremities,  and  showed  no  myotonic 
luring  the  free  inter\-als. 

o  this  class  of  cases  that  the  term  myotonia  ac- 
ould  be  alloted,  and,  in  my  estimation,  this  term 
:  restricted  in  its  use  to  cover  only  such  cases. 

myotonia  now  describes  a  special  form  of  spasm, 
ized,  as  we  have  seen,  by  the  myotonic  motor 
ind  the  myotonic  reaction;  for  all  cases  not  show- 
.st  these  phenomena  it  would  be  better  to  make    . 
me  other  designation. 

Talma  and  Fiirstner  have  published  cases  of 


520  GEORGE  W.  JACOBY. 

"myotonia  acquisita"  which  certainly  have  nothing  at  all 
in  common  with  the  congenital  form  of  the  disease,  as  the 
name  would  seem  to  indicate.  Talma's  cases  represent 
a  series,  showing  an  acquired  tendency  to  spasm,  occurring 
chiefly  upon  intended  movements,  the  muscles  involved, 
on  account  of  their  hyperexcitability,  being  easily  thrown 
into  a  state  of  tonic  spasm  by  various  irritants.  These 
spasms,  however,  increase  in  intensity  the  longer  the  mus- 
scles  are  used,  while  the  reaction,  which  Talma  describes 
as  being  similar  to  the  myotonic  reaction,  shows  upon 
careful  interpretation  nothing  more  than  an  abnormal  hy- 
perexcitability to  mechanical  and  electrical  irritants.  In 
Fiirstner's  case,  also,  the  myotonic  reaction  was  not  pres- 
ent, mechanical  and  electrical  examination  producing  ef- 
fects which  were  not  totally  dissimilar  to  this  reaction. 

It  would,  I  believe,  be  better  to  designate  all  cases 
which  show  simply  tonic  spasm  accompanying  or  follow- 
ing active  movements,  when  unaccompanied  by  the  other 
myotonic  signs,  by  the  term  which  Seligmiiller  has  sug- 
gested, namely,  intention  spasm  (a  spasm  occurring  upon 
intended  movements). 

Such  intention  spasms  have  been  described  in  connec- 
tion with  a  variety  of  disorders,  some  having  yet  other 
symptoms  in  common  with  myotonia  congenita,  others 
admitting  of  no  comparison  at  all  with  this  disease.  Such 
descriptions  show  that  intention  spasms  may  occur  in 
disease  of  any  part  of  the  muscular  and  ner\'^ous  system, 
and  are  especially  often  found  in  hysteria,  tetany  and  oc- 
cupation neuroses. 

A  case  of  this  nature,  but  which  showed  so  great  sim- 
ilarity with  the  myotonic  disorder  and  reaction  that  I  am 
doubtful  as  to  whether  it  is  not,  after  all,  a  '^myotonic 
condition,"  is  the  following:  Perhaps  it  would  be  well  to 
speak  of  such  cases  under  the  name  of  myotonia  trafisitoria. 
This  patient,  L.  G.,  was  presented  at  the  New  York  Neu- 
rological Society  in  May,  1892: 


ON  MYOTONIA. 


521 


Cigarmaker;  34  years  of  age;  Russian  by  birth.  The  fam- 
ily history,  so  far  as  obtainable,  is  negative,  the  father  dying 
at  49  of  some  acute  disease ;  the  mother  is  living  and  healthy. 
The  five  brothers  and  sisters  are  healthy.  Patient  himself 
was  always  well,  with  the  exception  of  a  chancre  in  1881.  No 
secondary  symptoms.  He  has  been  married  five  years;  his 
wife  has  had  three  healthy  children  and  no  miscarriages. 

About  the  end  of  February,  1892,  spasms  set  in  in  the 
fingers  of  both  hands;  especially  affected  were  the  index  and 
middle  fingers.  The  spasm  was  limited  to  the  flexor  muscles 
of  the  fingers,  and  occurred  only  upon  active  movement,  never 
spontaneously,  llius,  so  long  as  he  kept  his  fingers  open, 
there  was  no  trouble,  but  as  soon  as  he  closed  his  fingers 
upon  any  object,  a  spasm  ensued  in  the  flexors,  w^hich  pre- 
vented him  from  releasing  the  object  grasped.  The  trouble 
gradually  increased  in  extent,  soon  also  involving  the  wrist. 

He  has  never  complained  of  pain.  He  comes  for  treat- 
ment because  the  trouble  incapacitates  him  for  work.  He  is 
able  to  do  all  the  work  which  can  be  done  with  extended  fin- 
gers, such  as  rolling  the  cigars  on  a  flat  surface,  but  when  it 
is  a  question  of  finishing  the  point  by  turning  with  his  fingers, 
he  cannot  let  go  of  the  cigar  on  account  of  the  flexor  spasm. 

Examination,  May  ist,  1892. — Muscular  system  not  ab- 
normally developed.  The  muscles  of  the  hands,  forearms  and 
shoulders  are,  however,  large  and  well  formed,  while  the  other 
muscles  of  the  body  are  more  flabby  and  smaller.  The  in- 
ternal organs  are  normal.  No  fever.  Urine  contains  neither 
sugar  nor  albumin.  Pupils  equal;  react  promptly.  Ocular 
movements  free;  facial  muscles  unaffected.  Tongue  shows  no 
deviation.    Smell,  taste,  hearing,  normal. 

Upon  intended  movement  the  muscles  of  the  hand,  when 
these  are  closed  forcibly,  enter  into  a  state  of  tonic  spasm,  so 
that  the  hand  cannot  be  opened  for  a  number  of  seconds. 
This  intention  spasm,  in  addition  to  the  flexors  of  the  hand 
and  fingers,  involves  the  adductors  and  abductors  of  the 
thumb  and  fingers,  so  that  when  the  fingers  are  forcibly  spread 
or  voluntarily  pressed  together,  they  remain  in  either  of  these 
positions  without  being  under  control  of  the  will. 

These  flexion  spasms  are  most  marked  in  the  thumbs  and 
4th  and  5th  fingers,  the  2d  and  3d  not  being  so  much  affected. 
The  adductors  and  abductors  of  the  thumbs  and  the  deltoids 
show^  the  following  disorder: 

Mechanical  Excitation. — Quick,  sharp  blows  by  means  of 
a  percussion  hammer  produce  marked  contraction  of  the  en- 
tire muscle  (except  in  the  deltoid,  where  only  fibrillar  con- 
traction is  produced).  This  contraction  is  slow  and  tonic  in  its 
formation  and  duration,  lasting  from  15  to  20  seconds.  The 
same  lasting  contractions  may  be  obtained  by  pressing  or  roll- 


i 


522  GEORGE  IV.  JACOBY. 

ing  the  muscles  under  any  hard  object.    The  mechanical  ex- 
citation of  the  nerves  is  unchanged. 

Electrical  excitation  with  the  faradic  current  showed,  with 
strong  currents,  slowness  and  tonicity  of  the  contraction,  with 
an  after-duration  of  15  to  20  seconds. 

•  With  the  galvanic  current  there  was  found  in  the  same 
muscles  an  increased  excitability,  they  reacting  to  very  small 
currents,  and  tonicity,  with  after-duration,  being  produced  by 
stronger  currents  (6  M.  A.).  The  first  tonic  contractions  were 
always  obtained  with  the  An.  C,  and  it  then  required  i  to  2 
M.  A.  more  current  to  obtain  a  tonic  Ka.  C.  C,  while  the  re- 
lationship of  the  normal  quick  contractions  obtained  with 
minimal  currents  remained  unchanged  (Ka.  C.  C.  >  Aa.  C.  C.) 

At  that  time  no  other  muscles  showed  any  changes  what- 
soever, functional,  mechanical  or  electrical. 

Three  weeks  later  the  biceps  of  each  arm  was  found  to 
present  the  same  subjective  and  objective  disorder  as  the  other 
muscles.  This  condition  lasted  unchanged  until  September, 
1892,  when  it  gradually  improved  functionally,  the  My.  R., 
however,  persisting  to  the  same  extent. 

In  December  patient  claimed  that  he  was  perfectly  well, 
and  had  been  working  at  his  trade  uninterruptedly  since  two 
weeks.  Examination  failed  to  show  any  functional  disturb- 
ances, and  the  muscles  reacted  normally  to  mechanical  and 
electrical  stimuli. 

If  we  thus  apply  the  term  myotonia  only  to  such  cases 
as  present  the  myotonic  motor  disorder  and  the  myotonic 
reaction,  and  relegate  all  other  spasms  coming  on  upon 
voluntary  movements  to  the  category  of  intention  spasms, 
our  classification  of  myotonia  congenita,  myotonia  acqui- 
sita  and  myotonia  transitoria  will  at  once  make  the  claes 
spoken  of  clear.  The  diagnosis  of  myotonia  can  present  no 
difficulty,  and  its  differentiation  from  tetany,  pseudo- 
hypertrophy, spastic  spinal  paralysis,  and  even  from  Eulen- 
burg's  paramyotonia,  need  hardly  be  dwelt  upon.  In  the 
latter  affection  not  only  are  the  specific  myotonic  reac- 
tions absent,  but  the  muscular  stiffness  occurs  only  under 
the  influence  of  cold,  and  not  in  consequence  of  muscular 
action. 

The  result  of  the  microscopical  examination  of  the 
muscle  from  Case  i  makes  a  reconsideration  of  the  pa- 
thogeny of  Thomsen's  disease  interesting. 


Three  theories  regarding  t 
psychopathic,  the  neuropath! 
each  found  adherents. 

Against  the  psychopathi< 
weight  of  cHnical  evidence,  w, 
viewed. 

The  myopathic  theory,  or 
great  deal  in  its  favor,  especis 
anatomical  findings.    These  ai 

1,  The  hypertrophy  and  r< 
fibres. 

2.  The  increase  of  sarcolen 

3.  The  diPfuseness,  indistin 
transverse  striation,  and, 

4,  The  minute  changes  wh 
sisting  in  a  massing  together  t 
a  correspondingly  coarse  appe 
muscle,  while  in  others  these  e 
iy  perceptible  and  widely  separ 

These  anatomical  findings 
upon  the  examination  of  pie( 
the  living  body.  The  only  ai 
described  by  Dejerine  and  So 
ing  satisfactory  proof  to  the  1 
purely  myopathic  nature  of 
every  one  else  as  being  useless  i 

Certainly  many  of  the  ch; 
port  may  be  due  to  serous  in: 
tissue  and  to  secondary  chanj 
chyma,  thereby  nutritionally  pi 
cerebrum  and  cerebellum  were 
that,  even  allowing  that  the 
not  due  to  serous  infiltration, 


'  This  patient  died  of  an  acme  n 
and,  aside  from  the  muscular  change 
serous  iiifiitration  of  the  entire  bo 
and  oedema  of  the  iungs. 


524  GEORGE  n\  JACOBY. 

mains  unproven.  This  autopsy,  therefore,  being  unavail- 
able as  proof  in  support  of  the  myopathic  nature  of  the 
disease,  we  are  again  confined  to  that  proof  which  may 
be  derived  from  pieces  of  muscle. 

The  value  of  this  proof  has  been  seriously  affected  by 
the  investigations  of  Oppenheim  and  Siemerling  concern- 
ing the  influence  of  excision  upon  pieces  of  muscle  taken 
from  the  living  body.  Text  books  on  histology,  and  dif- 
ferent articles  upon  various  topics,  give  the  measurements 
of  muscular  fibres  taken  from  the  corpse  as  varying  from 
20  to  70  microns.  The  average  fibre  thus  obtained  meas- 
ures 50  microns.  Oppenheim  and  Siemerling  found  the 
following  measurements  in  muscles  excised  during  life: 

1.  Nonnal  case;  average,  69  microns;  maximum,  106 
microns. 

2.  Normal  case;  average,  93  microns;  maximum,  121 
microns. 

3.  Hysteria;  average,  74  microns;  maximum,  146  mi- 
crons. 

4.  Hysteria;  average,  69-93  microns;  maximum,  140 
microns. 

5.  Traumatic  neurosis;  average,  93  microns;  maxi- 
mum, 140  microns. 

Inasmuch  as  the  irritation  due  to  excision  causes  con- 
siderable contraction  of  the  excised  pieces,  as  a  result  of 
which  the  primary  fibres  become  shortened  and  corre- 
spondingly broadened,  Oppenheim  and  Siemerling  ex- 
cised pieces  of  muscle  from  the  adductor  femoris  of  a  liv- 
ing rabbit  (a)  simply;  (b)  after  preliminary  fixation  upon  a 
staff,  so  that  they  could  not  contract;  (c)  stretched  upon 
a  staff.  The  fibres  of  class  a  were  all  round,  and  meas- 
ured from  46  to  99  microns  in  diameter;  those  of  class  b 
were  all  polygonal,  and  had  a  diameter  of  22  to  66  mi- 
crons, while  those  of  class  c  measured  from  9  to  33  mi- 
crons. In  addition  to  this  preponderance  of  size  and 
change  in  form  of  the  simply  excised  fibres,  they  also  re- 
vealed the  presence  of  a  greater  number  of  nuclei. 


ON  MVOTOXl.-l. 


525 


The  description  of  the  extended  and  non-extended 
bres  from  my  case,  therefore,  conclusively  proves  that 
hese  observations  may  be  directly  applied  to  the  human 
ody,  simply  recognizing  that  my  fibres  were  taken  from 
case  in  which  the  mechanical  contractility  of  the  muscles 
'as  very  much  augmented,  and,  therefore,  the  figures  ob- 
lined  must  be  higher  than  those  obtained  through  sim- 
ar  excision  of  normal  muscles. 

Finally,  we  must  draw  the  conclusion  that  the  mus- 
ular  changes  hitherto  considered  pathognomonic  of 
homsen's  disease  are  merely  the  result  of  mechanical  ex- 
itation  of  the  muscles,  and  simply  corroborate  the  clinical 
ict  of  their  hypercontractility. 

Admitting,however,the  fact  that  the  muscular  changes 
jund  appear  to  be  of  a  secondary  origin,  the  existence 
f  a  functional  disorder  which  allows  the  muscles  to  over- 
ct  in  consequence  of  excitation,  cannot  be  denied, 
^'hether  this  functional  disorder  lies  primarily  in  the  mus- 
Lilar  or  central  nervous  system  is  a  question  which  cannot 
et  beanswered. 

Interesting,  and,  perhaps,  casting  some  light  upon  the 
athogenesis  of  this  peculiar  affection,  is  its  occurrence 
1  the  case  of  W,  G.,  after  an  attack  of  typhoid  fever. 

We  know  that  many  of  the  gross  disorders  of  the 
ervous  system  are  of  post-infectious  nature,  thus  it  must 
e  to-day  acknowledged  that  multiple  sclerosis  is  in  very 
lany  instances  the  result  of  an  antecedent  acute  infection. 

That  severe  infectious  diseases,  as  typhoid  and  diph- 
heria,  through  the  toxines  .produced  by  their  microbes, 
eleteriously  influence  the  very  impressionable  nervous 
ystem  is  undoubted;  and  it  has  even  been  shown  by 
tabes  that  the  microbes  themselves  may  migrate  into  the 
pinal  cord  and  into  the  nerve  cells,  without  causing  any 
3cal  lesion. 

After  the  elimination  of  such  toxines  or  microbes,  the 
ntire  organism  apparently  again  returns  to  its  normal 
tate,  but  who  can  say  whether  cells  so  acted  upon  are 


526  GEORGE  \V.  JACOBV. 

not  functionally  altered.  Certainly  it  has  long  been  known 
that  the  nerve  cells  of  adults  who  have  passed  through 
many  sicknesses  are  not  entirely  normal,  and  the  changes 
found  have  been  fully  described  by  Babes;  changes  which 
in  healthy  small  children  are  never  found.  On  the  other 
hand,  the  nerve  cells  of  adults  often  show  no  such  changes. 
This  fact  can  only  be  explained  by  the  assumption  of  an 
inherent  weakness  in  the  nerve  cells  of  certain  individuals, 
while  those  of  others  possess  more  power  of  resistance. 

There  can  be  no  objection  to  the  statement  that  such 
an  inherent  weakness  may  occur  hereditarily  in  many 
members  of  a  family;  just  as  whole  families  show  an  hered- 
itary weakness  of  brain  cells,  and  become  neurasthenics. 
But  this  disposition  in  the  majority  of  cases  lies  dormant 
until  stirred  up  by  some  accidental  cause.  In  the  his- 
tories of  muscular  dystrophies  the  precedence  of  such  an 
accidental  cause  in  the  shape  of  an  attack  of  measles,  scar- 
let, typhoid  is  not  unusual,  and  it  is  not  improbable  that 
in  the  affection  under  consideration  such  a  productive 
cause  has  in  many  instances  also  been  at  work. 

It,  therefore,  seems  to  me  permissible  to  look  upon 
the  disease  as  due  to  an  embryonal  developmental  disorder 
of  the  nerve  cells,  consisting  in  the  more  or  less  diminished 
resistance  of  these  cells  to  the  influence  of  certain  toxic 
processes,  and  that  these  intoxications  then  are  in  such 
predisposed  individuals  the  direct  producers  of  the  disease. 

Certainly,  our  knowledge  of  the  pathogeny  of  this 
disease  must  remain  obscure  until  a  careful  cytological 
examination  of  both  the  brain  and  spinal  cord  has  been 
made. 

LITERATURE. 

Talma  S.:     Deutsche  Zeitschr,  fiir  Nervenheilkunde,  p.  210,  1892. 
Fiirstner:    Archiv  fiir  Psychiatrie,  vol.  xxviii.,  p.  600,  1895. 
Erb,  W.:    Deutsches  Archiv  f.  klin.  Med..  1889.  p.  529,  vol.  xlv. 
Susskand,  A.:    Zeitschr.  f.  klin.  Med.,  vol.  xxv..  1894,  PP-  91-122. 
Jacoby,  G.  W. :    Journal  of  Nervous  and  Mental  Dis.,  March,  1897. 
Dejerine.  J.,  and  Sottas,  J.:    Revue  de  Med.,  xv.,  3,  p.  241,  1895. 
Oppenheim  and  Siemerling:     Centralblatt  f.  d.  med.  Wissensch., 
xxvii..  39.  41,  i88q. 

Hochwarth,  L.  v.  F. :    Zeitschr.  f.  klin.  Med.,  1888.  p.  424. 
Martins  and  Hansemann:    Virchow's  Archiv,  1889.  p.  587. 


ON  MYOTONIA, 


527 


DISCUSSION. 

Dr.  Graeme  M.  Hammond  presented  three  children,  two 
girls  and  a  boy,  and  all  members  of  the  same  family,  as  ex- 
amples of  myotonia  congenita.  Two  other  children  in  the 
family  showed  no  evidence  of  this  disease,  and  were  apparent- 
ly normal  in  all  respects.  In  the  three  cases  shown  the  dis- 
ease did  not  manifest  itself  until  the  eighth  year  of  life;  pre- 
vious to  that  age,  the  children  appeared  to  be  like  others,  ex- 
cepting that  they  were  very  dull,  and  made  little  progress  at 
school;  for  example,  the  boy,  who  is  now  fourteen  years  of 
age,  cannot  spell  words  of  even  four  letters.  All  three  chil- 
dren had  a  peculiar  facial  expression;  they  looked  depressed, 
and  were  subject  to  violent  crying  spells  at  the  slightest  provo- 
cation. One  of  the  girls  had  had  chorea,  and  subsequently 
developed  the  myotonic  disorder.  The  family  history  was 
unimportant,  and  contained  no  other  instances  of  this  dis- 
ease. All  of  the  children  had  had  chills  and  fever,  and  one 
of  the  girls  still  has  these  attacks  occasionally. 

The  disease  in  the  three  cases  was  entirely  confined  to  the 
hands  arid  arms.  The  rigidity  of  the  muscles  was  great,  and 
the  reflexes  were  sluggish.  The  electrical  reactions  were  nor- 
mal, except  that  tonic  contractions  were  produced,  the  same 
as  if  the  muscles  had  been  struck.  No  muscular  hypertrophy 
was  noticed.  The  palms  were  well  developed,  -but  the  strength 
of  the  arms  and  hands  was  much  less  than  it  should  have 
been.  The  legs  were  not  at  all  involved,  but  the  knee-jerks 
in  all  three  of  the  cases  were  almost  entirely  absent.  The  pe- 
culiar facial  expression.  Dr.  Hammond  said,  was  not  due  to 
rigidity  of  the  facial  muscles.  No  difficulty  was  experienced 
in  moving  the  jaws,  and  no  spasm  of  the  ocular  muscles  ex- 
isted. The  hand  could  readily  grasp  an  object,  but  relaxed 
with  difficultv.  The  mental  deficiencv  in  these  cases  seemed 
to  indicate  some  degenerative  cerebral  change,  perhaps  in 
the  pyramidal  cells  of  the  cortex.  Three  cases  occurring  in 
one  family  also  pointed  to  some  congenital  influence. 

In  conclusion,  Dr.  Hammond  said  he  did  not  present  these 
as  typical  cases  of  Thomsen's  disease,  but  simply  as  cases  of 
myotonia  congenita. 

Dr.  Theodore  Diller  said  he  had  had  an  opportunity  to 
examine  the  first  patient  referred  to  in  Dr.  Jacoby's  paper, 
and  in  that  case  the  symptom  complex  was  even  more  strik- 
ing than  in  the  three  children  shown  by  Dr.  Hammond.  In 
addition  to  the  other  symptoms,  a  distinct  spasm  of  the  ex- 
trinsic ocular  muscles  was  produced  by  movement  of  the 
orbicularis  palpebrarum.  The  patient  could  close  his  eyes 
tightly,  but  could  open  them  onlv  slowly,  and  with  a  distinct 
effort.     All  the  reactions  which  Dr.  Jacoby  mentioned  were 


528  GEORGE    W.  J  A  COB  Y. 

present.  The  wave  of  contraction,  which  various  writers  have 
referred  to,  could  not  be  eHcited.  Dr.  Diller  said  the  case  did 
not  impress  him  as  being  of  psychical  origin. 

Dr.  J.  J.  Putnam  inquired  whether  there  was  an  abnormal 
shortening  of  the  muscular  belly,  as  occurs  in  muscular  dys- 
trophy. 

Dr.  Jacoby  replied  that  such  a  change  in  the  muscles  had 
not  been  observed. 

Dr.  W.  G.  Spiller  said  he  knew  of  two  or  three  cases  re- 
ported in  the  literature,  in  which  intention  spasm  w^as  pres- 
ent. Two  were  cases  of  syringomyelia,  and  the  third,  one 
of  brain  tumor.  He  had  been  permitted  to  examine  the  speci- 
mens in  the  onlv  case  of  Thomsen's  disease  in  which  a 
necropsy  had  been  obtained — that  of  Dejerine  and  Sottas. 
The  lesions  in  the  muscles  resembled  those  described  by  Dr. 
Jacoby.  The  speaker  said  that  from  our  present  knowledge 
of  the  histological  conditions,  myotonia  and  progressive  mus- 
cular dystrophy  present  histologically  many  features  in  com- 
mon. 

Erb  has  ventured  the  opinion  that  progressive  muscular 
dystrophy  may  be  due  to  functional  changes  in  the  cord.  If 
this  view  is  correct,  the  sp>eaker  thought  it  very  remarkable 
that  such  a  striking  clinical  picture  as  we  see  in  advanced 
cases  of  this  disease  should  result  from  changes  which  cannot 
be  detected  by  tHe  microscope.  If  Erb's  theor>'  regarding  the 
spinal  origin  of  progressive  muscular  dystrophy  is  correct, 
such  a  theory  may  be  equally  true  of  myotonia. 

Dr.  Jacoby,  in  closing,  said  that  under  the  classification 
of  myotonia  only  such  cases  should  be  included  which  present 
certain  definite  symptoms.  In  addition  to  the  myotonic  dis- 
order and  mvotonic  reaction,  there  should  be  an  absence  of 
anything  pointing  to  gross  disease  in  the  central  nervous  sys- 
tem. Cases  which  do  not  fulfil  these  requirements  should  not 
be  called  myotonia,  but  should  be  classed  under  their  proper 
designation,  or  designated  as  intention  spasms.  The  so-called 
myotonic  changes  in  the  muscles,  which  have  been  described 
by  various  writers,  and  regarded  as  pathognomonic  of  this  dis- 
ease, have  been  found,  by  recent  observation,  to  be  not  at  all 
pathognomonic:  the  changes  have  been  found  to  depend  on 
the  extensive  shortening  of  the  muscles,  due  to  the  method 
of  preparing  them  for  microscopic  examination.  In  the  case 
of  Dejerine  and  Sottas,  it  w^as  reported  that  nothing  was 
found  in  the  spinal  cord,  but  the  cerebrum  and  cerebellum 
were  not  examined.  The  change^  in  the  muscular  tissues 
could  be  accounted  for  bv  the  fact  that  these  tissues  were  much 
infiltrated  with  serous  fluid. 


A  CASE  OF  AMAUROTIC  FAMILY  IDIOCY  WITH 
AUTOPSY.' 

By  FREDERICK  PETERSON,  M.  D. 

This  case  was  brought  to  my  office  in  November,  1897. 
It  was  then  an  infant  three  months  old,  female,  child  of 
Russian  Hebrew  parents.  The  mother  ^vas  28  years  old 
at  the  time  of  its  birth,  and  had  had  five  children  and  one 
miscarriage.  Of  the  five  children,  the  first  was  seven  years 
old  and  normal,  the  second  five  and  one-half  years  old  (a 
blind  idiot  now  on  Randall's  Island),  the  third  a  normal 
child  of  four  years,  the  fourth  a  blind  idiot,  which  died  at 
the  age  of  ten  months,  and  the  fifth  is  the  case  of  amau- 
rotic idiocy  described  in  this  paper.  Thus  there  were  three 
cases  in  this  family.  In  the  second  child  the  blindness 
was  not  noted  until  the  age  of  six  months.  In  the  fourth 
and  fifth  cases  it  was  not  noted  until  the  infants  were  four 
weeks  old.  The  blindness,  however,  may  have  existed 
at  birth.  My  patient  was  sent  to  Randall's  Island  in  Janu- 
ary, 1898,  and  died  there,  March  i6th,  at  the  age  of  7 
months  and  20  days. 

The  following  history  is  from  notes  taken  by  myself 
and  my  internes  at  the  Randall's  Island  Hospital  for 
Idiots,  Drs.  Elizabeth  Sturgis  and  F.  O'Neil: 

L.  L.,  7  months,  20  days. 

Family  History.  —  Mother,  28  years,  German,  healthy. 
Father,  29  years,  Russian,  said  to  have  some  lung  trouble 
causing  dyspnoea  on  exertion,  but  which  is  not  consumption. 
Historj'  negative  on  both  sides  tor  syphilis,  tuberculosis,  in- 
sanity, epilepsy  or  nervous  disease,  as  far  as  was  known.  No 
relationship  exists  between  parents. 

Personal  History. — Born  at  term,  labor  normal;  nursed 
four  weeks  and  was  then  fed  on  milk  and  water,  equal  parts. 

'Read  before  the  American  Neurological  Association,  May  27'h, 


53<5  FREDERICK  PETERSON. 

Up  to  the  time  of  admission,  mother  declared  her  to  be  as 
bright  as  her  other  children,  laughing  and  playing  with  her 
hands,  but  crying  much  both  night  and  day.  Did  not  follow 
objects  with  her  eyes,  but  pressed  her  hands  into  her  eyes  to 
a  certain  extent. 

Examination  showed  a  well-nourished  baby,  plump  and 
of  good  muscular  development. 

Skin. — ^A  naevus  under  chin  and  pigmented  naevus  on  left 
thigh. 

Eyes. — Media  clear;  pupils  somewhat  dilated,  equally;  a 
rotatory  up  and  down  movement,  but  no  fine  tremor;  con- 
junctivae, good  color;  owing  to  extreme  restlessness  of  child, 
the  fundus  could  not  be  seen.  The  eyes  were  examined  by 
Dr.  Percy  Fridenberg. 

Lungs,  heart,  liver  and  spleen  normal. 

Reflexes  not  increased,  no  rigidity,  no  paralysis. 

Head. — Antero-posterior  circumference,  15 J  inches. 

Chest. — Circumference,  16^  inches. 

Length  (of  child). — 25J  inches. 

Child  doing  very  well,  but  losing  weight  until  Feb.  loth, 
then  exposed  to  measles.  Stools  became  green  and  watery; 
food  was  refused  or  vomited;  temperature  was  raised,  loi  to 
102  deg.  F. 

Feb.  14th,  coryza  and  disti'nct  eruption  seen  on  tonsils  and 
throat. 

Feb.  i6th:  Temperature,  104. 

Feb.  17th:  Sent  to  measles  ward:  no  distinct  rash  ever  seen 
on  body.  Gastrointestinal  symptoms  continued  while  in 
quarantine,  refused  food.  About  February  27th,  rigidity  of 
neck  and  knees,  some  twitchings  of  muscles.  Heart  and  lungs 
negative. 

March  9th,  returned  to  Infant's  Hospital.  Became  weaker, 
did  not  take  much  nouristhment,  and  just  before  death  she  de- 
veloped what  was  diagnosed  as  purpura. 

Unfortunately  the  autopsy  on  this  case  was  delayed  fully 
forty  hours,  so  that,  although  it  was  cold  weather,  and  the 
body  was  well  preserved,  the  examination  of  the  finer  nerve 
structures  was  to  some  extent  interfered  with.  The  autopsy 
was  performed  by  Dr.  D.  Hunter  McAlpin,  Jr.,  to  whose  g^cat 
courtesy  I  am  indebted  for  the  following  notes,  and  also  for 
the  brain,  spinal  cord  and  parts  of  other  organs  used  later  for 
microscopical  investigation. 

Autopsy. — Body  is  that  of  a  very  emaciated  child.  Post- 
mortem discoloration  present  over  abdomen  and  back.  There 
is  a  large  number  of  small  hemorrhage  spots  of  a  purplish 
color  in  the  skin  covering  the  abdomen.  There  is  a  dark 
brown  pigmented  spot  f  in.  in  length  by  ^  in.  in  width  on 
anterior  surface  lower  third  thigh,  evidently  a  birth  mark. 


^ 


AMAUROTIC  IDIOCY.  53I 

The  skull-cap  is  o£  usual  thickness. 

The  surface  of  the  brain  is  markedly  cedematous  and  is 
congested.  The  brain  weighs  22  ounces.  Placed  at  once  in 
4;f  solution  of  formalin  for  further  examination.  The  pia  ma- 
ter of  the  spinal  cord  is  congested..  The  cord  is  quite  firm 
throughout 

The  peritoneum  is  smooth  and  glistening.  The  intestines 
are  distended  with  gas.  The  vermiform  appendix  is  ij  inches 
in  length,  its  lumen  is  patent.  The  mesenteric  glands  are  not 
enlarged. 

The  pleura  covering  the  upper  and  middle  lobes  is  smooth; 
adherent  to  the  costal  and  diaphragmatic  surfaces  of  the 
pleura.    The  right  lung  is  also  adherent  to  the  diaphragm. 

The  pleura  over  the  anterior  mai^n  and  in  the  interlobar 
fissure  of  the  left  lung  is  opaque.  Apex  of  the  lung  shows  a 
lai^e  emphysematous  bleb.  On  section  the  upper  lobe  is  of 
a  pale  pink  color.  On  pressure  a  frothy  straw  colored  fluid 
exudes.  The  pleura  over  the  entire  lower  lobe  is  opaque  and 
lustreless.  Color  of  lower  lobe  is  dark,  mottled  with  few  light 
areas.  There  are  small  nodules  ielt  throughout  the  lower 
lobe.  On  section  nodules  are  found  firm,  elevated  and  finely 
granular.    On  pressure  a  small  amount  of  mucus  exudes. 

The  pleura  covering  the  upper  and  middle  lobes  is  smooth; 
but  over  the  lower  lobe,  posteriorly  and  inferiorly,  it  has  lost 
its  smooth  and  glistening  appearance. 

Upper  lobe  is  light  pink  in  color,  and  exudes  a  frothy  fluid. 
At  apex  a  mucopurulent  material  can  be  expressed  from  the 
bronchi.  In  the  lower  lobe  there  are  few  areas  of  consolida- 
tion similar  to  those  in  the  left  lung. 

The  pericardium  is  smooth  and  free  from  fluid. 

The  heart  is  of  usual  size.  The  right  auricle  and  ventricle 
contain  dark  clots.  Left  auricle  and  ventricle  are  empty. 
-Aortic  valve  normal.  Endocardium  pale  and  opaque.  Heart 
muscle,  firm.  Color,  pale  pink.  The  other  valves  are  normal. 
Right  cavities  dilated.  \>r>'  small  amount  of  subpericardial 
fat.  The  foramen  ovale  is  closed  by  a  membranous  curtain, 
which  is  not  adherent  to  the  septum  at  its  upper  portion,  so 
that  a  probe  can  be  passed  between  the  two  auricles. 

The  kidneys  are  pale  in  color.  The  capsules  strip  o.Pf  leav- 
ing smooth  surfaces.  The  cortical  portions  have  an  opaque 
appearance.    The  markings  are  coarse. 

The  liver  is  normal  in  size.  Borders  shelving.  Capsule 
smooth  On  section  liver  tissue  is  drj-.  Lobules  distinct. 
Other  zones  pale  gray  in  color,  blood  vessel  wall  slightly 
thickened.. 

Spleen  small.  Capsule  smooth.  On  section  dark  plum 
color.     Glomeruli  prominent.     Consistency  firm. 

Left  suprarenal,  pale  yellow  color.  Firm.  Small  cavity 
in  centre.    Right  suprarenal,  same. 


532  l-REDERICK  PETERSON- 

Pancreas,  negative. 

Stomach,  normal  size.  Contains  a  few  milk  curds  and 
dark  brownish  material.  Mncous  membrane,  thin,  pale. 
Ru^iE,  obliterated.  Intestines,  distended  with  gas.  Contain 
yellowish  tUiid  material. 

iwu  HiKi  a  nail  ifct  above  the  iliocaecal  valve  is  a  Meckel's 
diverticulum  measuring  J  inches  in  length.  It  arises  near  the 
mesentery  and  has  a  small  mesenteric  attachment  of  its  own. 

Mucous  membrane  of  small  intestine  apparently  normal. 
Large  intestine  contains  yellowish  material.  The  solitary-  fol- 
licles are  prominent. 

Bladder,  empty,  mucous  membrane  normal. 

l.'tcrus.  ovaries  and  l"allopian  tube;;  appear  normal. 


Brain  of  amaurulic  idiot.     E.tpnsnrc  of  insula;  hypertrophic  gyru^: 

.Ajiatomical  findings:  CEdenia  and  congestion  of  the  brain, 
bronchu-pucumonia, pleurisy,  acute  parenchymatous  nepliriiis. 

-Macroscopic  Examination  of  the  Brain. — Grossly  examined, 
this  brain  shows  simply  a  few  morphological  features  charac- 
teristic of  defective  development.  On  the  lateral  aspect  (Fig. 
I.)  we  observe  confluence  of  the  central  with  the  Sylvian  fis- 
sure, exposure  of  the  insula  and  one  or  two  atrophic  gyri.  On 
the  superior  surface  there  is  little  to  remark  upon  except  un- 
usual asymmetry  (Kig.  II.). 

Microscopical  Examination. — The  microscopical  investi' 
gation  was  carried  out  at  the  laboratory  of  the  College  of  Phy- 
sicians and  Surgecns  by  Dr.  James  Ewing  and  the  author, 
and  the  results  are  as  follows: 


AMAUROTIC  IDIOCY.  533 

The  conical  areas  about  tlie  calcarine  fissures  seem  to 
be  uniformly  deficient  in  cells,  and  in  some  segments  the 
ni'.mber  of  cells  appears  very  distinctly  reduced.  A  striking 
feature  of  this  portion  of  the  cortex  is  the  minute  size  of  tlie 
cells,  very  few  distinct  somatochromes  being  seen  except  in 
tlie  innermost  layer.  The  separation  of  the  cells  into  layers 
in  this  region  is  much  less  definite  than  is  normal.  The  cells 
arc  moderately  deficient  in  chromatic  substance.  There  ap- 
pears to  be  no  difference  in  the  structure  of  the  right  and  left 
side  in  this  region. 


Brain  of 

In  the  motor  areas  the  cells  are  markedly  deficient  in  num- 
ber, especially  in  the  second  and  third  layers,  irregular  in  size, 
uneven  in  distribution,  and  uniforniiy  deficient  in  chromatic 
substance.  The  abundance  of  large  nuclei  without  demon- 
strable cell  body  in  all  layers  of  this  and  other  regions  sug- 
gests either  deficient  development  or  permanent  atrophy. 

In  the  hypertrophic  lobule  described  in  the  left  motor 
cortex   the  cells  are  markedly  deficient  in  number. 

None  of  the  large  stichochromts  ordinarily  seen  in  the 
motor  cortex  were  anywhere  found,  but  in  some  segments 


534  FREDERICK  PETERSON. 

rather  large  cells,  forty  to  fifty  microns  in  diameter  were  pres- 
ent, of  nearly  homogeneous  appearance. 

Throughout  the  frontal  cortex,  less  distinctly  in  the  tem- 
I)oro-sphenoidal  lobe,  the  cells  showed  the  same  deficiency 
in  number,  and  irregularity  in  shape  and  distribution,  noted 
in  the  other  regions. 

Lumbar  Cord. — Nearly  all  of  the  cells  are  quite  normal. 
There  are  a  few  artificial  changes,  consisting  in  marked  shrink- 
age of  cell  bodies  and  rupture  of  processes.  Some  cells  show 
postmortem  clouding  of  cell  body  and  nucleus,  and  irregularity 
of  chromatic  masses.  A  very  few  cells  show  nearly  complete 
absence  of  chromatic  bodies. 

Cervical  Cord. — The  anterior  horn  cells  appear  normal. 
A  distinct  group  of  medium-sized  cells,  situated  in  the  poster- 
ior and  external  segment  of  the  anterior  horn  shows  typical 
axonal  degeneration.  Many  posterior  internal  cells  are  moder- 
ately deficient  in  chromatic  substance. 

Nucleus  XII. — The  cells  seem  deficient  in  number,  but 
show  no  distinct  pathological  alteration  of  the  chromatic  sub- 
stance. 

Nucleus  X. (Superficial)  and  Nucleus  Ambiguus. — ^Thecells 
show  moderate  but  uniform  diminution  in  size  of  the  chromatic 
bodies.  In  some  cells  the  chromatic  bodies  are  almost  entirely 
absent,  a  few  traces  remaining  at  the  periphery  of  the  cell  body 
only. 

The  limits  of  the  third  and  fourth  nuclei  are  indistinct. 
The  cells  of  this  region  are  deficient  in  number.  Many  appear 
shrunken.  None  of  them  contain  well-formed  chromatic  bodies, 
but  nucleus  and  cell  body  are  homogeneous,  diffusely  stained, 
and  contain  few  scattered  granules  of  chromatic  substance. 

The  olives  are  very  well  developed  and  cells  are  very  abund- 
ant.   The  cells  appear  normal. 

Purkinje's  cells  show  only  postmortem  changes. 

Corpora  Quadrigemina. — The  cells  of  this  region  are  very 
deficient  in  number,  usually  of  small  size,  ten  to  fifteen  microns 
in  diameter,  belonging  to  Nissl's  class  of  arkyochromes,  al- 
though a  few  appear  to  lack  distinct  cell  body,  being  classed 
therefore  as  karyochromes.  A  few  cells  also  measure  30  to 
35  microns  in  diameter.  There  are  no  distinct  evidences  of 
recent  chromatolysis  or  of  chronic  atrophy.  The  tissue  con- 
tains an  unusually  large  number  of  arterioles  and  capillaries. 
In  the  deeper  portion  of  the  posterior  corpus  quadrigeminum 
are  several  groups  of  tw^o  to  four  large  cells,  40  to  70  microns 
in  diameter,  circular  on  section,  and  closely  resembling  the 
cells  of  the  posterior  spinal  ganglia.  These  cells  contain  an 
abundance  of  circularly  arranged  chromophilic  bodies,  and 
some  of  them  show  moderate  central  chromatolvsis. 

Internal  Geniculate  Bodies. — These  nuclei  contain  a  mcder- 


P 


AMAUROTIC  IDIOCY. 


535 


ate  number  of  somatochrome  cells,  about  20  to  25  microns 
in  diameter,  and  rather  fewer  karyochromes,  both  uniformly 
distributed  throughout  the  tissue.  ITie  larger  cells  are  arkyo- 
chrome  in  type  and  do  not  show  any  recent  or  old  pathological 
changes. 

External  Geniculate  Bodies. — These  bodies  exhibit  seven 
distinct  layers  of  cells.  There  is  first  a  narrow,  superficial 
layer  of  small  karyochromes  with  distinct  cell  body.  The 
numbers  of  these  cells  vary  considerably  at  different  points. 
Beneath  them,  increasing  in  breadth,  as  one  descends  are  six, 
dividing  at  times  into  nine,  layers  of  larger  arkyochromes, 
30  to  40  microns  in  diameter,  and  among  which  are  also  a  few 
karyochromes. 

No  pathological  changes  could  be  detected  in  any  of  these 
cells,  other  than  deficiency  in  number.  The  arterioles  and  ca- 
pillaries of  this  region  are  very  numerous. 

Sympathetic  System. — In  some  of  the  sympathetic  ganglia, 
lying  on  the  aorta,  near  the  cceliac  axis,  the  cells  are  present 
in  normal  numbers  and  show  various  grades  of  central  chroma- 
tolysis. 

Nerve  Trunks  and  Fibre  Tracts. — For  the  study  of  fibres 
and  tracts,  sections  were  made  of  the  occipital  cortex  of  either 
side,  the  geniculate  bodies,  corpora  quadrigemina,  chiasm 
and  optic  nerves,  at  two  points  in  the  medulla,  and  in  the  cerv- 
ical and  lumbar  cord.  These  sections  were  stained  by  Van 
Gieson's,  Marchi's,  and  Pal's  methods,  but  owing  to  the  orig- 
inal fixative  used,  formalin,,  satisfactory  results  were  obtained 
only  from  the  first  of  these  methods.  In  sections  stained  by 
picro-acid  fuchsine,  no  distinct  abnormalities  were  seen  in  any 
region  of  the  central  nervous  system.  The  various  tracts  in 
the  cord  and  medulla  seemed  to  be  normal  in  development, 
and  the  axis  cylinders  and  myelin  sheaths  were  intact.  The 
optic  nerves  were  not  distinctly  deficient  in  size  or  number 
of  fibres.  The  optic  chiasm  and  radiations  were  apparently 
normal. 

It  seemed  probable,  on  comparison  with  sections  of  normal 
brains,  that  the  development  of  fibres  in  the  cerebral  con- 
volutions was  moderately  deficient,  especially  in  the  occipital 
region,  but  this  condition  was  far  less  evident  than  the  great 
deficiency  of  cells  noted  in  these  regions. 

On  comparison  of  the  various  sections  of  the  cortex  and 
cerebral  ganglia  in  the  present  case  with  sections  from  the 
same  region  in  normal  infants,  the  abnormalities  described 
became  strikingly  apparent.  In  the  normal  infant's  brain  the 
cells  are  arranged  in  very  distinct  vertical  columns,  as  well  as 
in  longitudinal  rows  which  in  sections  stained  by  methylene 
blue  are  plainly  visible  to  the  naked  eye.  In  the  present  case 
nearly  all  traces  of  the  vertical  columns  were  missing,  and  the 


:(    i,  I 


!•  1    r 


536  FREDERICK  PETERSON. 

separation  into  longitudinal  rows  was  very  indistinct.  More- 
over, the  cortical  cells  were  very  deficient  in  number  as  well 
as  in  size  and  content  of  chromatic  substance. 

These  changes  were  noted  throughout  the  cerebral  cortex, 
but  were  specially  evident  in  the  optic  centres  and  ganglia. 
In  the  absence  of  demonstrable  lesions  in  fibres  and  tracts,  these 
cellular  abnormalities,  together  with  the  increased  number  of 
blood  vessels  previously  noted, constitute  the  main  pathological 
features  of  the  case. 

X'iscera. — Sections  of  the  kidney,  liver,  spleen,  lung,  supra- 
renal and  pancreas,  failed  to  show  any  noteworthy  lesions 
other  than  an  advanced  fatty  infiltration  of  the  liver. 

Eyes. — ^The  two  eyes  were  removed  and  immediately  placed 
in  formalin.  One  was  given  to  Dr.  Carl  Koller  for  examin- 
ation, but  his  report  has  not  yet  been  made.  The  other  was 
given  to  Dr.  Ward  A.  Holden,  whose  report  is  as  follows : 

One  eye  was  received  in  formol  5  per  cent.  The  retina  was 
found  to  be  detached  at  the  macula,  a  postmortem  change, 
which  prevented  the  recognition  of  any  existing  gross  patho- 
logical conditions.  Sections  cut  in  paraffin  and  stained  by 
Nissl's  method  showed  advanced  postmortem  changes:  the 
vessels  contained  numbers  of  bacilli,  the  rods  and  cones  were 
destroyed,  the  ganglion  cells,  bipolar  cells,  and  nuclei  of  the 
rods  and  cones  were  vacuolated.  In  most  of  the  ganglion  cells 
the  vacuolation  had  been  so  excessive  that  the  cell  bodies  were 
more  or  less  completely  broken  down  so  that  nothing  can  be 
said  as  to  their  size  in  life.  The  nuclei  took  on  a  faint  diffuse 
stain,  and  the  nucleoli  were  well  marked.  Nissl  granules  were 
present.  An  attempt  to  stain  the  optic  nerve  by  Weigert's 
n^ethod  was  not  successful  after  the  formol  hardening.  Haema- 
toxylin-eosin  preparations  of  the  nerve  revealed  no  patholog- 
ical changes. 

From  this  unsatisfactory  examination  of  the  eyes  it  cannot 
be  said  that  pathological  changes  existed  in  life.  If  patholog- 
ical changes  in  the  ganglion  cells  existed,  however,  they  were 
not  in  an  advanced  stage. 

Conclusions:  The  brain  shows,  both  macroscopically 
and  microscopically,  a  condition  of  defective  development, 
and  this  corroborates  the  findings  in  the  several  autopsies 
made  in  these  cases  (with  the  single  exception  of  that  of 
Hirsch,  reported  at  this  meeting).  The  pathological  con- 
ditions are  limited,  as  far  as  the  fine  structures  are  con- 
cerned, to  the  nerve  cells  of  the  cortex  and  medulla,  which 
were  found  markedly  deficient  in  number  and  in  develop- 


i 


AMAUROTIC  IDIOCY. 


537 


ment  in  the  occipital  region  about  the  calcarine  fissure, 
in  the  temporo-sphenoidal  lobes,  in  the  frontal  lobes,  in 
the  motor  areas,  in  the  corpora  quadrigemina  and  genicu- 
late bodies,  and  in  the  third  and  fourth  cranial  nuclei. 
Postmortem  changes  did  not  aflfect  the  importance  of 
these  findings.  As  regards,  however,  the  alteration  of  the 
chromatic  substance  of  the  cell,  this  must  be  referred 
largely  to  the  general  condition  of  the  patient  before 
death,  and  not  to  the  disease  under  discussion.  No  defi- 
nite changes  in  the  fibres  or  imperfect  developments  o£ 
the  tracts  were  discovered. 


165.  SuR  i,A  VALHUR  cuNiQUE  DE  PYRAMiDON     (The  Clinical  Value 
of  Pyramidon).     R.  Lepine  (Lyon  Medical,  85,  1897,  p.  215). 

This  new  claimant  for  antipyretic  and  analgesic  honors  is  a  de- 
rivative of  antipyrine,  and  is  said  to  be  three  times  as  effective  and 
four  times  as  poisonous  as  this  drug. 

The  above  author  has  employed  it  in  twenty  cases  of  various 
nervous  ailments,  and  to  the  extent  of  his  experience  has  nothing 
but  praise  for  the  new  remedy.  He  has  found  it  very  efficacious  in 
stilling  pain,  and  has  seen  no  ill  effects  of  any  kind  from  amounts 
up  to  45  grains  a  day,  the  usual  dose  being  four  grains,  three  to  five 
limes  daily.  A  case  of  tabes  is  instanced  for  the  lightning  pains  of 
which  the  usual  analgesics  afforded  no  relief,  even  morphine  in  con- 
siderable doses  being  without  effect,  but  in  which  10  to  12  grains  of 
pyramidon  three  or  four  times  daily  made  the  patient  entirely  com- 
fortable for  several  weeks,  at  the  end  of  which  time  the  paroxysms; 
of  pain  ceased.  In  all  the  other  cases  but  one  the  drug  relieved  the; 
pain  from  which  the  patients  suffered,  and  this  exception  was  an 
extremely  bad  case  of  neurasthenia  with  generalized  pain  that  had  re- 
sisted all  other  modes  of  treatment.  In  most  of  the  patients  the 
author  compared  the  results  obtained  from  pyramidon  and  15  gr. 
doses  of  antipyrine,  and  without  exception  the  former  remedy  was 
preferred. 

He  has  also  used  the  drug  as  an  antipyretic  in  typhoid  fever  with 
excellent  results,  but  considers  that  his  experience  is  as  yet  too  limited 
to  draw  positive  conclusions.  He  feels  sure,  however,  that  the  remedy- 
is  of  real  value  and  merits  an  extended  trial.  Patrick. 


THE  PATHOLOGICAL  ANATOMY  OF  "A  FATAL 
DISEASE  OF  INFANCY,  WITH  SYMMETRICAL 
CHANGES  IN  THE  REGION  OF  THE  YELLOW 
SPOT"  (WARREN  TAY),  "AMAUROTIC  FAM- 
ILY IDIOCY"  (SACHS),  'INFANTILE  CERE- 
BRAL DEGENERATION"  (KINGDON  AND 
RUSSELL).! 

By  WILLIAM  HIRSCH,  M.  D. 

The  first  case  of  this  peciiHar  disease  has  beendescribed 
in  the  year  1881  by  Waren  Tay,  under  the  name  of  *'  Sym- 
metrical Changes  in  the  Region  of  the  Yellow  Spot  in 
Each  Eye  of  an  Infant."  Since  that  time  a  number  of 
other  cases  have  been  brought  to  light  by  different  ob- 
servers, so  that  the  total  list  up  to  to-day  amounts  to  26 
cases,  including  my  own.  For  quite  a  number  of  years 
after  Tay's  first  publication,  various  observers  paid  almost 
exclusive  attention  to  one  particular  symptom  of  the 
disease — that  is,  to  the  peculiar  ophthalmoscopical  con- 
dition. Only  after  some  time  was  it  realized  that  we  had 
to  deal,  not  with  a  localized  affection  of  the  eye,  but  with 
a  more  extensive  disease  of  the  central  nervous  system. 
The  credit  for  having  first  called  the.  neurologists'  atten- 
tion to  this  peculiar  affection  belongs  to  B.  Sachs.  The 
clinical  symptoms  have  ever  since  been  so  accurately  de- 
scribed that  nothing  new  can  be  added  in  this  respect  for 
the  present.  The  main  features  of  the  disease,  which  are 
almost  absolutely  uniform  in  all  cases,  are  the  following: 

The  parents  of  these  children  are  strong  and  healthy, 
and  give  no  history  of  syphilis  or  tuberculosis.  They  all 
belong  to  the  same  race;    they  are,  with  few  exceptions. 

^  The  figures  accompanying  this  paper  are  photographs  from  dia- 
grams made  for  a  demonstration  at  the  twenty-fourth  annual  meeting 
of  the  American  Neurological  Association,  on  which  occasion  this 
paper  was  read. 


FATAL  DISEASE  OF  INFANCY. 


539 


eastern  Jews.  There  are  always  several  children  of  the 
same  mother  affected.     In  some  cases  there  are  healthy 

children  between  the  affected  ones;  in  others,  all  the  chil- 
dren in  the  family  are  affected  in  the  same  way.  The  sex 
seems  not  to  have  any  influence  on  the  disease.  The  chil- 
dren are  born  apparently  in  good  health  and  develop  nor- 
mally up  to  the  third  or  fifth  month  of  age.  Between 
the  third  and  eighth  month  the  muscles  begin  to  become 
flabby  and  weak.  The  child  is  no  longer  able  to  sit  up  or 
to  hold  up  its  head.  The  reflexes  remain  present,  as  a 
rule.  In  some  cases  the  extremities  become  rigid  and 
contracted;  mental  development  is  arrested;  the  children 
become  dull  and  apathetic;  the  eyesight  gradually  dimin- 
ishes to  complete  blindness.  In  most  cases  there  is  a 
marked  hyperacuity,  and  some  children  are  hypersensitive 
to  touch.  The  most  characteristic  symptom,  which,  in 
fact,  gave  rise  to  the  discovery  of  the  disease,  is  the 
peculiar  changes  on  the  retina.  The  assumption  of  some 
observ^ers,  that  these  changes  are  congenital,  is  apparently 
erroneous.  When  the  peculiar  ophthalmoscopical  picture 
has  developed,  we  find  in  the  region  of  the  yellow  spot  a 
whitish  opacity,  the  centre  of  which  shows  a  cherry-red 
spot.  The  discs  appear  at  first  normal,  but  undergo 
atrophy  later  on.  The  following  is  the  history  of  my  own 
case: 


L.  P.,  son  of  healthy  parents  of  the  eastern  Jewish  race, 
was  brought  to  my  clinic  in  July,  1896.  The  child,  which 
was  then  ten  months  old,  had  developed  well  until  the  age  of 
six  months,  when  it  began  to  be  weak  in  the  back,  so  that  it 
lost  the  ability  to  sit  up.  The  mother  stated  that  she  had  lost 
two  other  children  at  the  age  of  eighteen  and  twenty  months, 
respectively,  which  apparently  presented  the  same  condition 
as  the  patient.  The  muscles  of  the  whole  body  were  very 
flabby,  and  the  child  was  unable  to  hold  up  its  head  or  to  sit 
without  support.  It  had  normal  perception  of  light,  and  there 
was  marked  hyperacuity — a  symptom  which  the  mother  had 
also  observed  in  the  two  other  children.  The  reflexes  were 
present;  sensation  was  normal;  the  internal  organs  were  also 
in  a  normal  condition.     The  ophthalmoscopical  examination 


m 


\n 

^1 


540  WILLIAM  HIRSCH. 

revealed  the  typical  picture  described  above.  The  child  con- 
tinued to  become  gradually  weaker,  until  it  died,  on  the  27th 
of  July,  1897,  twenty-two  months  old.  An  autopsy  was  made 
four  hours  after  death. 

So  far  five  autopsies  have  been  performed — two  by 
Sachs  and  three  by  Kingdon  and  Russell.  In  the  first 
case  of  Sachs,  only  the  cortex  of  the  brain  was  examined; 
in  the  second  case,  sections  were  made  through  all  parts 
of  the  cortex,  of  the  ganglia,  of  the  optic  chiasm,  of  the 
pons,  the  medulla  and  the  cervical  cord.  The  result  of  the 
examination  of  these  two  cases  was  alike.There  was  an  equal 
change  of  the  pyramidal  cells  throughout  the  whole  cortex  of 
the  brain.  The  contours  of  the  cells  were  rounded,  and  the 
cells  exhibited  every  possible  change  of  their  protoplas- 
modic  substance.  In  the  neuroglia  there  were  no  evident 
changes,  nor  was  there  any  distinct  sclerosis  in  any  part 
of  the  brain.  The  blood  vessels  were  found  perfectly  nor- 
mal in  every  respect.  The  spinal  cord,  it  was  said,  con- 
tained no  changes  in  the  gray  matter,  but  exhibited  a  de- 
generation of  the  lateral  areas,  including  the  pyramidal 
tracts,  and  extending  to  the  periphery.  From  these  find- 
ings the  conclusion  was  drawn  that  the  disease  was  con- 
fined to  the  cells  of  the  cortex  of  the  brain,  and  consisted 
of  an  arrested  development  of  this  organ. 

Quite  in  accordance  with  this  view  was  the  result  of 
the  three  autopsies  of  Kingdon  and  Russell.  They  found 
the  same  changes  in  the  pyramidal  cells  of  the  cortex,  and 
state  expressively  that  the  basal  ganglia,  the  cerebellum, 
the  cells  of  the  posterior  column  nuclei,  and  the  gray  mat- 
ter of  the  spinal  cord  exhibited  no  changes  whatsoever. 
In  the  lateral  tracts  they  found  the  same  degeneration 
which  had  been  described  by  Sachs. 

On  the  strength  of  these  findings  these  authors  also 
were  led  to  believe  that  the  disease  was  limited  to  the  cor- 
tex of  the  cerebrum.  They  did  not,  however,  agree  with 
Sachs  in  the  assumption  of  an  arrested  development,  but 
considered  the  condition  a  degenerative  process.  The 
nature  of  this  process  w^as  left  an  open  question. 


FATAL  DISEASE  OF  INFANCY. 


541 


In  accordance  with  their  respective  views,  Sachs  pub- 
lished his  first  cases  under  the  title  of  "Arrested  Cerebral 
Development"  and  "Agenesis  Corticalis,"  while  Kingdon 
and  Russell  called  the  disease  "Infantile  Cerebral  Degen- 
eration." Recognizing  the  insufficient  anatomical  base 
on  which  the  disease  stood  at  that  time,  Sachs  preferred 
a  clinical  designation,  and  proposed  the  name  of  "Amau- 
rotic Family  Idiocy." 

I  will  now  refer  to  the  result  of  the  post-mortem  ex- 
amination of  my  own  case,  which  I  hope  will  throw  some 
light  on  the  different  questions: 

As  stated  before,  the  autopsy  was  made  four  hours  after 
death.  The  skull  was  thick  and  symmetrical,  and  both  fon- 
tanelles  were  closed.  The  dura  was  adherent  to  the  skull. 
The  pia  could  easily  be  removed  from  the  brain.  The  micro- 
scopical inspection  of  the  brain  showed  no  abnormal  condi- 
tions. There  was  no  oedema  of  the  convexity,  and  no  increase 
of  fluid  in  the  lateral  ventricles.  There  were  no  abnormalities 
of  fissuration,  except  an  unusual  prolongation  of  the  second 
temporal  fissure.  The  entire  brain,  with  the  medulla  oblon- 
gata and  the  spinal  cord,  was  put  immediately  after  the  re- 
moval in  a  10  per  cent,  formaline  solution.  Both  the  eyes 
were  removed,  and  one  put  in  formaline  and  the  other  in 
Miiller's  fluid.  After  the  hardening  process  the  whole  cen- 
tral nervous  system  was  cut  into  small  pieces  and  imbedded  in 
parafline.  Serial  sections,  var^^ing  in  thickness  from  one  to 
four  microns,  were  made  through  the  whole  spinal  cord,  the 
medulla  oblongata,  corpora  quadrigeniina,  optic  thalamus, 
nucleus  caudatus,  chiasm,  optic  nerves,  and  through  the  entire 
cortex  of  the  cerebrum  and  cerebellum.  The  sections  were 
stained  with  various  aniline  dyes,  as  methylene  blue,  eosin, 
thionin,  nigrosin,  fuchsin  and  with  different  kinds  of  haema- 
toxylin. 

For  practical  reasons  I  will  begin  the  description  of  the 
different  sections  with  that  of  the  spinal  cord.  I  found  the 
same  degeneration  of  the  pyramidal  tracts  which  had  been 
described  by  the  other  observers.  But,  in  addition  to  this, 
there  are  very  pronounced  changes  throughout  the  entire  gray 
matter  of  the  cord.  All  the  nerve  cells  of  the  anterior,  as  well 
as  of  the  posterior,  horns  are  enormously  enlarged.  They 
appear  blown  up  and  round  in  shape.  The  nucleus  is  well 
defined,  and  invariably  moved  toward  the  periphery  of  the 
cell  body.     It  contains  a  nucleolus  which  is  stained  dark  and 


542  WILLIAM  HtRSCH. 

has  a  sharp  outline.  The  cell  body  is  surrounded  by  a  mem- 
brane. On  account  of  the  enormous  enlargement,  the  cells 
appear  much  more  numerous  than  normally,  so  that  some 
parts  of  the  gray  matter  seem  to  consist  almost  exclusively  of 
cells.  The  most  peculiar  aspect  is' offered  by  the  motor  cells 
of  the  anterior  horns.  (Fig.  I.)  They  are  more  than  twice 
their  normal  size.  Many  of  them  appear  as  round  masses, 
without  any  nucleus.  This,  however,  can  be  shown  by  serial 
sections  to  be  due  to  the  direction  of  the  cut  through  the  eel!. 
In  fact,  all  the  motor  cells  contain  a  nucleus  and  nucleolus. 
Some  of  the  cell  bodies  are  vacuolated,  the  vacuoles  being 
lined  with  a  membrane.  The  processes  of  the  cells,  the  den- 
drites, as  well  as  the  axis  cylinder,  seem  to  be  very  few.  and 
often  they  appear  to  be  broken  off  the  cell.      In  most   in- 


liorn   of  the  cervical   part  c 


stances  the  cells  are  immediately  surrounded  by  connective 
tissue,  the  pericellular  space  being  small  or  missing  altogether. 
The  nucleus,  which  is  invariably  situated  near  the  periphery 
of  the  cell  body,  is  surrounded  by  a  dark  zone,  which  gradually 
shades  ofT  into  a  more  or  less  colorless  area.  When  we  come 
to  study  the  minute  structure  of  these  cells  with  a  high  power, 
we  find  that  the  Xissl  bodies  have  disappeared  entirely.  The 
dark  zone  around  the  nucleus  ccrsists  of  a  granular  mass, 
which  is  probably  formed  by  broktn-up  Nissl  bodies,  which 
appear  to  be  in  a  condition  of  pulverization.  The  light  area 
of  the  cell  body  is  made  up  of  a  very  fine  network.  In  a  very 
few  instances  the  dark  zone  around  the  nucleus  contains  a  few 
normal  chromatic  bodies. 


FATAL  DISBASE  OF  INFAS'CY. 


The  cells  of  the  posterior  horns  (Fig.  II.)  are  also  changed 
in  the  same  manner.    They,  too,  through  their  enormous  en- 


FiG,  n. 

Cross-section  through  the  posterior  horn  of  the  cervical  part  of 
the  spinal  corU. 

largement,  appear  very  numerous,  and  wherever  the  section 
has  occurred,  above  or  below  the  nucleus,  the  cell  looks  Hke 
a  big,  round  mass,  without  any  definite  structure.  As  we  ap- 
proach the  medulla  oblongata,  we  find  the  same  changes  in 


Cross-section  throiigh  the  motor  imclens  of  the  trieeminal  nerve. 

all  the  nerve  cells;  not  only  all  the  nuclei  of  the  cranial  nerves, 
from  the  hypoglossus  to  the  oculomotorius,  but  also  the  cells 
of  the  reticulum,  the  olivary  bodies,  the  pons,  are  all  changed 


544 


WILLIAM  HIRSCH. 


in  the  same  typical  manner.  According  to  the  conditions  of 
their  natural  shape,  they  appear  also  different  in  their  morbid 
condition.  The  cells  of  the  olivary  bodies  are  round  in  shape, 
showing  a  sharply  defined  nucleus  and  nucleolus.  The  cells 
of  the  reticulum  and  the  pons  appear  as  oval-shaped  bodies, 
and,  owing  to  the  fact  that  the  nucleus  is  pushed  to  the  peri- 
phery of  the  cell  body,  a  great  many  cells  are  cut  so  that  the 
nucleus  does  not  appear  in  the  section. 

There  are  some  groups  of  cells  which  seem  to  have  under- 
gone still  further  changes  of  decomposition.  Such  groups  are 
principally  found  among  the  nuclei  of  the  cranial  nerves.  The 
motor  nucleus  of  the  trigeminal  nerve,  for  instance,  contains 
cells  which  exhibit  this  condition.  (Fig.  III.)  The  nucleus 
has  lost  its  sharp  outline,  and  the  nucleolus  can  hardly  be 


Fig.  IV. 
Cross-section  tlirougli  the  nucleus  ambiguus. 

recognized  at  all.  Tlie  cell  bod\'  is  filled  by  irregular  masses — 
apparently  detritus  of  the  normal  protoplasm.  Such  masses 
of  detritus  are  especially  accumulated  at  the  periphery  of  the 
cell  body,  and  also  in  the  pericellular  lymph  space.  Cells  of 
other  groups,  as,  for  instance,  in  the  nucleus  ambiguus,  are 
remarkable  for  their  peculiar  elongated  shape.  (Fig.  Iv.)  The 
dark  zone  around  the  nucleus  shows  distinct  traces  of  the  Nissi 
bodies,  and  the  rest  of  the  eel!  body,  as  in  the  cells  of  the 
anterior  horns,  is  made  up  of  a  fine  network.  The  nucleus 
appears  as  a  homogeneous  body,  and  the  darkly  stained  nu- 
cleolus contains  a  light  spot  in  its  centre.  The  cells  of  the  sub- 
cortical ganglia,  the  optic  thalamus,  the  nucleus  caudatus  and 
the  corpora  quadrigemina  exhibit  exactly  the  same  condition 
as  the  other  cells.    The  cells  of  the  substantia  nigra  show  the 


FATAL  DISEASE  OF  INFANCY. 


545 


pigment  very  plainly,  and  otherwise  exhibit  the  same  changes 
of  the  nucleus  and  cell  body. 

The  cortex  itself,  which  was  examined  throughout  the 
entire  brain,  shows  the  same  typical  changes  all  over.  (Fig.  V.) 
The  different  layers  of  the  pyramidal  cells  can  still  be  well 
differentiated;  the  cells  themselves,  however,  are  changed  in 
the  same  typical  manner.  They  are  all  considerably  swollen, 
so  that  at  some  regions  hardly  anything  but  cells  is  to  be  seen. 
The  nucleus  is  displaced  to  the  periphery  of  the  cell  body,  and 
in  some  instances  projects  considerably  beyond  the  surface. 
The  cells  are  nearly  all  of  oval  shape,  and  there  is  not  a  single 
cell  in  all  the  specimens  which  has  retained  its  pyramidal  char- 
acter. 

Comparatively  small  changes  are  found  in  the  cerebellum. 


Cross  section  through  the  cortex  o(  the  first  frontal  convolution. 

The  granular  area  shows  no  abnormal  condition  at  all,  while 
the  Piu^kinje  cells  appear  to  be  affected  in  some  way,  showing 
a  much  less  distinct  structure  than  under  normal  conditions, 
without,  however,  exhibiting  the  enlargement  of  the  circum- 
ference of  the  cell  body  that  was  observed  in  all  the  other 
nerve  cells  of  the  nervous  system. 

The  cross  sections  through  the  optic  tract  and  the  chiasm 
showed  complete  degeneration.  The  cauda  equina  was  found 
to  be  perfectly  normal,  and  so  were  all  the  roots  of  the  spinal 
cord. 

The  eyes  have  been  kindly  examined  by  Dr.  Holden,  whose 
detailed  report  follows  this  paper. 

The  ganglion  cells  of  the  vesicular  layer  of  the  retina  have 
been  found  in  the  same  swollen  condition  as  the  cells  of  the 


546  IVILLIAM  HIRSCH. 

central  nervous  system,  and  it  is  due  to  this  condition  of  the 
cells  that  we  find  the  peculiar  ophthalmoscopical  picture  in 
this  disease.  As  is  well  known,  the  only  part  of  the  retina 
in  which  the  vesicular  layer  consists  erf  more  than  one  single 
layer  of  ganglion  cells  is  the  macula  lutea.  Here  we  have 
an  accumulation  of  from  six  to  seven  layers  of  cells,  and  it  is 
easily  understood  that  when  these  cells  become  enormously  en- 
larged, and  their  bodies  offer  an  opaque  character  during  life, 
they  will  produce  the  peculiar  whitish  opacity  in  the  region 
of  the  macula. 

So,  then,  we  have  an  equal  affection  of  all  the  nerve 
cells  of  the  entire  nervous  system,  the  main  features  of 
which  are  a  condition  of  chromatolysis  and  other  degen- 
erative processes  of  the  protoplasm,  combined  with  con- 
siderable swelling  of  the  cell  body  and  displacement  of 
the  nucleus  toward  the  periphery  of  the  cell.  The  neu- 
roglia has  been  found  to  be  perfectly  normal,  and  no  af- 
fection of  the  blood  vessels  could  be  noticed  through  the 
entire  system. 

There  seems  to  be  a  discrepancy  between  these  find- 
ings and  those  of  the  previous  observers,  the  latter  claim- 
ing only  an  affection  of  the  cerebral  cortex.  This,  how- 
ever, seems  to  be  due  to  the  differences  of  the  hardening 
process.  Sachs,  as  well  as  Kingdon  and  Russell,  has 
hardened  the  brain  and  cord  in  Miiller's  fluid,  which  does 
not  permit  of  the  study  of  the  minute  structure  of  the 
cells.  Especially,  changes  in  the  smaller  cells,  as  those 
of  the  posterior  horns  of  the  cord  and  the  medulla  ob- 
longata, cannot  be  recognized  in  specimens  hardened  in 
Miiller's  fluid.  That,  in  fact,  Sachs'  second  case — in  his 
first  case  only  the  cortex  had  been  examined — offered  the 
same  change  of  the  motor  cells  in  the  anterior  horns  of  the 
cord  as  in  my  case,  can  easily  be  recognized  from  his  speci- 
mens even  to-day.  Dr.  Sachs  was  kind  enough  to  put 
some  of  his  specimens  at  my  disposal,  and  when  we  came 
to  compare  them  with  my  own,  it  was  evident  that  we 
had  to  deal  with  perfectly  analogous  conditions.  Al- 
though the  Miiller's  fluid  specimens  do  not  show  the  pe- 


FATAL  DISEASE  OF  INFANCY. 


547 


culiar  structure  of  the  cells,  they  show,  however,  sufficient- 
ly well  the  enlargement  of  the  circumference  of  their 
bodies  in  the  anterior  and  posterior  horns,  which  could 
easily  be  overlooked,  since  changes  in  the  structure  of  the 
cells  necessarily  escape  observation.  Inasmuch  as  the  posi- 
tive findings  of  Kingdon  and  Russell,  whose  cases  were 
also  hardened  in  Miiller's  fluid,  are  in  perfect  harmr^ny 
with  those  of  Sachs  and  myself,  I  do  not  hesitate  to  as- 
sume that  their  negative  statement  also  could  be  modified 
in  the  same  way  as  Sachs',  and  that  the  morbid  changes 
in  their  cases,  too,  were  not  confined  merely  to  the  cortex 
of  the  brain. 

So,  it  seems,  then,  to  be  an  established  fact  that  we 
have  to  deal  not,  as  it  was  supposed,  with  an  isolated  cor- 
tical lesion,  but  with  an  aflfection  of  the  entire  nervous 
system.  The  next  question  to  be  decided  would  be:  Of 
what  nature  is  this  affection?  Have  we  to  deal,  as  Sachs 
claims,  with  an  arrested  development,  or,  as  Kingdon  and 
Russell  maintain,  with  a  degenerative  process — that  is,  an 
acquired  disease? 

Against  the  theory  of  an  arrest  of  development  stand 
both  the  clinical  and  anatomical  facts.  It  is  generally 
stated  that  these  children  are  born  in  good  health  and 
well  developed.  In  my  own  case  the  intelligent  mother, 
who  had  previously  lost  two  children  of  the  same  disease, 
watched  the  baby  with  the  greatest  anxiety,  and  still 
could  not  detect  any  morbid  sign  before  the  age  of  six 
months.  Of  great  importance  for  the  proper  judgment 
of  the  nature  of  the  disease  is  the  fact  that  the  peculiar 
ophthalmoscopical  picture  develops  only  comparatively 
late,  sometimes  long  after  the  other  symptoms  have  made 
their  appearance.  Since  we  know  now  that  the  peculiar 
condition  of  the  macula  lutea  is  due  to  a  certain  change 
of  the  ganglion  cell  layer,  we  are  justified  in  assuming 
that  the  cells  have  been  normal  before  the  appearance 
of  this  peculiar  picture.  Besides  this,  there  is  no  analogue 
in  the  whole  embryology  to  this  special  affection  of  the 


11 


548  WILLIAM  HIRSCH. 

nerve  cells,  nor  could  any  arrest  of  development  account 
for  an  affection  of  all  the  nerve  cells,  and  nothing  but  the 
nerve  cells,  of  the  entire  system. 

If,  then,  we  have  to  deal  with  an  acquired  disease,  of 
what  nature  and  of  what  origin  could  such  disease  be? 
The  total  absence  of  any  affection  of  the  blood  vessels,  as 
it  could  be  stated  in  my  case,  as  well  as  in  the  other  cases, 
justifies  us  in  excluding  any  inflammatory  process.  Pri- 
mary idiopathic  diseases  of  the  nerve  cells  occur  only  as 
systemic  diseases;  but  no  disease  is  known  in  which  simul- 
taneously all  the  nerve  cells  of  the  entire  system  become 
diseased.  Besides,  in  systemic  diseases  the  anatomical 
picture  of  the  cells  is  quite  different  from  what  we  have 
found  here.  There  we  have  the  typical  picture  of  atrophy 
of  the  cell,  while  here  we  have  an  anatomical  condition 
which  does  not  correspond  to  any  of  the  idiopathic  cell 
affections  at  all. 

The  only  theory,  then,  which  is  left,  and  which  in  fact 
corresponds  in  every  respect  to  the  clinical  and  anatomical 
aspect  of  these  cases,  is  to  assume  a  toxic  condition;  to 
assume  the  action  of  a  poison  on  the  nerve  cells.  That 
poisons  are  really  apt  to  act  that  way  is  a  well-established 
fact.  The  anatomical  picture  of  these  cells  also  corre- 
sponds in  every  respect  to  those  found  after  experimental 
poisoning.  The  chromatolysis,  the  swelling  of  the  body, 
the  displacement  of  the  nucleus,  the  destruction  and 
breaking  off  of  the  dendrites  and  the  axis  cylinder;  all 
these  are  well  known  features  of  poisoning,  and,  in  point 
of  fact,  symptoms  unknown  in  any  other  condition.  We 
have  to  distinguish  between  two  different  ways  in  which 
a  poison  might  affect  the  nerve  cells.  It  might  either  act 
directly  on  the  cells,  or  it  might  produce  a  disturbance  in 
the  nutrition,  and  so,  by  changing  their  metabolism,  cause 
a  degeneration  of  the  protoplasm.  The  total  absence  of 
any  morbid  changes  in  the  blood  vessels  or  in  the  neurog- 
lia, the  fact  that  the  pathological  changes  are  confined 
to  the  nerve  cells  exclusively,  lead  me  to  believe  that  the 


FATAL  DISEASE  OF  INFANCY. 


549 


virus,  whatever  it  may  be,  exerts  a  direct  action  on  these 
cells,  an  assumption  which  I  think  finds  further  support 
in  the  anatomical  appearance  of  the  cells  themselves. 

The  next  question,  then,  would  be:  Of  what  nature  is 
this  poison,  and  where  does  it  come  from?    This  question 
cannot  be  answered  yet  with  any  amount  of  certainty. 
It  would,  of  course,  seem  very  tempting  to  assume  a  toxic 
condition  of  the  mother's  milk,  as  this  would  also  easily 
explain  the  family  type  of  the  disease.     But  there  are 
other  possibilities  to  be  considered,  and  so  this  question 
must  be  left  open  for  further  investigation.     So  much, 
however,  I  think  can  be  said  with  certainty  to-day — that 
this  peculiar  affection  does  not  consist  of  an  arrest  of 
development,  but  is  an  acquired  disease  affecting  the 
nerve  cells  of  the  entire  system,  produced  by  some  poison. 
I  would  suggest  that  as  soon  as  the  diagnosis  of  such  a 
case  has  been  made,  the  child  be  taken  from  its  mother's 
breast,  and  all  future  children  be  fed  with  other  nourish- 
ment.    Future  investigations  will  have  to  be  directed 
toward  the  clinical  examination  of  the  blood,  and  the  ex- 
cretions of  these  children,  and  of  the  milk  of  the  mother, 
and  it  may  be  hoped  that  by  these  means  all  questions 
as  to  the  nature  and  etiology  of  this  interesting  disease 
may  be  definitely  determined. 


1 66.  KvsTES    Du    Cerveau     (Cerebral     Cysts.)       Jaboulay,     (Lyon 
Medical,  vol.  87,  Jan.  23d,  1898). 

This  is  a  brief  report  of  operation  on  eight  non-parasitic  cysts 
of  the  brain  by  an  author  who  is  very  active  in  cerebral  surgery. 
Most  of  the  patients  were  epileptic,  and  the  majority  of  the  cysts 
were  secondary  formations  following  cranial  injury.  By  far  the  best 
result  obtained  was  in  the  case  of  a  young  man  who,  a  year  before, 
had  sustained  a  fracture  of  the  skull,  for  which  a  trepanation  was 
done.  He  developed  epilepsy,  and  in  the  cicatricial  tissue  a  cyst  was 
found  and  emptied.  It  is  noted  that  after  the  operation  *'the  seizures 
disappeared  almost  completely."  Of  the  remaining  seven  cases,  the 
patients  either  succumbed  to  the  operation,  were  entirely  unreUeved 
or  showed  a  "slight  amelioration,"  with  the  exception  of  the  last,  who 
had  been  operated  upon  only  a  month  before,  and  who  seemed  de- 
cidedly improved.  On  the  whole,  the  report  shows  again  the  fruitless 
results  of  indiscriminate  operations  on  the  brain.  Patrick. 


M 


PATHOLOGICAL  REPORT  ON  THE  EYES  OF  DR. 
HIRSCH'S  PATIENT  WITH  AMAUROTIC  FAM- 
ILY IDIOCY.^ 

By  ward  a.   HOLDEN,  A.  M..  M.  D., 

New  York 

The  upper  diagram  in  Chart  A  represents  roughly  the 
ophthalmoscopic  picture  characteristic  of  amaurotic  fam- 
ily idiocy,  and  the  lower  diagram  represents  a  correspond- 
ing section  of  the  posterior  part  of  the  eyeball  passing 
through  the  optic  disc  and  macula  lutea.  In  these  cases 
the  macular  region  is  occupied  by  an  oval,  gray  patch 
about  twice  as  broad  as  the  optic  disc,  and  having  a  red 
spot  in  its  centre.  In  nearly  30  cases  that  have  been  re- 
ported the  eye  changes  have  been  remarkably  uniform. 

As  regards  the  explanation  of  this  fundus  picture, 
which  has  often  been  compared  to  the  change  following 
embolism  of  the  central  artery  of  the  retina,  clinicians 
have  been  inclined  to  believe  it  to  be  due  to  a  retinal 
oedema,  rendering  the  retina  opaque,  and  obscuring  the 
normal  red  color  of  the  choroid,  except  in  the  fovea  cen- 
tralis, where  the  retina  is  very  thin.  This  view  was  taken 
also  by  Treacher  Collins,  the  former  pathologist  of  Moor- 
fields,  who  made  a  miscroscopic  examination  of  the  eyes 
of  two  patients.  He  reported  that  there  was  a  spacing  out 
of  the  tissues  in  the  outer  reticular  layer,  indicative  of 
oedema,  and  no  apparent  changes  in  the  other  layers.  But 
he  regarded  his  examinations  as  unsatisfactory,  since  in 
all  the  eyes  examined  the  retina  about  the  macula  was 
thrown  up  into  a  fold,  a  common  postmortem  change. ' 
The  retinal  elements  in  such  folds  are  always  spaced  out,  so 
that  a  deceptive  appearance  of  oedema  is  presented  even 
in  healthy  eyes.  The  fact  that  Collins  noticed  no  changes 
in  the  ganglion  cells  is  not  surprising,  since  little  atten- 


'Rcad  at  the  twenty-fourth  annual  meeting  of  the  American  Neu- 
rological Association.  May.  1898. 


AMAVROTIC  FAMILY  IDIOCY. 


551 


i  given  to  the  retina!  ganglion  cells,  as  a  rule,  and 
ly  any  attempts  have  been  made  to  study  them 
)dern  cytological  methods, 

le  eyes  on  which  I  wish  to  report  were  removed  by 
irsch  four  hours  after  death,  and  were  hardened,  one 
iller's  fluid  and  one  in  formol,  10  per  cent.  In  the 
1  eye  the  retina  remained  in  position  at  the  macula, 
iter  hardening,  the  gray  patch  at  the  macula  was 


Chart  A. 
per  diagram   represenling  the   fundus   picture;   lower   diaKram 
iting  a  corresponding  seclion  of  the  eyeball:  the  dark  line  in 
na  indicating  the  layer  of  ganglion  cells. 

s  in  life.  Horizontal  and  vertical  sections  were  cut 
;h  the  maculas,  and  longitudinal  and  transverse  sec- 
through  the  nerves,  after  celloidin  and  paraffin  im- 
ig.  and  every  applicable  stain  was  used.  The  find- 
>ere  checked  in  every  possible  way  by  comparison 
ither  eyes,  in  order  to  rule  out  errors  of  interpreta- 


552 


WARD  A.  HOLDEN. 


tion.  The  eyes  of  an  infant  dead  of  the  same  disease, 
pneumonia,  were  prepared  in  exactly  the  same  way,  and 
cellular  alterations  due  to  postmortem  changes,  strong 
hardening  solutions,  and  various  general  diseases  were 
studied  at  great  length.  The  work  was  done  in  the  Pa- 
thological Institute  of  the  New  York  State  Hospitals. 

In  the  normal  retina  the  ganglion  cells  vary  from  lo  to 
30  microns  in  diameter,  and  in  the  periphery  of  the  retina 
where  the  cells  are  scattered,  large  cells  abound,  but  in  the 
macular  region,  where  the  ganglion  cell  layer  is  several 


Chart   B. 

Fig.  I.  A  retinal  ganglion  cell  stained  with  ha^matoxylin-eosin. 
Fig.  II.  The  same  with  Wcigert's  haMnatoxylin.  Fig.  III.  The 
same  stained  by  Nissl's  method.  Fig.  IV.  A  retinal  ganglion  cell 
from  Dr.  Peterson's  case  stained  bv  Nissl's  method. 

cells  deep,  the  cells  are  mostly  small,  irregularly  pear- 
shaped,  and  packed  close  together. 

Sections  of  the  Miiller's  fluid  eye  stained  with  haema- 
toxylin-eosin  showed  the  average  size  of  the  ganglion 
cells  to  be  increased  and  the  average  shape  to  bealteredto- 
ward  the  globular.  (Fig.  I.,  Chart  B.)  The  nuclei  were 
mostly  near  the  centre  of.  the  cells.  The  cell  body  with 
this  stain  appeared  homogeneous,  but  when  similar  sec- 
tions were  stained  by  Weigert's  method  or  with  hematein 
the  entire  body  of  the  cells  appeared  to  be  filled  with 
coarse,  black  granules.    (See  Fig.  II.) 


AMAUROTIC  FAMILY  IDIOCY. 


55S 


In  Nissl  preparations  of  the  formol  eye,  at  first  glance, 
nothing  was  seen  of  the  ganglion  cells  but  their  nuclei, 
which  stained  deeply  and  were  coarsely  granular.  (Fig. 
III.)  Under  a  1-18  immersion  the  cell  membrane  and 
the  cyto-reticulum  could  be  clearly  made  out,  but  no  Nissl 
granules  were  present,  and  the  cell  body  had  the  appear- 
ance of  having  had  its  liquid  contents  withdrawn,  leaving 
the  naked  cell  framework.  (Fig.  III.)  These  staining 
reactions  characterize  the  cell  absolutely. 

Furthermore,  comparison  with  Dr.  van  Gieson's  he- 
matein  preparations  of  the  brain  of  Dr.  Sachs'  patient, 
which  was  hardened  in  Miiller's  fluid,  and  comparison  with 
Dr.  Hirsch's  Nissl  preparations  of  the  brain  of  his  pa- 
tient, hardened  in  formol,  showed  that  the  staining  reac- 
tions in  the  cerebral  and  the  retinal  cells  in  each  case,  al- 
lowing for  their  difiference  in  size,  were  identical.  In  the 
eyes  of  Dr.  Peterson's  patient,  who  died  at  seven  months 
of  age,  the  autopsy  being  made  forty  hours  after  death,, 
postmortem  vacuolation  was  found  in  the  ganglion  cells 
(Fig.  IV.),  but  the  nuclei  were  not  granular,  and  the  nu- 
cleoli were  distinct,  while  Nissl  granules  were  present  in 
the  cell  bodies;  the  advanced  changes  found  in  both  nu- 
clei and  cell  bodies  in  Dr.  Hirsch's  patient  were  here  want- 
ing. 

No  actual  oedema  of  the  retina  was  found  on  careful 
comparisons  with  preparations  of  normal  eyes  cut  in  the 
same  directions  and  thicknesses.  The  other  layers  of  the 
retina  were  apparently  normal,  excepting  the  rods  and 
cones,  which  in  their  outer  segments  had  undergone  the 
usual  early  postmortem  change.  The  ciliary  nerves  were 
normal,  and  no  ganglion  cells  giving  these  peculiar  stain- 
ing reaction3  were  found  in  the  ciliary  body. 

The  optic  nerve  showed  an  absence  of  the  myelin  in 
many  fibres  in  each  bundle,  and  the  neuroglia  tissue  was 
increased — in  other  words,  the  condition  was  that  of 
simple  degeneration. 

The  changes  in  the  gangHon  cells  readily  explain  the 


M 


554  WARD  A.  HOLDEN. 

4 

fundus  picture,  which,  indeed,  admits  no  other  anatomical 
explanation. 

In  the  fovea  centrahs  gangUon  cells  are  practically 
absent.  At  the  margins  of  the  fovea  the  ganglion-cell 
layer  abruptly  increases  in  thickness,  until  it  is  from  6  to 
ID  cells  deep.  A  disc  diameter  from  the  fovea,  horizon- 
tally in  either  direction,  the  ganglion-cell  layer  has  thinned 
down  to  a  layer  from  3  to  4  cells  deep;  two  disc  diameters 
from  the  fovea  it  is  from  2  to  3  cells  deep,  and  beyond  this 
it  thins  down  further  to  a  layer  from  i  to  2  cells  deep, while 
in  the  periphery  of  the  retina  it  is  a  single  broken  layer  ot 
scattered  cells  (see  diagram,  Chart  A).  Above  and  below 
the  fovea  centralis,  in  the  vertical  meridian,  the  ganglion- 
cell  layer  thins  out  ratlier  more  rapidly  than  in  the  hori- 
zontal meridian.  The  oval  gray  patch  occupies,  therefore, 
exactly  that  portion  of  the  retina  in  which  the  layer  of 
enlarged  and  altered  ganglion  cells  is  four  or  more  cells 
deep.  At  the  margins  of  the  patch,  where  the  ganglion - 
cell  layer  is  thinner,  the  faint  gray  color  fades  away  gradu- 
allv  into  the  normal  red  of  the  fundus.  Near  the  fovea 
centralis,  where  the  ganghon-cell  layer  is  thickest,  the 
gray  color  is  most  intense,  and  in  the  fovea  centralis,  where 
ganglion  cells  are  wanting,  the  red  color  of  the  choroid 
shows  through,  appearing  darker  by  reason  of  contrast 
with  the  surrounding  light  gray. 

Tay,  who  first  described  this  disease,  and  also  King- 
don  have  followed  the  course  of  the  fundus  changes.  They 
have  found  that  the  fundus  is  normal  until  after  the  third 
month.  Then  a  haziness  appears  in  the  macular  region, 
and  the  usual  picture  is  fully  developed  in  the  fifth  or  sixth 
month.  At  this  time  the  infant  often  has  eiiough  vision 
to  follow  a  light.  A  month  or  two  later,  the  macular  pic- 
ture remaining  the  same,  vision  is  lost,  and  the  optic  nerve 
becomes  atrophic.  Although  the  macula  lutea  is  not  fully 
differentiated  at  birth,  its  layer  of  ganglion  cells  is  five 
or  six  cells  deep,  and  the  fact  that  the  retina  is  then 
ophthalmoscopically  transparent  indicates  that  the  gan- . 


r 


AMAUROTIC  FAMILY  IDIOCY.  555 

glion  cells  cannot  be  much  affected,  if  at  all.  The  optic 
nerve  atrophy  which  follows  the  appearance  of  the  macular 
changes  is  to  be  interpreted,  perhaps,  as  both  an  ascending 
and  "a  de'scending-  degeneration — a  breaking  down  of  the 
neuraxons  of  the  affected  retinal  ganglion  cells  and  of  the 
affected  ganglion  cells  in  the  basal  ganglia. 

We  have  thus  found  a  common  explanation  for  the 
symptoms  of  this  complex  affection,  and  have  shown  it  to 
be  pathologically  a  unit.  The  ocular  neurons  have  under- 
gone a  primary  alteration,  like  the  cerebral  neurons.  Nor 
should  this  cause  surprise,  when  wc  remember  that  the 
retina  and  the  optic  nerve  are  genetically  a  portion  of  the 
brain,  being  developed  embryologically  from  the  same 
medullary  tube  of  involuted  ectoderm.  Embryologically 
related  to  the  brain,  the  inner  layers  of  the  developed  ret- 
ina are  so  similar  in  histological  structure  to  the  cerebral 
cortex  that  they  are  known  as  the  cerebral  stratum  of  the 
retina.  Analogous,  embryologically  and  histologically,  we 
have  seen  also  that  the  retina  and  cortex  may  suffer 
analogous  primary  pathological  changes.  And  in  future 
investigations  of  nervous  diseases,  we  must  consider  the 
retina  a  division  of  the  central  nervous  system,  which  is 
quite  as  worthy  of  study  by  the  pathologist  as  are  the 
brain  and  cord. 

DISCUSSION. 

Dr.  B.  Sachs  said  that  it  was  a  great  satisfaction  to  him 
that  a  paper  read  by  him  ou  this  subject  before  the  associa- 
tion, eleven  years  ago,- had  led  to  so  interesting  a  discussion. 
He  was  firmly  convinced  that  amaurotic  family  idiocy  was 
a  morbid  entity,  which  he  knew  would  be  placed  upon  a  firmer 
basis  by  the  extensive  pathological  studies  made  by  Drs. 
Hirsch,  Holdcn  and  Peterson.  The  speaker  said  that  when 
he  first  entered  upon  the  study  of  this  special  disease,  he  had 
no  theory  in  mind  as  regarded  its  causation,  and  even  to  this 
day  he  liua^d  not  formulated  any  theory,  nor  did  he  think  that 
the  time  for  such  a  formulation  had  arrived. 

Dr.  Sachs  stated  that  considerable  emphasis  had  been 
placed  upon  the  circumstance  that  a  disease  which  was  sup- 
posed to  be  a  congenital  one  did  not  apparently  develop  its 


556  AMAUROTIC  FAMILY  IDIOCY. 

symptoms  until  four  or  five  months  after  birth.  His  answer 
to  that  statement  was  that  the  latter  fact  did  not  prove  that 
the  disease  was  not  congenital,  because  it  was  extremely  diffi- 
cult to  prove  that  a  child  under  the  age  mentioned  was  per- 
fectly normal  in  every  respect.  Moreover,  in  a  case  which 
had  been  under  his  observation,  he  had  been  able  to  satisfy 
himself  that  the  child,  when  only  three  months  old,  was  men- 
tally deficient.  The  statement  of  the  mother  in  regard  to  the 
mental  condition  of  the  child  at  a  very  early  age  was  not  al- 
ways conclusive.  As  these  patients  grow  older,  both  the  men- 
tal and  physical  deterioration  become  more  marked,  and 
many  of  them  die  in  a  condition  of  marasmus.  This  last  fact 
he  wished  especially  to  emphasize. 

As  regards  the  seat  of  the  lesions  in  these  cases,  the  speaker 
said  that  Dr.  Hirsch  had  done  excellent  work  in  showing 
that  the  disease  is  not  restricted  merely  to  the  brain  or  cerebral 
cortex,  but  may  affect  the  entire  nervous  system,  including 
even  the  cells  in  the  gray  matter  of  the  cord.  The  cellular 
changes  are  similar  throughout  the  central  nervous  system, 
and  the  pathological  findings  of  Dr.  Hirsch  were  entirely  in 
accord  with  those  in  two  cases  of  his  own,  one  examined 
eleven  and  the  other  nine  years  ago.  The  speaker  said  that 
in  his  earlier  researches  on  this  subject  he  had  interpreted 
the  disease  as  being  chiefly  cortical  in  origin,  but  even  at  that 
time  he  had  a  suspicion  that  the  lesions  were  not  confined 
to  the  cortex,  and  Dr.  H.  Knapp,  who  had  examined  the 
eyes  in  his  first  case,  insisted  at  the  time  that  it  would  some 
day  be  found  that  the  changes  in  the  optic  nerves  were  parallel 
to  the  changes  in  the  cortex.  In  Dr.  Sachs'  second  case 
the  changes  were  present  in  the  brain  and  spinal  cord;  the 
changes  in  the  latter  region  he  at  first  ascribed  to  secondary 
degeneration,  but  later  on  he  came  to  the  conclusion  that  they 
were  the  result  of  arrested  development.  Kingdon  and  Rus- 
sell, on  the  other  hand,  were  the  first  to  claim  that  the  changes 
were  due  to  degeneration.  Dr.  Sachs  was  of  the  opinion  that 
an  arrest  of  development  is  necessarily  followed  by  a  degenera- 
tion, and  for  that  reason  he  did  not  think  there  was  such  a 
radical  difference  between  the  interpretation  put  upon  the 
cases  by  Kingdon  and  RusseH,  and  now  by  Dr.  Hirsch».and 
that  of  himself. 

With  regard  to  the  cause  of  this  degenerative  process.  Dr. 
Sachs  said  that,  while  the  theory  advanced  by  Dr.  Hirsch 
was  very  interesting,  it  was  probably  influenced  to  some  extent 
by  the  theory  of  another  illustrious  author,  who  had  attempted 
to  explain  hereditary  influence  on  the  basis  of  a  toxic  infec- 
tion. The  speaker  said  he  could  not  believe  that  a  disease 
so  widespread  as  this,  which  begins  at  the  same  period  of 


AMAUROTIC  FAMILY  IDIOCY.  557 

life,  -and  which  involves  several  members  of  the  same  family 
and  leaves  others  exempt,  could  be  due  to  any  toxic  influence 
that  is  known  to  us.  As  an  argument  against  the  theory  that 
the  disease  was  carried  through  the  mother's  milk,  the  speaker 
cited  his  first  two  cases,  who,  although  Jewish  children,  were 
not  raised  on  mother's  milk. 

Dr.  Sachs  said  that,  personally,  he  had  no  theory  to  offer 
regarding  the  causation  of  this  disease.  He  thought  it  was 
in  line  with  many  of  the  hereditary  diseases,  and  we  must  ac- 
cept it  as  a  hereditary  family  disease  of  the  central  nervous 
system.  It  certainly  tnears  a  close  clinical  relationship  to  other 
hereditary  family  affections,  particularly  to  those  characterized 
by  blindness,  for  example,  or  to  those  characterized  by  spastic 
paraplegia  and  forms  of  mental  defect. 

The  evidence  furnished  bv  Dr.  Hirsch  of  involvement  of 
the  gray  matter  of  the  spinal  cord  explains  why  in  some  cases 
the  paralysis  is  spastic  and  in  others  flaccid  (as  in  Sachs'  first 
patient).  In  conclusion.  Dr.  Sachs  said  that,  while  he  re- 
garded this  as  a  widespread  disease  of  the  central  nervous 
system,  he  did  not  believe  that  the  spinal  cord  need  always  be 
affected,  and  th^t  in  some  instances  the  disease  may  be  chiefly 
cerebral.    ""^ 

Dr.  Carl  Koller  had  seen  five  cases  of  this  interesting  affec- 
tion. Two  cases,  which  he  had  published  a  few  years  ago  in 
a  p^per  read  before  the  American  Ophthalmological  Society, 
had  been  the  immediate  occasion  of  this  question  being  taken 
up  again  by  Dr.  Sachs.  A  number  of  cases  had  been  reported 
in  quick  succession,  and  a  thorough  study  made  of  it  clinically 
by  Dr.  Sachs,  and  later,  pathologically,  by  Dr.  Hirsch,  whose 
painstaking  and  exhaustive  research  had  greatly  contributed 
to  our  understanding  of  the  disease. 

Dr.  Koller  said  that  the  characteristic  ophthalmoscopic 
changes  in  the  macula  were  not  congenital,  and  were  not 
found  until  between  the  fifth  and  seventh  months.  In  two  of 
Kingdon's  cases,  which  were  exaniined  in  the  earlier  months 
of  life,  they  were  missing,  and  in  two  cases  of  the  speaker, 
which  were  examined  in  the  first  two  months  of  life,  they  were 
also  absent.  One  of  the  latter  was  the  identical  case  which 
Dr.  Peterson  had  just  reported  in  his  paper.  The  speaker 
said  he  had  examined  that  child  five  times  between  the  eighth 
and  sixteenth  weeks  of  its  life,  the  ophthalmoscopic  examina- 
tion being  negative,  altliough  other  unmistakable  signs  were 
present  which  proved  that  the  case  belonged  to  this  class.  Trt 
the  other  case,  the  characteristic  changes  developed  later. 

Dr.  Koller "  thought  that  the  atrophy  of  the  optic  nerve 
in  these  cases  made  its  appearance  considerably  later  than 
the  changes  in  the  macula,  and  developed  gradually.    As  to 


558  IVARD  A.  HOLD  EN. 

whether  the  former  depends  on  the  latter,  or  whether  one  was 
independent  of  the  other,  that  point  remained  for  pathologists 
to  determine,  but  it  seemed  reasonably  certain  that,  as  a  rule, 
the  ocular  changes  were  not  congenital. 

Another  question  arising  in  connection  with  this  subject 
was  whether  these  patients  ever  had  sight,  in  our  meaning 
of  the  word;  whether  they  were  bbrn  blind,  or  with  a  vision 
already  impaired  by  existing  cerebral  changes;  or  whether 
they  were  born  with  a  vision  equal  to  the  low  degree  per- 
taining to  the  newborn,  with  degeneration  setting  in  before 
the  vision  became  developed  to  a  higher-p^'rte.    At  all  events, 
the  behavior  of  the  children  with  regard  to  their  vision  was  not 
normal  at  the  time  when  no  ophthalmoscopic  changes  were 
visible,  and  the  conclusion  was  permissible  that  vision  was 
impaired  by  cerebral  degeneration  lying  pretty  far  back.    In 
one  of  the  speaker's  cases  the  mother  had  fier  suspicions  in 
regard  to  the  child's  eyesight  as  early  as  the  fourth  week  of 
life.     In  the  two  cases  he  had  examined  in  the  8th  and  9th 
weeks  he  had  received  the  impression  that  vision  was  already 
impaired.     The  light  of  a'  candle  in  a  dark  room  was  not 
followed  by  the  eyes,  and  no  prompt  reaction  of  the  pupils 
could  be  produced.    The  pupils  l^ecame  slowly  narrower  when 
exposed  to  light,  and  slowly  dilated  in  the  dark.    The  speaker 
thought  these  two  facts  certainly  deserved  weight,  considering 
the  diflficulty  which  exists  as  to  how  much  vision  such  young 
children  enjoy. 

Dr.  Charles  K.  Mills  concurred  Avith  Dr.  Sachs  in  re]2:ard 
to  the  nature  of  amaurotic  family  idiocy.  The  word  **con- 
genital"  in  connection  with  these  cases  seemed  to  him  to 
be  sometimes  misused.  In  many  of  these  cases  the  clinical, 
and,  possibly,  the  pathological,  evidences  of  the  disease,  so 
far  as  can  be  demonstrated,  are  not  observed  until  weeks, 
months,  years,  or  even  decades,  after  the  birth  of  the  indi- 
vidual, and  in  this  sense  they  are  not  congenital;  but  these 
cases,  along  with  some  of  the  forms  of  diplegia  and  of  muscu- 
lar atrophy,  and  perhaps  of  Huntington's  chorea  and  develop- 
mental insanities,  belong  to  a  grpat  embryonal  class.  The 
potentiality  of  development  in  these  cases  is  limited,  and  it 
may  be  weeks,  months  or  years  before  the  symptoms  make 
their  appearance.  Whether  the  immediate  pathological  con- 
ditions which  initiate  the  manifestations  of  the  disease  are 
toxic  or  non-toxic,  sooner  or  later  the  degenerative  process 
will  manifest  ftself,  if  the  individual  .survives  long  enough. 

Dr.  F.  X.  Dercum  said  that  he  had  reported  one  family  in 
which  three  of  the  four  children  suflFered  from  spasmodic  di- 
plegia and  idiocy.  Sachs,  Freud,  and  others  had  reported 
similar  instances.     In  his  three  cases  the*  symptoms  of  the 


AMAUROTIC  FAMILY  IDIOCY.  '  559 

deg-enerative  process  manifested  themselves  in  each  instance 
immediately  after  measles;  the  only  child  that  escaped  did  not 
contract  measles.  Such  observations  as  these,  Dr.  Dercuni 
thought,  tended  to  strengthen  the  toxic  theory  of  amaurotic 
family  idiocy. 

Dr.  W.  G.  Spiller  reported  the  case  of  a  child,  bom  of 
healthy  parents,  but  who  had  an  aunt  insane  and  an  uncle 
who  was  feeble-minded.  Tlie  child  had  presented  no  symp- 
toms detectable  by  the  parents  until  he  went  to  school,  when 
he  was  npticed  to  be  somewhat  feeble  mentally.  His  gait 
and  speech  were  rather  slow;  he  lisped  slightly,  and  his  cir- 
culation was  imperfect.  As  time  went  on,  spastic  symptoms 
developed,  and  gradually  became  very  marked;  the  reflexes 
were  much  exaggerated,  intention  tremor  was  noticed,  the 
speech  became  scanning,  and  was  finally  lost.  Tlie  later  de- 
velopments were  incoordination,  feeble  mentality,  muscular 
contractures,  intense  atrophy,  and  finally  complete  paralysis. 
When  the  boy  was  thirteen  years  old,  bilateral  optic  atrophy 
was  noted,  but  it  may  have  existed  for  some  years  before  the- 
examination  was  made.  The  child  died  at  the  age  of  fifteen. 
A  microscopical  examination  showed  distinct  degeneration  of 
the  pyramidal  tracts  of  the  cord.  The  cells  of  the  anterior 
horns  and  the  spinal  roots  appeared  to  be  little  altered.  The 
brain  could  not  be  obtained. 

Dr.  Spiller  said  he  did  not  consider  this  case  a  typical 
one  of  amaurotic  family  idiocy,  and  yet  it  bore  certain  re- 
semblances to  this  disease.  It  seemed  to  him  to  have  a  closer 
relation  to  the  pseudo-sclerosis  of  Westphal  and  Striimpell, 
for  the  pyramidal  tracts  were  not  normal  in  all  instances.  As 
only  five  cases  of  this  pseudo-sclerosis  are  now  on  record,  Dr. 
Spiller  was  inclined  to  regard  his  case  as  a  sixth.  The  report 
will  be  published  in  detail  later. 

Dr.  Hirsch,  in  closing,  said  he  did  not  think  we  could  dis- 
pense with  the  distinction. between  a  disturbance  of  develop- 
ment and  an  acquired  disease.  To  accept  the  statement  that 
an  arrest  of  development  is  identical  with  an  acquired  disease 
would  mean  to  destroy  wilfully  the  most  valuable  scientific 
work  of  the  last  decades.  In  the  nervous  system,  as  elsewhere 
in  the  body,  a  certain  predisposition  to  disease  may  be  in- 
herited; tuberculosis,  for  example,  although  a  strong  predis- 
position to  it  may  be  inherited,  cannot  develop  without  the 
presence  of  the  tubercle  bacilli.  The  speaker  said  he  did  not 
question  the  fact  that  children  who  develop  amaurotic  family 
idiocy  were  born  with  a  normal  nervous  system.  If  the 
changes  in  the  macula  lutca  arc  produced  by  changes  in  the 
ganglion  cells,  we  must  assume  that  as  long  as  the  former 
changes  are  absent  the  ganglion  cells  are  normal,  and  it  is 


^6o  IVARD  A.  HOLDEN. 

to-day  a  clinically  established  fact  that  the  children  are  not 
bOm  with  the  peculiar  condition  in  the  macula  lutea,  but  that 
this  develops  during  the  course  of  the  disease.  In  his  case 
the  optic  tract  was  atrophied;  this  atrophy  was  secondary;  it 
was  an  acquired  condition;  the  child  was  not  bom  with  it, 
but  had  impaired  vision  up  to  the  age  of  eight  months. 

Dr.  Hirsch  said  he  agreed  with  the  previous  speakers  that 
the  toxic  origin  of  this  disease  was  still  an  open  question.  As 
regards  tlie  milk  theory,  he  did  not  think  it  was  disproven 
by  the  instance  cited  by  Dr.  Sachs,  where  two  Jewish  children, 
who  afterward  developed  the  disease,  had  been  brought  up 
by  Christian  wet-nurses.  From  the  fact  that  all  the  cases 
which  have  been  observed  so  far  belonged  to  the  Jewish  race, 
it  does  not  follow  that  the  toxin  must  also  necessarily  be  of 
Jewish  origin. 

The  speaker  said  he  wished  to  take  exception  to  the  state- 
ment that  amaurotic  familv  idiocv  was  in  line  with  other 
hereditary  diseases.  He  knew  of  no  other  inherited  family 
disease  where  all  the  nerve  cells,  and  nothing  but  the  nerv-e 
cells,  in  the  body  became  affected;  the  condition,  so  far  as  he 
knew,  had  no  analogy  in  pathology.  Furthermore,  in  this 
disease  the  degenerated  cells  had  a  typical  appearance,  only 
analogous  to  what  we  see  in  poisoning,  and  that,  in  spite  of 
this,  they  had  certain  characteristics  of  their  own,  was  in  ac- 
cordance with  the  modem  view  that  every  poison  load  a  spe- 
cific action  on  nerve  cells. 


167.  Dei^ire  de  perskcution;  kysxe  dermoide  de  l'ovaire;  i^aparo- 
TOmir;  disparition  dks  troubles  mentaux  (Delirium  of  Per- 
secution; Dermoid  Cyst  of  the  Ovary;  Laparotomy;  Cessation  of 
the  Mental  Trouble).  A.  Voisin  (La  France  Med.  et  Paris  Med., 
Feb.  1 2th,  '97). 

Under  this  title  the  author  publishes  the  following  case:  The 
patient,  with  a  neuropathic  family  history,  had  a  pessary  introduced 
for  prolapsis  uteri,  six  years  ago.  Beinp:  a  virgin,  this  treatment  made 
such  an  impression  on  her  as  to  disturb  her  mental  faculties,  and  she 
became  sad  and  at  times  showed  violent  temper.  Later  on  she  devel- 
oped marked  delirium  of  persecution,  with  hallucinations  of  sight  and 
hearing,  accused  several  persons  of  plotting  against  her,  and  tried  to 
commit  suicide  twice.  In  November  last,  laparotomy  was  performed, 
and  a  large  multilocular  ovarian  cyst  extracted.  For  two  days  after 
the  operation  the  patient  was  somewhat  excited,  then  all  the  cerebral 
disturbances  ceased  permanently.  The  foregoing  observations  of  men- 
tal disturbance,  being  cured  by  a  surgical  operation,  is  considered  as 
extremely  rare  and  interesting,  inasmuch  as  one  is  accustomed  to  ob- 
serve mental  symptoms  develop  subsequent  to  surgical  interference 
upon  the  female  genital  organs.  Macalestee. 


"^tviscopc. 


lyith  the  Assistance  of  the  Following  Collaborators: 

Chas. Lewis  ALLEN,M.D.,Wash.,D.C.R.  K.  Macalkster,  M.D.,  N.Y. 
J.  S.  Christison,  M.D.,  Chicago,  111.  J.  K.  Mitchell.  M.D.,  Phila.,  Pa 
A.  Freeman,  M.D.,  New  York.  H.  Patrick,  M.D.,  Chicago,  III. 

S.  E.  Jelliffe,  M.D.,  New  York.  Joseph  Sailer,  M.D.,  Phila..  Pa. 
Wm.C.Krauss,M.D.,  Buffalo,  N.Y.  Henry  L.  Shively,  M.D.,  N.Y. 
W.  M.  Leszynsky,  M.D.,  New  York  A.  Sterne,  M.D.,  Indianapolis. 


ANATOMY  AND  PHYSIOLOGY. 

i68.  NoTK  ON  ** Thorns"  and  a  Thkorv  ok  thk  Constitution  of 
Grey  Matter.   A.  Hill  (Brain,  20,  1897.  p.  131). 

**  Granules,"  or  if  one  prefers  Cajal's  term,  **  thorns,"  hav©  been 
supposed  to  be  dots  of  naked  protoplasm,  by  means  of  which  the 
-dendrites  establish  connections  with  the  terminal  end  brushes  of  nerve 
fibres.  The  author  here  presents  a  brief  note,  in  which  he  states  that 
they  are  universally  present  but  exist  in  a  variety  of  forms,  four  of 
which  he  details.  He  believes  them  to  be  structures  imperfectly  re- 
vealed by  any  of  our  known  methods.  The  great  variation  in  form 
leads  him  to  the  belief  that  a  "thorn  is  really  the  cell  end  of  an  un- 
stainable  nerve  filament  surrounded  by  a  film  of  staining  cell  plasm." 
The  author's  brief  notes  with  reference  to  the  nervous  mechanism  arc 
of  interest  in  view  of  Apathy's  recent  observations  respecting  the 
continuity  of  fibrils  and  their  arrangement.  Jelliffe. 


169.  Action  de  la  lumiisre  color^e  sur  la  retinb.  (Action  of 
Colored  Lights  on  the  Retina).  E.  Porgcns  (Annales  de  la  Soc. 
Royale  des  Science  Medicales  et  Nat.  de  Bruxelles,  1897,  6,  p.  i). 

The  results  of  the  author's  studies  on  the  action  of  monochromatic 
lights  on  the  movements  of  pigment  and  the  morphologic-histo-chem- 
ical  changes  in  the  nervous  cells  of  the  retina  were  substantially  as 
follows: — 

The  migration  of  pigment  is  at  its  maximum  for  the  blue,  at  a 
minimum  for  red.  Thus  it  is  not  the  intensity  of  the  light  which 
causes  this  migration,  as  physics  show,  that  red  light  is  more  intense 
than  blue. 

When  a  single  eye  is  illuminated  the  pigment  in  the  retina  of  the 
closed  eye  also  migrates,  varying  with  the  character  of  the  light  The 
contraction  of  the  cones  following  the  action  of  the  various  spectral 
portions  of  light  varies.  The  quantity  of  the  nuclei  contained  in  the 
rods  and  cones  diminishes  under  the  action  of  the  rays  of  the  spectrum 
but  not  in  a  degree  corresponding  with  the  luminosity.  This  decrease 
is  at  its  maximum  for  the  red,  and  at  a  minimum  for  the  green. 

Basophil  structures  in  the  cells  were  more  acted  upon  than  acido- 
phil or  neutrophil  portions.    The  action  of  the  X  rays  was  negative. 

Ely. 


562  PERISCOPE, 

170.    DE     !«' importance     FUNCnt)NErj.E    DtJ     CORPS     CEIJ.ULAIRE     DU 

NEURONE  (On  the  Functional  Importance  of  the  Cell  Body  of  the 
Neuron).    C.  A.  Pugnat  (Revue  Neurologique,  6,  1898,  p.  158). 

The  author  presents  a  brief  summary  of  the  ideas  of  Cajal,  van 
Gehuchten,  and  Lugaro,  with  reference  to  the  relation  of  the  cell  body 
to  the  dendritic  and  axis  cylinder  processes  of  the  nerve  cells.  He 
discusses  Cajal's  so-called  laws^  and  maintains  that  they  are  open  to 
much  well-founded  criticism.  The  author  himself  holds  that  the  neuron 
is  a  nervous  cellular  unit,  possessing  two  types  of  conductors,  proto- 
plasmic processes  and  the  axis  cylinder  process,  but  it  also  possesses 
a  centre,  which  is  genetic,  trophic  and  functional,  which  is  nothing  else 
but  the  cell  body.  Jelliffe. 

171.  Some  Judgments  of  the  Stze  of  Famiijar  Objects.      H,  K. 
Wolfe  (American  Journal  of  Psychology,  1898,  9,  p.  138). 

The  author  experimented  on  nearly  eleven  hundred  persons  with 
coins  and  currency  bills.  The  following  are  his  more  important  de- 
ductions:—r 

1.  Young  children  underestimate  the  size  of  coins  and  bills. 

2.  Mature  persons  of  intelligence  overestimate  the  size  of  the 
silver  dollar,  half  dollar  and  quarter  dollar. 

3.  All  classes  of  persons  underestimate  the  size  of  the  dime,  nickel 
and  bill. 

4.  Girls  overestimate  their  coins  and  their  equivalent  squares  more 
than  boys  do.  In  other  problems  of  this  investigation  the  boys  rftade 
the  larger  figures. 

5.  The  judgm'ents  of  the  eighth-grade  children  were  more  uniform 
than  the  fourth-grade  on  university  students. 

6.  Within  the  same  class  age  causes  no  appreciable  effect. 

Christison. 


172.  A  Graphic  Study  of  Tremor.     A.  A.  Eshner  (Jour,  of  Ex- 
perimental Med.,  2,  1897,  p.  301). 

The  author,  in  an  extended  series  of  observations,  studies  the  fol- 
lowing questions:  i.  Whether  or  not  a  demonstrable  tremor  exists 
in  healthy  individuals;  2.  whether  or  not  any  relation  or  gradation 
exists  among  various  kinds  of  tremor:  and,  3.  whether  or  not  various 
forms  of  disease  show,  as  to  their  tremor,  distinguishing  characterist- 
ics.   The  summary  of  the  conclusions  reached  is  as  follows: 

1.  All  muscular  movements  are  made  up  of  a  series  of  elementary 
contractions  and  relaxations,  which  may  be  appreciable  as  tremors  in 
conditions  of  both  health  and  disease. 

2.  The  difTerences  between  different  tremors  are  of  degree  rather 
than  of  kind,  i.  e.,  no  form  of  tremor  is  distinctive  of  any  one  disease 
or  group  of  diseases. 

3.  No  definite  relation  exists  between  one  form  of  tremor  and 
any  other. 

4.  The  frequency  of  movement  is  in  inverse  ratio  to  the  amplitude, 
and  vice  versa. 

5.  Habitual  movements  are  performed  with  greater  freedom  from 
tremor  than  unusual  movements. 

6.  There  is  no  material  diflerence  between  the  movements  of  the 
two  sides  of  the  body,  except  as  related  to  proposition  5. 

The  paper  is  well  illustrated  with  tracings  and  the  apparatus  used 
well  described.  Jelliffe. 


PERISCOPE.  563 

PATHOLOGY. 

173.  SUR     LES     MODIFICATIONS     HISTOLOCIOWS     PKS     CKLT.UI.KS     NER- 

VEUSES  DANS  i/]&TAT  DE  KATiGUK.  (Tlu  Histologica  Modifications 
in  Nerve  Cells  during  Fatigue).  A.  M.  Pugnal  (La  France 
Med.,  44th  year,  p.  745), 

The  studies  of  diflfcrent  authorities  on  the  modifications  that  nerve 
cells  undergo,  in  diflferent  stages  of  fatigue,  have  yielded  contradictory 
results  up  to  the  present  time,  and  the  author  enumerates  his  observa- 
tions of  histological  changes  in  the  spinal  ganglia  of  young  cats,  which 
are  best  adapted  to  experimentations  and  the  preparations  of  nerve 
fibres,  to  which  the  electrodes  are  applied.  These  latter  are  placed  at 
a  distance  of  three  or  four  ctms.  from  the  ganglion,  in  order  to  avoid 
any  mechanical  irritations  by  the  electrical  current,  and  it  is  generated 
by  a  Lecianche  cell  with  induction  coil.  The  manifestations  of  fatigue 
observed  in  nerve  cells  are  a  diminution  of  the  cellular  volume  and 
its  nucleus,  and  disappearance  of  the  protoplasmatic  chromatine  sub- 
stance. As  the  stimulation  is  kept  up  the  chromatine  granules  become 
less  visible  by  degrees,  disappearing  to  a  great  extent  at  the  end  of 
about  sixteen  minutes,  when  they  are  seen  only  in  the  periphery  of 
the  cell  in  an  annular  arrangement.  When  the  stage  ol  exhaustion 
is  reached — about  twenty-four  minutes  of  stimulation — the  chromatine 
granules  are  entirely  absent  in  the  cytoplasm,  which  latter  takes  on 
a  pale  uniform  tone,  the  nerve  cell  contracting  in  a  manner  as  not  to 
fill  its  reticulum  completely,  and  the  nucleus  diminishing  in  size,  with 
indistinct  outlines.  Other  changes  found  in  the  nucleus,  or  its  emigra- 
tion towards  the  periphery  of  the  cell,  described  by  others,  are  not 
confirmed. by  the  author.  In  regard  to  the  two  principal  factors  con- 
cerned in  the  experimental  fatigue  of  nerve  cells,  viz:  the  intensity  and 
duration  of  stimulation,  the  former  is  of  paramount  importance,  it 
proving  that  a  strong  current,  acting  but  a  short  time,  causes  much 
more  marked  cellular  changes  than  a  weaker  one  of  longer  duration. 

Macalester. 

174.  RiJCKENMARKSBEFUNDK  BEX  Gehtrntumorkn  (Findings  in  the 
Spinal  Cord  in  Cases  of  Brain  Tumor).  Josef  Ursin  (Deutsche 
Zeitschrift  fiir  Nervenheilkunde,  11,  1897,  p.  i6g). 

Ursin  reports  three  cases  of  brain  tumor  with  changes  in  the 
posterior  columns  of  the  spinal  cord.  In  two  of  these  the  degeneration 
was  of  an  ascending  type,  and  due  to  involvement  of  the  posterior 
roots,  but  in  the  third  it  was  evidently  primary,  for  the  posterior  roots 
were  degenerated  at  their  entrance  into  the  cord  only  in  the  upper  part 
of  the  cervical  region.  Changes  in  the  ganglion  cells  of  the  cord 
were  noted  in  all  three  cases,  but  only  in  one  was  the  extraspinal 
portion  of  the  posterior  roots  altered.  Meningeal  involvement  was 
not  observed  in  any  of  the  cases. 

Two  views  are  held  regarding  the  alteration  of 'the  posterior 
columns  in  cases  of  brain  tumor:  (i)  the  degeneration  results  from 
increased  pressure  of  the  cerebrospinal  fluid  (Mayer),  and  (2)  that 
the  degeneration  occurring  in  cases  of  malignant  growths  is  analo- 
gous to  what  is  seen  in  the  peripheral  nerves  in  such  conditions 
(Dinkier). 

If  Mayer's  view  were  correct,  the  degeneration  of  the  posterior 
roots  would  be  greatest  where  the  pressure  is  greatest,  i.  e.,  in  the 
lower  parts  of  the  spinal  cord,  but  in  a  number  of  cases  the  degenera- 
lion  has  been  found  to  be  most  intense  in  the  cervical  region,  and  in 
others  no  signs  of  increased  intracranial  pre>siire  have  been  noted.  ()r 
where  these  signs  have  been- present  the  dop:emTation  of  the  posterior 
roots   has  been   comparatively    slight.      Mayer's   view   also    does    not 


564 


PERISCOPE, 


explain  the  ffreater  involvement  of  the  roots  of  one  side  of  the  cord. 
In  reply  to  Mayer's  statement  that  if  the  toxic  theory  were  correct, 
the  extraspinal  portion  of  the  posterior  roots  would  be  the  first 
to  suffer,  inasmuch  as  this  part  is  surrounded  by  the  cerebrospinal 
fluid,  but  that  actually  in  cases  of  brain  tumor  this  portion  of  the 
roots  is  relatively  intact,  Ursin  refers  to  the  well-known  cases  of 
toxic  degeneration  of  the  posterior  roots  as  seen  in  pellagra,  ergotism, 
diabetes,  etc.,  in  which  the  extraspinal  portion  of  the  posterior  roots 
was  not  degenerated,  and  which  resemble  in  this  respect  the  cases  of 
brain  tumor. 

Ursin  believes  that  the  lesions  in  the  spinal  cord  in  cases  of  brain 
tumor  may  be  an  intramedullary,  primary  degeneration  of  the  pos- 
terior columns,  changes  in  the  ganglion  cells,  and  changes  in  the 
remaining  white  matter,  and  in  addition  to  these  lesions  the  extra- 
medullary  portion  of  the  posterior  roots  may  be  aflfected.  The  cause 
is  to  be  found  in  intoxication  and  malnutrition.  Sfiller. 

175.  Detailed  Report  upon  the  Clinicai,  and  Pathological 
Features  of  Six  Gasbs  which  Came  to  Autopsy.  A.  N. 
Ohlmacher  (Bulletin  of  the  Ohio  Hospital  for  Epileptics,  January, 
1898,  p.  4). 

Six  cases  of  epilepsy  are  here  reported  upon  with  more  than  usual 
attention  to  details;  they  form  the  basis  of  a  second  paper  of  the 
author.  "  Upon  the  Resemblance  of  the  Foregoing  Cases  of  Epilepsy 
to  Certain  Diseases  Associated  with  Thymic  Hyperplasia,"  p.  43,  in 
which  the  author  discusses: 

1.  Thymic  asthma. 

2.  Sudden  death  in  adults  with  persistent  thymus. 

3.  Exophthalmic  Goitre. 

The  author  shows  that  in  four  of  the  cases  of  epilepsy  there  was 
a  marked  increase  of  the  thymus,  and  he  further  adds  that  while  four 
cases  do  not  form  a  basis  for  weighty  conclusions,  still,  when  these 
four  cases  are  of  a  disease  in  which  the  morbid  anatomy  has  always 
been  dark;  in  which  a  constant  gross  lesion  in  even  four  consecutive 
cases  has  been  almost  unknown;  and  in  which,  unfortunately,  at- 
tention has  been  almost  exclusively  centred  upon  the  brain, — ^then  the 
discovery  of  a  uniformly  characteristic  condition,  outside  of  the 
brain,  even  in  four  cases,  carries  with  it  a  hopeful  suggestion.  Fur- 
ther, when  it  happens  that  the  peculiar  morbid  anatomy  fits  in  with 
several  other  conditions  in  which  certain  clinical  analogies  can  be 
shown,  and  particularly  when  these  conditions  are  almost  as  mys- 
terious as  epilepsy,  then  it  seems  justifiable  to  direct  careful  attention 
to  the  various  relations  suggested  by  the  study. 

"  One  thing  must  be  certain,  and  that  is,  that  somewhere,  some- 
how the  peculiar  morphological  anomalies  found  in  our  few  cases  of 
epilepsy  and  also  noted  in  thymic  asthma,  thymic  sudden  death  and 
possibly  Basedow's  disease,  will  be  found  to  have  more  than  mere 
accidental  bearing,  for  assuredly  it  is  not  nature's  habit  to  leave  behiijd 
in  a  certain  unfortunate  class  of  human  beings  a  series  of  morbid 
anatomical  conditions,  such  as  those  we  have  considered,  without  some 
weighty  purpose  behind  her."  Jelliffe. 

176.   BaCTERIOLOGIE    DE  deux    CAS    DE    CHOREE    AVEC    ENDOCARDITB 

(Bacteriolojrv  of  two  Cases  of  Chorea  with  Endocarditis).     M. 
Apcrt  (La  Med.  Moderne,  8,  i8g8,  p.  80). 

M.  Apcrt,  Soc.  dc  Biologic,  in  two  cases  of  chorea  with  endocard- 
itis observed  in  the  service  of  M.  Dieulafoy,  made  cultures  from  the 
blood  in  milk,  by  the  procedure  suggested  by  Thiroloix.  In  the  first 
case,  in  which  the  chorea  was  already  disappearing,  the  cultures  re- 


\ 


PERISCOPE,  565 

mained  sterile.  In  the  second,  a  chorea  at  its  height,  a  diplococcus 
of  granular,  oval  shape  without  a  capsule  was  observed,  staining  with 
Gram,  apparently  identical  with  that  described  by  M.  Triboulet  in 
cases  of  acute  articular  rheumatism. 

It  should  be  added  that  both  the  chorea  patients  upon  whom  the 
investigations  were  made,  had  had  alternating  attacks  of  chorea  and 
acute  rheumatism.  Mitchell. 

177.  On  Certain  Changes  in  the  Celi*s  op  the  Ventral  Horns 

AND  OF  THE  NUCLEUS  DORSAUS  (CLARKII)  IN  EPIDEMIC  CEREBRO- 
SPINAL Meningitis.  Lewellys  F.  Barker  (British  Medical  Journal, 
ii.,  1897,  p.  1839). 

The  author  describes  two  kinds  of  alteration.  First,  slight  changes 
in  the  cells  of  the  anterior  horns,  such  as  occur  from  various  poisons, 
and  which  he  attributes  to  the  toxaemia  of  the  disease,  viz.:  (i)  the 
disappearance  of  the  stainable  substance  of  Nissl  from  the  dendrites 
or  from  portions  of  the  dendrite  or  of  a  cell  body;  (2)  the  formation 
of  nodular  swellings  of  the  dendrites,  these  swellings  corresponding  to 
pathological  accumulations  of  the  stainable  substance;  and  (3)  a  ten- 
dency to  disorganization  of  individual  Nissl  bodies,  especially  at  the 
periphery  of  the  cell. 

Second,  lesions  not  at  all  similar  to  the  first,  but  practically  iden- 
tical with  those  which  take  place  in  the  cell  body  of  a  neuron  after 
an  injury  of  the  axon  which  belongs  to  it.  These  latter  changes  were 
found  in  the  cells  of  the  anterior  horns  and  in  those  of  Clarke's  columns. 
The  alterations  in  the  anterior-horn  cells  are  attributed  to  the  involve- 
ment of  the  anterior  nerve  roots  in  the  meningeal  inflammation; 
those  in  the  cells  of  Clarke's  columns,  not  to  an  aSection  of  the  pos- 
terior roots,  but  to  the  damage  done  to  the  direct  cerebellar  tracts. 
The  meningitis  was  particularly  intense  at  this  part  of  the  periphery 
of  the  cord,  and  the  fibres  of  this  tract  are  supposed  to  be  neuraxons 
of  the  cells  of  Clarke's  columns.  Patrick. 

178.  Die  Coli*oidenTartung  des  Gehirns  (Colloid  Degeneration 
of  the  Brain).  A.  Alzheimer  (Archiv  f.  Psychiatrie,  30,  1898, 
p.  19). 

The  author  describes  two  cases  of  colloid  degeneration.  The  first 
occurred  in  a  case  of  general  paresis  with  optic  atrophy  and  character- 
istic convulsive  attacks.  The  sections  showed  leptomeningitis  and 
pachymeningitis  and  chronic  colloid  degeneration  of  the  large  ganglion 
cells  of  the  cortex. 

A  second  case  showed  unilateral  convulsions,  loss  of  memory  and 
stupor,    and  finally  hemiplegia  and  coma. 

The  autopsy  showed  colloid  degeneration 'of  the  convolutions  of 
the  right  hemisphere  and  basal  ganglia,  with  secondary  softening  in 
the  basal  ganglia  and  crura. 

A  chemical  and  micro-chemical  study  of  the  colloid  substance  in 
both  cases  showed  the  following  characters.  It  is  soluble  when  fresh 
in  warm  water;  with  picro-carmine,  or  with  double  staining  with  car- 
mine and  haematoxylin  the  colloid  substance  colors  a  decided  red,  es- 
pecially in  specimens  hardened  with  bichromate.  With  Van  Gieson's 
mixture  colloid  stains  a  light  red,  distinguishing  it  from  hyaline  sub- 
stance. Eosin  stains  it  deep  red,  and  Rosin's  mixture,  which  is  to  be 
specially  recommended,  stains  colloid  flesh  red,  nuclei  bluish  green, 
blood  cells  yellowish  red  and  the  rest  of  the  tissue  a  light  red. 
Weigert's  fibrin  staining  methods  also  give  good  differential  stains. 

The  best  results  were  obtained  with  bichromate  hardening.  Al- 
cohol is  not  good  for  colloid.  The  vessels  were  not  aflFected  in  the  de- 
generation.    The  paper  is  well  illustrated  and  is  a  noteworthy  con- 


566 


PERISCOPE. 


trihution  to  our  knowledge  of  a  type  of  tissue  degeneration  and  an 
excellent  discussion  of  the  micro-chemical  means  we  possess  whereby 
one  may  differentiate  the  many  closely  allied  forms.  Jelliffe. 

CLINICAL  NEUROLOGY. 

179.  Tumor  of  the  Meningks  in  thk  Region  of  the  Pituitary 
Body  pressing  on  the  Chiasma.  J.  W.  Sterling  (Annals 
of  Ophthalmology,  6,  1897,  p.  15). 

The  author  reports  a  case  of  this  character.  The  patient 
was  a  man  forty-two  years  of  age  with  total  blindness  of 
the  left  eye,  and  complete  right  hemianopsia  of  the  right  eye  There 
was  a  history  of  alcoholism,  but  none  of  syphilis.  There  was  optic 
atrophy.  Both  knee-jerks  were  slightly  exaggerated.  No  motor  or 
sensory  disturbances.  Frequent  flushings  and  perspiration  of  the  head 
and  back  of  the  neck  occurred.  The  further  course  of  the  case  was 
very  slow,  six  years  elapsing  before  death.  In  about  eighteen  months 
he  was  totally  blind.  He  became  fat  and  flabby,  always  had  a 
good  appetite,  and  was  preatly  troubled  with  continuous  sleepiness. 
The  post-nioitem  cxauiiuatior.  revealed  a  tumor  as  large  as  a  hen's 
egg  growing  from  the  meninges  and  pressing  on  the  front  of  the 
chiasma.     Microscopically  it  proved  to  be  an  endothelioma. 

Leszynsky. 

180.  A  Case  of  BulIvET  in  the  Left  HEMisprtERE  of  the  Brain 
Shown  bv  Skiagraph.  James  Bell  (Annals  of  Gynaecology  and 
Pediatry,  10,  1897,  p.  353). 

A  little  girl,  four  and  a  half  years  old,  accidentally  discharged  an 
English  "Bulldog"  revolver,  one  bullet  entering  her  brain.  The  bullet 
entered  the  forehead  over  the  centre  of  the  left  orbit,  and  rather  less 
than  half  way  from  the  margin  of  the  orbit  to  the  edge  of  the  hairy 
scalp.  She  did  not  lose  consciousness,  nor  show  any  signs  of  special 
suffering.  She  was  sent  to  the  General  Hospital,  w^here  she  was 
chloroformed,  and  an  attempt  to  remove  the  foreign  body  was  made. 
Four  fragments  of  bone  were  removed  from  the  brain  substance — one 
of  them  from  a  depth  of  an  inch  and  a  quarter  from  the  dura  mater. 
Some  dark  blood  clots  and  brain  detritus  escaped  alongside  of  the 
forceps.  The  operation  was  attended  with  failure,  as  at  each  attempt 
to  grasp  the  bullet  with  the  open  blades  of  a  forceps  it  receded  further 
into  the  cerebral  substance.  All  efforts  were  finally  abandoned. 
The  wound  was  allowed  to  heal  by  drainage  and  granulation.  The 
patient  suffered  no  ill  effects  from  the  operation,  and  made  a  rapid 
recovery.  The  child  since  being  discharged  from  the  hospital  never 
suffered  from  headache  or  any  other  brain  symptom.  She  was  alway 
a  bright  child,  but  her  parents  consider  her  even  brighter  than  be- 
fore the  accident. 

In  August,  1896  (the  accident  occurred  in  January,  1894),  the 
little  girl  was  skiagraphed  by  Professor  Callender,  of  McGill  Uni- 
versity. The  skiagraph  distinctly  showed  the  bullet  in  the  brain. 
Plates  accompany  this  report.  Abrahams. 

181.  The  Ocular  Manifestations  of  intracranial  Tumor. 
Martin  (Lancet,  July  loth,  1897,  p.  81). 

In  an  editorial  discussion  of  the  work  of  the  author,  based  on  an 
analysis  of  six  hundred  cases  of  intracranial  tumor  the  Journal  of  the 
American  Medical  Association  (September  4th,  1897)  summarizes  the 
results  as  follows.  The  distribution  of  the  new  growths  was:  Cerebel- 
lum,  138;   motor  area,   120;   frontal   area,  61;   pons  and  medulla,   45; 


PERISCOPE.  567 

paricto-occipital  area,  37;  basal  ganglia,  36;  centrum  ovale,  30; 
temporo-sphenoidal  area,  28;  pituitary,  26;  general,  19;  corpora 
quadrigeniina  15;  corpus  callosuni,  13;  crura,  5.  The  nature 
of  the  growths  was  as  follows:  sarcoma,  126;  glioma,  82;  tuberculous, 
72;  cystic,  44;  gumma,  36;  glio  sarcoma,  30;  hyjl'atids,  21;  carcinoma, 
II ;  other  varieties,  179.  Of  all  cases  of  intracranial  tumor  68.8  per 
cent,  occur  among  males.  Headache  is  more  likely  to  be  absent  in 
connection  with  tumors  of  the  motor  area  and  of  the  corpus  callosum 
than  in  connection  with  tumors  situated  elsewhere.  The  tumor  is 
generally  situated  on  the  side  on  which  internal  strabismus  is  noted. 
Onl/'Jimited  localizing  value  is  conceded  at  present  to  optic  neuritis, 
but  the  hope  is  expressed  that  imprbved  methods  of  examination  now 
in  course  of  adoption  will  give  it  greater  value  in  the  future.  When 
a  difference  in  degree  of  optic  neuritis  in  each  eye  exists,  it  is  more 
than  twice  as  probable  that  the  tumor  is  on  the  side  on  which  the 
neuritis  is  the  more  marked.  It  should  further  be  borne  in  mind,  i. 
That  optic  neuritis  is  constantly  present  in  association  with  tumors 
of  the  corpora  quadrigeniina.  2.  That  it  is  present  in  8g  per  cent,  of 
cases  of  cerebellar  tumor  and  of  tumor  of  the  posterior  part  of  the 
cerebrum.  3.  That  it  is  absent  in  nearly  two-thirds  of  the  cases  of 
tumor  of  the  pons  and  medulla  and  of  the  corpus  callosum.  4.  That 
it  is  least  frequently  met  with  in  cases  of  tuberculous  tumor,  and  is 
most  common  in  cases  of  glioma  and  cystic  tumor.  Shively. 

182.  Die  amaurotischb  Famitjare  Idiotie  (The  Amaurotic  Fami- 
ly Idiocy).  B.  Sachs  (Deutsche  medicinischc  Wochenschrift, 
24,  1898,'  p.  33)' 

Sachs  states. that  twenty-seven  cases  of  this  interesting  form  of 
idiocy  have  been  reported.  The  children  afflicted  with  this  disease 
appear  to  be  normal  during  the  first  weeks  of  life,  but  after  two  to 
eight  months  they  take  less  interest  in  their  surroundings,  become  un- 
able to  sit  up  or  hold  up  their  heads,  and  make  few  voluntary  move- 
ments. Failure  of  sight  is  noticed  after  some  months.  Weakness 
of  the  extremities  becomes  spastic  paralysis,  but  may  be  flaccid.  Con- 
vulsions are  rare.  The  reflexes  may  be  exaggerated,  normal  or  di- 
minished. Blindness,  due  to  changes  in  the  macula  lutea  and  optic 
atrophy,  is  usually  total  at  the  end  of  the  first  year,  by  which  time 
the  child  is  also  idiotic.  The  disease  attacks  several  children  in  the 
same  family.  Occasional  symptoms  are  nystagmus,  strabismus,  hy- 
peracusis  or  deafness.  Macular  changes  have  been  found  in  all  the 
reported  cases.  ^ 

In  the  two  cases  examined  by  Sachs  degenerative  changes  were 
found  in  the  large  pyramidal  cells  and  fibres  of  the  cerebral  cortex. 
The  vessels  were  normal,  and  there  were  no  signs  of  inflammation. 
Degeneration  of  the  crossed  motor  tracts  was  noticed  in  one  case, 
though  this  may  possibly  have  been  arrested  development  of  these 
tracts.  The  aetiology  is  unknown,  but  the  disease  is  not  due  to 
syphilis.  Spiller. 

183.  CENTRAI.E  BEIDERSKIllGE  AmXUKCSK   INPOIXE   ycN   METASTATI- 
SCHEN  ASCESSES    IN     BElftEN*   OCCIPITAI.I^APPEN     OHNK    SONSTIGE 

Heerdsymptome  (Bilateral  Central  Amaurosis  Resulting  from- 
Metastatic  Abscesses  in  Both  ■<')ccipital  Lobes  Without  Other  Focal 
Symptoms),  H.  »Heinersdorff  (Deutsche  med.  Wochenschrift,  23 
1897,  p.  230). 

Cases  of  bilateral  amaurosis  from  lesions  in  both  occipital  lobes 
are  uncommon,  and,  according  to  Heinersdorff,  all  the  cases  which 
have  been  reported  have  been  due  to  softening  of  the  -cerebral  sub- 


568 


PERISCOPE. 


stance  in  consequence  of  emboli.  The  writer  reports  a  case  which  he 
states  is  the  only  one  of  its  kind  in  the  literature.  A  man  became  com- 
pletely blind  within  fourteen  days,  and  suffered  from  transitory  head- 
ache and  fever.  An  abscess  developed  in  the  groin.  The  pupils  reacted 
distinctly  though  slowly  to  light.  The  eyegrounds,  the  urine,  the 
power  of  motion  and  sensation  were  normal  The  patient  was  some- 
what somnolent,  and  died  in  coma  a  few  weeks  after  the  loss  of  sight. 
At  the  autopsy  an  abscess  was  found  in  the  region  of  the  liver,  and 
one  in  each  occipital  lobe.  The  lateral  ventricles  were  filled  with  pus. 
The  cerebral  abscesses  were  supposed  to  have  been  metastatic. 

Spiller. 

184.  A  Cask  op  Tumor  of  the  Oblongata.  H.  S.  Upson  (Annals 
of  Ophthalmology,  6,  1897,  p.  136). 

The  author  reports  the  case  of  a  girl  seven  years  of  age.  who 
was  quite  well  until  she  was  three  years  old.  Then  she  began  to  have 
convulsions,  consisting  of  loss  of  consciousness,  frothing  at  the  mouth 
and  general  rigidity,  but  there  were  no  clonic  spasms.  Within  a 
month  after  the  onset  she  began  to  lose  power  in  the  left  hand,  and 
later  in  the  left  leg.  No  convulsions  in  last  three  years.  Very  little 
headache  was  complained  of.  Right  facial  paralysis  with  lagophthal 
mos,  right  convergent  strabismus  with  paralysis  of  the  external  rectus. 
Left  Upper  extremity  paralyzed.  Walking  impossible — the  feet  can- 
not be  moved  at  all,  but  the  leg  can  be  bent  at  the  knee  rather  feebly. 
No  sensory  disturbance.  All  reflexes  exaggerated  on  the  left  side. 
No  ankle-clonus.  No  tenderness  on  percussion  over  the  skull.  Pupils 
normal.  No  optic  neuritis.  Later  she  was  unable  to  sit  up.  Diffi- 
culty in  mastication  and  deglutition,  and  double  optic  neuritis. 

Leszynsky. 

185.  Tumor  (Gijoma)  of  thk  Lkft  Tkmporai.  Lobe  of  the 
Bratn;  Attempted  Rkmovai,.  M.  Allen  Starr  and  R.  S.  Weir 
(Medical  News,  11,  1897,  p.  170). 

The  authors  report  an  interesting  case  of  brain  surgery.  The 
patient,  a  woman  jet.  55,  showed  a  slowly  progressing  motor  aphasia^ 
to  which  was  added,  after  three  months,  a  rather  rapidly  increasing 
right  hemiplegia.  The  localization  was  therefore  made  of  a  tumor  in 
the  left  third  frontal  convolution  growing  backward  and  inward,  so 
as  as  to  compress  the  motor  tract  in  its  passage  toward  the  internal 
capsule.  On  this  diagnosis  an  operation  was  undertaken,  but  it  failed 
to  reveal  any  tumor  in  the  part  exposed.  The  patient,  of  course,  was 
not  relieved  of  any  of  her  symptoms.  The  wound  healed  perfectly 
without  suppuration,  the  sutures  being  removed  on  the  fourth  day. 
and  her  pulse  was  quite  regular  and  natural,  but  she  gradually  sank 
into  a  comatose  condition,  the  hemiplegia  becoming  absolute  and  the 
aphasia  total.  She  died  quietly  on  the  eighth  day  after  operation. 
At  the  autop.sy  the  tumor,  an  infiltrating  vascular  glioma:  was  found 
deep  within  the  apex  of  the  temporal  lobe.  It  must  from  its  location 
have  produced  pressure  inward  and  upward,  as  any  pressure  down- 
ward or  outward  was  prevented  by  the  walls  of  the  skull.  Such  pres- 
sure naturally  affected  the  function  of  the  parts  compressed,  and  as 
these  were  the  third  frontal  convolution  and  the  island  of  Reil  with 
the  motor  tracts  beneath  it  in  the  Ctipsule,  the  symptoms  were  neces- 
sarily misleading.  Shively. 

186.  Kin  Fa IX  von  Tumor  dkr  inner kn  Kapski,.     (Brain  Tumor). 
Jacobson  (Centralbl.  f.  Ncrvenhcilkunde,  8,  1897.  p.  244). 

The  author  reports  a  case  of  cerebral  tumor  somewhat  unusual 
in  several  aspects. 


PERISCOPE.     •'"—I  569 

The  patient,  a  child  of  5,  while  confined  to  the  bed  with  a  series 
of  acute  diseases,  gradually  developed  spastic  weakness  of  the  left  side 
with  some  anaesthesia.  The  paresis  continued  to  increase  after  the 
patient  was  out  of  bed  and  constituted  the  only  symptom,  except 
moderately  choked  discs,  and  toward  the  last  a  few  attacks  of  faintness 
without  loss  of  consciousness.  The  choked  discs  completely  disap- 
peared and  did  not  return,  and  because  of  this  and  the  inconspicuous 
general  symptoms,  the  author  was  inclined  to  diagnose  a  focus  of 
cerebral  softening  rather  than  tumor.  The  autopsy  revealed  a  tumor, 
about  the  size  of  the  thumb,  in  the  left  cerebellar  hemisphere,  and  an- 
other, as  large  as  a  small  apple,  in  the  right  cerebrum  that  destroyed 
the  entire  lenticular  nucleus,  most  of  the  posterior  limb  of  the  internal 
capsule,  and  part  of  the  optic  thalamus.    Both  were  solitary  tubercles. 

The  author  explains  the  absence  of  severe  general  disturbance,  as 
well  as  spontaneous  disappearance  of  the  choked  discs,  by  the  fact  that 
the  bones  of  the  cranial  vault  had  become  very  thin  and  elastic,  allow- 
ing them  to  bulge,  thus  in  some  degree  preventing  great  increase  of 
intracranial  pressure.  He  does  "not  consider,  however,  that  the  dis- 
appearance of  choked  disc  from  relief  of  pressure  is  absolutely  con- 
clusive proof  of  the  mechanical  pressure  as  opposed  to  the  toxic  cause 
of  this  condition,  as  an  operation  diminishing  intracranial  pressure 
may  be  conceived  to  allow  of  the  re-establishment  of  a  natural  circu- 
lation in  the  lymph  channels,  which  permits  the  removal  of  toxic 
agents  that  presumably  cause  the  optic  neuritis. 

In  the  discussion  Oppenheim  confirmed  the  disappearance  of  the 
choked  discs  in  the  present  case  in  spite  of  the  growth  of  the  tumor, 
and  was  inclined  to  favor  the  mechanical  origin  of  the  optic  neuritis. 

Schuster  also  reported  the  disappearance  of  choked  disc  in  a  tumor 
case.  A  young  woman  who  presented  all  the  principal  symptoms  of 
tumor  was  put  on  inunctions  of  mercury  and  large  doses  of  potassium 
iodide,  whereupon  the  headaches  ceased  and  the  choked  disc  disap- 
peared.  Some  months  later  she  suddenly  died,  and  the  autopsy  revealed 
in  the  left  posterior  fossa  a  glioma,  the  size  of  a  hen's  egg,  which 
showed  no  trace  of  any  action  of  the  iodide.* 

Greeff  thought  that  clinically  as  well  as  pathologically  a  differ- 
ence should  be  made  between  pure  choked  disc  (passive  congestion) 
and  optic  neuritis.  The  latter  means  severe  change  in  the  nerve  fibres; 
the  former  may  exist  to  a  marked  degree  without  damage  to  the  optic 
nerve  and  with  normal  vision  and  visual  fields.  Patrick. 

187.  GuoM  DKR  Medui,i,a  OBLONGATA.  (Glioma  of  the  Medulla  Ob- 
longata). J.  Collins  (Deutsche  Zeitschr.  f.  Nervenheilk.,  10,  1897, 
p.  453). 

The  first  symptom  noticed  in  this  case  was  parsesthesia  in  the 
fingers  of  the  left  hand  and  later  in  the  left  upper  and  left  lower  limbs. 
Incoordination  of  the  left  hand  and  left  leg,  paresthesia  in  the  left 
side  of  neck  and  occipital  region,  insecurity  in  the  standing  position 
with  inclination  toward  the  right  side,  exaggeration  of  both  patellar 
reflexes,  ankle  clonus  of  the  right  side  with  some  diminution  of  motor 
power  on  this  side  of  the  body,  almost  complete  analgesia  of  the  body, 
and  especially  on  the  left  side,  with  preservation  of  tactile  sense  were 
noted.  The  cardinal  symptoms  of  brain  tumor — optic  neuritis, 
vomiting,  vertigo,  headache,  etc.,  were  absent.  There  were,  therefore, 
no  distinct  localizing  symptoms.  At  the  autopsy  the  oblongata  was 
found  to  be  asymmetrically  increased  in  size,  and  a  new  growth  pro- 

*  A  similar  case  has  been  seen  by  the  rcTiewer  who  referred  the  good  effects  of  the 
iodide  to  the  relief  of  the  secondary  oedema,  and  hence  the  pressure,  without  any 
diange  in  the  growth  itself. 


570 


PERISCOPE. 


jected  from  the  dorsal  aspect  into  the  fourth  ventricle.  The  oblongata 
was  a  mere  shell  about  the  tumor.  Microscopic  examination  showed 
that  the  growth  was  a  glioma,  and  that  it  had  in  large  part  destroyed 
the  oblongata,  although  the  symptoms  had  been  rather  indefinite  and 
had  lasted  nearly  two  years.  Sfiller. 

188.  A  Cask  of  Cerebrai,  Ur-«mia  with  Catalkptoid  Attitudbs. 
E.  J.  Kempf  (American  Practitioner  and  News,  23,  1897.  p.  40). 

A  woman,  aged  29,  had  convulsions  in  her  first  three  confinements. 
The  fourth,  fifth  and  sixth  labors  were  normal.  In  the  seventh,  con- 
vulsions again  came  on  just  as  the  first  stage  of  labor  w^as  about 
completed,  and  lasted  for  several  hours.  Afterward  the  patient  be- 
came quiet  for  several  days;  everything  was  normal.  On  the  fourth 
day  she  again  had  convulsions.  During  the  next  two  weeks  a  difficulty 
of  breathing  developed  gradually  into  the  peculiar  rhythm  of  Chcync- 
Stokes  respiration.  There  was  no  visceral  or  pelvic  inflammation, 
and  no  odor  to  the  lochia.  The  temperature  oscillated  between  97  and 
104°  F.  At  times  there- were  vomiting,  double  vision  and  hallucinations. 
The  amount  of  urine  varied  between  16  and  35  ounces,  the  quantity  of 
albumin  between  i  and  16  grains  per  ounce  and  the  total  urea  excreted 
amounted  to  from  200  to  400  grains  in  the  twenty-four  hours.  The 
urine  also  contained  mucous,  epithelial  and  hyaline  casts.  At  times 
she  would  walk  without  much  effort  and  seemed  to  possess  full  con- 
sciousness; then  without  any  premonition  she  would  pass  into  a  state 
of  hebetude;  on  lifting  her  hand  it  was  noticed  that  the  joints  were 
rigid  and  the  arm  remained  in  the  position  in  which  it  had  been  held, 
but  gradually  descended  by  its  weight  to  its  place  on  the  bed.  The 
legs  were  in  the  same  condition  as  the  arms.  In  spite  of  the  rigidity 
and  delusions,  she  had  not  lost  all  consciousness  but  was  in  a  state 
of  hebetude  from  which  she  could  be  aroused  for  a  few  seconds.  When 
she  recovered  full  consciousness,  she  described  some  of  her  impres- 
sions and  talked  about  her  delusions.  It  was  not  therefore  a  case  of 
true  catalepsy.  The  convulsions  were  of  a  tonic  type  and  of  a  cata- 
leptoid  character,  and  the  cerebral  symptoms  were  evidently  of  the 
nature  of  uraemic  manifestations.  The  patient  improved  slowly  and 
though  still  an  invalid  is  now  able  to  be  up  and  do  light  housework. 
The  cataleptoid  condition  described  in  this  case  is  a  phenomenon 
only  discovered  when  carefully  looked  for.  In  this  patient  it  lasted 
for  nearly  three  weeks.  The  cerebral  phenomena  are  to  be  attributed 
to  certain  pathological  changes  due  to  the  retention  of  effete  products. 
An  interesting  point  in  the  case  is  that  a  patient  can  have  four  distinct 
attacks  of  puerperal  convulsions  and  continue  to  live.  Another  inter- 
esting feature  was  the  recurrence  first  of  puerperal  convulsions  of  a 
clonic  form  with  apparent  recovery  and  after  a  few  H;  v-  t:i"  cataleptoid 
condition,  lasting  three  weeks  and  followed  by  -'  •'■  <ient  recovery. 
It  is  plausible  to  say  this  is  one  of  those  cases  fon-i  <\y  classed  under 
the  title  of  hysteria,  but  which  more  and  more  are  1  ei:i;4  understood 
as  due  to  a  poisoned  condition  of  the  system  caused  I 
assimilative  or  excretory  organs. 


defect  of  the 
Freeman. 


189.  ZwEi  FXtj.k  von  Tabks  Dorsaus  MIT  Spkrmtnum-Poehi,  bb- 
HAxnici;r  (Two  Cases  of  Tabes  Treated  with  Sperminum-Poehl). 
M.  Werbitzky  (Deutsche  Med.  Wochensch.,  23,  1897,  p.  67;  Ther- 
apeutische  Beilage). 

The  author  concludes  that  the  treatment  has  resulted  in  increase 
of  all  forms  of  sensory  impressions,  with  diminution  of  pain  and  im- 
provement of  the  general  tone.  There  was  increase  in  muscular 
strength  and  muscular  sensibility,  diminution  of  the  ataxia,  and  an 
improvement  in  the  eye  symptoms.  Vogel. 


r  T-.f  i^  FTf  r<Tr<TTiYr>T^^TTrf  nf  TTf  rrf  nf  Tf'  .f  T-Tf  .  .f  rfnTrif  ii^  rrjr. 


I  Cocaine  Discoids  "Sd^Ms" : 

f  The  Safest,  Most  Effident,  and  Convenient  Means 
\  for 'Prodttdng  Local  Anaesthesia, 

I  Cocaina  IMscoids  consist  of  pure  cocaine  bydrochlorate,  irithont  admixtttre  of  foreign 

f  material  to  impair  its  activity,  and  in  quantities  accurately  detonnined  by  weight.  Owing  to 

'  their  mode  of  manufacture,  not  toeing  compressed,  theydissolveteadilv  in  one  drop  of  water. 

f  Instead  of  keepine  on  band  ready-made  solutions,  which  are  liable  to  detenorate,  the 

^  doctor  has  no^  at  ois  dicpoaal  a  means  of  obtaining 

'f  Frexhly  Prepared  Cocaine  Solutloiu  of  Any  Desired  Atrenstb 

f  at  a  tnotaenfs  notice,  and  the  quantity  of  the  drug  employed  during  oncesthesia  is  always 

t  known,  and  not  a  matter  of  conjecture. 

E  Cocaine  Djscoids  are  indicated  in  all  conditions  demanding  the  use  of  tbia  drug,  as  a 

t  local  ansGthetic,  as  in  the  treatment  of  diseases  of  tlie  eyes,  nose  and  throat,  in  general 

L  Slurry,  and  in  dentistry,  especially  for  cataphoresis. 

\  Par  tube  of         Pv  1»ttl4  ot 

t  Piscoida  containing  ^  gr.  .14  .50 

\  "  "         tgr.  .16  .56 

t  "  "  i  gr.  .16  .60 

£  "  "  Jgr.  .18  .70 


Cocaine  Discoids  are  manufactured  solely  by 

Schieffelm&Co.,Nev)York.  ^ 


f.t.  .*..fc.  .fc.  .fc.  .».  jA.  .*.  .*.  .ii.A..*.  .l..i..A..A.  .A..*. . 


Schieffeim's   1, 

c/l[kaline  c/lntiseptic  and  'Prophylactic.  ] 

Bensolyptas  h  an  agreeable  alkaline  solution  of  various  highly 
approved  antiseptics,  so  combined  that  one  supplements  the  action  of 
the  other.    Its  ingredients  are  all  of  recognised  value  in  the  treatment 

Catarrhal  c4ffedions 

because  of  their  cleansing,  soothing,  and  healing  properties.  Benso- 
l^ptus  is  highly  recommended  in  all  diseases  of  the  nose  and  throat, 
both  acute  and  chronic,  and  as  a  mouth-ivash  and  dentifrice.  _  It  is 
also  indicate  for  internal  use  in  affections  of  the  stomach  and  intes- 
tines 'Ufhere  nn  agreeable,  unirritating,  and  efficient  antiseptic  and 
antifermmtative  is  required. 

Pamphlets  on  apoticaiion  to 

Schieffelin  &  Co.,  New  York. 


linota  slmfk saatriede- 
mitiment  theprecursor  of 
mostcases  of  Summer  D/aj^ 
thoea  In  children?  An  not 
the  majoilh/ -af  theae  cases 
Dy^pHcIn  orliln?  Wla/nof- 
admlnlater 


ear/yf  j/ou  'my  '  'nip  if  in 
/he  6uJ."  By  rlShHni  the 
(flies/ion  and  VJpplulnS 
the  iackini  fermenns  do 
you  not  pave' /he  u/ay  for 
subsequent  antla^lc  /reat- 
mentf 
Qaaiiy-eouiaeieHioniatioa^f 

/faa  any  ofher  fine  ^ 
/rea/me/rt  prova</  merv 
e/flec/ua/.'         ,     , 

otmpits  Am/ 
fittfvfut9  efieo 


r^al^^  .C7  1838  ', 


[Rental  Disease 

Articles. 

ClAL  PARALYSIS.* 
[OMAS.  M.  D., 

Fohoi  Hopkins  UoiTRiUy:  Kmrologlit  of 

^reat  deal  of  interest  has  been 
lalitjes  of  muscles.  The  ab- 
i,  or  parts  of  muscles,  has  been 
id  although  such  a  congenital 
mon,  still  a  considerable  num- 
d. 

sem  to  be  particularly  prone 
iment,  as  by  far  the  greatest 
las  to  do  with  these  muscles. 
:linic,  and  Kalisher^  have  col- 
cases.  Many  of  the  cases 
lormalities,  such  as  malforma- 
vebbed  fingers,  etc.,  etc. 
gain  in  1892,  called  attention 


Ceurological  Association.  May,  il 
,-..  vol  exlvi.,  1896,  p.  163. 
Ibl.,  vol.  XV..  1896,  pp.  685,  732. 
^ochenschr.,  xxxv..  No.  6,  7,  li 


572  //.  M-  THOMAS. 

to  an  interesting  group  of  cases,  in  which  there  was  a 
congenital  defect  in  the  movements  of  the  eyes,  com- 
bined, at  times,  with  a  similar  defect  in  the  facial  muscles. 
With  these  he  associated  certain  cases  which  developed 
in  infancy  or  childhood,  and  called  them  all  infantile 
nuclear  atrophy  (infantilen  Kemschwund),  for  he  be- 
lieved that  the  process  was  essentially  the  same  in  all  the 
cases — a  degeneration  and  atrophy  of  the  nuclei  of  the 
cerebral  nerves. 

The  muscles  of  the  eye  were  affected  in  all  of  the 
cases  that  Mobius  collected.  That  the  facial  muscles 
might  be  affected  alone,  he  thought  was  probable,  al- 
though he  had  been  unable  to  find  any  record  of  such 
cases. 

Schultze,*  in  1892,  and  Bernhardt,^  in  1894,  report 
cases  of  unilateral  congenital  facial  paralysis.  I  shall  re- 
fer to  these  cases  again. 

Kunn,®  of  Vienna,  in  1895,  in  a  monograph  considers 
the  congenital  defects  in  the  movements  of  the  eyes.  (Die 
angeborenen  Beweglichkeitsdefecte  der  Augen.)  He  has 
abstracted  and  tabulated  all  the  cases  he  could  find  in 
literature.  Among  these  73  cases,  there  were  1 1  in  which 
the  facial  muscles  were  also  involved.  He  refers  to  sev- 
eral cases  of  uncomplicated  congenital  facial  muscular  de- 
fect. As  opposed  to  Mobius,  he  makes  a  sharp  distinc- 
tion between  congenital  cases  and  those  which  develop 
after  birth,  and,  as  the  anatomical  basis  for  the  congenital 
cases,  he  assumes  a  lack  of  development  somewhere  in  the 
motor  path  from  the  brain  to  the  muscles. 

Last  year  Schmidt^  reported  a  case  in  which  there  was 
an  absence  of  the  left  pectoral  major,  combined  with  de- 
fects in  the  muscles  supplied  by  the  XH.,  VH.  and  VI. 
cerebral  nerves. 


*Schultzc:    Neiirolog.  Centralbl,  xL,  1892,  p.  425. 
"Bernhardt:    Ibid.,  xiii.,  1894,  p.  2. 

"  Kunn:    Beitrage  ziir  Augenhcilkundc,  Heft  xix.,  1895,  p.  i. 
^Schmidt:    Deutsche  Zeitschrift.  f.  Nervenheilk.,  x.,  1897.  o.  400. 


i 


CONGENITAL  FACIAL  PARALYSIS.         *'    573 

From  this  short  glance  at  the  Hterature,  it  may  be 
stated  that  congenital  abnormaHties  of  the  muscles  oc- 
cur not  very  infrequently;  that  they  are  most  common  in 
the  pectoral  muscles  and  the  muscles  of  the  eyes,  and 
that  the  facial  muscles  are  at  times  implicated,  usually 
in  association  with  those  of  the  eyes,  but  at  times  alone. 

The  facial  defect,  when  it  has  been  combined  with  that 
of  other  muscles,  has  been  bilateral;  when  it  has  been  un- 
complicated, it  has  been  unilateral. 

As  far  as  I  have  been  able  to  discover,  a  satisfactory 
case  of  congenital  facial  diplegia  has  not,  or,  rather,  had 
not  been  reported  until  I  showed  one  of  my  cases  to  the 
Johns  Hopkins  Hospital  Medical  Society.  The  two  cases 
which  I  have  observed  have  an  added  interest,  as  thcv 
are  brothers. 

Seth  O.,  aet.  21;   Basher  O.,  aet.  19. 

The  |>arents  of  these  two  bovs  are  strong,  healthy  country 
people.  There  is  no  history  of  alcoholism  and  no  reason  to 
suspect  syphilis.  Tlie  mother's  aunt  gave  birth  to  a  child  with 
only  one  arm,  and  the  mother  herself  had  a  baby  with  a  de- 
formed foot.  This  child  lived  only  two  hours.  Other  than 
this  there  is  no  history  in  the  family  of  congenital  deformities. 
The  mother  accounts  for  the  ccndition  of  her  boys  by  "ma- 
ternal impression'',  as  she  had  been  very  much  affected,  while 
pregnant  with  the  first  boy,  by  hearing  of  a  minister  in  her 
church  who  was  unable  to  move  any  of  the  muscles  of  his  face. 
Before  the  birth  of  the  second  case  she  was  very  anxious  for 
fear  that  this  child  would  be  born  also  with  a  deformed  face. 
It  may  be  remarked  in  passing,  that  her  anxiety  about  the 
faces  of  the  subsequent  children,  of  whom  there  were  three, 
all  boys,  had  no  effect  upon  th'e  development  of  their  facial 
muscles.  An  elder  daughter  is  also  perfectly  normal.  Three 
other  children  died  in  infancy. 

Case  I. — Seth  O.,  aet.  21.  The  patient,  a  second  child,  was 
born  without  instnmients,  although  the  labor  was  difficult  and 
protracted.  His  mother  noticed  soon  after  his  birth,  that  his 
under  lip  drooped,  and  that  he  did  not  close  his  eyes  when 
sleeping.  He  was  able  to  suck  without  difficulty  by  the  use 
of  his  tongue.  When  he  was  old  enough  to  smile,  his  face 
remained  expressionless.  The  patient  learned  to  walk  at  thir- 
teen months,  and  to  talk  when  about  two  years  old,  although 
he  has  never  learned  to  pronounce  certain  words  distinctly. 


574  M.  Af.  THOMAS. 

Dentition  began  very  early,  ilie  nrst  tooth  being  cut  when 
he  was  iittle  more  than  six  weeks  old.  He  developed  norm- 
ally, learned  to  run  and  play  games  as  other  boys,  and  except 
for  his  expressionless  face  there  was  nothing  to  be  noticed 
about  him.  He  left  school  when  be  was  twelve,  as  he  then 
became  sensitive  as  to  his  appearance.  As  a  child  he  was  ill 
with  measles,  and  his  mother  thinks  that  his  deafness  is  a  rt- 


Ft:;.   I.     (Case   i.) 

suit  of  this  disease,  althcngh  he  had  no  discharge  from  'i'^ 
cars,  or  any  symptoms  referable  to  it. 

The  examination  (Nov.  3d,  i8y6)  at  his  home  in  a  ticig"' 
boring  State,  shows  him  to  be  in  general  a  well -develops' 
young  man,  rather  shorter  than  the  average  {Fig.  I.)  9'* 
intelligence  seems  to  be  good,  his  speech  is  somewhat  m- 


coxcjixrr.iL  i-acial  paralysis.  575 

distinct,  as  the  labials  cannot  be  given  their  proper  sounds. 
B  is  pronounced  D,  ]•"  ech.  AI  is  N,  V  is  eh  or  ge,  the  sound 
of  W  is  poorly  {;iven.  His  face  is  perfectly  expressionless, 
forehead  smooth,  without  wrinkles,  eyes  wide  open,  mouth 
open,  lower  lip  large  and  everted.  The  lobe  of  the  left  ear 
is  misformed,  there  heing  a  distinct  division  between  the  part 
next  to  the  cheek  and  the  rest  of  the  ear.  On  the  right  side 
there  is  some  indication  uf  this  abnortnalitv.     His  teeth  are 


Fio.   II.     (Cast  2.)     Face  in  repose. 

fairly  well  formed.  The  senses  of  fniell  and  sight  show  no 
marked  abnormality.  His  eyeballs  arc  not  especially  prom- 
inent, are  straight  and  freely  moveable  in  all  directions,  and 
there  is  no  nystagmus.  The  pupils  are  equal  and  react  to  light 
and  during  accommodation. 

The  muscles  of  mastication  act  well  and  equally  on  the 
two  sides.  Sensation  in  the  face  is  normal,  and  the  sense  of 
taste  is  unnflfccted. 


576  H-  M.  THOMAS. 

The  patient  is  entirely  unable  to  raise  or  to  contract  his 
eyebrows.  \\  ben  trying  to  close  iiis  eyes,  the  eyeballs  are 
rolled  up  and  the  iippi-r  lids  are  somewhat  relaxed.  He  is 
unabk  to  elevate  his  upper  lips  or  to  pucker  his  mouth,  or 
indeed  to  close  it.  On  the  risfht  side  he  is  able  to  draw  the 
angle  of  his  mouth  somewhat  outwards.  Tliis  motion  is  im- 
imssibte  on  the  left  side.   He  can  depress  and  retract  the  angles 


I'ln,  111.    (.Case  2.)     Face  in  repose. 

The  muscles  of  the  soft  palate  act  normally;  the  pharyngeal 
reflex  is  active.  lie  protrudes  his  tongue  in  the  middle  line, 
and  is  able  to  move  it  freely  in  all  directions.  The  action  of 
of  his  mouth  by  the  action  of  the  platysmse.  An  electrical 
examination  could  not  be  made.  The  patient  is  quite  deaf  in 
both  ears,  being  just  able  to  hear  a  loud-ticking  watch  upon 
contact. 


COXCEXITAL  FACIAL  PARALYSIS.  577 

his  heart  is  normal  in  all  respects.  The  muscles  of  his  shoulder 
girdle,  arms,  hauds,  trunk  and  legs  are  well  developed  and 
of  normal  strength.  The  deep  reflexes  are  normal,  and  no 
other  abnormality  of  any  kind  is  discovered. 

Case  II,— Basher  O.,  ;et.  19. 

Birth  norma!.  The  defect  in  the  baby's  lace  was  noticed 
fthortlv  after  his  birth.      He  was  nble  to  nurse,  as  was  his 


Fic.  IV.     (Case  2.)     Showing  extent  of  voluntary  control  of  muscles. 

brother,  by  the  use  of  his  tongue.  He  developed  very  much 
as  his  brother  did.  When  he  learned  to  speak,  there  was  the 
same  difficulty  in  pronouncing  words,  etc.  He  cut  his  teeth 
at  the  usual  time.  He  was  an  active  boy,  fond  of  all  out-door 
games.  The  facial  defect  never  changed  from  his  earliest 
infancy.     He  has  learned  to  smoke,  holding  the  cigarette  in 


578  H.  M.  THOMAS. 

his  tongue,  and,  indeed,  he  has  taught  his  tongue  to  do  many 
of  the  services  that  are  usually  performed  by  the  lips. 

Present  condition.    Nov.,  1896.    Figs.  II.  to  V. 

The  patient  is  a  well -developed  youth.  His  inteliigence 
is  good.  His  speech  shows  the  defect  noted  in  the  case  of  his 
brother,  that  is,  he  is  unable  to  pronounce  the  labials.  His 
face  is  remarkably  expressionless,  eyes  are  wid«  open  am! 


Fio,   V.      (Case  2.)      Faradic   stimulation   of   platysma. 

prominent,  mouth  is  held  open,  lower  lip  is  large  and  pendu- 
lous. The  lower  jaw  is  protruded,  the  lower  teeth  being  more 
than  half  an  inch  beyond  the  upper  teeth.  His  teeth  are  poorly 
develoi>ed.  The  lobe  of  the  right  ear  is  notched,  in  a  similar 
manner  to  that  of  his  brother. 

The  patient's  vision  is  normal,  his  eyes  are  in  the  median 


CONGENITAL  FACIAL  PARALYSIS.  579 

line,  freely  moveable  in  all  directions,  and  there  is  no  nystag- 
mus. The  pupils  are  equal  and  react  to  light  and  during  ac- 
commodation. The  muscles  of  mastication  are  unaffected. 
the  sensation  of  the  face  is  normal.  Taste  is  acute  on  the  fore 
part  of  the  tongue.  He  is  unable  to  elevate  or  contract  his 
forehead  in  the  least.  When  endeavoring  to  close  his  eyes, 
the  eyeballs  are  rolled  upward  and  the  lower  lids  are  relaxed 
(fig.  IV.).  He  cannot  elevate  his  upper  lip,  but  is  able  to  re- 
tract and  depress  the  comers  of  his  mouth  by  the  use  of  the 
platysma.  The  buccinators  have  also  retained  some  power. 
Electrical  stimulation  from  the  root  of  the  facial  nerve  causes 
contraction  in  the  muscles  which  can  be  voluntarily  moved, 
and  in  those  moving  the  ear.  By  direct  stimulation  the  pla- 
tysma can  be  brought  into  play  (Fig.  V.).  It  takes  relatively 
strong  current  to  produce  these  contractions.  The  patient  is 
deaf  in  both  ears,  and  can  hear  a  loud-ticking  watch  only 
when  it  is  within  two  inches  of  his  ears.  The  movements  of 
the  soft  palate  and  tongue  are  normal.  The  pharyngeal  re- 
flexes are  normal.  The  development  in  the  arms,  trunk  and 
legs  is  excellent.    Nothing  else  abnormal  is  noticed. 

The  patient  entered  the  hospital  in  Dr.  Halsted's  wards 
and  underwent  two  plastic  operations  devised  to  bring  his  lips 
closer  together.  In  the  first  operation  a  bit  of  lower  jaw  was 
excised,  and  in  the  second  the  redundant  portion  of  the  lip 
was  cut  away.  There  was  marked  improvement,  his  lips  be- 
ing nearly  approximated. 

During  the  second  operation  it  was  noticed  that  there  was 
very  little  muscular  tissue  in  the  lip,  it  being  composed  largely 
of  fat.  Fibres  of  what  was  supposed  to  be  the  platysma  were 
made  out. 

That  the  muscle  defect  in  these  cases  is  a  congenital 
one,  I  think  cannot  be  doubted.  In  the  first  place,  the 
mother  is  quite  sure  that  the  defect  was  present  when  the 
children  were  bom,  although  she  cannot  state  that  she 
noticed  the  deformity  immediately  after  birth.  The  fact 
that  the  malformation  occurred  in  two  members  of  the 
same  family,  and  that  it  is  bilateral,  speaks  for  its  congeni- 
tal origin,  and  the  occurrence  of  other  faults  in  develop- 
ment, the  misshaped  ears,  and,  possibly,  the  deafness,  lends 
added  weight  to  this  view.  The  character  of  the  paralysis 
itself  is  quite  similar  to  that  which  was  found  in  the  other 
congenital  cases. 

There  are  14  cases  of  facial  paralysis  combined  with 


580  H.  M.  THOMAS. 

eye-muscle  defect;  these  have  been  reported  by  Graefe,* 
1880;  Harlan,^  1881;  Chisolm/^  1882;  Armaignac,^^  1886; 
M6bius,^2  jggg.  Schapringer,"  1889;  Bernhardt/*  1890; 
Bloch/*^  1891;  Fryer,^«  1892;  Bach,"  1893;  Remak/» 
1894;  Gesepy/^  1894;  Schmidt  (loc.  cit.),  and  Procopo- 
vici,^^   1896. 

I  have  not  included  Rechin's  two  cases,  because  in  the 
one  the  onset  is  said  to  have  been  in  the  fourth  year,  and 
in  the  other  there  was  no  true  facial  paralysis,  nor  Hanke's 
case,  as  the  history  of  the  onset  is  not  satisfactory. 

In  these  14  cases,  the  defect  in  the  VII.  nerve  was  com- 
bined with  that  in  the  VI.  no  less  than  12  times,  and  in  7 
cases  there  were  no  other  cranial  nerves  involved.  In  one, 
the  sensory  portion  of  the  V.  was  also  involved,  and  in 
another  there  was  a  partial  defect  of  the  motor  V.  and 
of  the  XII.,  and  in  2  cases  the  external  ophthalmoplegia 
wa^  practically  complete,  involving  the  III.  and  IV.  nerves 
as  well  as  the  VI.  The  fifth  case  is  the  interesting  one 
reported  by  Schmidt,  in  which,  combined  with  the  pa- 


'Graefe:    Case  4,  Handbuch  d.  ges.  Augenheilk.,  1880,  vol.  vi., 
p.  60  ,  cit.  from  Kunn. 

•Harlan:    Case  i,  Trans,  of  the  Am.  Opthal.  Soc,  1881,  p.  216, 
"Congenital  Paralysis  of  Both  Abducens  and  Both  Facial  Nerves." 

^^'Chisolm:  Archives  of  Ophtholmology,  vol.  xi.,  1882,  p.  323. 

'^Armaignac:    Case  3,  Rev.  Clin.  d'Oculistique,  November,   1886, 
cit.  from  Kunn. 

*•  Mobius:     Miinch.    med.   Wochenschr.,    1888,    No.   667,    "Uebcr 
angeborene  doppelseitige  Abducens  Facialislahmung." 

"  Schapringer:    New  York  med.   Monatschrift,   December,   1889; 
Boston  Med.  and  Surg.  Jour.,  1889,  p.  635. 

"  Bernhardt:    Neurolog.  Centralbl.,  1890,  vol.  ix.,  p.  419.  "Ucber 
angeborene  einseitige  Trigeminus  Abducens  Facialislahmung." 

"Bloch:    Berlin  Thesis,  1891. 

"  Fryer:  Ann.  Opthal.  u.  Otolog.,  Kansas  City,  1892,  "Case  of  Con- 
genital, Bilateral,  Ext.  Opthal.  and  Cong.  Bilateral  Facial  Paral- 
ysis," cit.  from  Kunn. 

"Bach:    Centralbl.  f.  Nervenheilk.,  xvi.,  1893,  P-  57- 

"Remak:    Neurolog.  Centralbl.,  1894,  No.  7,  "Ein  Fall  von  cin- 
seitigem  angeborenem  Defect  des  Platysma  myoides." 

"Gesepy:   Arch.   d'Opthal.,   xiv.,    1894,   No.  5,   273,   "  Deux*  Cas 
d'Ophthalnioplegie  Congen.  Externe." 

**  Procopovici :  Arch.  f.  Augenheilk.,  xxxiv.,  p.  34,  "  Ueber  ange- 
borene, beiderseitige  Abducens  Facialislahmung. 


tt 


CONGENITAL  FACIAL  FAHALVSIS.  5S1 

ralysis  of  the  VII.  and  VI.  nerves,  there  was  an  unequal 
paralysis  of  the  XII.  pair,  the  left  more  than  the  right, 
and  an  absence  of  the  pectoralis  major  muscle  on  the 
left  side. 

The  defect  was  bilateral  in  all  of  these  12  cases,  except 
in  Bemhardt's  case,  in  which  the  paralysis  was  confined 
to  the  right  VII.,  VI.  and  V.  nerves.  Bernhardt  believed 
that  the  condition  was  caused  by  some  injury  to  the  nerves 
at  the  base  of  the  brain,  which  they  had  received  dur- 
ing birth,  and  it  is  doubtful  whether  the  case  should  be 
included  with  the  others.  I  shall  have  to  return  to  this 
case,  in  speaking  of  the  pathology  of  the  condition. 

The  two  cases  in  which  the  VI.  nerve  was  normal  are 
of  particular  interest.  The  first  is  that  of  Armaignac,  in 
which  there  was  a  left-sided  defect  of  the  orbicularis  palp., 
and  probably  also  of  the  frontalis,  combined  with  paralysis 
of  the  levator  palp,  and  the  superior  rectus  on  the  same 
side.  Remak's  case  is  the  second.  In  this  case  the  left 
platysma,  including  the  quadratus  and  triangularis  menti, 
was  absent  or  paralyzed,  and  there  was  also  a  bilateral 
defect  in  the  levator  and  the  superior  rectus. 

As  a  rule,  all  the  muscles  supplied  by  the  VII.  were 
not  affected.  In  Schmidt's  case  there  was  complete 
paralysis.  The  notes  in  Fryer's,  Bernhardt's,  Schap- 
ringer's  and  Bach's  cases  are  not  specific  on  this 
point.  Therefore,  in  the  10  cases  in  which  there  was 
a  definite  note,  the  paralysis  was  incomplete  in  9. 
The  muscles  which  draw  the  mouth  outwards  and 
downwards  (the  platysma,  etc.)  are  particularly  likely  to 
be  spared.  They  were  spared  alone  four  times;  once  the 
orbicularis  palp,  was  also  not  affected,  and  in  two  other 
cases  the  paralysis  was  confined  to  the  upper  branch  of 
the  VII.  In  Bloch's  case  this  paralysis  was  of  the  lower 
branch  of  the  VII.  In  Remak's  patient  the  platysma, 
the  quadratus  menti,  and  the  triangularis  menti  were  the 
only  muscles  paralyzed,  involving  just  the  muscles  which 
are  usually  spared. 


I 


582  H.  M.  THOMAS. 

There  are  6  cases  in  which  there  was  an  uncomplicated 
congenital  facial  paralysis.  These  have  been  reported  by 
Stephan,^^  Henoch,"  Schultze,^^  Bemhardt,^*  Procopo- 
vici^^  and  Bernhardt.^®  I  have  not  included  Delprat's  case 
(cit.  after  Mobius),  as  there  is  the  definite  history  of  the 
onset  at  three,  after  an  acute  illness;  nor  Kunn's  case,  as 
there  is  here  a  very  different  condition,  a  right  hemi- 
atrophy of  all  the  structures  of  the  face  below  the  eye; 
bones  as  well  as  muscles. 

In  all  of  these,  except  in  Procopovici's  case,  the  defects 
were  unilateral,  three  times  on  the  left  and  twice  on  the 
right  side.  I  shall  speak  of  Procopovici's  case  a  little  fur- 
ther on,  as  it  belongs  more  to  the  cases  which  I  have 
been  reporting  than  to  these. 

In  all  but  Stephan's  and  Henoch's  cases  the  paralysis 
was  incomplete,  and  it  was  the  muscles  about  the  mouth 
that  were  spared.  In  fact,  the  clinical  picture  differs  in 
no  way,  except  in  being  unilateral  and  uncomplicated, 
from  that  of  the  VII.  nerve  paralysis  in  the  combined 
cases.  Bernhardt,  in  trying  to  answer  the  question  as  to 
whether  these  cases  should  be  considered  as  strictly  con- 
genital, shows  that  they  differ  in  no  way  from  those  which 
are  caused  by  injury  to  the  VI I.  nerve.  That  all  the 
muscles  supplied  by  the  VII.  nerve  are  not  paralyzed,  and 
that  there  is  no  secondary  contraction,  does  not,  as  Kunn 
thought,  serve  to  distingish  them. 

Facial  paralysis  due  to  the  injury  of  the  nerve  at  birth 
is  not  a  very  uncommon  accident;  it  is  usually  caused  by 
the  application  of  forceps,  but  may  occur  even  during 


I 


I  » 


"Stephan:    Rev.  de  Med.,  July,  1888,  p.  548,  and  Nederl.  Tijd- 
schrift,  1888,  p.  113,  cit.  from  Bernhardt. 

'"Henoch:  Vorlesungen  iiber  Kinderh.,  1897,  ix.  Auflage.     Also 
abst.  Bernhardt,  Neurolog.  Centralbl.,  ix.,  p.423. 

Schultze:    Neurolog.  Centralbl.,  xi.,  1892,  No.  14,  p.  425. 

**  Bernhardt:    Neurolog.  Centralbl.,  1894,  xiii.,  p.  2. 

Procopovici:    Arch.  f.  Augenheilk.,  1896,  xxxiv.,  p.  44. 

Bernhardt:    Neurolog.  Centralbl.,  xvi.,  1897,  p.  296. 


CONGENITAL  FACIAL  PARALYSIS. 


58: 


normal  labor.  ^'^  ^®  This  paralysis  is,  in  the  great  ma- 
jority of  cases,  a  transient  one,  and  the  recovery  is  quite 
complete.  In  some  cases,  however,  the  paralysis  does  not 
get  well,  and  the  condition  persists  throughout  life.  When 
this  is  the  case,  the  symptoms  are  identical  with  those  de- 
scribed in  the  five  cases  under  discussion. 

As  an  example  of  this,  I  may  give  briefly  the  history  of 
a  case  that  I  have  had  under  observation  for  some  time. 
The  patient  is  a  young  man  of  excellent  health,  who,  ex- 
cept for  his  facial  paralysis,  shows  no  abnormalities.  He 
has  been  told  by  his  parents  that  the  condition  was  no- 
ticed directly  after  birth,  and  that  his  birth  was  very  pro- 
tracted and  difficult.  He  thinks  forceps  were  used,  al- 
though of  this  he  is  not  certain.  He  is  certain,  however, 
that  the  paralysis  has  always  been  ascribed  to  injuries 
received  to  his  face  during  birth,  and  that  the  condition 
has  not  changed  since  he  can  remember.  At  present  the 
left  side  of  his  face  is  almost  completely  paralyzed.  The 
forehead  cannot  be  raised  nor  the  eye  closed,  nor  the  upper 
lip  elevated,  and  the  lips  cannot  be  puckered.  He  can, 
however,  draw  the  left  angle  of  his  mouth  outwards, 
throwing  the  cheek  into  longitudinal  folds.  He  is  not 
able  to  contract  voluntarily  the  platysma  on  either  side. 
Electrical  stimulation  of  the  left  VH.  nerve  causes  con- 
tractions of  the  muscles,  moving  the  angle  of  the  mouth 
outwards,  and  nothing  else.  Another  patient,  a  woman, 
34  years  old,  who  has  a  left-sided  facial  paralysis,  gives 
the  history  of  having  had  it  since  her  birth,  which  was 
non-instrumental;  but,  as  I  have  been  unable  to  confirm 
the  history,  I  shall  simply  mention  it  in  passing. 

Bernhardt,  with  great  fiaimess,  concludes  that,  al- 
though the  occurrence  of  an  isolated,  unilateral,  congeni- 
tal facial  paralysis,  or,  perhaps,  better,  an  incomplete  de- 
velopment of  the  nerves  and  muscles  in  the  distribution 

"Geyl:    Centralbl.  f.  Gynakologie,  xx.,  1896,  p.  634. 
"Knapp:    Ibid.,  xx.,  1896,  p.  705. 


« 


584  H.  M.  THOMAS. 

of  the  facial  nerve  on  one  side,  cannot  be  denied,  still,  its 
occurrence  has,  as  yet,  not  been  definitely  demonstrated. 

Procopovici  (loc.  cit.  p.  45)  refers  briefly  to  an  in- 
teresting case,  which  he  says  had  lately  come  under  ob- 
servation. It  is  that  of  a  man,  18  years  old,  in  whom 
there  had  been,  since  his  birth,  a  paralysis  of  the  upper 
branch  of  the  facial  nerve.  All  the  muscles  which  are 
supplied  by  the  facial  nerve  were  active,  except  only  the 
orbicularis  oculi  and  the  frontalis,  which  were  paralyzed 
on  both  sides  in  almost  equal  intensity.  In  other  respects 
the  patient  was  well.    (This  is  the  full  note.) 

Procopovici  refers  also  to  another  case  in  the  foot- 
note on  page  44.  A  woman,  aged  34,  had  been  born  with 
a  paralysis,  which  was  more  intense  on  the  right  side.  It 
affected  the  muscles  of  the  forehead,  the  orbicularis  palpe- 
brarum and  all  the  muscles  of  the  face.  The  muscles  of 
the  soft  palate  were  not  affected.  Meynert  thought,  on 
account  of  the  distribution,  that  it  was  a  peripheral  pa- 
ralysis of  all  the  branches  of  the  facial  nerve,  external  to 
the  Fallopian  canal.  Accidents  during  birth  were  to  be 
excluded.  The  abducens  was  normal,  and  hearing  was 
unaffected. 

These  are  the  only  two  cases  that  I  have  been  able  to 
find  of  uncomplicated  bilateral  congenital  facial  paralysis, 
and  in  these  cases  the  histories  are  so  meagre  that  it  is 
difficult,  or  impossible,  to  definitely  determine  their  char- 
acter. The  first  of  these  cases  appears  to  me  to  be  par- 
ticularly interesting,  as  the  paralysis  involves  the  upper 
branch  of  the  facial  nerve,  the  branch  which  is  beHeved 
by  some  to  arise  near  the  nucleus  of  the  third  nerve.  In 
this  connection  I  shall  recall  Armaignac's  case,  in  which 
there  was  a  congenital  defect  of  the  orbicularis  palpe- 
brarum and  of  the  frontalis  of  the  left  side,  combined  with 
a  similar  defect  in  the  levator  palpebrae  and  rectus  su- 
perioris  of  the  same  side.  In  Gesepy's  case,  in  which  there 
was  a  bilateral  paralysis  of  the  orbicularis  palpebrarum, 
there  was  complete  external  ophthalmoplegia. 


CONGENITAL  FACIAL  PARALYSIS. 


585 


As  for  the  pathological  basis  which  underlies  this  in- 
teresting condition,  very  little  can  be  definitely  said.  Its 
pathology  is  almost  entirely  speculative.  Mobius,  who 
was  the  first  to  make  any  exhaustive  study  of  these  cases, 
associated  the  cases  of  congenital  paralysis  of  the  facial 
and  abducens  nerves  with  the  other  cases  of  congenital 
paralysis  of  the  eye  muscles,  and  he  brought  these  con- 
genital cases  into  relation  with  cases  which  developed  in 
infancy  and  childhood,  and  presented  symptoms  which 
were  quite  similar.  That  the  congenital  cases  might  be 
due  to  some  defect  in  development,  an  aplasia  of  the  motor 
apparatus,  Mobius  recognized,  but  he  thought  it  was  bet- 
ter to  assume  the  same  process  for  both  the  congenital 
and  acquired  cases,  and  this  process  he  believed  to  be  an 
atrophy  of  the  nuclei  from  which  the  nerves  arise. 

Kunn,  in  his  monograph,  written  several  years  after 
Mobius'  second  paper,  reviews  the  whole  literature,  and 
makes  a  sharp  distinction  between  the  congenital  and 
the  acquired  cases.  He  bases  this  distinction  upon  what 
he  considers  definite  clinical  differences;  these  are  in  re- 
lation to  the  paralysis  of  the  ocular  muscles,  and  do  not 
particularly  concern  us  at  this  time.  He  believes  that  the 
congenital  cases  are  not  due  to  an  atrophy  of  the  nuclei, 
but  should  be  considered  as  a  defect  in  the  development 
in  the  motor  mechanism,  and  he  announces  the  theory 
that  the  defect  may  be  anywhere  in  the  motor  path,  from 
the  cortex  of  the  brain  to  the  muscles.  Kunn  admits 
that  this  theory  is  based  on  a  very  slight  anatomical  foun- 
dation. 

In  congenital  defects  of  the  eye  muscles,  which  have 
been  operated  upon,  the  muscles  have  at  times  been  found 
wanting,  and  at  times  in  every  degree  of  development,  up 
to  what  appeared  perfectly  normal  muscles.  In  certain 
cases  microscopic  examination  of  a  bit  of  excised  muscle 
showed  a  condition  quite  similar  to  that  which  is  de- 
scribed in  progressive  muscular  dystrophy.  In  regard 
to  the  central  nervous  system,  there  are  really  no  ex- 


586  H.  M.  THOMAS. 

aminations  that  speak  definitely  as  to  the  condition  of  the 
nuclei  in  these  cases.     Bernhardt  examined  the  brain  in 
a  case  in  which  the  right  VII.  nerve,  the  VI.  nerve  and 
the  sensory  portion  of  the  V.,  on  the  same  side,  were 
paralyzed.     The  defect  was  noticed  shortly  after  birth. 
The  child  died  when  it  was  nine  months  old.    Two  foci  of 
softening  were  found — one  superficial  in  the  right  side  of 
the  pons,  the  other  more  extensive  in  the  right  corpora 
quadrigemina.    The  nuclei  of  the  cerebral  nerves  were  said 
to  be  normal.    The  peripheral  nerves  were  not  examined. 
Bernhardt  himself  believes  that  there  was  an  injury  to 
these  ner\'^es  at  the  base  of  the  brain  during  birth,  and  it  is 
very  doubtful  whether  this  case  should  be  included  with 
the  strictly  congenital  cases.     Siemerling^*  describes  the 
autopsy  on  a  man  who  had  had  a  congenital  ptosis  of  the 
left  eye,  and  who  died  from  general  paresis.    He  found  a 
degeneration  in  certain  cells  of  the  nucleus  of  the  third 
nen^e.      The  degeneration  was  bilateral,  and  suggested 
rather  a  later  process  than  one  which  had  been  in  ex- 
istence for  fifty  years.    The  character  of  the  process,  and 
the  fact  that  the  patient  had  general  paresis,  and  that 
the  lesion  was  bilateral,  whereas  the  muscle  defect  was 
unilateral,  would  seem  to  justify  Kunn's  objection  to  con- 
sidering this  a  conclusive  case. 

But  it  would  seem  to  me  that  Kunn  was  probably  right 
in  distinguishing  the  congenital  cases  from  the  acquired 
cases,  and,  from  the  point  of  view  of  congenital  facial 
paralysis,  it  is  interesting  to  note  that  Mobius  was  un- 
able to  find  a  case  of  abducens-facial  paralysis  which  de- 
veloped in  childhood.  The  case  which  he  referred  to  as 
a  doubtful  case,  that  of  John  Thompson,^^  seems  more 
likely  to  have  been  due  to  a  neoplasm  of  the  medulla  than 
to  a  nuclear  atrophy. 

That  congenital  facial  paralysis  is  almost .  always  as- 


**Siemerling:   Arch.  f.  Psych.,  xxiii.,  1892,  p.  764. 
**  Edinburgh  Med.  Jour.,  vol.  xxxvii.,   1891,  p.  262. 


i 


CONGENITAL  FACIAL  PARALYSIS. 


587 


sociated  with  paralysis  of  the  VI.  nerve  would  lead  one  to 
believe  that  the  mal-development  is  in  the  medulla,  near 
the  origin  of  these  two  nerves.  That  the  nuclei  of  both 
nerves  need  not  always  be  affected  together  is  shown  by 
the  occurrence  of  uncomplicated  congenital  VI.  nerve 
paralysis,  and  there  seems  no  reason  for  assuming  that 
such  a  condition  could  not  occur  in  the  nucleus  of  the 
VII.  nerve,  and  that  is  what  I  assume  has  happened  in 
the  boys  whose  cases  I  have  reported.  If,  in  fact,  a  mal- 
development,  or  perhaps  a  non-development,  of  the  nu- 
clei accounts  for  the  occurrence  of  these  cases,  it  does  not 
follow  that  the  muscles  themselves  must  be  absent.  The 
cases  which  Frl.  v.  Leonowa^^  reported  demonstrate  that 
muscles  may  develop  independently  of  the  central  nervous 
system.  She  examined  two  monsters  which*  were  entirely 
without  brain  or  spinal  cord.  The  dorsal  root-ganglia 
and  nerves  growing  from  them  had  developed,  as  had  the 
muscles.  In  many  cases  of  congenital  ptosis  curious  as- 
sociated movements  occur  in  relation  to  movements  of 
the  jaw,  and  this  would  also  indicate  that  the  defect  was 
in  the  nucleus,  and  that  this  associated  movement  had 
its  representation  apart  from  the  nucleus  of  the  third 
nerve,  probably  in  the  nucleus  of  the  V.  nerve. 

That  there  may  be  a  cono^enital  absence  of  the  muscles, 
the  cases  of  the  absence  of  the  pectoral  and  other  muscles 
seem  to  prove,  but  it  is  hard  to  understand  why  such  a 
defect  should  be  strictly  limited,  as  it  was  in  our  cases, 
to  the  distribution  of  one  nerve,  if  the  nervous  mechanism 
had  nothing  to  do  in  determining  it,  and  when  we  as- 
sociate with  this,  as  so  often  happens,  a  defect  in  just  that 
one  of  the  six  external  muscles  of  the  eye  whose  nucleus 
lies  in  close  relation  to  the  VII.  nucleus,  any  other  ex- 
planation than  a  defect  of  these  nuclei  seems  very  far- 
fetched, 

Schmidt's  case,  in  which  there  was  a  defect  in  the  VL 

"v.  Leonowa:    Neurolog.  Centralbl.,  1893,  pp.218  and  262;    1894, 
P    729. 


i 


588  H,  M.  THOMAS. 

and  VII.  nerves,  combined  with  absence  of  the  left  pec- 
toralis  major  muscle,  does  not  demonstrate  that  the  pro- 
cess was  the  same  in  the  muscles  of  the  face  and  the  muscle 
of  the  chest.  Congenital  abnormalities  are  rarely  un- 
associated  with  other  malformations,  and  even  if  we  as- 
sume a  different  cause  for  the  absence  of  the  pectoralis 
major  and  paralysis  of  the  facial  muscles,  it  would  not 
be  surprising  that  they  both  might  occur  in  the  same  in- 
dividual. We  do  not,  however,  know  the  cause  of  the 
congenital  absence  of  individual  muscles,  and  it  may  de- 
pend upon  some  fault  in  the  development  of  the  central 
nervous  system. 

There  is  no  proof  that  a  congenital  abnormality  in  the 
upper  motor  segment  could  produce  defects  of  this  charac- 
ter, and  I  agree  with  Mobius  that  such  a  lesion  is  not  to 
be  assumed.  In  conclusion,  we  must  acknowledge  that 
we  do  not  know  the  anatomical  basis  for  the  cases  of  con- 
genital facial  paralysis,  but  it  is  more  in  accordance  with 
the  known  facts  to  assume  some  fault  in  the  development 
of  the  nucleus  of  the  VII.  nerve  to  account  for  these  cases. 

FACIAL     PARALYSIS     COMBINED     WITH     EYE-MUSCLE 

DEFECT. 

Graefe:  Handb.  d.  ges.  Augenheilk.,  1880,  vol.  vi.,  p.  60. 
Cit.  from  Mobius.  Left  VII.  nerve  paralyzed.  Right 
upper  and  middle  branches  weak.  Bilateral  VI.  nerve 
paralyzed.     Smell  and  taste  somewhat  affected. 

Harlan:  Trans,  of  the  American  Ophthal.  Soc,  1881,  p. 
216.  Bilateral  paralysis  of  VII.  and  VI.  nerves  (com- 
plete?). Taste  normal.  The  platysma  active.  Slight 
downward  movement  of  mouth. 

Armaignac:  Revue  cHn.  d'OcuHstique.  November,  1886. 
Cit.  from  Kunn.  Left  paralysis  of  orbicularis  palp, 
(frontalis  probably),  and  levator  palpebrae  and  rectus 
superioris. 

Chisolm:  Archives  of  Ophthalmology,  vol.  xi.,  1882,  p. 
323.  Bilateral  paralysis  of  VII.  and  VI.  nerves.  Muscles 
about  lower  lip  retaining  some  power. 


CONGENITAL  FACIAL  PARALYSIS.  589 

Mobius:  Munch,  med.  Wochenschr.,  1888,  p.  667.  Bi- 
lateral paralysis  of  VII.  and  VI.  nerves.  Some  reten- 
tion of  muscles  about  mouth.  Left  side  moved  a  little 
out  while  talking.  Elect,  m.  m.  which  draw  mouth  out 
and  down  L.  and  R.  are  excitable.  Also  buccinators. 
Smell,  hearing  and  taste  normal. 
Schrapringer:  Boston  Med.  and  Surgical  Journal,  1889, 
p.  635.  Bilateral  paralysis  of  VII.  and  VI.  nerves.  Pa- 
ralysis of  motor  V.  and  XII.  nerves.  VII.  nerve 
paralysis  not  specified  as  to  extent.  Other  congeni- 
tal abnormalities, 
Bernhardt:  Neurolog.  Centralbl.,  1890,  vol.  ix.,  p.  419. 
Paralysis  of  right  VII.  and  VI.  nerves,  also  sensory 
disturbance.  Infant,  autopsy. 
Rechin;  Klin.  Monatsbl.  fiir  Augenheilk.,  1891,  p.  340. 
Cit.  from  Kunn.  Two  cases,  doubtful.  First  said  to 
have  developed  at  four  years.  Bilateral  paralysisofVII., 
especially  lower  branch.  Nearly  complete  ophthal.  ex- 
ternal. Second  case,  facial  muscles  thin,  badly  de- 
veloped, but  not  paralyzed.  React  normally  to  elec- 
tricity. Ophthalmoplegia  ext.  All  muscles  of  body 
badly  developed. 
Bloch:  Berlin  Thesis,  1891.  Case  28,  Boy  nine  months 
old.  Bilateral  paralysis  of  VI.  nerve.  Bilat.  paralysis  of 
VII.  nerve,  lower  branch.  Bilat.  club-foot  and  other 
abnormalities.  The  affection  was  congenital.  {Note 
short.) 
Fryer:  Ann.  Ophthal.  u.  Otolog.,  Kansas  City,  1892.  Cit. 
from  Kunn.  Bilateral  paralysis  of  VII.  and  VI.  nerves. 
Bach:  Centralbl.  f.  Nervenheilk.,  xvi.,  p.  57,  1893.  Man 
27.  Bilateral  ptosis.  Bilat.  ophthal.  ext.  Condition 
congenital.  Facial  muscles  were  flaccid.  Frontalis 
and  corrugator  contracted.  Eyes  can  be  closed.  Fea- 
ttffes  expressionless.  Lips  moved  only  slighly  during 
speech;  no  absolute  paralysis.  Operation  on  ptosis. 
Muscle  norma%  placed.  No  noticeable  abnormality. 
Remak:     Neurolc^.  Centralbl..  1894.,  No.  7.     Paralysis  of 


590  H.  M.  THOMAS. 

left  VII.  nerve,  and  bilateral  paralysis  of  levator  and 
superior  rect.  The  platysma,  the  quadratus  and  tri- 
angularis menti  were  the  only  facial  muscles  affected. 

Gasepy:  Arch.  d'Ophthal.,  xiv.,  1894,  No.  5,  p.  273.  Cit. 
from  Kunn.  Bilateral  paralysis  of  VII.  nerve  (orbic. 
palp.)  and  ophthal.  ext.  nearly  complete. 

Hanke:  Wiener  klin.  Wochenschr.,  1894,  46.  Abstr. 
Schmidt's  Jahrbiicher,  vol.  246,  p.  22.  Doubtful  case. 
History  of  onset  unsatisfactory.  The  "staring  look" 
had  always  existed.  Woman,  26.  L.  ptosis  7  years  pre- 
viously. Examination:  Facial  muscles  flaccid.  Muscles 
about  mouth  and  eyes  less  exc.  to  elect.    Ophthal.  ext. 

Procopovici:  Arch.  f.  Augenheilk.,  xxxiv.,  1896,  p.  34. 
Bilateral  paralysis  of  VII.  and  VI.  nerve.  Muscles 
about  angle  of  mouth  retained  and  the  orbicularis  palp. 

Schmidt:  Deutsche  Zeitschr.  f.  Nervenheilk.,  x.,  1897,  p. 
400.  Paralysis  bilateral  of  VII.  and  VI.,  also  of  XII. 
L>R.  Also  absence  of  left  pectoral  maior.  The  VII. 
nerve  paralysis  was  complete. 

UNCOMPLICATED  CONGENITAL  FACIAL  PARALYSIS. 

Delprat:  Weekb.  v.  het  Nederlandsch.  Tijdschr.  vor. 
Geneok.,  November  29th,  1890,  No.  22,  p.  697.  Cit. 
from  Mobius.  Not  accepted  by  Mobius,  but  included 
by  Kunn.  Onset  said  to  have  been  after  an  acute  ill- 
ness when  3  years  old.  Examined  when  16.  Right, 
weakness  of  muscles  which  elevate  mouth,  especially 
zygmoid  maj.  Left,  weakness  of  all  muscles  except 
corrugator  supercillii,  orbicularis  palp,  and  the  zyg- 
moid.    Decreased  elec.  excitabilty.     Left  amblyopia, 

Henoch:  Vorlesungen  iiber  Kinderheilk.,  1897,  ix.  Auf- 
lage,  p.  22.  Boy,  10.  Left  VII.  nerve  paralysis,  which 
had  existed  since  birth;  also  paralysis  of  soft  palate 
and  deafness  on  left  side.  No  condition  in  ear  to  ac- 
count for  deafness. 

Stephan:  Revue  de  Med.,  1888,  July,  p.  548.  Abst.  Bern- 
hardt, Neurolog.  Centralbl.,  ix.,  p.  423.    Noticed  soon 


CONGENITAL  FACIAL  PARALYSIS. 


591 


after  birth.     Examined  when  32.     Left  VII.  nerve 
paralyzed.    Soft  palate  paralyzed.    M.  M.  not  excitable 
to  elec.    Taste  normal.    Deaf  in  left  ear. 

Schultze:  Neurolog.  Centralbl.,  xi.,  1892,  No.  14,  p.  425. 
Noticed  directly  after  birth.  Examined  when  4.  Total 
left  VII.  nerve  paralyzed.  Pupils  L  >  R.  Slight  nys- 
tagmus in  lateral  position.  Elec.  examination,  strong 
current  causes  contraction  in  left  orbicularis  oris,  and 
nothing  else  on  left  side.  This  muscle  is  not  noted  as 
acting  normally.     No  other  abnormality. 

Bernhardt:  Neurolog.  Centralbl.,  1894,  xiii.,  p.  2.  No- 
ticed 2  weeks  after  birth.  Examined  when  24.  R. 
VII.  nerve  paralyzed  (forehead,  eye  and  upper  lip). 
Muscles  of  under  lip  and  chin  retained.  Only  the  ac- 
tive muscles  respond  to  elec.  from  nerve.  Slight  nys- 
tagmus in  lateral  position.    Taste  normal. 

Kunn:  Beitrage  zur  Augenheilk.,  Heft  xix.,  1895,  p.  i. 
Case  doubtful.  Noticed  just  after  birth.  Examined  at 
16.  Abnormal  development  of  right  side  of  face.  Eyes 
and  forehead  normal.  Below,  marked  asymmetry  of 
face.  Masseters  and  bones  less  developed.  Weakness 
but  no  actual  paralysis  of  VII.  and  V.  nerves.  Normal 
electrical  response.     Taste  normal. 

Bernhardt:  Neurolog.  Centralbl.,  xvi.,  1897,  p.  296.  No- 
ticed in  first  days  of  life.  Examined  when  7.  Face, 
R.  VII.  nerve  paralysis.  Muscles  of  lower  lid  acted, 
and  she  could  pucker  her  lips  as  in  whistling.  Elect, 
examination:  Marked  decreased  excitability  in  orbic. 
oris  to  direct  current.  Is  excitable  from  other  side. 
Nothing  from  nerve.    Taste  could  not  be  tested. 

Procopovici:  Arch.  f.  Augenheilk.,  xxxiv.,  1896,  p.  34. 
Case  I.  Since  birth.  Examined  at  18.  Bilateral  paral- 
ysis of  orbic.  oculi  and  frontalis.  No  other  abnormality. 
Case  II.  Noticed  soon  after  birth.  Examined  at  34. 
Bilateral  weakness  of  VII.  nerve,  R.  more  than  L.  Eye 
muscles  normal.    Hearing  normal. 


592  H,  M.  THOMAS, 

DISCUSSION. 

Dr.  Wm.  G.  Spiller  referred  to  the  relationship  between 
the  condition  described  by  Dr.  Thomas  and  progressive  mus- 
cular dystrophy  of  the  Landouzy-Dejerine  type.  In  the  latter 
affection  the  muscles  about  the  eyes  and  mouth  are  much 
involved,  and  the  disease  may  exist  for  years  with  the  atrophy 
limited  to  the  muscles  of  the  face.  In  the  patients  whom  Dr. 
Spiller  had  seen,  one  might  easily  believe,  at  first  sight,  that 
the  seventh  nerves  were  affected.  The  existence  of  the  di- 
sease in  Dr.  Thomas'  cases,  in  two  members  of  the  same  family, 
was  suggestiive  of  progressive  muscular  dystrophy,  though 
the  speaker  did  not  intend  to  make  a  diagnosis  different  from 
that  formed  by  Dr.  Thomas. 

Dr.  B.  Sachs  said  that  while  listening  to  Dr.  Thomas' 
paper,  it  occurred  to  him  that  the  cases  reported  were  possibly 
instances  of  progressive  muscular  dystrophy  of  the  Landouzy- 
Dejerine  type.  If  the  condition  could  be  traced  back  to  birth, 
however,  that  would  militate  against  the  latter  diagnosis.  In 
one  of  the  photographs  shown  by  Dr.  Thomas  it  appeared  that 
the  eyelids  could  be  very  nearly  closed,  if  not  completely  so, 
which  would  lead  one  to  entertain  the  id'ea  that  the  muscular 
element  was  very  much  more  at  fault  than  the  neural.  The 
speaker  said  he  was  inclined  to  believe  that  in  these  various 
forms  of  congenital  defective  development,  the  defect  was  not 
observed  merely  in  the  neural  part  of  the  motx>r  tract,  but 
that  other  parts  of  the  body  were  also  poorly  developed.  In 
one  case  which  he  had  reported,  a  defect  of  the  pectoralis 
major  muscle  was  found  in  connection  with  a  distinct  defect 
of  the  scapula.  It  was  probable,  he  thought,  that  these  cases 
were  not  necessarily  neural  in  origin;  while  some  of  them 
might  be,  others  showed  that  the  muscular  or  osseous  system 
alone  was  involved. 

Dr.  Hugh  T.  Patrick  inquired  whether  an  electrical  exam- 
ination of  the  eighth  nerve  was  made? 

Dr.  B.  Onuf  asked  whether  Dr.  Thomas  attributed  any 
etiologicai  importance  to  maternal  impression  in  these  cases. 

Dr.  Thomas,  in  closing,  said  he  did  not  believe  that  ma- 
ternal impression  had  anything  to  do  with  the  disease  in  the 
cases  he  had  reported.  It  might  be  of  interest,  however,  to 
state  that  in  one  case  in  the  literature  where  a  child  was  born 
with  a  facial  defect,  the  mother,  during  her  pregpnancy,  had 
made  frequent  visits  to  a  physician,  who  was  treating  her 
mother  with  electricity  for  a  facial  paralysis. 

Dr.  Thomas  said  that  the  question  of  a  probable  relation- 
ship between  this  condition  and  progressive  muscular  dys- 
trophy had  been  brought  up  before,  and  while  the  anatomical 


CONGENITAL  FACIAL  PARALYSIS. 


593 


changes  in  the  muscles  in  certain  cases  of  congenital  ptosis 
were  quite  similar  to  those  found  in  this  disease,  this  did  not, 
by  any  means,  demonstrate  that  the  cause  of  the  atrophy  was 
the  same.  In  his  cases  the  defects  of  development  were  not 
confined  to  the  muscles  of  the  face;  there  was  also  a  defect  of 
the  ear  and  a  defect  in  the  hearing,  and  on  this  account  he 
regarded  the  symptoms  as  congenital.  In  reply  to  Dr.  Patrick, 
the  speaker  said  he  did  not  make  an  electrical  test  of  the  eighth 
nerve.  In  conclusion  he  expressed  the  opinion  that  it  would 
be  unusual  to  see  a  case  of  muscular  dystrophy  of  the  facial 
type  which  dated  from  birth  and  persisted  until  the  twentieth 
year,  in  which  only  the  muscles  of  the  face  were  affected. 


190.  La  mai^die  du  sommeii*  et  son  bacii^i^e  (The  Sleeping 
Sickness  and  its  Bacillus).  Cagigal  and  Lepierre  (La  M6decine 
Moderne,  9,  1898,  p.  60). 

Cagigal  and  Lepierre,  the  authors,  observed  a  negro,  16  years  of 
age,  a  native  of  Angola,  who  suffered  with  the  sleeping  sickness  for 
three  years.  He  was  in  the  hospital  of  Coimbre  more  than  two 
months,  during  which  time  there  was  an  elevation  of  temperature, 
with  remissions,  up  to  some  weeks  before  death,  but  during  this 
latter  period  the  temperature  was  constantly  subnormal.  The  only 
physical  peculiarity  further  was  constant  passage  of  ammoniacal  urine 
with  an  excess  of  phosphates  and  relative  azoturia.  The  examination 
of  the  blood  showed  a  constant  presence  of  bacilli  and  spores.  The 
cultures  of  blood  from  the  arm  and  hand  on  serum,  gelose,  gelatine, 
bouillon  and  peptone  resulted  as  follows:  At  moderate  temperatures 
most  of  the  media  remained  sterile,  except  those  of  serum  and  gela- 
tine, which  produced  homogeneous  colonies,  the  serum  after  three 
days,  the  gelatine  only  after  four  weeks.  With  the  culture  upon  serum 
the  same  results  were  obtained  as  with  the  blood.  There  was  some 
difficulty  in  development  of  the  microbe  upon  the  culture  media 
except  with  serum,  a  point  upon  which  the  authors  insist  The  mi- 
crobe observed  in  the  blood  and  cultures  is  a  straight  bacillus,  some- 
times incurved,  a  little  larger  at  the  extremities  than  at  the  centre;  it 
makes  filaments,  it  is  very  little  mobile,  takes  anilin  stains  well,  does 
not  color  with  Gram,  and  appears  not  to  have  any  processes;  free 
spores  were  observed  both  in  the  cultures  and  in  the  interior  of  the 
microbes.  The  general  aspect  of  the  preparations  resembles  those 
of  the  anthrax  bacillus;  the  growth  is  best  at  a  temperature  of  from 
30  to  y7  degrees  C;  a  moist  heat  of  75  degrees  C.  kills  it  in  a  minute; 
it  is  a  true  aerobic  bacillus. 

Postmortem — Some  microbes  were  found  in  the  intraperitoneal 
fluid.  Inoculations  of  rabbits  and  guinea  oigs  produced  certain  ef- 
fects not  unlike  those  observed  in  the  human  subject — identical  tem- 
perature-curves, sub-normal  temperature  preceding  death,  loss  of 
weight,  an  appearance  of  depression,  feebleness,  especially  of  the  hind 
ouarters,  ammoniacal  urine,  and  death  in  from  twenty-five  to  fifty 
days.  Mitchell. 


A  CASE  OF  MULTIPLE  SYPHILITIC   NEURITIS.^ 

By  frank  R.  fry,  A.  M.,  M.  D., 

St.  Louis. 

The  subjoined  history  will,  perhaps,  be  traced  more 
satisfactorily  if  first  epitomized  as  follows:  Male,  32  years 
of  age.  March,  1897,  a  rather  severe  headache,  which 
yielded  to  antisyphilitic  treatment  within  about  ten  days. 
June,  a  syphilitic  lesion  of  the  tonsil.  July  and  August, 
headache  again,  but  not  severe;  no  symptoms  of  focal  dis- 
ease of  the  nervous  system.  October  26th,  a  sudden  right 
hemiplegia,  involving  the  arm  and  leg,  but  not  the  face; 
probably  due  to  a  lesion  at  the  internal  capsule;  no  other 
lesions  of  the  central  nervous  system.  November  15th, 
beginning  of  a  paraplegia  with  hyperaesthesia  and  anaes- 
thesia of  all  the  extremities,  especially  of  the  hands  and 
feet,  and  later  a  complete  paraplegia,  with  flaccid  muscles 
and  reaction  of  degeneration  in  the  legs,  and  absent  knee- 
jerk,  and  marked  weakness  of  the  hands  and  forearms.  A 
diagnosis  of  multiple  neuritis,  involving  all  of  the  ex- 
tremities. March,  1898,  returning  motility,  and  later  a 
gradual  recovery  from  paraplegia,  with  returning  knee- 
jerk. 

In  particular,  the  history  is  as  follows: 

E.  A.  W.,  aged  32  years;  a  large,  well-built  man;  German 
parentage;  family  history  unimportant;  no  previous  illness  of 
importanice;  good  habits;  never  has  used  tobacco  or  alcohol 
excessively;  city  salesman  for  a  wholesale  queenswarc  house. 

He  first  consulted  me  March  13th,  1897,  complaining  of 


'Read  at  the  twenty-fourth  annual  meeting  of  the  American  Neu- 
rological Association,  May,  1898. 


kr 


MULTIPLE  SYPHILITIC  NEURITIS. 


5J5 


headache  and  lassitude.  I  concluded  that  he  was  suffering 
from  a  grippe  cephalea,  and  prescribed  accordingly.  He 
called  several  times  within  a  week.  The  treatment  afforded  no 
relief.  March  22d  he  complained  a  great  deal  of  his  head. 
In  the  course  of  a  careful  examination  I  found  the  temporal 
ridges  and  shins  slightly  tender  to  pressure.  On  antisyphilitic 
treatment,  the  headache  entirely  disappeared  within  about  ten 
days,  and  his  general  condition  was  much  improved.  A  care- 
ful inquiry  and  physical  examination  at  this  time  failed  to 
elicit  a  history  or  signs  of  syphilis,  save  the  periosteal  tender- 
ness just  mentioned.  Subsequently,  however,  I  obtained  from 
him  data  which  pointed  quite  conclusively  to  an  infection  in 
September  of  1896.  I  tried  to  impress  him  with  the  necessity 
of  keeping  himself  under  observation  and  treatment,  but  after 
two  weeks,  being  very  much  occupied,  he  discontinued  his 
visits. 

June  22d  he  returned,  complaining  of  a  sore  throat.  He 
stated  that  he  had  discontinued  all  treatment  a  month  after 
his  last  visit,  having  felt  entirely  well.  I  found  a  large  ex- 
cavated ulcer  on  the  left  tonsil,  and  the  glands  at  the  angle 
of  the  jaw  swollen  and  painful.  He  was  examined  by  Dr. 
W.  C.  Glasgow,  who  pronounced  the  condition  syphilitic. 
After  this  I  saw  him  at  intervals  of  a  few  days  to  two  weeks, 
and  treatment  was  continued  with  fair  regularity  all  summer. 
The  lesions  in  the  throat  and  neck  disappeared  slowly. 

My  notes  show  that  on  July  25th  and  August  13th  he  was 
complaining  a  good  deal  of  headache,  and  that  I  made  careful 
examinations  without  finding  evidences  of  disease  of  the 
nervous  system. 

October  24th,  in  my  absence  from  the  city,  he  came  to 
the  office  and  was  examitied  by  Dr.  M.  A.  Bliss,  who  found 
him  with  a  right  hemiplegia.  He  had  retired  the  evening  be- 
fore with  a  numb,  heavy  feeling  in  the  neck,  shoulder  and 
arm,  and  awoke  in  the  morning  with  the  hemiplegia  and  some 
slight  headache  and  dizziness.  He  stated  that  he  had  been 
feeling  the  paraesthesiae  in  shoulder  and  arm  for  some  days 
prior  to  the  stroke,  and  had  ascribed  the  condition  to  rheu- 
matism. 

He  was  admitted  to  the  Missouri  Baptist  Sanitarium  Oc- 
tober 26th,  and  remained  there  until  February  13th,  1898 — 
III  days.  During  this  time  I  saw  him  almost  daily,  and  kept 
full  notes  of  the  case.  October  26th — ^the  day  after  admission 
— I  made  a  general  examination.  Patient  walked  with  a  hemi- 
plegic  gait,  atnd  the  grasp  of  the  right  hand  was  feeble.  He 
had  a  partial  right  hemiplegia,  involving  the  leg  most,  the 
hand  less,  and  the  face  and  tongue  not  at  all.  He  could  ascend 
the  stairs  unassisted,  and  had  fair  use  of  his  hand,  for  example, 
in  dressing  and  feeding  himself.    The  knee-jerk  and  wrist-jerk 


596  FRANK  R.  FRY. 

oh  the  right  side  were  exaggerated.  The  sensorium  was  clear. 
He  still  complained  of  slight  vertigo,  especially  on  bending 
over  or  on  suddenly  rising  from  a  seat.  He  also  complained 
of  paraesthesiae  in  the  arm  and  hand,  numbness  and  heaviness. 
The  expulsive  force  of  the  bladder  was  somewhat  weakened. 
In  fhis  connection  I  will  state  that  th-e  condition  of  the  bladder 
remained  practically  the  same  through  the  course  of  his  ill- 
ness. It  was  never  necessarv  to  use  a  catheter.  None  of  the 
cranial  nerves  were  involved,  and  there  was  no  evidence  at 
this  time  of  more  than  one  lesion  of  the  nervous  system.  It 
seemed  probable  that  this  was  a  gumma,  and  that  it  was  lo- 
cated at  the  internal  capsule.  Dr.  L.  Bremer  saw  the  patient 
a  few  days  after  he  entered  the  sanitarium,  and  concurred  in 
our  opinion  of  the  probable  nature  and  location  of  the  lesion. 

Active  antisyphilitic  treatment  was  continued.  At  the  end 
of  two  weeks  there  was  considerable  improvement  in  the 
general  condition  of  the  patient  and  that  of  the  paretic  mem- 
bers, yet  I  felt  that  he  was  not  responding  to  treatment  as  well 
as  could  be  desired. 

November  15th  to  20th  he  began  to  make  frequent  com- 
plaints of  numbness  and  weakness  in  his  feet  and  legs.  More 
careful  observations  on  the  20th  showed  that  there  was  some 
hyperaesthesia,  which  was  greater  in  the  left  foot  and  leg. 
Within  a  few  days  the  left  foot  and  leg  were  as  paretic  as  the 
right.  By  December  6th  he  was  unable  to  walk,  and  took  to  a 
roller  chair;  meantime,  he  was  complaining  of  an  increasing 
tingling,  numbness  and  weakness  in  the  hands. 

December  loth  his  condition  was  as  follows:  A  symmetri- 
cal paraplegia;  he  could  not  walk,  but  could  get  into  his 
chair  with  the  assistance  of  an  attendant.  The  muscles  were 
fiabby  and  slightly  tender  to  pressure.  Both  knee-jerks  were 
gone.  He  complained  of  an  unpleasant  degree  of  hyperaes- 
thesia of  both  hands  and  feet  and  legs  and  forearm,  and  mostly 
of  those  of  the  left  side.  The  grasp  on  both  hands  was  en- 
feebled. 

During  the  following  month  there  was  little  change  in  his 
condition.  Mild  galvanism  was  applied  daily  by  Dr.  M.  W. 
Hoge,  and  it  was  noticed  that  in  the  muscles  of  the  legs  es- 
pecially there  was  a  qualitative  change  in  the  reaction,  the  A. 
C.  C.  being  equal  to  or  greater  than  the  C.  C.  C. 

January  loth  (1898),  he  seemed  to  be  getting  stranger  in 
his  legs.  On  January  i8th  he  first  undertook  to  walk  with  the 
assistance  of  two  attendants,  and  from  that  date  gained  rapid- 
ly, so  that  at  the  end  of  two  weeks  he  was  moving  about  his 
room  with  the  suppwtrt  of  a  walking-stick.  The  gait  was  not 
spastic;  there  was  a  distinct  toe-drop,  the  so-called  steppage 
gait. 

He  has  been  constantly  under  observation  since  leaving 


i 


MULTIPLE  SyPHlUTlC  NEURITIS.  597 

the  sanitarium,  February  13th.  Improvement  has  steadLy 
continued.  March  29th,  returning  knee-jerks  were  first  demo.i- 
strated;  the  right  quite  feeble  without  re-en(orcement,  the  left 
only  showing  with  re -enforcement, 

April  4th,  loth,  i8th,  25th,  he  still  complained  of  slight 
numbness  of  his  fingers  and  toes,  and  of  considerable  sensi- 
tiveness of  the  plantar  and  palmar  surfaces,  and  some  general 
slig'ht  soreness  and  stiffness  of  the  muscles  of  the  extremities. 
The  aesthesiometer  showed  only  slight  obtundity  of  tactile 
sense. 

May27th,an  examination  showed  the  followii^:  The  pupi.s 
were  equal  and  reacted  normally.  The  face  was  symmetrical; 
no  evidence  of  involvement  of  any  of  the  cranial  nerves.  On 
a  stifj  dynamometer  the  right  hand  registered  170,  the  left  155. 
He  had  a  powerful  grip,  Ihe  right  knee-jerk  was  considerably 
stronger  than  the  left,  the  latter  only  coming  out  well  on  re- 
enforcement.  Station  was  good,  and  there  was  no  incoordina- 
tion in  any  of  his  movements.  He  could  alight  from  a  street 
car  before  it  came  to  a  full  stop.  He  could  walk  twenty  blocks 
without  much  fatigue,  and  averaged  about  two  hours  a  day 
on  his  feet  about  his  place  of  business,  but  was  conscioils  of 
not  having  regained  his  normal  strength  and  endurance.  The 
aesthesiometer  showed  that  the  tactile  sense  of  the  fingers  was 
not  quite  up  to  normal,  and  he  still  had  occasional  very  slight 
stiffness  and  numbness  in  the  left  hand.  After  sitting  for  some 
time,  he  felt  some  stifTness  of  the  legs,  which  soon  wore  away 
on  moving  about.  Occasionally  he  had  a  slight  headache  in 
the  temples,  causing  passing  annoyance. 

The  treatment  throughout  has  consisted  of  inunctions  of 
mercurial  ointment,  one  to  two  drachms  daily,  in  courses  of 
fifteen  to  thirty  days.  Between  these  courses  iodide  of  sodium 
was  given  in  increasing  doses,  the  largest  reached  at  any  time 
being  100  grains,  t.  i.  d.  Strychnine  was  used  almost  continu- 
ously in  doses  of  1-15  to  1-30  grain,  t.  i.  d.,  and  mild  galvanism 
a  good  part  of  the  time. 

I  believe  that  the  existence  of  an  extensive  multiple 
neuritis  in  this  case  will  be  conceded,  and  that  the  man- 
ner in  which  it  was  engrafted  upon  the  hemiplegia  fur- 
nishes a  very  unusual  clinical  picture  for  a  syphilitic  case. 
Superficially,  it  bore  a  resemblance  to  the  so-called  syphi- 
litic triplegia,  i.  e.,  a  paraplegia  of  spinal  origin  following 
upon  a  hemiplegia  of  a  cerebral  origin.  But  I  think  I 
have  given  an  extended  enough  history  of  the  case  to  show 
that  it  could  not  have  been  mistaken  for  this  rather  fa- 


598  FRANK  R.  FRY. 

miliar  condition,  or  for  a  diplegia  due  to  extensive  cere- 
bral syphilis. 

I  have  assumed  that  the  neuritis  was  of  syphilitic 
origin,  not  simply  because  the  patient  was  syphilitic  and 
the  disease  rather  intractable  to  treatment,  but  because 
there  seemed  to  be  no  other  probable  explanation  of  it. 
Thre  was  nothing  in  his  occupation  or  habits  which  pre- 
disposed him  to  it.  He  had  never  shown  rheumatic  or 
lithaemic  tendencies,  and  had  no  renal  trouble.  Mercury 
had  been  used  before  the  neuritis  appeared,  but  it  was  not 
discontinued.  On  the  contrary,  it  was  used  more  freely 
after  the  neuritis  was  manifest  than  before  its  appearance. 
There  were  at  no  time  the.  evidences  of  a  mercurial  ca- 
chexia. In  January  for  a  few  days  the  teeth  were  a  little 
tender  when  jarred  together,  and  this  was  the  nearest 
apppoach  to  the  full  physiologic  effect  of  the  drug  ob- 
served at  any  time,  although  constant  watch  for  this  ef- 
fect was  kept.  A  diflfuse  polyneuritis  from  mercury  is  a 
very  rare  occurrence,  and  a  condition  of  the  kind  without 
considerable  pain  and  local  lesions  in  the  joints  and  mus- 
cles and  an  apparent  cachexia  would  be  still  more  rare. 

The  rarity  of  an  extensive  peripheral  neuritis  due  to 
syphilis  is  noticed  by  all  authorities,  and  generally  they 
call  attention  to  the  distinction  which  should  be  made 
between  a  neuritis  proper  and  a  postsyphilitic  degenera- 
tion of  peripheral  nerves.  The  necessity  of  this  distinc- 
tion from  a  pathological  and  clinical  standpoint  is  evident 
enough.  Usually  there  would  not  be  much  difficulty  in 
making  it  clinically.  Yet  I  can  understand  that  situations 
may  occur  where,  for  a  time  at  least,  the  symptoms  may 
be  confusing. 

It  will  be  noticed  in  this  case  that  the  syphilis  was 
about  one  year  oM  at  the  time  the  neuritis  developed. 

DISCUSSION. 

Dr.  Charles  L.  Dana  said  that  his  experience  with  multiple 
neuritis  and  with  syphilitic  affections  of  the  nervous  system 


MULTIPLE  SYPHILITIC  NEURITIS. 


599 


had  been  such  tliat  he  had  come  to  regard  it  as  almost  a  patho- 
logical law  that  multiple  neuritis  never  results  from  syphilis. 
Personally,  he  had  never  seen  a  case  of  that  kind,  and  those 
which  he  had  seen  reported  in  literature  seemed  to  be  open 
to  some  other  interpretation.  One  case — ^that  of  a  patient 
who  had  been  under  his  observation  for  a  long  time,  and 
which  he  did  not  at  all  regard  as  one  of  syphilitic  multiple 
neuritis — was  afterwards  recorded  as  such  by  another  phy- 
sician. In  order  to  prove  such  a  condition,  every  other  pos- 
sible cause  of  the  neuritis  must  be  excluded.  Dr.  Dana  said 
he  had  specimens  in  his  possession  from  a  case  where  a  rather 
profuse  syphilitic  exudation  into  the  substance  of  the  cord 
in  the  cervical  and  lower  thoracic  regions  produced  symptoms 
somewhat  like  those  reported  by  Dr.  Fry.  In  the  ordinary 
cases  of  multiple  neuritis  usually  much  more  pain  and  rather 
more  paralysis  •  are  found  than  seemed  to  be  present  in  Dr. 
Fry's  case.  On  the  other  hand,  we  know  that  multiple  neuritis 
is  not  infrequent,  and  is  sometimes  due  to  causes  which  we 
cannot  clearly  make  out.  While  alcohol  is  a  very  common 
cause,  we  frequently  see  cases  which  must  be  explained  other- 
wise. 

Dr.  Sachs  said  that  while  he  did  not  care  to  venture  an 
opinion  as  to  whether  Dr.  Fry's  case  was  one  ol  syphilitic 
multiple  neuritis  or  not,  he  thought  Dr.  Dana  had  stated  the 
other  side  of  the  question  a  little  too  strongly.  The  speaker 
was  of  the  opinion  that  the  evidence  of  a  multiple  neuritis  or 
peripheral  neuritis  of  syphilitic  origin  had  been  fairly  well 
established.  Some  time  ago  he  had  reported  the  case  of  a  man 
who  had  had  a  number  of  manifestations  of  syphilis  of  the 
nervous  system,  among  them  bei/ng  ptosis  and  hemiplegia, 
and  from  all  of  these  he  had  recovered  under  specific  treat- 
ment. At  one  time  he  had  developed  a  flaccid  paraplegia 
without  vesical  symptoms,  and  later  a  distinct  ulnar  neuritis, 
characterized  by  pain  along  the  distribution  of  the  nerve; 
at  the  same  time  he  had  mucous  patches,  and  all  these  symp- 
toms disappeared  in  the  course  of  a  few  weeks  under  proper 
treatment.  Of  course,  it  was  possible  that  this  was  a  mere 
coincidence,  but  we  have  considerable  evidence  to  show  that 
occasionally  tlie  peripheral  nervous  system  may  be  directly 
diseased  as  a  result  of  previous  syphilitic  infection. 

Dr.  Dana  stated  that  he  did  not  deny  the  possibility  of  a 
syphilitic  neuritis  of  single  nerves,  but  of  a  multiple  neuritis. 

Dr.  M.  Allen  Starr  agreed  with  Dr.  Dana,  He  did  not 
think  we  should  confound  a  peripheral  neuritis,  due  to  a  gum- 
ma, with  the  typical  features  we  have  in  mind  when  we  speak 
of  multiple  neuritis,  which  is  a  clinical  entity  with  well  known 
and  characteristic  symptoms.     Although  he  had  been  on  the 


IT 


600  FRANK  R.  FRY. 

lookout  for  a  case  of  multiple  neutntis  of  S3rphilitic  origfin 
during  the  past  ten  years,  he  had  never  seen  one  which  he  was 
willing  to  pronounce  as  distinctly  syphilitic. 

Dr.  J.  J.  Putnam  indorsed  the  statements  of  Drs.  Dana 
and  Starr.  He  had  never  seen  a  case  of  multiple  neuritia 
wlikh  was  clearly  of  specific  origin. 

Dr.  Leonard  Weber  said  that  fifteen  years  ago  he  had 
read  a  paper  before  the  New  York  Academy  of  Medicine,  in 
which  he  had  reported  a  series  of  125  cages  of  syphilis  which 
had  been  under  his  observation  more  or  less  constantly  for 
twenty  years.  Although  at  that  time  the  clinical  features 
of  multiple  nteuritis  were  not  so  well  understood  as  now,  he 
could  not  recall  a  single  case  in  that  series  which  presented 
any  of  the  characteristic  symptoms  of  multiple  neuritis. 

Dr.  Fry,  in  closing,  said  Dr.  Dana  and  Dr.  Putnam  had 
very  justly  called  attention  to  the  importaint  fact  that  multiple 
neuritis  is  often  due  to  causes  which  we  cannot  make  out 
Therefore,  it  would  be  difficult  to  prove  that  any  case  was  due 
to  syphilis.  In  this  case  it  seemed  so  probable  that  syphilis 
was  the  cause  that  he  had  ventured  to  report  it  as  such. 


191.  Pellotin  (Squibb's  Ephemeris,  Jan.,  1897). 

This  is  an  alkaloid  found  in  a  species  of  Mexican  cactus.     It  is 
not  soluble  in  water,  but  its  hydrochlorate  is.    Dr.  Hefter,  of  Leipsig, 
observed  in  himself  that  after  taking  five  centigrammes  (three-quarters 
of  a  grain)  he  seemed  very  drowsy  and  ultimately  fell  asleep.     Dr. 
Jolly,  of  Berlin,  then  gave  it  to  a  number  of  patients  m  the  neurolog- 
ical wards  of  the  Charite  Hospital  in  Berlin.    The  first  was  a  man  with 
alcoholic  neuritis,  who  after  an  injection  of  four  centigrammes  became 
very  drowsy  and  in  a  hour  later  slept  four  hours.    Dr.  Hefter  observed 
in  himse!f  a  iffiiiiwiahfri  puise-rate,  and  the  same  was  perceptible  ia 
this  patient —  during  the  tirst  hoar  oi  whose  sleep  the  pulse  fell  to  56 
per  minute,  rising  again  to  76  before  he  awofrr.    A  patient  with  mul- 
tiple sclerosis  took  five  centigrammes  during  the  afternoon^  and  after 
half  an  hour  he  also  slept  soundly  for  several  hours.    Similar  resute 
were  obtained  in  other  cases.    In  tabes  the  soporific  action  was  satis- 
factory, but  the  pains  returned  when  the  patients  awoke.    In  delirium 
tremens  the  effect  was  less  prompt;  twelve  centigrammes  (equal  to 
one  and  three-quarter  grains;  were  needed  to  quiet  a  patient,  but  no 
sleep  followed.    Some  patients  complained  of  giddiness  and  declined 
to  take  the  medicine,  but  the  greater  number  did  not  suffer  so.    Prof. 
Jolly  says  that  six  centigrammes  (equal  to  about  one  grain)  are  equal 
to  one  gramme  (155^  grains)  of  trional,  or  two  grains  of  hydrate  of 
chloral.  Freeman 


LONG  REMISSIONS  IN  EPILEPSY  AND  THEIR 

BEARING  ON  PROGNOSIS.* 

By  WHARTON  SINKLER,  M.  D. 

The  question  as  to  the  curability  of  epilepsy,  as  well 
as  to  what  constitutes  a  cure  in  this  disease,  is  as  far  from 
being  settled  as  it  was  a  century  ago.  Having  chanced  to 
see  recently  several  cases  of  epilepsy  in  which  there  have 
been  long  intermissions  of  the  fits,  I  have  been  led  to  look 
up  the  subject,  and  am  surprised  to  find  that  but  few  au- 
thors have  attempted  to  define  what  should  be  considered 
a  cure  of  epilepsy.  In  other  words,  how  many  years  should 
a  patient  be  free  from  convulsive  seizures  before  he  should 
be  regarded  as  cured?  Neither  has  any  attention  been 
paid  to  occurrence  of  long  periods  of  freedom  from  at- 
tacks. The  majority  of  writers  on  the  subject  of  epilepsy 
devote  their  attention  merely  to  the  pathology  and  treat- 
ment of  the  disease.  A  number  of  observers  report  cases 
in  which  there  has  been  cessation  of  the  attacks  under  the 
influence  of  certain  remedies,  and  reference  is  made  by 
some  authors,  Neimeyer,  for  example,  to  the  fact  that 
cases  are  seen  in  which  long  intervals  between  the  fits 
occur  independently  of  treatment.  Every  writer  on  the 
subject  of  epilepsy  asserts  that  the  disease  is  curable  in 
varying  proportions.  Some,  for  instance,  declaring  *'that 
a  large  proportion  are  susceptible  of  cure,"  but  none  pro- 
nounce at  what  period  after  the  cessation  of  the  attacks 
in  an  epileptic  it  is  justifiable  to  consider  that  the  case  is 
cured. 

Dana^  says  that  five  to  ten  per  cent,  of  epileptics  get 
well,  but  he  does  not  say  what  he  considers  a  cure.    Gow- 


*Read  before  the  American  Neurological  Association,  May,  1898. 
^Dana:  Text  Book  on  Diseases  of  the  Nervous  System,  p.  411. 


>ri 


•^^l, 


602  WHARTON  SINKLER. 

ers*  says  occasionally  convulsions  occurring  in   infancy 
cease  at  four  or  five  years  of  age;  after  twenty  years  spon- 
taneous cessation  does  sometimes  occur,  but  it  is  too  rare 
to  be  reckoned  upon.    He  does  not  say  how  long  the  fits 
must  be  kept  away  before  a  cure  is  established.     Osler^ 
quotes  Hypocrites*  opinion  as  holding  good  at  the  present 
day,  namely,  "that  the  prognosis  in  epilepsy  is  unfavorable 
when  the  disease  is  congenital,  or  when  it  endures  to  man- 
hood, and  when  it  occurs  in  a  grown  person  without  any 
previous  cause  the  cure  may  be  attempted  in  young  per- 
sons, but  not  in  old."    Ross*  says  a  few  cases  of  epilepsy 
are  completely  cured,  but  he  also  fails-  to  say  what  he 
means  by  a  cure.     Nothnagel**  says  epilepsy  is  curable; 
that  spontaneous  cures  occur  in  four  or  five  per  cent,  of 
the  cases,  and  that  some  cases  are  actually  cured  by  treat- 
ment, but  he  does  not  define  his  idea  of  what  a  cure  is,  nor 
does  he  refer  to  the  length  of  time  which  he  has  known  to 
elapse  after  an  arrest  of  the  convulsions.  Hamilton*  thinks 
that  some  cases  of  epilepsy  are  curable,  but  does  not  refer 
to  any  given  period  which  must  elapse  before  the  case 
may  be  considered  as  cured.     Niemeyer^  says  that  "in 
some  patients  a  year,  or  even  several  years,  may  elapse 
ere  a  new  attack  occurs.     Recovery  must  be  regarded  as 
rare,  and  we  must  beware  of  building  our  hopes  too  san- 
guinely  upon  long-continued  intermission  of  fits."    Gray* 
makes  a  more  definite  statement  in  regard  to  remissions 
in  epilepsy.    He  says  that  cases  may  be  free  from  attacks 
for  ten,  fifteen,  or  even  twenty  years,  and  that  in  his  own 
practice  he  has  known  remissions  of  several  years,  six  or 
seven.    In  reference  to  cure,  he  says  that  it  is  still  an  un- 
determined matter  as  to  what  constitutes  a  cure. 


*  Gowers:    Nervous  Diseases,  vol.  ii.,  p.  760. 

*  Osier:    Practice  of  Medicine,  p.  954. 

*  Ross:    Nervous  Diseases,  vol.  xi.,  p.  941. 

'  Nothnagel :    Ziemssen  Encyclopaedia,  vol.  xiv.,  p.  277. 
•Hamilton:    Pepper's  System  of  Medicine,  vol.  v.,  p.  499. 
'  Niemeyer:    Practice  of  Medicine,  vol.  xi.,  p.  361. 

*  Gray:   System  of  Nervous  Diseases  by  American  Authors,  p.  303. 


REMISSION^  IN  EPILEPSY. 


603 


Starr^  has  analyzed  167  cases  of  epilepsy  as  to  the 
frequency  of  the  attacks,  and  found  that  in  nine  cases  the 
interval  was  one  year  and  over.  Weber^^  records  a  case  of 
epilepsy  in  which  no  fit  had  occurred  for  ten  years  up  to 
the  time  that  the  case  was  reported,  and  he  gives  another 
case  in  which  there  was  an  interval  of  five  years. 

I  have  collected  twenty-four  cases  of  idiopathic  epi- 
lepsy, in  which  there  have  been  remissions  varying  from 
two  years  to  twenty-nine  years.  These  cases  have  been 
taken  from  the  case  books  at  the  Orthopaedic  Hospital 
and  Infirmary  for  Nervous  Diseases,  and  from  my  own 
practice,  and  my  friend,  Dr.  H.  P.  Boyer,  has  kindly 
given  me  the  notes  of  two  cases  under  his  own  care,  in 
which  the  remissions  were  twelve  and  thirteen  years,  re- 
spectively. In  none  of  the  patients  was  any  surgical  op- 
eration performed.  The  length  of  the  remissions  is  shown 
in  the  following  table: 

Length  of  remission  in  twenty-four  cases: — Two  years, 
I  case;  from  2  to  3  years,  2  cases;  from  3  to  5  years,  9 
cases;  from  5  to  9  years,  8  cases;  1 1  years,  i  case;  15  years, 
I  case;  21  years,  i  case;  29  years,  i  case. 

The  case  in  which  the  longest  remission  occurred,  that 
of  29  years,  is  as  follows:  A  male,  aged  38  years,  had  con- 
vulsions while  teething,  and  which  continued  until  he  was 
eight  years  old.  He  had  then  no  attack  until  his  thirty- 
fifth  year,  when  there  was  a  return  of  the  epilepsy,  and 
the  convulsions  recurred  at  short  intervals  until  he  was 
seen,  three  years  later. 

Another  striking  example  of  long  remissions  is  that 
of  Mrs.  L.  With  the  exception  of  attacks  of  migraine 
from  which  she  suffered,  she  was  quite  well  until  her  mar- 
riage, at  the  age  of  28  years.  Two  weeks  after  marriage 
she  had  the  first  attack  of  which  she  was  aware,  and  the 


•Starr:    Familiar  Forms  of  Nervous  Diseases,  p.  258. 

"Weber:    Report  of  160  Cases  of  Epilepsy,  Boston  Medical  and 
Surgical  Journal,  May  25,  1895. 


6o4  WHARTON.  SINKLER. 

convulsion  recurred  at  intervals  varying  from  four  to  ten 
weeks,  always  during  sleep.  During  her  first  pregnancy 
she  had  but  one  attack,  but  this  was  a  prolonged  one.  in 
which  there  was  a  condition  of  status  epilepticus.  At  45 
years  of  age,  the  attacks,  which  had  lasted  for  sixteen 
years,  ceased,  and  there  was  an  interval  of  12  years,  in 
which  she  had  none.  The  menopause  did  not  occur  until 
she  was  51  years  of  age,  or  six  years  after  the  attacks  had 
ceased.  When  57  years  of  age  the  attacks  began  again, 
and  there  was  no  assignable  cause  for  their  return,  except 
that  she  had  been  assiduously  nursing  a  sick  mother  for 
a  year.  When  seen  by  me,  in  November,  1894,  the  at- 
tacks had  become  rather  more  frequent.  Under  the  use 
of  moderate  doses  of  the  bromides  with  belladonna,  there 
was  an  interval  of  fifteen  months  in  which  she  had  no 
attack.  The  attacks  then  returned,  and  occurred  about 
once  a  month. 

Another  patient  had  no  attack  for  an  interval  of  21 
years.  The  patient  was  a  male,  who  had  his  first  seizure 
when  he  was  seven  years  of  age.  The  attacks  were  fre- 
quent, but  only  slight.  He  continued  to  have  the  fits,  in 
spite  of  various  forms  of  medication,  including  the  bro- 
mides in  large  quantities,  until  he  was  17  years  old.  At 
that  time  he  was  ordered  a  prescription  containing  am- 
monium bromide,  tincture  of  belladonna,  and  tincture  of 
aconite  root.  After  taking  this  prescription  for  a  few 
days,  he  became  violently  excited  and  maniacal.  The 
pupils  were  dilated,  and  it  was  considered  that  he  was 
suffering  from  belladonna  poisoning.  Soon  after  the  med- 
icine was  stopped  he  recovered  his  normal  condition,  and 
from  that  time,  until  his  38th  year,  there  was  no  convul- 
sion of  any  kind.  The  attacks  then  began  again,  gen- 
erally in  the  form  of  petit  mal,  but  at  intervals  of  a  few 
weeks  there  was  a  general  convulsion.  Another  case  of 
interest  was  that  of  T.  J.  K.,  male.  He  had  no  convulsion 
in  infancy,  and  had  sustained  no  injury  to  the  head.  When 
he  was  10  years  of  age  he  had  an  epileptic  convulsion  one 


REMISSIONS  IN  EPILEPSY.  605 

- .  ■  •■  i. 

night.  For  a  year  he  had  no  other,  but  the  attacks  then 
beg-an  to  occur  at  intervals  of  one  a  day  to  one  in  two  or 
three  months.  When  he  was  26  or  27  years  of  age,  tiie 
attacks  ceased,  and  the  arrest  could  not  be  traced  to  any 
medication  or  change  in  his  mode  of  life.  When  he  was 
41  years  old,  i.  e.,  after  an  interval  of  21  years,  the  at- 
tacks returned,  and  when  seen  four  months  after  the  re- 
currence he  was  having  about  two  attacks  a  month. 

To  these  cases  may  be  added  the  following,  in  which 
there  was  an  arrest  of  the  attacks  and  no  return  up  to  the 
time  when  the  patient  was  last  seen:  Edgar  S.  was  14 
years  old  when  he  had  the  first  attack.  The  seizures  con- 
tinued until  he  was  18  years  of  age.  He  had  no  recurrence 
of  the  attacks  for  five  years  and  four  months  when  last 
heard  from.  T.  H.  M.,  male,  was  20  years  of  age  when 
he  had  his  first  attack.  The  attacks  have  always  been 
nocturnal.  They  continued  for  1 1  years,  and  then  ceased,, 
and  when  seen  a  short  time  ago  he  stated  that  he  had 
had  no  attack  for  six  years.  A.  R.,  male,  was  9  yeai's  of 
age  wdien  he  had  the  first  attack.  The  attacks  continued 
for  four  vears,  and  there  had  been  no  recurrence  after  two 
and  a  half  years.  A  brother  of  the  above  was  first  seized 
with  epilepsy  at  nine  years  of  age.  He  had  attacks  for 
four  years,  and  had  had  no  recurrence  for  five  years,  when 
last  heard  from.  In  some  of  the  above  cases  the  arrest 
of  the  attacks  could  be  attributed  to  medication,  but  in  a 
few  the  attacks  seemed  to  cease  without  treatment. 

After  consideration  of  the  cases  above  referred  to,  in 
which  after  prolonged  intervals,  even  as  long  as  twenty- 
nine  years,  there  has  been  a  recurrence  of  the  disease,  we 
are  forced  to  the  conclusion  that  it  is  not  justifiable  to 
consider  any  case  of  epilepsy  cured,  no  matter  how  great 
has  been  the  interval  of  freedom  from  attacks  and  ap- 
pearance of  normal  health.  Notwithstanding  this  un- 
favorable conclusion,  the  study  of  these  cases  brings  out 
a  fact  which  is  satisfactory,  for  it  shows  that  remissions 
of  many  years'  duration  may  occur,  in  which  the  patient 


I 


6o6  WHARTON  SINKLER, 

is  in  normal  health,  and  is  able  to  pursue  his  life,  as  if  he 
had  never  suffered  from  epilepsy. 

DISCUSSION. 

Dr.  Edward  D.  Fisher  woiild  take  the  view  that  most 
observers  do  regarding  epilepsy — that  it  probably  belongs  to 
the  class  of  incurable  diseases;  but,  while  saying  this,  he  did 
net  mean  that  it  was  not  susceptible  of  considerable  improve- 
ment by  treatment.  The  fact  of  the  occurrence  of  these  re- 
missions between  epileptic  seizures  would  seem  to  prove  that. 
He  had  frequently  met  with  remissions  of  two,  three  and  five 
years.  Again,  he  had  seen  epilepsy  occurring  in  childhood,  at 
the  usual  period  of  the  tenth  or  fifteenth  year,  and  then  dis- 
at)pearing  until  some  later  period  of  life — e.  g.,  the  climacteric, 
or  after  some  great  strain.  The  value  of  the  paper  just  pre- 
sented lay  in  the  clinical  demonstration  of  this  peculiarity  of 
epilepsy.  This  also  goes  to  show  how  little  is  really  known 
of  the  true  pathology  of  the  disease. 

Dr.  Hugh  T.  Patrick,  of  Chicago,  had  seen  a  long  re- 
missiofli  in  a  lady,  now  about  seventy-two  years  old,  who  suf- 
fered from  epilepsy,  apparently  the  result  of  arterial  sclerosis. 
She  had  genuine  epilepsy  as  a  girl,  as  shown  by  her  history. 
This  lasted  until  the  time  of  her  marriage;  then  she  had 
petit  mal  until  the  time  of  her  menopause,  at  forty-five  years, 
when  the  attacks  ceased  entirely,  until  the  age  of  seventy,  so 
far  as  could  be  ascertained  by  careful  questioning  of  herself 
and  children.  When  seventy  years  oid,  she  began  again  to 
have  attacks  of  rather  typical  epilepsy. 

Dr.  Patrick  said  he  had  now  under  his  care  a  young 
woman  who  had  been  advised  to  get  married  as  a  cure  for 
her  epilepsy.  She  followed  this  advice  at  the  age  of  twenty, 
and,  strangely  enough,  did  not  have  an  attack  for  two  years 
and  a  half.  She  had  two  pregnancies.  Tliis  was  the  only 
case  that  he  had  known  of  in  which  there  had  been  any 
remedial  effect  from  marriage. 

Dr.  W.  L.  Worcester  thought  that,  perhaps,  in  discussing 
the  curability  of  epilepsy,  it  would  be  well  to  determine  just 
what  is  meant  by  the  term  *'epilepsy."  It  was  pretty  well 
known  that,  on  enquiring  into  the  history  of  epileptics  in 
whom  the  disease  was  said  to  have  begim  at  the  age  of  pu- 
berty, it  would  be  found  that  the  patient  suffered  from  con- 
vulsions in  infancy.  If  these  infantile  convulsions  were  a  part 
of  the  disease,  it  would  be  an  example  of  long  remissions,  but 
instances  frequently  occur  in  which  precisely  siimilar  con- 
vulsions are  observed  in  infancy  for  a  number  of  months,  and 


t 


RFMISSIONS  IN  EPILEPSY. 


607 


yet  these  convulsions  cease,  and  nothing  more  of  the  kind 
occurs  in  after-Hfe.  The  question  was:  Are  these  to  be  con- 
sidered cases  of  recovery  from  epilepsy,  or  are  they  attacks 
of  an  entirely  different  kind? 

Dr.  Joseph  Collins  said  he  wished  to  say  another  word 
about  a  case  of  epilepsy  whose  histor\'  be  had  presented  to 
the  association  three  years  ago.  The  patient  had  been  op- 
erated upon,  after  he  liad  had  two  distinct  epileptic  seizures, 
Jacksonian  in  character,  the  initial  manifestation  being  in  the 
right  index  finger.  He  was  operated  upon  8  months  after 
the  first  attack,  and  an  area  of  meningo-encephalitis  was  ex- 
tirpated. This  was  more  than  3  years  ago,  and  as  yet  he  had 
had  no  relapse. 

Dr.  Collins  had  looked  over  his  notes  on  epilepsy  since 
receiving  the  programme  of  this  meeting,  and  had  found  that 
out  of  about  300  cases  of  epilepsy  which  had  been  under  his 
observation,  5  had  been  practically  cured.  Although  he  had 
seen  a  greater  number  of  cases,  many  of  them  were  of  little 
service  to  him,  as  they  had  been  seen  in  his  wards  of  the 
City  Hospital,  and  had  been  distributed  since  then  to  other 
institutions.  Of  300  available  cases,  in  5  the  disease  had 
ceased  for  a  period  of  from  three  to  eight  years.  One  was  a 
young  girl,  who  had  formerly  been  under  the  treatment  of 
Brown  Sequard,  who  seemed  to  have  a  magic  power  in  the 
treatment  of  epilei>sy.  From  the  thirteenth  to  the  twenty- 
seventh  vear  she  had  had  no  return  of  the  attacks.  Another 
case  was  a  young  man,  whose  attacks  of  epilepsy  were  in  the 
form  of  violent  headaches  during  a  period  of  three  to  five  years, 
afterw^hich  the  typical  convulsive  form  developed.  He  had  lived 
four  years  witliout  any  further  attacks.  The  treatment  in  the 
first  case  had  been  stopped  for  about  six  years;  in  the  second 
case  it  had  been  stopped  for  about  two  years,  without  any 
return  of  the  symptoms.  The  third  case  was  that  of  a  young 
woman  who  had  had  a  peculiar  form  of  epilepsy,  beginning 
with  the  dreamy  state  described  by  Crichton  Browne,  Cowers 
and  others,  ahd  followed  by  what  might  be  called  hallucinatory 
attacks — attacks  in  which  she  saw  places  to  which  she  had 
never  been.  This  was  followed  in  a  few  years  by  typical  epi- 
lepsy. She  had  had  no  attack  for  three  years,  but  was  still 
under  treatment.  Another  case  was  that  of  a  young  girl,  18 
years  old,  who  had  now  been  free  from  attacks  for  nearly 
three  years.    She  was  still  under  treatment. 

The  treatment  in  all  these  cases  was  what  might  be  termed 
the  orthodox  bromide  plan.  Dr.  Collins  thought  that  his 
statistics  were  corroborative  of  the  statements  which  had  been 
made  by  others  concerning  the  curability  of  epilepsy.  In  his 
opinion,  the  attacks  would  cease  after  treatment  in  about  one 


i 


6o8  WHARTON  SINKLER. 

case  in  twenty,  provided  the  treatment  was  sufficiently  careful 
and  comprehensive. 

Dr.   Graeme   M.   Hammond   said  that   in   this  disease  it 
seemed  hardly  fair  to  consider  attacks  which  were  ten  to 
twenty-five  years  apart  as  consecutive  attacks  of  the  same 
illness.    The  fact  that  patients  have  epileptic  seizures  does  not 
like  scarlet  fever,  make  the  persons  less  liable  to  have  attacks 
in  the  future.    There  must  have  been  some  cause  for  the  epi- 
lepsy in  each  case,  but  the  disease  having  been  recovered  from 
under  treatment,  there  was  no  reason  why  something  might 
not  have  occurred  to  that  individual  and  reproduced  the  epi- 
lepsy.    He  would  consider  such  cases  as  examples  of  cures 
with  epilepsy  developed  anew.     He  had  always  believed  that 
when  a  case  had  gone  for  three  years  without  any  treatment 
and  without  any  attacks,  the  case  was  cured.     It  was  almost 
impossible  to  state  any  accurate  time  after  which  these  cases 
should  be  considered  cured,  but  he  would  consider  a  patient 
certainly  cured  who  had  gone  ten  or  eleven  years  without  a 
seizure.     Simply  because  at  the  end  of  that  time  there  was 
another  convulsion,  he  would  not  think  it  fair  to  say  that  this 
was  a  remiission  of  ten  or  eleven  years'  duration ;  it  was  rather 
an  example  of  recovery  from  the  disease  and  of  a  renewal  of 
the  malady  from  another  cause. 

Dr.  Sinkler,  in  closing,  said  that  the  point  just  raised  by 
Dr.  Hammond  was  a  very  interesting  one,  and  one  which  he 
had  considered  without  arriving  at  any  definite  conclusion. 
The  conditions  in  epilepsy  were  much  like  those  in  tic  doulou- 
reux or  in  neuralgic  affections,  where  an  unstable  condition 
of  the  ganglia  or  of  the  cortex  brought  about  a  recurrence  of 
the  attacks.  In  many  of  tliese  cases  there  was  no  assignable 
cause  for  the  disease. 

In  his  paper  he  had  excluded  all  cases  in  which  the  attacks 
were  Jacksonian,  and  also  cases  of  infantile  eclampsia.  He 
had  seen  a  few  cases  in  which  traumatic  epilepsy,  or  epilepsy 
due  to  brain  tumor,  had  been  relieved  by  operation,  the  attacks 
having  been  absent  for  three  to  five  years.  Keen,  in  one  of 
his  papers,  had  stated,  that  if  a  patient  were  free  from  attacks 
for  five  years  after  operation,  he  should  be  regarded  as  cured. 


192.  Thomsbn's   Disease.       A   Family   History.    •  J.    C.    Clemesha 

Buffalo  Med.  Jour.  53,  1897,  p.  16). 

An  interesting  family  history  is  here  presented  of  an  affection, 
generally  attacking  the  younger  members  of  the  family.  It  shows 
itself  in  complete  facial  paralysis,  affections  of  the  limbs  and  the  trunk, 
and  is  characterized  by  loss  or  diminution  of  reflexes  and  of  mechanical 
and  electrical  excitability  of  the  muscles. 

The  family  chart  shows  that  the  disease  was  most  marked  in  the 
grandmother.  In  the  second  generation  the  disease  was  less  severe, 
and  in  the  third  still  less  and  at  greater  time  intervals.         Jelliffe. 


REPORT  OF  A  CASE  OF  PURULENT  INTERNAL 
PACHYMENINGITIS,  COMPLICATING  MID- 
DLE-EAR  DISEASE.^ 

By  WILLIAM  M.  LESZYNSKY,  M.  D., 

Conftulting:  Neurologist  to  the  Manhattan  Eye  and  Bar  U>spital,  etc. 

E.  C,  male,  23  years  of  age,  was  admitted  to  the  Man- 
hattan Eye  and  Ear  Ho^ital,  February  3d,  1898.  For  many 
years  he  had  been  the  subject  of  chronic  suppurative  otitis, 
affecting  both  ears.  The  granulations  in  the  right  auditory 
canal  u'ere  curetted,  and  the  tympanic  cavity  thoroughly 
cleared  the  day  before  his  admission. 

This  was  soon  followed  by  an  evening  temperature  of  104.20 
F.  He  complained  of  pain  in  the  right  ear  and  mastoid  region, 
and  there  was  tenderness  over  the  mastoid  and  along  the 
course  of  the  sterno-mastoid  muscle  of  the  same  pide.  For 
four  days  these  symptoms  continued  unabated,  with  the  addi- 
tion of  rigors  and  daily  exacerbations  of  temperature,  ranging 
from  103  to  105.6  degrees,  and  a  correspciKiing  pulse  rate 
from  104  to  12©.  (See  chart.)  There  was  no  evidence  of  in- 
flammation of  any  of  the  internal  viscera.  Repeated  examin- 
ation of  the  blood  showed  the  absence  of  Plasmodium.  Noth- 
ing abnormal  was  found  in  the  urine.  The  ocular  fundi  were 
normal,  and  the  neurological  investigation  proved  n-egative. 

The  right  mastoid  was  then  opened,  and  the  sinuses  ex- 
plored with  negative  result.  Although  the  other  ear  was  the 
seat  of  chronic  suppurative  otitis,  neither  pain  nor  tenderness 
was  complained  of.  This  was  followed  by  increasing  hebetude, 
rigors  at  intervals,  and  temperature  at  times  reaching  106 
degrees,  terminating  in  profuse  sweating.  Vomiting  occurred 
occasionally.  On  the  15th,  inst.  (twelve  days  after  admission), 
it  was  noticed  that  he  was  unable  to  speak,  but  could  under- 
stand what  was  said  to  him.  I  was  then  asked  to  examine  the 
patient  again. 

I  found  him  aphasic,  being  unable  to  utter  a  word,  while 
he  understood  both  spoken  and  gesture  language.  It  was 
impracticable  to  make  any  further  tests  in  this  direction.  There 
was  right  facial  paresis,  affecting  only  the  lower  branches. 
The  pupils  were  unequal,  the  right  pupil  being  dilated  to  6 


*Read  at  the  twenty-fourth  annual  meeting  of  the  American  Neu- 
rological Association,  May,  1898. 


6lO  WILLIAM    M.  LESZYXSKY. 

mm.  Reaction  to  light  was  preserved  in  both.  The  ophthal- 
moscope revealed  bilateral  papillitis  with  "choked  disk"  in  the 
left  eye.  Shght  tenderness  was  present  on  percussion  over  the 
left  parietal  region,  but  the  patient  signified  by  a  negative  nod 
that  he  had  no  headache.  There  was  no  evidence  of  mastoid 
or  finus  involvement  on  the  left  side. 

The  right  upper  extremity  was  paralyzed,  the  flexors  show- 
ing a  moderate  amount  of  rigidity  upon  passive  movement. 
In  the  right  lower  extremity,  the  posterior  muscles  and  the 
tibial  group  were  paretic.  The  knee-jerks  were  exaggerated 
and  ankle  clonus  was  present,  both  being  more  marked  on 


the  right  side.  The  cremasteric  and  plantar  reflexes  were 
present,  and  equal  on  both  sides.  The  abdominal  reflex  was 
absent  on  the  right  side,  but  well  marked  on  the  left. 

There  was  no  gross  disturbaiiKe  of  sensibility.  The  pa- 
tient's mental  state  would  not  permit  of  the  finer  tests. 

The  continual  rigors,  high  temperature  and  sweating,  in 
the  absence  of  other  indications,  pcinted  to  a  septic  process, 
mo6t  Hkely  the  result  of  infective  sinus  thrombosis.  The  pro- 
visional diagnosis  was  made  of  left  temporo-sphenoidal  ab- 
scess, involving  the  motor  tract,  and  exploration  advised. 
The  operation  was  performed  by  Dr.  Pomeroy,  but  no  pus 


PURULENT  INTERNAL  PACHYMENINGITIS. 


6ll 


was  found.  The  patient  was  almost  moribund,  and  required 
abundant  stimulation  before  being  removed  from  the  table. 

Within  a  few  hours  active  delirium  developed,  and  he  had 
to  be  restrained.  Fourteen  epileptic  convulsions  occurred  dur- 
ing the  night,  consisting  in  conjugate  deviation  of  the  eyes  to 
the  right,  followed  by  tonic  and  clonic  spasm,  aflfecting  only 
the  right  side  of  the  face  and  the  right  arm.  Each  attack 
lasted  a  minute  and  a  half.  The  coma  increased  and  death 
supervened. 

Autopsy,  17  hours  later.  Examination  was  limited  to  the 
head.  The  external  surface  of  the  dura  was  normal  in  appear- 
ance. Upon  opening  the  dura,  the  entire  convexity  of  the 
brain  on  the  left  side  was  found  covered  with  thick  foetid  pus, 
but  at  no  point  was  there  any  adhesion  between  the  dura  and 
pda.  The  dura  over  the  left  fronto-parietal  region  was  very 
much  thickened  and  opaque,  and  contained  several  hemor- 
rhagic extravasations.  The  internal  surface  was  the  seat  of 
profuse  purulent-  exudation,  which  evidently  originated  in  its 
structure. 

There  was  only  a  very  slight  dtg^ee  of  leptomeningitis, 
which  was  circumscribed  over  the  convexity  and  involved  the 
left  third  frontal  gyrus,  and  extended  upward  about  two-thirds 
of  the  length  of  the  central  convolutions.  These  cortical  arec  s 
had  undergone  well  marked  softening.  The  external  suffac:? 
of  the  left  temporo-sphenoidal  lobe  was  sunken  inward,  and 
there  were  masses  of  dotted  blood  in  the  middle  cranial  fossa, 
the  result  of  previous  surgical  exploration. 

There  was  no  sigri  of  abscess  in  either  temporo-sphenoidal 
lobe.  The  brain  tissue  and  pia  were  intensely  congested 
throughout.  The  ventricles  were  empty,  and  there  was  no 
cerebral  oedema.  On  the  contrary,  the  brain  tissue  seemed 
comparatively  dry. 

The  basal  ganglia  were  apparently  normal,  and  no  indica- 
tion was  found  of  softening  or  hemorrhage  in  the  internal 
capsule.  The  right  hemisphere  showed  nothing  abnormal. 
The  cerebellum,  pons,  medulla  and  the  vessels  at  the  base 
were  normal.  The  usual  pyramidal  decussation  was  present. 
No  microscopical  examinaition  was  made.  On  the  left  side 
the  roof  of  the  tympanum  was  entirely  destroyed  by  caries. 

This  was  probably  the  source  of  the  pus  formation.  The 
sinuses  in  this  region  were  completely  disorganized.  On  the 
right  side  the  petrous  pyramid  was  somewhat  discolored,  sug- 
gesting commencing  necrosis.    The  lateral  sinus  was  normal. 

In  reviewing  this  case,  a  few  remarks  bearing  upon  the 
question  of  diagnosis  may  prove  of  interest.     Those  of 


I) 

i: 

V 
t' 
* 


6l2  IVILUAM    M.  LESZYNSKY. 

US  who  have  had  the  opportunity  of  seeing  many  cases  of 
middle-ear  disease  associated  with  cerebral  symptoms,  re- 
cognize the  difficulties  that  often  arise  in  forming  even 
a  presumptive  diagnosis  as  to  the  location  of  the  cerebral 
lesion,  before  localizing  symptoms  are  discoverable. 

During  the  first  week  several  examinations  were  made 
with  negative  results,  so  far  as  localization  was  concerned, 
and  at  no  time  was  Gerhardt's  symptom  (occlusion  of  the 
internal  jugular  vein)  demonstrable. 

As  the  previous  acute  symptoms  were  limited  to  the 
right  ear  and  mastoid,  the  possibiHty  of  the  complicating 
cerebral  lesion  being  on  that  side,  and  a  non-decussation 
of  the  motor  tract  were  also  discussed.  The  condition  of 
the  left  eye,  however,  and  the  fact  that  the  man  had  al- 
ways been  right-handed,  led  to  the  immediate  abandon- 
ment of  such  a  view. 

In  order  to  explain  the  cause  of  the  rapidly  developed 
aphasia  and  motor  paralysis,  several  conditions  were  taken 
into  consideration.  Arterial  thrombosis,  hemorrhage  and 
embolism  were  excluded  for  obvious  reasons,  and  the 
question  whether  we  had  to  deal  with  either  a  left  tem- 
poro-sphenoidal  abscess,  or  purulent  lepto-m^ningitis,  was 
seriously  considered.  In  the  absence  of  severe  headache, 
delirium,  convulsive  seizures,  etc.,  which  so  frequently  ac- 
company purulent  meningitis,  complicating  sinus  throm- 
bosis, the  presumptive  diagnosis  was  made  of  abscess  of 
the  left  temporal  lobe,  involving  the  motor  speech  centre 
and  the  pyramidal  tract. 

At  no  time  before  operation  was  headache  complained 
of,  and  there  was  only  very  slight  tenderness  on  percussion 
over  the  left  parietal  region.  Neither  were  any  localized 
spasms  manifested,  which  might  lead  to  the  assumption 
of  irritation  of  the  cortical  cells  in  the  Rolandic  area.  It 
was  agreed  that  all  of  the  general  symptoms  indicated 
systemic  infection  from  septic  sinus  thrombosis,  but  it  is 
to  be  regretted  that  the  opposite  (left)  mastoid  and  the 
adjacent  sinuses  were  not  explored  early  in  the  course  of 


! 


PURULENT  INTERNAL  PACHYMENINGITIS.         613 

the  disease,  as  the  chronic  supurative  otitis  was  bilateral. 
This  patient  was  seen  by  me  in  consultation  with  Dr. 
O.  D.  Pomeroy,  to  whom  I  am  indebted  for  the  privilege 
of  observing  and  reporting  the  case. 


A   CASE  OF  SEROUS  (ALCOHOLIC)    MENINGITIS   SIMU- 
LATING   BRAIN    TUMOR.      BY    THEODORE    DILLER. 

M.  D.   (See  p.  441.) 

DISCUSSION. 

Dr.  E.  B,  Angell,  of  Rochester,  said  that  about  a  year  ago 
he  had  seen  a  patient  who  was  under  treatment  by  Dr.  koe 
for  middle-car  trouble.  Subsequently  the  patient  developed 
maniacal  delirium  without  focalizing  symptoms.  The  general 
symptoms  were  those  of  septicaemic  infection.  Choked  disk 
was  not  present.  When  the  man  became  delirious,  the  question 
of  opening  the  skull  and  searching  for  pus  was  considered, 
but  exploration  was  deferred  from  time  to  time,  and  the 
patient  ultimately  made  a  full  recovery  witliout  surgical  inter- 
ference. 

Dr.  G.  L.  Walton,  of  Boston,  thought  it  would  have  been 
interesting  to  have  known  the  order  of  paralysis  in  Dr.  Les- 
zynsky's  case.  The  rule  has  been  laid  down  by  Macewen  that 
a  temporo-sphenoidal  abscess  working  inwards  should  first 
affect  the  leg,  then  the  arm,  and  finally  the  face;  whereas  in 
case  of  extension  upwards,  the  inverse  order  is  foilowed.  The 
case  was  seen  too  late  to  establish  this  point,  but  the  fact  that 
the  arm  was  decidedly  paralyzed,  while  the  face  and  leg  were 
only  slightly  so,  would  tend  to  show  that  neither  order  was 
followed  here,  and  yet  the  naturul  diagnosis  was  abscess  in 
this  locality. 

Dr.  Walton  thought  it  possible  that  further  experience 
would  teach  that  this  order  points  by  exclusion  to  meningitis, 
but  the  exact  diagnosis  was  baffling  at  the  best,  especially 
when  we  remember  that  the  process  may  be  metastatic,  as 
well  as  by  direct  extension.  In  the  only  case  of  temporo- 
sf^enoidal  lesion,  confirmed  by  autopsy,  coming  under  his 
observajtion  since  the  publication  of  Macewen's  book,  the 
extension  was  inwards,  and  the  leg  was  first  paimlyzed,  thus 
falling  under  his  rule. 

Dr.  W.  L.  Worcester,  of  Danvers,  Mass.,  said  that  in  con- 
nection with  the  case  of  Dr.  Diller,  he  was  in  doubt  whether 
the  post-mortem  findings  accounted  for  all  the  symptoms. 
An  exudation  of  serous  fluid  into  the  meninges  is  frequently 
misinterpreted:  it  does  not  necessarily  imply  an  inflammatory 


r 


614  WILLIAM    M.  LESZYNSKY. 

condition,  although  it  may  have  done  so  in  this  case.  The 
cranium  is  a  closed  cavity,  and  if  there  is  an  increase  in  the 
quantity  of  fluid  within  it,  there  must  be  a  loss  of  something 
else.  There  was  no  special  thickening  of  the  meninges,  and 
the  pathological  findings  did  not  account  for  the  symptoms 
of  multiple  neuritis. 

Dr.  F.  X.  Dercum  remarked  that  it  was  a  well  known  fact 
that  serous  meningitis  was  apt  to  be  mistaken  for  bram  tumor. 
In  serous  meningitis  we  are  liable  to  have,  for  some  unknown 
reason,  a  high  grade  of  optic  neuritis.  Indeed,  this  is  a  much 
more  frequent  occurrence  than  in  purulent  meningitis.  Dr. 
Dercum  thought  that  the  meningitis  in  Dr.  Diller's  case  could 
hardly  be  attributed  to  alcohol.  The  whole  subject  of  menin- 
gitis serosa  was  still  an  open  one,  but  it  was  a  well  known 
fact  that  its  most  marked  symptoms:  diffused. headache,  optic 
neuritis  and  nervous  symptoms,  vague  in  character,  suggest 
brain  tumor  in  a  silent  region. 

Dr.  Leszynsky,  in  closing,  said  that  the  course  of  the  paral- 
ysis in  his  case  would  not  permit  us  to  exclude  temporal  ab- 
scess, as  an  abscess  in  that  location  might  also  involve  the  arm 
and  face  fibres  more  than  the  leg  fibres.  While  Macevven's 
views  and  experience  might  apply  to  his  own  cases,  the  speaker 
thought  they  could  not  be  accepted  as  an  absolute  law. 

Dr.  Dilkr  stated  that  in  his  case  there  was  considerable 
serous  exudate,  but  no  pus.  Meningeal  inflammation  was 
present  in  spots.  The  patient  gave  a  very  clear  history  of  pro- 
longed indulgence  in  alcoholic  stimulants,  and  alcoholic  neu- 
ritis was  undoubtedly  present.  Several  writers,  among  them 
Quincke,  Prinice,  and  Oppenheim,  have  referred  to  the  sim- 
ilarity of  the  symptonw  of  serous  meningitis  and  brain  tumor. 
As  a  rule,  these  cases  have  been  mistaken  for  brain  tumors. 


195.  Effect  of  Study  for  Examinations  on  the  Nervous  and 
Mental  Conditions  of  Female  Students.  Frances  M.  Drury 
and  Clara  F.  Folsom  (Psychological  Rev.,  5,  1898,  p.  55). 

Twenty-five  subjects  were  tested  in  the  following  order:  (i)  For 
ftcadiness,  (2)  for  fatigue,  (3)  for  steadiness  after  fatigue,  (4)  for 
memory,  and  (5)  for  discriminative  ability.  The  experiments  were  first 
made  under  normal  conditions,  and  again  during  the  mid-year  period. 
The  conclusion  reached  was  that  "the  nervous  condition  of  the  sub- 
jects was  in  a  slight  degree  less  steady  during  mid-year  examinations 
than  it  was  normally,  but  that  the  mental  condition  was  much  im- 
proved, thought  being  more  sure  and  active.     Their  results   show: 


(l)  In  steadiness  9  were  improved,  11  less  steady,  and  5  unchanged, 
2)  In   ' 
ha.d  less  capacity,  and  in  5  no  change.     (3)  In  memory  18  improved 


i 


^        ,, _       ^ —    _._   — ^ ^  ^ ^^        „ _  — __  —  ^  ^  _, 

fatigue  12  improved  (greater  capacity  for  mental  arithmetic), 


and  7  were  worse.  (4)  In  discriminative  ability  10  overestimated  lines 
more  than  normally,  4  underestimated  lines  more  than  normally,  and 
IX  kept  their  normal.  Christison. 


ilociets  W'tpovts. 


PHILADELPHIA  NEUROLOGICAL  SOCIETY. 

April  25th,  1898. 
The  President,  Dr.  Francis  X.  Dercum,  in  the  chair* 
Dr.  F.  X.  Dercum  presented  a  case  of 

TABES  WITH  INTERCURRENT  HEMIPLEGIA,  WITH  RE- 
TURN OF  THE  KNEE-JERK  UPON  THE  PARALYZED 
SIDE. 

The  family  history  of  the  patient,  a  brakeman,  was 
negative.  He  had  had  one  attack  of  gonorrhoea,  but  de- 
nied syphilis.  He  mafried  in  1873,  and  his  wife  has  had 
four  children,  all  of  whom  are  living  and  well,  and  has 
had  no  miscarriages.  In  1883,  while  working  on  a  rail- 
road, he  was  run  over  by  two  cars;  his  body  was  b«tdly 
bruised,  and  he  sustained  a  compound  fracture  of  the 
skull.  He  was  unconscious  two  days;  was  operated  upon, 
and  apparently  fully  recovered. 

Some  years  afterward  he  noticed  that  he  was  becom- 
ing unsteady  and  awkward  in  his  movements,  and  by  the 
latter  part  of  March,  1896,  these  symptoms  had  increased 
to  such  an  extent  that  he  could  accomplish  his  work  only 
by  great  effort.  He  does  not  recall  any  other  symptoms. 
He  was  finally  obliged  to  stop  work  altogether.  He  re- 
mained in  this  condition  until  October  29th,  1896.  On 
this  date  he  went  to  bed  about  8  o'clock,  apparently  as  well 
as  usual.  During  the  night,  as  he  expresses  it,  he  *'went 
crazy";  he  lost  all  power  in  his  right  arm  and  leg,  talked 
with  difficulty,  and  was  out  of  his  mind  and  ver>'  violent, 
attempting  to  injure  persons  about  his  bed.  It  was  neces- 
sary to  hold  him.  He  remained  in  this  condition  about 
three  weeks,  after  which  his  mind  gradually  became  clear. 
When  he  recovered  his  senses,  he  talked  with  difficultv, 


k 


6l6  PHILADELPHIA  NEUROLOGICAL  SOCIETY. 

and  his  right  arm  and  leg  were  paralyzed,  the  arm  being 
the  most  affected.  He  noticed  also  that  his  vision  was 
becoming  impaired,  and  three  months  after  the  attack  of 
paralysis  the  right  eye  was  quite  blind.  The  patellar  re- 
flexes were  absent.  He  has  remained  in  this  state  ever 
since. 

At  present  the  patient  walks  with  difficulty,  requirin-' 
assistance  after  every  few  steps.  A  right-sided  hemiplegia 
exists,  the  right  arm  being  semi-flexed  and  the  fingers  held 
in  a  position  of  secondary  contracture;  while  the  right 
leg  is  dragged  in  walking.  A  study  of  the  movements 
of  the  left  arm  and  leg  reveals  decided  ataxia,  especially 
in  the  leg.  On  handling  the  right  arm,  very  little  re- 
sistance is  experienced  in  extending  the  forearm  or  the 
fingers.  In  other  words,  secondary  rigidity  is  but  slight- 
ly, if  at  all,  present,  although  the  position  involuntarily 
assumed  by  the  arm  is  that  of  secondary  contracture. 
The  right  leg  also  is  flaccid.  On  testing  the  knee-jerks 
the  left  is  absent,  but  the  right  quite  marked.  No  ankle 
clonus,  however,  can  be  elicited,  nor  can  any  tendon  re- 
action be  discovered  in  the  right  arm. 

The  sensation  in  the  legs  is  somewhat  retarded.  An 
examination  of  the  eyes  reveals  the  presence  of  Argyll 
Robertson  pupils.  The  pupils  are  contracted  to  two  mm. 
in  idiameter.  The  optic  nerve  of  the  right  eye  is  com- 
pletely atrophic,  and  the  left  also  is  atrophied,  especially 
upon  the  temporal  side.  Vision  in  the  right  eye  is  en- 
tirely absent. 

A  study  of  this  case  permits  of  no  other  conclusion 
than  that  this  is  an  instance  of  tabes,  in  which  a  hemi- 
plegia occurred,  in  all  probability  due  to  hemorrhage  into 
the  internal  capsule,  and  in  which  the  knee-jerk  returned 
upon  the  paralyzed  side.  Dr.  Hughlings  Jackson  reported 
a  similar  case  some  years  ago.  The  return  of  the  knee- 
jerk  is  explained  by  Dr.  Dercum  as  follows: 

The  tonus  of  the  muscles  depends  not  only  upon  the 
impulses  streaming  into  the  cord  from  the  motor  area 
of  the  brain,  but  also  upon  the  impulses  streaming  into 
the  cord  from  all  the  other  areas  of  the  cortex,  from  the 
basal  ganglia,  the  pons  and  medulla  oblongata.  It  would 
seem  to  be  the  function  of  the  neurons  of  the  motor  area 
to  direct  and  control  these  impulses  through  the  lateral 
tract.     The  lateral  tract  being  destroyed,  it  follows  that 


PHILADELPHIA  NEUROLOGICAL  SOCIETY.  617 

the  impulses  streaming  into  the  cord  from  other  sources 
cause  an  elevation  of  the  muscle  tonus  above  the  normal 
upon  the  paralyzed  side.  It  is  in  this  way  that  we  can 
best  account  for  the  rigidity,  contracture  and  exaggerated 
tendon  reaction^  in  ordinary  cases  of  hemiplegia,  and  this 
theory  certainly  enables  us  to  explain  the  curious  phe- 
nomenon of  a  return  of  the  knee-jerk  in  a  case  of  tabes. 

DISCUSSION. 

Dr.  Wharton  Sinkler  asked  whether  Dr.  Dercum  could 
give  any  explanation  of  the  fact  that  the  knee-jerk  had  not 
returned  on  both  sides.  In  hemiplegia,  occurring  in  previous- 
ly healthy  individuals,  there  is  grossly  exaggerated  knee-jerk 
on  each  side,  as  the  result  of  degeneration  in  both  pyramidal 
tracts. 

Dr.  Dercum  replied  that  in  ordinary  hemiplegia  we  do 
not  have  a  degeneration  which  is  absolutely  confined  to  one 
side  of  the  cord.  There  are  a  certain  number  of  fibres  which 
do  not  decussate,  and  there  are  others  which,  though  they 
decussate,  are  connected  with  the  so-called  sound  side  of  the 
cord,  so  that  the  pathological  elevation  of  the  muscle  tonus  is 
shared  by  both  sides.  In  his  case  the  muscle  tonus  had  been 
sufficiently  raised  on  the  paralyzed  side  to  cause  a  return  of 
the  knee-jerk,  but  not  on  the  "sound"  side. 


Dr.  A.  Ferree  Witmer  exhibited 

A  CASE  OF  AMYOTROPHIC  LATERAL  SCLEROSIS. 

The  patient  was  a  male  of  45  years,  temperate,  a  lathe 
worker,  and  with  a  good  family  history.  He  had  had 
typhoid  fever  seven  years  previously.  His  personal  history 
otherwise  was  negative.  His  present  illness  dates  from  De- 
cember, 1896.  The  onset  was  slow.  The  first  symptom 
was  quivering  of  the  muscles  at  the  base  of  the  left  thumb. 
The  wasting,  rapidly  involving  the  entire  upper  extremi- 
ties, began  in  the  left  hand.  During  the  progress  of  the 
disease  the  left  arm  became  entirely  denuded  of  hair, 
which,  however,  at  the  present  time  is  fully  restored.  For 
the  past  nine  years  he  has  been  sexually  weak,  but  has 
had  no  disturbances  of  bladder  or  rectum. 

At  present  marked  wasting  of  both  upper  extremities, 
especially  of  the  left,  is  noted.  The  flexion  and  extension 
on  the  left  side  are  nil.  The  paralysis  is  flaccid  (type  of  Ley- 


•  : 


I" 


r. 

"'i 


6l8  PHILADELPHIA  NEUROLOGICAL  SOCIETY. 

den).  The  electrical  reactions  with  the  galvanic  current 
are  quantitatively  lessened,  being  absent  over  the  most 
atrophied  parts.  Deglutition  and  respiration  are  normally 
.performed.  The  gait  and  station  are  normal.  The  knee- 
jerks  are  plus.  Abortive  clonus  exists  on  the  right 
side,  but  clonus  is  marked  on  the  left  side.  The  elbow 
jerks  are  present  on  the  left  side.  No  disturbance  of  the 
special  senses  or  of  general  sensibility  is  noted.  The  trophic 
disturbance  and  non-involvement  of  the  lower  extremi- 
ties Dr.  Witmer  considered  particularly  noteworthy. 

DISCUSSION. 

Dr.  Spiller  thought  that  the  case  could  hardly  be  considered 
one  of  pachymeningitis  cervicalis  hypertrophica,  chiefly  on 
account  of  the  absence  of  pain  and  sensory  disturbances.  Un- 
less we  should  regard  it  as  one  of  the  rare  instances  of  syringo- 
myelia, without  involvement  of  the  sensory  fibres,  it  could 
hardly  be  a  case  of  syringomyelia.  The  symptoms  were  not 
those  of  spinal  tumor  or  myelitis,  but  were  those  which  we  be- 
lieve result  from  lesions  of  the  lateral  columns  and  anterior 
horns  of  the  cord. 

Dr.  John  K.  Mitchell  said  that  it  is  very  common  in  trophic 
lesions  to  see  both  loss  of  the  hair  and  growth  of  the  hair. 
Sometimes  the  growth  will  be  increased  at  first,  or  the  hair 
may  at  first  drop  out,  and  then  return  with  increased  growth, 
or  the  growth  may  increase  late.  As  to  theories,  he  had  none 
to  offer;  but  all  of  these  conditions  he  had  seen  following 
nerve  lesions.  He  believed  that  sometimes  a  part  of  the 
increase  is  due  to  the  rubbing  and  the  applications  resorted  to 
as  measures  of  treatment. 

Dr.  Witmer  stated  that  he  had  called  particular  attention 
to  the  change  in  the  growth  of  the  hair,  because  that  is  sup- 
posed to  be  due  to  trophic  lesions,  and  trophic  lesions  are 
said  not  to  be  present  in  amyotrophic  lateral  sclerosis. 


Dr.  J.  W.  McConnell  presented 

A  CASE  OF  OBJECTIVE  TINNITUS  IN  A  PATIENT  WITH 

GRAVE  HYSTERICAL  SYMPTOMS. 

The  patient  was  a  woman,  20  years  old.  In  1890  a 
habit  spasm  of  the  facial  muscles  seemed  to  follow  a  severe 
accidental  hemorrhage.  The  aflfection  was  migratory,  im- 
plicating first  one,  then  another  group  of  muscles.     She 


PHILADELPHIA  NEUROLOGICAL  SOCIETY.  619 

always  had  perfect  control  of  the  tongue,  but  had  oc- 
casional attacks  of  paralysis  of  the  right  lower  extremity. 
This  condition  persisted  for  four  years,  and  was  followed 
by  a  state  of  perfect  health  for  eighteen  months.  In  1895, 
absent-mindedness  and  loss  of  memory  evidenced  a  change 
in  her  character,  and  tonic  convulsions,  general  in  char- 
acter, but  without  loss  of  consciousness,  were  added  to 
the  symptomatology.  These  convulsive  seizures  were  of 
two  kinds,  one  the  mother  described  as  "unconscious 
spells,"  in  which  the  patient  seemed  to  fall  asleep  for  two 
or  three  minutes  without  muscular  movements.  The  other 
variety,  "conscious  spells,"  were,  according  to  the  descrip- 
tion, tonic  convulsions  without  loss  of  consciousness. 
Shortly  after  these  attacks  began  three  nails  of  one  foot 
dropped  off,  apparently  spontaneously;  those  of  the  other 
foot  seemed  ready  to  drop,  but  were  not  shed. 

The  "unconscious"  spells  later  took  on  a  different 
form.  Consciousness  seemed  to  be  lost.  There  was  no 
spasm,  but  the  patient  assumed  attitudes  of  joy,  sorrow 
or  prayer,  or  performed  acts  suggested  by  her  conversa- 
tion or  employment  immediately  previous  to  the  onset 
of  the  attack.  She  never  fell,  never  Injured  herself,  some- 
times opened  and  sometimes  closed  her  eyes,  recovered 
almost  immediately,  and  continued  her  work  or  talk. 

She  now  has  hyperesthesia  of  ovarian,  mammary  and 
spinal  regions.  At  times  there  is  apparently  no  secretion 
of  urine,  at  least,  none  is  passed  through  the  natural  pas- 
sage for  as  long  as  forty-eight  hours.  Then,  again,  she 
has  polyuria.  She  says  she  "has  a  clock  in  her  head,"  and 
by  listening  a  few  inches  from  the  right  ear  a  distinct 
ticking  or  chcking  noise  is  heard,  averaging  ninety-four 
times  a  minute.  It  is  not  synchronous  with  the  pulse,  and 
is  audible  with  the  mouth  shut  or  open. 

Under  hypnotic  suggestion  the  patient  has  vastly  im- 
proved, and  many  of  the  symptoms  mentioned  have  dis- 
appeared. Dr.  McConnell  thought  that  the  case  was  one 
of  grave  hysteria. 


Dr,  John  K.  Mitchell  read  a  paper  on 
CASES  OF  TRIGEMINAL  SPASM:  RESECTION— PROBABLE 
PRESENCE  OF  SENSORY  FIBRES  IN  THE  SEVENTH 
NERVE.    (See  page  392)- 


620  PHILADELPHIA  NEUROLOGICAL  SOCiETY. 

DISCUSSION. 

Dr.  Charles  K.  Mills  thought  that  the  first  explanation 
which  Dr.  Mitchell  suggested  was  more  probably  the  correct 
one,  although  it  was  true  that  some  records  indicated  a  sensory 
distribution  in  the  seventh  nerve.  He  said  that  members  of 
the  society  would  probably  recall  that  he  had  directed  atten- 
tion, and  was  probably  the  first  to  do  this,  to  the  fact  that  both 
in  hysterical  and  in  organic  hemiansesthesia  we  very  common- 
ly have  preservation  of  sensation  in  certain  portions  of  the 
face  on  the  affected  side  of  the  body,  that  part  being  usually 
a  part  or  all  of  the  region  here  indicated.  He  referred  to  a 
diagram  in  his  book  illustrating  this.  One  of  his  cases  was 
a  patient  upon  whom  an  autopsy  showed  a  lesion  in  the  thal- 
amus and  a  portion  of  the  internal  capsule.  This  would  indi- 
cate that  each  side  of  the  neuraxis  supplies  both  sides  of  the 
face,  near  the  median  line,  with  nerves  of  common  sensibility. 
Destruction  of  one  side,  therefore,  would  not  necessarily  cause 
anaesthesia,  or,  at  least,  persistent  anaesthesia,  on  either  side 
in  this  region. 

Dr.  Spiller  called  attention  to  the  very  careful  dissections 
made  by  Zander,  which  show  that  the  diagrams  representing 
the  distribution  of  the  fifth  nerve  are  incorrect.  The  fibres  of 
the  different  branches  of  the  fifth  nerve  go  further  than  we 
suppose.  He  had  seen  cases  of  facial  paralysis  in  which  pain 
was  marked,  and  thought  that  it  is  a  mistake  to  say  that  the 
facial  nerve  is  purely  motor. 

Dr.  John  K.  Mitchell  remarked  that  if  the  explanation  of 
Dr.  Mills  is  the  correct  one,  viz.,  that  both  sides  of  the  face  are 
supplied  by  each  nerve,  we  should  not  expect  to  find  anaes- 
thesia at  all  immediately  after  operation.  A  careful  study  of 
the  sensory  changes  in  a  sufficient  number  of  cases  of  facial 
palsy  would  help  to  settle  the  question  under  dispute. 


Dr.  Wharton  Sinkler  reported 

A  CASE   OF   FUNCTIONAL  TREMOR   SIMULATING   DIS- 
SEMINATED SCLEROSIS. 

A  young  man,  aged  25  years,  suffered  from  an  ex- 
cessive and  exaggerated  intention  tremor.  He  had  an 
excellent  family  history;  had  always  been  temperate  in  his 
habits,  and  denied  any  venereal  disease.  About  eighteen 
months  before  coming  under  observation  he  noticed  a 
slight  jerking  in  the  left  leg  while  walking,  and,  soon 
after,  tremor  on  voluntary  effort  was  observed   in   the 


Ir 


PHILADELPHIA  NEUROLOGICAL  SOCIETY.         62 1 

right  hand.  The  symptoms  became  markedly  accentu- 
ated, in  spite  of  complete  rest  in  bed  for  several  weeks, 
and,  finally,  the  patient  became  unable  to  walk  on  ac- 
count o£  want  of  control  of  the  right  leg.  A  coarse  tremor 
in  the  left  arm,  whenever  any  attempt  was  made  to  move 
it,  was  developed  to  such  an  extent  that  he  was  unable 
to  make  any  use  of  the  arm.  Internal  squint,  from  pa- 
ralysis of  the  right  internal  rectus,  also  existed. 

The  patient  said  that  at  one  period  he  was  uncon- 
scious of  his  surroundings.  He  held  conversation  when 
necessary,  but  afterward  did  not  remember  what  occurred 
during  this  time.  After  the  tremor  had  lasted  for  eight 
or  nine  months  in  the  left  arm  and  leg,  the  right  arm  and 
leg  became  affected,  and  as  the  tremor  developed  in  the 
right  side,  the  left  side  recovered.  He  was  seen  by  the 
speaker  in  November,  1897.  At  that  time  he  was  able  to 
walk,  but  required  assistance,  as  incoordination  in  the 
movements  of  the  left  leg  was  marked,  and  as  a  result 
there  was  a  tendency  to  pitch  to  one  side.  The  left  arm 
and  leg  were  apparently  normal.  He  used  the  left  hand 
for  shaving,  writing,  and  for  general  purposes,  without 
any  tremor  whatever.  Any  attempt  to  use  the  right  hand 
brought  on  excessive  tremor,  which  was  identical  with 
the  intention  tremor  of  disseminated  sclerosis.  While  at 
rest  no  tremor  was  present  in  the  arm  or  leg.  The  knee- 
jerks  were  excessive,  but  no  ankle  clonus  was  noted.  No 
facial  paralysis  existed,  although  the  expression  was  blank. 
The  speech  was  slow,  drawling  and  scanning,  and  the 
patient  was  easily  moved  to  laughter  or  tears.  His  mental 
condition  did  not  seem  to  be  up  to  the  average.  An  ex- 
amination of  the  eyes  revealed  no  changes  in  the  muscles 
or  in  the  fundi. 

After  being  under  treatment,  for  three  or  four  weeks 
his  condition  improved  very  materially,  and  he  was  able 
to  walk  about,  but  soon  after  there  was  exacerbation  in 
all  of  the  symptoms,  and  a  return  of  tremor  to  the  left 
side.  Then  tremor  developed  in  the  hands  while  they 
were  at  rest.  In  January,  1898,  after  a  month  of  absolute 
quiet  and  the  use  of  the  Paquelin  cautery  to  the  nucha, 
and  the  administration  of  hyoscyamus,  the  patient  be- 
gan to  improve  again,  and  became  able  to  feed  himself 
with  the  left  hand,  and  to  walk  about  with  assistance. 
At  the  present  time  the  patient's  condition  is  as  follows: 
There  is  no  tremor  in  either  limb  while  at  rest,  but  any 


622      PHILADELPHIA   NEUROLOGICAL  SOCIETY, 

attempt  at  movement  with  the  right  arm  brings  on  ex- 
cessive tremor.  Slight  tremor  is  still  present  in  the  left 
hand,  but  this  does  not  interfere  materially  with  the  use 
of  the  hand.  Dr.  Sinkler  considered  the  case  one  of  func- 
tional tremor,  and  thought  that  it  was  probably  hysterical, 
although  many  of  the  stigmata  of  hysteria  were  absent. 

DISCUSSION. 

Dr.  James  Hendrie  Lloyd  said  that  the  diagnosis  of  func- 
tional tremor  is  an  important  and  interesting  point  in  clinical 
study.  He  thought  that  the  important  question  was  the  elim- 
ination or  establishment,  as  the  case  might  be,  of  hysteria. 
Where,  as  in  Dr.  Sinkler's  case,  the  tremor  was  shifting  in 
character,  passing  from  one  side  to  the  other,  the  inference  was 
very  strong  in  favor  of  the  possibility  of  its  hysterical  origin.  He 
hardly  thought  that  the  absence  of  sensory  stigmata  and  of 
contraction  of  the  visual  fields  was  positive  proof  against  hys- 
teria. A  few  years  ago  he  put  on  record  a  very  interesting 
case  of  hysterical  tremor,  associated  with  anorexia  and  great 
emaciation.  In  that  case  the  symptoms  were  shifting,  coming 
and  going,  with  some  affection  of  speech  and  constant  vomit- 
ing. That  patient  made  a  perfect  recovery.  She  has  since 
married  and  had  several  children.  Cases  of  this  form  of  hys- 
teria have  been  recorded  as  cases  of  disseminated  sclerosis 
cured  by  hypnotism.  A  French  observer,  Luys,  has  claimed 
that  he  cured  two  cases  of  disseminated  sclerosis  by  hyp- 
notism, with  the  aid  of  revolving  mirrors.  Dr.  Lloyd  had  no 
doubt  these  were  cases  of  hysterical  tremor,  not  disseminated 
sclerosis. 

Westphal  once  described  two  cases  of  pseudo-sclerosis,  in 
which  the  autopsies  were  entirely  negative.  Without  these 
autopsies  the  cases  would  probably  have  continued  to  be  re- 
garded as  organic.  This  "pseudo-sclerosis"  of  Westphal  has 
been  justly  relegated  by  French  critics  to  hysteria. 

Dr.  John  K.  Mitchell  was  astonished  to  hear  any  one  lay 
stress  on  the  absence  of  changes  in  the  visual  fields  as  evi- 
dence against  hysteria.  These  changes  are  rather  the  excep- 
tion than  the  rule  in  hysteria.  Not  more  than  one  in  eight 
or  ten  has  distinct  concentric  narrowing  of  the  fields,  and  not 
more  than  one  in  twenty  any  change  in  the  color  fields. 

He  had  under  observation  a  case  of  hysterical  tremor  which 
resembled  in  character  that  described  by  Dr.  Dercum  and  Dr. 
Parker  as  being  brought  on  by  continuous  slight  muscular  ef- 
fort of  one  kind.  The  man  even  had  been  thrown  to  the  floor 
by  the  violence  of  the  general  clonic  movement  resulting  from 
the  tremor,  which  had  its  origin  in  the  effort  to  supinate,  or 
to  hold  supine,  the  right  hand. 

(To  he  continued) 


r 


"gtviscopt. 


With  the  Assistance  of  the  Following  Collaborators: 


ChasXewis  ALLEN,M.D.,Wash.,D.C 
J.  S.  Chkistison,  M.D.,  Chicago,  111. 
A.  Freeman,  M.D.,  New  York. 
S.  E.  Jelliffe,  M.D.,  New  York. 
Wm.C.Krauss,M.D.,  Buffalo,  N.Y. 
W.  M.  Leszynsky,  M.D.,  New  York. 


R.  K.  Macalbsteil  M.D..  N.Y. 
T.  K.  Mitchell.  M.D.,  Phila.,  Pa 
H.  Patrick,  M.D.,  Chicago,  111. 
Joseph  Sailer,  M.D.,  Phila.,  Pa. 
Henry  L.  Shively,  M.D.,  N.  Y. 
A.  Sterne,  M.D.,  Indianapolis. 


ANATOMY  AND  PHYSIOLOGY. 

194.  Present  Methods  of  Preparation  of  the  Nervous  System 
H.  J.  Berkley  (Am.  Jour.  Insanity,  54,  1898,  p.  333). 

The  present  article  gives  an  excellent  summary  of  the  technique 
which  may  be  followed  in  the  study  of  the  nervous  system.  It  is  a 
useful  and  timely  resume. 


•195.  The   Intracranial   Circulation   in   Some   of   its  Aspects 
George  Elder  (British  Medical  Journal,  2,  1897,  p.  1,414). 

After  a  number  of  careful  experiments  and  a  full  consideration 
of  the  work  of  others,  the  author  comes  to  the  following  conclusions: 

1.  In  the  unenclosed  skull  there  are  two  very  evident  forms  of 
pulsation  of  the  brain — (a)  the  arterial,  (b)  the  respiratory;  the  for- 
mer produced  in  the  arteries,  the  latter  in  the  veins. 

2.  In  the  closed  skull  the  venous  side  of  the  circulation  is  of  the 
greatest  importance,  and  respiration,  acting  through  the  veins,  takes 
an  important  role  in  the  intracranial  circulation. 

3.  During  inspiration  in  the  open  skull  the  aspiration  of  blood 
from  the  cranial  veins  is  accompanied  by  compression  of  the  vessels 
and  retraction  of  the  brain. 

4.  In  the  closed  skull  a  similar  withdrawal  of  blood  from  the 
veins  occurs,  accompanied  by  decrease  in  the  intracranial  pressure. 

5.  There  is  no  flow  of  cerebro-spinal  fluid  from  the  spinal  cavity 
to  the  intracranial  cavity,  either  with  respiratory  movement  or  with 
arterial  pulsation,  as  has  usually  been  supposed. 

6.  In  all  probability,  accompanying  the  emptying  of  the 
large  veins  during  inspiration,  there  is  dilatation  of  the  arteries. 
(This  may  be  accompanied  by  an  increased  rate  of  flow  in  the  carotid 
artery  as  compared  with  the  other  arteries  in  the  body  above  the 
level  of  the  diaphragm,  which  are  otherwise  under  somewhat  similar 
conditions.)  So,  during  expiration,  the  dilatation  of  the  intracranial 
veins  will  be  accompanied  by  narrowing  of  the  arteries.  The  flow  of 
blood  through  the  capillaries  will  remain  constant. 


*U 


624 


PERISCOPE. 


7.  With  arterial  pulsation  lateral  pressure  is  exerted  on  the  intra- 
cranial veins,  leading  to  an  increased  flow  of  blood  from  the  skull. 

8.  These  movements  of  the  veins,  with  respiratory  movements 
and  with  arterial  pulsation,  will  occur  in  the  large  veins  leading  into 
the  intracranial  venous  sinuses,  the  walls  of  which  are  themselves 
incompressible. 

9.  Similar  movements  of  alternating  compression  and  dilatation 
of  the  arteries  and  veins  probably  occur  also  in  the  spinal  column, 
the  cavity  of  which  is  to  be  looked  on  as  being  practically  closed,  just 
as  the  cranial  cavity  is. 

10.  In  all  cases  of  sudden  increase  of  pressure  affecting  both 
cranial  and  spinal  cavities  there  will  practically  be  no  variation  in  the 
quantity  of  blood  present  in  the  cavities.  There  will  only  be  either 
(a)  a  variation  in  the  amount  of  blood  in  one  side  of  the  circulation 
as  compared  with  the  other,  arterial  at  the  expense  of  venous,  or  vice 
versa,  or  (b)  an  alteration  in  the  rate  of  flow  through  the  capillaries. 
In  rises  of  pressure  lasting  some  time  there  may  be  alteration  of  the 
quantity  of  blood  inside  the  cavities,  resulting  from  alteration  in  the 
rate  of  secretion  or  of  absorption  of  cerebro-spinal  fluid. 

11.  The  point  of  importance  in  alterations  of  pressure  inside  the 
skull  is  the  rate  of  flow  through  the  capillaries.  Steady  flow  through 
the  capillaries — "adiaemorrhysis,"  as  it  has  been  called  by  Geigel — 
may  go  on  under  very  low  intracranial  pressure  or  under  compara- 
tively high.  (Hill.) 

12.  Increased  intracranial  pressure  from  an  effusion  into  the 
cranium — for  example,  a  hemorrhage — leads  first  of  all  to  flow  of 
cerebro-spinal  fluid  from  the  cranial  to  the  spinal  cavity,  so  giving 
a  respite  for  a  certain  length  of  time  to  the  intracranial  circulation. 
If  the  effusion  goes  on  there  is,  first,  compression  of  the  larger 
veins,  which  leads,  after  it  has  taken  place  to  a  certain  extent,  to  in- 
terference with  the  flow  of  blood  through  the  capillaries — adiae- 
morrhysis— and,  if  the  pressure  still  rises,  to  actual  compression  of 
the  capillaries  and  true  anxmia  of  the  brain. 

13.  When  tracings  are  taken  of  the  pulsations  of  the  brain,  w^ith 
rise  of  pressure  two  forms  of  pulse  wave  may  be  seen:  (i)  Where 
■wave  is  less  ample  and  still  anacrotic,  as  it  is  under  normal  conditions; 
(2)  where  wave  is  higher  and  tends  to  become  katacrotic.  The  for- 
mer occurs  much  more  frequently  than  the  latter,  and  seems  to  be 
present  in  what  may  be  termed  "passive"  increase  of  intracranial 
pressure,  that  is,  where  the  intracranial  pressure  is  increased  from 
alteration  of  the  circulation  in  the  rest  of  the  body. 

14.  In  some  conditions  the  intracranial  circulation  seems  to  vary 
independently  of  the  circulation  elsewhere.  This  would  tend  to  show 
that,  although  the  blood  vessels  of  the  brain  are  not  directly  con- 
trolled from  the  general  vasomotor  centre,  there  must  be  some  local 
mechanism  for  altering  their  calibre.  Patrick. 

196.   I  RBFI^ESSI  VilSCOI«ARE  NKI.LB  MBMBRA  B  NBL  CBRVBI^IX)    DBI^I,' 
HUOMO  PER     VARIE     STIMOTJ   E  PER     VARIE    CONDIZIONI     FISIOLO- 

GiCHE  B  SPBRIMENTAU  (The  Vascular  Reflexes  of  the  Meninges 
and  Brain  of  Man  due  to  Various  Stimuli  and  Various  Physiologi- 
cal and  Experimental  Conditions).  M.  L.  Patrizi  (Revista  Speri- 
mentali  di  Freniatris,  23,  1897). 

In  an  extended  article  of  over  eighty  pages,  copiously  illus- 
trated with  diagrams  and  pulse  tracings,  the  author  presents  a  most 
elaborate  and  careful  study,  historical  as  well  as  experimental.  The 
conclusions  reached  by  the  author  are:  (i)  The  reflexes  of  the  blood 
vessels  in  man  follow  the  fundamental  principles  of  localization  and 


PERISCOPE.  625 

extension  observed  for  other  reflexes,  (z)  The  localized  vascular  re- 
flex is  more  direct  than  the  radiated  vascular  reflex.  (3)  The  influ- 
ence of  the  cerebrum  over  the  spinal  centres  is  manifest  in  the  matter 
of  the  vascular  reflexes.  (4)  The  time  for  the  vessel  reflex  for  sensi- 
tive stimuli  is  3  seconds  for  the  arm  and  s  seconds  for  the  leg.  (5) 
The  reflex  (or  the  cerebral  vessels  for  sensory  stimulation  has  a  la- 
tency not  less  than  the  arm  reflex  for  the  same  stimulus.  (6)  During 
sleep  vessel  reflex  action  is  retarded,  diminishing  from  the  centre 
toward  the  periphery,  and  not  appreciable  in  the  lower  leg.  {7)  Dur- 
ing sleep  the  movements  of  the  blood  in  the  brain,  following  stimuli, 
are  probably  active  and  self-regulating  reflexes.  (8)  In  the  limbs  the 
vascular  reflex  for  sensorial  stimuli  and  for  psychic  stimuli  requires 
about  4  seconds  longer  than  reflexes  for  sensitive  stimuli.  (9)  Each 
sense  stimulated  gives  its  own  vascular  reaction.  (10}  Some  sensorial 
stimuli  provoke  vaso-motor  reactions  with  greater  force  than  others. 

Jellipfe. 

PATHOLOGY. 

197.  AZIONB  DHLLA  TOSSINA  DIPTERICA  SUI.  SISTEMA  NERVOSA.       CON- 
TRIBUTO  AJJJL  PATOGEMESI  DELLA  PARALYSI    DIPTERICA    (Action  of 

the  Diphtheria  Toxin  on  the  Nervous  System).     E^io  Luisada  e 

Dante  Pacchioni.  Torino  (Giomale  dclla  R.  j\ccademia  di  Medi- 

cina  di    Torino,  6(,  1898,  p.  77). 

These  investigations,  under  the  direction  of  Prof.  G.  Neya,  sought 
the  vulnerability  of  the  nervous  tissues  to  the  diphtheric  toxines,  and 
injected  the  toxic  material  in  (i)  the  cerebral  cortex,  in  the  Rolandic 
area:  (2)  in  the  vertebral  cavity,  near  the  medulla,  and  (3)  in  the 
sheath  of  the  sciatic  nerve.  The  animal  experimented  upon  was  the 
dog.  13  being  under  observation,  and  the  elfects  of  the  diphtheric 
toxines  obtained  from  Dr.  Belfonti,  of  the  Sero therapeutic  Institute 
of  Milan,  were  studied  from  a  clinical  and  a  n  at  o  mo -pathological 
point  of  view.  The  results  obtained  by  these  investigations  may  be 
summarized  as  follows;  i.  The  diphtheric  toxines,  applied  directly 
to  the  nervous  system,  provoke  a  profound  lesion  at  the  point  o(  ap- 
plication, characterized  anatomically  by  an  inflammation  and  a  de- 
generation. 

2.  These  lesions  are  propagated  more  or  less  extensively  from 
the  point  of  application. 

3.  In  the  dogs  not  previously  immunised  by  the  anti -diphtheric 
serum,  and  which  had  been  injected  by  a  dose  sufficiently  toxic,  the 
phenomena  of  local  reaction  and  also  those  of  a  general  intoxication 

4.  In  immunised  dogs  the  diphtheric  toxines  provoked  constantly 
alterations  of  the  central  nervous  system,  Intense,  locaUsed,  but  of 
less  extent  than  those  produced  in   dogs  non-immunised. 

5.  The  toxine  applied  directly  to  the  medulla  is  propagated 
rapidly  in  all  directions,  preferring  the  posterior  columns,  the  gray 
matter  and  the  central  canal  as  routes.  In  consequence  of  the  bulbar 
invasion  death  occurred  in  the  animals  more  rapidly  when  the  toxinej 
were  introduced  into  the  medulla  than  when  applied  to  any  other  por- 
tion of  the  cerebro- spinal  axis.  When  the  toxines  were  introduced 
in  the  cerebral  cortex,  characteristic  lesions  of  these  regions  were 
manifested.  Death  occurred  later,  through  propagation  of  the  poison 
to  the  medulla. 

6.  Toxines  introduced  into  the  sheath  of  the  sciatic  nerve  pro- 
voked an  inflammatory  process  more  or  less  intense,  but  more  circum- 
scribed than  in  the  central  nervous  system.     From  the  nerve  the 


626  PERISCOPE. 

toxines  ascended  to  the  medulla,  chiefly  through  the  posterior  col- 
umns, and  thus  provoked  an  ascending  myelitis. 

7.  The  lesions  produced  upon  the  neuroglia  by  the  direct  ap- 
plication of  the  toxines  are  the  same  as  described  by  Vassale,  Donag- 
gio  and  others  in  the  various  intoxications  and  infective  processes. 
In  the  oblongata  the  prevalent  alterations  are  found  in  the  crossed 
pyramidal  tracts  and  posterior  columns. 

8.  The  alterations  produced  by  the  toxines  affect  the  nerve 
fibres  more  than  any  other  part  of  the  nervous  tissue.  These  lesions 
affect  principally  the  myelin,  and  consist  in  a  physical  inodification 
of  the  same,  whereby  the  connections  between  the  various  nerves 
are  lost.  There  is  partially  a  chemical  modification  of  the  myelin 
also  present. 

9.  The  local  action  of  the  toxines  has  much  importance  in  the 
genesis  of  various  paralyses  as  seen  in  the  human  family, attacking  first 
the  sheaths  of  the  nerves,  then  the  nerves,  then  later  the  nerve  centres 
in  the  oblongata.  Krauss. 

198.  Bbitrag  zur  PaThgi^ogib  der  Gangi^ienzelle  (Contribution 
to  the  Pathology  of  the  Ganglion  Cell).  O.  Juliusburger  and  £. 
Meyer  (Monatsschrift  fiir  Psychiatrie  und  Neurologic,  3^  1898, 
p.  316). 

These  writers  conclude,  from  their  examination  of  a  number  of 
cases,  that  the  changes  which  occur  in  the  chromophilic  elements  of 
the  ganglion  cells  are  quantitative,  vary,  therefore,  only  in  intensity, 
and  do  not  differ  in  character  in  the  various  diseases.  They  cannot 
distinguish  betw^een  the  "reaction  at  distance"  and  the  primary  lesions 
of  the  cells.  The  structural  cellular  changes  are  simply  the  manifes- 
tations of  altered  cell  vitality.  According  to  their  views,  the  chromo- 
philic elements  are  capable  of  regeneration.  Spiller. 

199.  Zur  Pathoi^ogie  der  Hemiplegien  im  Gepolge  des  Keuch- 
HUSTENS  (Contribution  to  the  Pathology  of  Hemiplegia  Result- 
ing from  Pertussis).  Hans  Luce  (Deutsche  Zeitschrift  fiir  Nerven- 
heilkunde,  12,  1898,  p.  272). 

A  boy  of  five  years  became  hemiplegic  immediately  following  a 
convulsive  attack  in  whooping  cough.  Death  occurred  after  two 
days.  A  careful  microscopical  examination  failed  to  reveal  a  suf- 
ficient cause  for  the  hemiplegia.  No  hemorrhage  within  the  nervous 
system  was  found.  Clonic  convulsions,  especially  marked  on  the 
paralyzed  side,  indicated  that  the  paralysis  must  be  of  cortical  origin, 
and  similar  to  that  occurring  in  Jacksonian  epilepsy.  Considerable 
importance  is  laid  by  the  author  on  the  accumulation  of  CO2  in  the 
repeated  convulsive  attacks.  Luce  believes  that  the  hemiplegia  oc- 
curring in  pertussis  is  due  to  meningeal  hemorrhage,  or  has  no  de- 
tectable anatomical  lesions,  and  that  hemorrhage  within  the  inner 
capsule  or  elsewhere  in  the  motor  tracts  has  not  been  demonstrated 
as  the  cause  of  such  hemiplegia.  Spiller. 

200.  Lesions  histologiques  de  la  cellule  nerveusb  dans  le 
TicTANOS  ET  L*iMMUNiTfe  ANTi-T^ANiQUE  (Fine  Histological  Le- 
sions of  the  Nervous  Cellule  in  Tetanus  and  Anti-Tetanic  Im- 
munity). MM.  Chantemesse  et  Marinesco  (La.  Med.  Moderne, 
9,  1898,  p.  79). 

The  idea  that  the  development  of  tetanus  is  due  to  a  combination 
of  the  tetanic  poison  with  the  nervous  cellule  is  not  new.  The  au- 
thors have  stated  in  a  new  fashion  the  confirmation  of  the  theory 


PERISCOPE. 


627 


by  stating  the  alterations  produced  by  the  toxin  in  the  nerve  cells. 
TTicy  examined  the  alterations  in  the  large  cells  of  the  anterior  horn 
of  the  cord  in  guinea  pigs  after  a  fatal  dose  of  tetanus  toxin  was 
given  in  such  proportion  as  to  make  it  act  slowly.  Some  of  the 
animals  received  only  the  toxin,  others  a  mixture  of  toxin  and  anti- 
toxin, others  anti-toxin,  twenty-four  hours  after  the  administration 
of  toxin. 

Their  final  conclusions  are  that  the  toxin  produced  decided 
lesions  in  the  spinal  cells,  which  might  disappear  if  the  animal  lived 
long  enough.  The  mixture  of  toxin  and  anti-toxin  produced  no 
appreciable  symptoms,  and  the  autopsy  showed  very  slight  changes 
in  the  nucleus  and  the  nucleolus. 

The  nerve  cell  has  an  afhnity  for  the  tetanic  toxin  and  the  latter 
for  anti-toxin.  The  precise  nature  of  the  cellular  reaction  cannot 
be  decided.  It  may,  however,  be  concluded  from  these  observations 
that  immunity  to  the  tetanic  poison  shows  itself  in  the  form  of  ap- 
preciable anatomical  changes  in  the  nerve  cells.  If  immunity  against 
infection  is  due  to  the  action  of  phagocytes,  immunity  to  soluble 
poisons  is  a  function  of  the  resistance  of  the  nerve  cells,  a  phenomenon, 
that  is  to  say,  essentially  histogenic  in  character.  Mitchell. 

CLINICAL  NEUROLOGY. 

201.  PaRALYSIE  DOULOUREUSE  DU  facial  nerve,  AVEC  HERPfeS  ZOSTER 

DE  l'oreille  (Painful  Paralysis  of  the  Facial  Nerve  with  Herpes 
Zoster  of  the  Ear).  M.  L.  Jacquet  (Bulletins  et  Memoires  de  la 
Soc.  Med.  des  Hopitaux  de  Paris,  15,  1898,  p.  405). 

Jacquet  reports  a  case  of  left  facial  paralysis,  which  had  lasted 
five  days.     In  addition  to  the  well-known  signs,  he  notes: 

1.  A  swelling  of  the  preauricular  region. 

2.  A  red  and  painful  cedema  of  the  left  ear,  on  the  concha  of 
which  a  group  of  herpetic  vesicles  was  found. 

3.  A  very  painful  point  just  below  the  auditory  canal. 

4.  Pain  on  pressure  over  all  the  facial  muscles  of  the  left  side. 

5.  Increase  in  temperature  in  the  skin  of  the  left  side  of  the 
face. 

All  these  signs  developed  in  one  night  after  the  patient  had  been 
exposed  to  a  draught  The  writer  speaks  of  this  as  a  painful  paralysis 
of  the  muscles  supplied  by  the  facial  nerve,  with  vasomotor  and 
trophic  disturbances,  probably  resulting  from  exposure  to  rold. 
The  points  of  emergence  of  the  fifth  nerve  were  not  painful.  Jacquet 
believes  that  neuralgia  of  the  facial  nerve  is  more  common  than  is 
usually  believed,  and  may  exist  with  or  without  paralysis  of  this 
nerve.  He  reported  a  case  of  neuralgia  of  the  seventh  nerve  without 
paralysis  in  the  preceding  number  of  this  journal.  He  is  inclined  to 
believe  that  sensory  fibres  are  contained  in  the  seventh  nerve. 

Spiller. 

ao2.  Die  Rontg^n-Strahlen  im  Dienste  der  Hirn-Chirurgie 
(The  Rontgen  Rays  in  the  Surgery  of  the  Brain).  S.  E.  Hen- 
schen  (Mitteilungen  aus  den  Grenzgebieten  der  Medizin  und 
Chirurgie,  3,  1898,  p.  283). 

A  man  was  shot  through  the  left  eye,  and  was  unconscious  three 
weeks.  When  he  regained  consciousness  he  could  neither  speak  nor 
understand  what  was  said  to  him,  and  was  hemiplegic  on  the  left 
side.  Memory  and  speech  gradually  returned.  About  a  year  after 
the  injury  he  suflFered  from  headache  in  the  right  occipital  region. 
The  position  of  the  bullet  was  determined  by  the  circumstances  at- 


628  PERISCOPE. 

tending  the  shooting,  by  the  clinical  symptoms  and  by  a  Rontgen 
photograph.  The  bullet  entered  through  the  inner  portion  of  the 
left  eye,  and  as  the  revolver  was  fired  from  the  left  side,  the  bullet 
was  supposed  to  have  crossed  the  median  line.  The  bullet  had  evi- 
dently gone  upward,  or  otherwise  the  man  would  have  died  from 
hemorrhage  from  the  large  basal  vessels,  or  from  injury  to  the 
pons  and  medulla  oblongata.  Inasmuch  as  the  man  was  hemiplegic 
on  the  left  side,  and  the  sense  of  smell  was  completely  lost,  and  the 
chiasm  was  not  injured,  the  bullet  must  have  passed  above  the  latter, 
and  into  the  right  hemisphere.  As  the  hemisphere  was  complete,  the 
injury  probably  was  not  cortical,  and  yet  the  inner  capsule  could  not 
have  been  entirely  destroyed,  as  the  left-sided  anaesthesia  was  not 
very  pronounced.  The  vision  in  the  lower  left  quadrant  of  the  right 
eye  (the  left  eye  was  destroyed)  was  somewhat  diminished,  and  this 
was  supposed  to  be  due  to  a  lesion  of  the  dorsal  bundle  of  the  optic 
fibres.  The  bullet  was  believed  to  be  between  the  parietal  and  oc- 
cipital lobes,  sub-cortical,  and  somewhat  higher  than  the  calcarine 
fissure.  The  Rontgen  photograph  showed  the  supposed  location  of 
the  bullet  to  be  correct,  an  operation  was  performed,  and  the  bullet 
was  found  on  the  border  of  the  angular  gyrus,  somewhat  higher  than 
the  calcarine  fissure.     The  patient  recovered  from  the  operation. 

Henschen  believes  that  the  dorsal  bundle  in  the  occipital  oortion 
of  the  optic  fibres  (from  the  external  geniculate  body  to  the  cal- 
carine fissure)  innervates  the  dorsal  retinal  quadrant.  This  has  been 
shown  to  be  true  of  this  bundle  in  the  optic  tract  and  in  the  calcarine 
fissure.  In  this  case  vision  was  diminished  in  the  lower  nasal  quad- 
rant, and  the  position  of  the  bullet  confirmed  his  theory. 

Spiller. 

203.   L'ASYM^RIE  CRANTO-FACIALE  DANS  I^'H^MIPLtelB  SPASMODIQUE 

iNFANTii^E  (Cranio    Facial    Asymmetry    in    Spasmodic    Infantile 
Hemiplegia).      Dr.  Fere  (Jour,  des  Conn.  Med.,  16,  1897,  p.  2l^z)- 

Deformities  of  the  face  and  skull,  in  infantile  hemiplegic  subjects, 
are  considered  rare  by  some  authors,  while  by  others  of  common  oc- 
currence, which  divergence  of  opinions  Dr.  Fere  ascribes  to  the  diffi- 
culty in  making  correct  measurements.  These  were  taken  by  him  in 
the  following  manner:  i.  Anterior-posterior  diameter  of  the  head, 
from    the    external    occipital    protuberance   to    the    tubera   frontal ia. 

2.  The  dimensions  of  the  orbit,  in  transversal  and  vertical  directions. 

3.  The  dimensions  of  the  mandibula,  from  the  lateral  protuberance 
of  the  chin  to  the  angulus.  In  normal  people  these  measurements 
are  subject  to  certain  variations,  but  generally  symmetrical.  In  fifteen 
cases  of  infantile  hemiplegia  observed,  the  author  found:  Flattening 
of  the  tuber  frontale  on  the  affected  side  in  7,  equal  or  increased 
antero-posterior  diameter  in  the  remaining  8  cases;  diminution  of  the 
orbit  vertically  in  10,  the  other  5  cases  remaining  unchanged..  The 
mandibula  on  the  hemiplegic  side  showed  shortening  in  12  cases 
(80  per  cent.),  and  when  well  worked  gave  rise  to  lateral  deviations 
of  the  chin  and  lower  jawbone.  This  atrophy  is  often  associated  with 
a  deformity  at  the  junction  of  the  body  and  angles  of  the  man- 
dibula— a  deformity  frequently  met  with  in  degenerates,  described 
by  Albrecht  as  lemurian  apophysis,  and  supposed  to  be  of  atavistic 
nature,  but  in  reality  due  to  malformation  of  the  teeth  and  alveolar 
process. 

The  ears  of  infantile  hemiplegics  present  frequently  anomalies 
in  this  formation,  as,  for  instance,  deformity  of  the  tragus,  anti-tragos 
and  lobule,  and  the  presence  of  Darwin's  tubercle.  This  latter  may 
be  multiple,  and  is  due  to  abnormal  development,  not  having  any 
resemblance  or  connection  with  the  so-called  monkey  ears,  as  main- 


IP 


PERISCOPE,  629 

tained  by  atavism  enthusiasts.  The  conclusions  reached  in  the  fore- 
going considerations  are:  Certain  disproportions  and  deformities  of 
the  face  and  extremities,  developing  at  an  advanced  stage  of  evolution 
in  consequence  of  a  cerebral  lesion,  have  no  relation  to  atavism  what- 
ever, nor  are  the  same  anomalies  necessarily  pathognomonic  signs 
of  degeneracy.  ,  Macalester. 

204.   ZUR  DIAGNOSTISCHEN    BEDEUTUNG    DER    LUMBALPUNCTION     (The 

Diagnostic    Value    of    Lumbar    Puncture).      A.    Schiff    (Wiener 
klin.  Wochenschrift,  11,  1898,  p.  199). 

Schiff  has  studied  the  literature  on  lumbar  puncture,  and  added 
a  number  of  new  cases.  The  procedure  has  been  disappointing  thera- 
peutically, but,  by  affording  relief  of  pressure  in  such  conditions  as 
tumor,  hydrocephalus  and  meningitis,  has  occasionally  been  of  value 
in  the  treatment  of  pain,  convulsions,  vomiting,  etc.  The  reports  of 
very  favorable  results  from  lumbar  puncture  in  serous  meningitis  are 
not  numerous.  The  operation  has  been  of  more  value  from  a  diag- 
nostic standpoint  than  from  a  therapeutic,  and  has  enabled  a  diagnosis 
of  meningitis,  and  even  its  peculiar  form,  to  be  made  in  many  cases. 
It  is  important  to  determine  whether  meningitis  is  present  when 
symptoms  of  cerebral  abscess  or  sinus  thrombosis  develop  after 
middle  ear  disease,  and  a  cloudy,  very  albuminous,  purulent  exudate 
containing  bacteria  proves  the  presence  of  meningitis,  and  is  a  contra- 
indication to  operation.  Operation  may  be  performed  if  the  findings 
are  negative,  although  meningitis  is  not  positively  excluded  by  such 
findings.  Even  a  large  amount  of  albumin  in  the  cerebrospinal  ffuid 
is  not  a  proof  of  inflammation.  Cloudiness  of  the  fluid  is  a  proof 
of  the  existence  of  meningitis.  The  fluid  is  clear  in  all  such  processes 
as  tumor,  abscess  and  sinus  thrombosis,  and  in  many  cases  of  tuber- 
culous meningitis.  Negative  findings  may  be  obtained  in  tuberculous 
meningitis,  and  occasionally  in  purulent  meningitis.  Tubercle  bacilli 
often  cannot  be  found  in  tuberculous  meningitis.  Schiff  lays  great 
importance  on  the  coagulability  of  the  fluid.  Coagulation,  when 
blood  is  not  present  in  the  fluid,  indicates  a  meningitic  process  even 
when  the  fluid  is  clear.  The  name  of  serous  meningitis  is  given  to 
a  number  of  diseases.  This  condition  is  found  as  a  complication  of 
otitis  media,  and  simulates  cerebral  abscess.  The  coagulability  of 
the  fluid  in  serous  meningitis  demands  more  careful  study.  Schiff 
believes  that  lumbar  puncture  should  be  employed  in  every  case  of 
meningitis  and  endocranial  complication  of  otitis  media 

Spiller. 

205.  "Ergotisme  ht  asphyxik  locale  des  extr^mit^*'  (Ergotism 
and  Local  Asphyxia  of  the  Extremities).  Mongour  (Archives 
Cliniques  de  Bourdeaux.  6,  1897,  p.  325). 

The  author  describes  the  case  of  a  woman  of  35  years  old  pre- 
senting the  following  symptoms:  When  her  hands  were  exposed  to 
cold,  they  speedily  became  exsanguinated  and  white,  showing  no 
bluish  tint  whatsoever.  At  the  same  time  the  tissues  covering  the 
backs  of  the  hands,  up  to  the  wrists,  took  on  a  wooden  hardness,  not 
pitting  upon  pressure,  and  by  their  extreme  rigidity  preventing  all 
movements  of  flexion.  There  was  no  pain,  but  a  sensation  of  ex- 
treme cold  in  the  affected  members.  The  hardness  was  greater,  the 
lower  the  temperature:  at  night  softening  took  place  sufficiently  to 
allow  flexion  of  the  fingers,  and  the  same  effort  could  be  accom- 
plished by  day  if  the  patient  wore  gloves. 

The  hands  were  always  moist,  even  when  the  asphyxia  was  most 
marked.     There  was  neither  qualitative  nor  quantitative  alteration  of 


630 


PERISCOPE. 


sensibility.  The  finger  nails  were  diseased,  especially  upon  their 
under  surface,  and  whitlows  had  developed  upon  the  left  middle  finger, 
the  right  index  and  right  ring  finger.  Their  evolution  was  painless, 
but  in  such  as  had  cicatrized  the  scar  was  painful  upon  pressure  and 
sometimes  spontaneously.  Outside  of  the  local  lesions,  the  patient 
was  healthy. 

The  author  concludes  that  the  opinion  of  Ehlers  (of  Copenhagen) 
that  symmetrical  asphyxia  of  the  exremities  is  always  due  to  ergo- 
tism is  not  justified,  as  in  the  case  related  ingestion  of  ergot  in  any 
way  can  be  positively  excluded.  Allen. 

206.  Hemorragic  meninges  (sus-arachnoidienne  primitive^  SifeGI- 

ANT    AU    niveau    DE    LA    MOlTlfe    DROITE    DE    LA    PROTUBERANCE, 
AYANT  PRODUIT  PAR  COMPRESSION  UNE  H^MIPLEGIE  ALTERNE  DU 

TYPE  Millard-Gubler  avec  paralysie  de  l*abducens  drote 
(Meningeal  Hemorrhage,  Limited  to  One  Side  of  the  Pons  and 
Causing  Crossed  Paralysis).  M.  Levet  (Lyon  Med.  30,  1898, 
p.  365. 

A  woman  of  74  years  was  suddenly  taken  with  vomiting  and 
weakness.  When  seen  two  hours  later  the  pulse  was  regular  and 
slow,  respiration  rapid  without  stertor,  pupils  normal,  no  paralysis 
but  profound  coma.  The  following  day  there  was  distinct  left  hemi- 
plegia, with  complete  paralysis  of  the  face  on  the  right  side.  There 
was  no  fever,  respiration  was  stertorous  and  the  coma  persisted.  The 
next  day  she  regained  consciousness  for  a  short  time,  but  rapidly 
became  unconscious  again,  and  remained  so  until  death,  five  days 
after  the  onset.  Two  days  before  death  paralysis  of  the  right  ab- 
ducens  was  noticed. 

At  the  autopsy  a  firm  epipial  clot  was  found  over  the  right  side 
ot  the  pons,  and  there  was  some  slight  extravasation  of  blood  over  al- 
most the  entire  brain.  The  hemorrhage  apparently  came  from  the 
basilar  artery.  So  far  as  the  author  has  been  able  to  learn,  the  case 
is  unique.  Patrick. 

PSYCHOLOGY   AND   PSYCHIATRY. 

207.  The   Psychology   of   Reading.    J.  O.  Quartz  (Psychological 
Rev.,  December,  1897,  Supplement). 

The  author  occupies  a  special  number  of  the  Review  with  the 
methods  and  results  of  his  experiments.    The  results  are  as  follows: 

1.  Colors  are  more  easily  perceived  than  geometrical  forms,  iso- 
lated words  than  colors,  and  words  in  construction  than  disconnected 
words. 

2.  The  visual  type  of  persons  are  slightly  more  rapid  readers 
than  the  auditory  type. 

3.  Rapid  readers  not  only  do  their  work  in  less  time,  but  do 
superior  work.  They  retain  more  of  the  substance  of  what  is  read 
or  heard  than  do  slow  readers. 

4.  Lip  movement  is  a  serious  hindrance  to  speed  of  reading,  and 
consequently  to  intelligence  of  reading.  The  disadvantage  extends 
also  to  reading  aloud. 

5.  Apart  from  external  conditions  the  chief  factors  contributing 
to  rapidity  of  reading  are  physiological,  intellectual  and  mental 
equipment.  Christison. 

208.  The   Psycho-Physiology   of  the  Moral  Imperative.     Jas. 
H.  Lueba  (American  Journal  of  Science,  8,  1897,  p.  528). 

The  author  contributes  an   elaborate  article  on   this   subject,   ift 


PERISCOPE,  63 1 

which  he  lays  down  the  thesis  that  the  "Moral  Imperative  is  the 
psychic  correlate  of  a  reflective  cerebro-spinal,  ideo-motor  process, 
the  efferent  end  of  which  is  organized  into  motor  tracts  coordinated 
for  a  specific  action."  It  is  not  a  spontaneous  or  instinctive  act,  but  a 
categorical,  and  thus  involves  reason  and  a  conscious  motive.  It  is  a 
reflective  act,  as  distinguished  from  a  voluntary  act,  and,  therefore, 
does  not  contain  "effort"  or  the  provision  of  the  possible  motor  con- 
clusion, as  is  the  case  in  voluntary  acts.  It  comes,  not  unannounced, 
but  unasked  for.  It  is  independent  of  passion,  emotion  or  sentiment. 
It  is  the  correlate  of  a  purely  cerebro-spinal  reflective  motor  process. 
Emotion  and  feeling  may  be  an  after  development. 

The  "moral"  arc  is  (i)  reflective,  (2)  wholly  cerebro-spinal,  and 
(3)  it  has  a  clean-cut  coordinated  motor  conclusion  prompting  to  a 
conclusion.  The  non-moral  arc  is  the  same,  but  differs  in  not  having 
an  imperative  or  "oughtness"  character.  The  conclusion  of  the  moral 
imperative  process  urges  to  a  specific  action  affecting  some  being. 
The  less  the  moral  imperative  experience  contains  an  impulse  toward 
the  execution  of  the  command,  the  clearer  it  is. 

"The  motor  conclusions  of  a  reflective,  non-sympathetic  impera- 
tive ideo-motor  experience  are  always  approved  of  as  final."  "The 
moral  imperative  is  the  correlate  of  the  latest  and  highest  biological 
differentiation,  since  it  requires,  as  a  condition  of  its  existence,  the 
independence  of  the  cerebro-spinal  from  the  sympathetic  nervous 
system." 

"It  appears  that  the  crusade  of  the  ethico-religious  consciousness 
is  a  war  of  the  cerebro-spinal  self  against  the  cerebro-sympathetic 
self."  Christison. 

209.  A  Study  of  the  Excretion  of  Urea  and  Uric  Acid  in 
Melancholia  and  in  a  Case  Presenting  Recurrent  Periods 
OF  Confusion  and  Depression.  C.  M.  Hibbard  (Am.  Jour- 
Insanity,  54,  1898,  p.  503). 

The  author  presents  the  following  conclusions  from  an  investiga- 
tion with  urea  and  uric  acid  excretion  in  melanchoHa,  based  on  work 
done  in  the  McLean  Hospital,  from  1891  to  1895: 

1.  The  amounts  of  urine  and  solids  are  generally  diminished, 
and  they  usually  increase  with  the  patient's  improvement. 

2.  The  specific  gravity  is  normal. 

3.  The  urea  and  uric  acid  are,  as  a  rule,  diminished. 

4:  The  diminution  in  nitrogenous  excretions  is  due,  in  most 
cases,  to  a  diminished  ingestion  of  proteids,  but  in  some  it  may 
possibly  result  from  a  lessened  absorption  of  food. 

5.  The  ratio  of  uric  acid  to  urea  shows  no  constant  relation  to 
the  mental  condition.  Jelliffe. 

210.  Paralytische  Geistesstorung  in  Folge  von  Zuckerkrank- 
HEiT  (diabetische  Pseudo-Paralyse ) .  [Diabetes  and  General 
Paresis  (Diabetic  Pseudo-Paralysis)].  R.  Landenheimer  (Arch.  f. 
Psychiatric,  29,  1896-1897,  p.  546). 

The  author  concludes  from  a  study  of  several  cases  of  his  own 
and  a  review  of  the  literature: 

1.  It  is  not  yet  proven  that  general  paresis  can  be  caused  by 
diabetes  mellitus.  The  histories,  postmortem  examinations,  etc.,  of 
the  cases  thus  far  regarded  as  having  been  caused  by  this  disease 
are  not  exhaustive  nor  conclusive  enough. 

2.  In  some  cases  of  diabetes  there  is  developed  a  symptom  com- 
plex, which  in  many  respects  resembles  some  clinical  types  of  genefal 
paresis.  In  the  absence  of  any  pathological  basis  these  may  be  re- 
garded as  cases  of  diabetic  general  paresis. 


632 


PERISCOPE, 


In  one  case  of  the  authors  an  anti-diabetic  treatment  resulted  in 
a  marked  improvement  of  the  patient,  thus  serving  to  confirm  the 
relationship  in  this  case.  Jeli^iffs:. 


211.  Mental  Phases  of  Tuberculosis.     Harriet  C.  B.  Ale^cander, 
M.D.  (Medicine,  4,  1898). 

Alienists  not  only  recognize  the  spes  phthisica  as  an  expression 
of  exhaustion,  but  recognize  likewise  another  symptom,  which    izinder- 
lies  much  of  the  difficulty  in  treating  seemingly  sane  victims    of    pul- 
monary tuberculosis.    This  mental  symptom,  which  is  so  marked  that 
it  always  arouses  suspicion  of  tuberculosis,  as  a  complication  o£   psy- 
chosis at  least,  is  suspicion.    The  general  mental  state  of  the  phtil^isical 
is  essentially  that  of  the  primary  confusional  lunatic  plus  em.o'tiona/ 
mobility.     There   is   usually  alternating   depression,    emotionstl      mo- 
bility, intensification  of  the  egotism  common  to  invalids,  and     st    stis- 
picional  mental  state  (Spitzka).    This  suspicional  mental  state    ij»ndcr- 
lies  the  refusal  of  and  changes  in  medicinal  treatment  if  the   x>s.tient 
be  at  home,  and  the  refusal  of  food  if  he  be»in  an  insane  hospital .        '^^^ 
most  decided  symptom  which  appears  in  the  insane  in  the  larvsLX     state 
of  the  disease  is  this  suspicion.     In  them,  for  this  reason,  pl-»ysicai 
examination  is  often  difficult,  and  cough,  hectic,  etc.,  are  often  aL'tosetvi. 
Frequently  a  far  advanced  phthisis  comes  to  a  standstill,  but  d^x^^*^^" 
strable  decrease  of  the  mental  symptoms  is  followed  by  reappe^^"^"^^^ 
of  the  pulmonary.     It  is  possible  to  predict  tuberculosis  ^roxi^       *"^ 
mental  symptoms  (Clouston).    If  these  cases  have  been  acute  alt     ^^^f^ 
the  acute  stage  is  short,  and  passes  rapidly  into  an  irritable,  exci*^^*p'^> 
sullen  and  suspicious  state.    There  is  want  of  fixity  of  purpose.  -■^  ^^ 

intellect  at  first  is  not  so  much  obscured  as  there  is  disinclinat£<^^^     |^ 
exert  it.     If  there  be  any  one  single  tendency  characteristic,  it  is     S'^^- 
picion.    The  influence  of  phthisis  on  many  forms  of  insanity  is  'tc?     "^^ 
troduce  a  suspicional  element  not  hitherto  present.     In  some     c^^^^j 
the  emotional  depression  produced  by  phthisis  in  ordinary  typ^s   j^^ 
insanity  may  proceed  so  far  as  melancholia  in  the  true  sense  ot    the 
term.     The  possible  influence  of  the  toxin  of  the  tubercle  bacill'^s  ^^ 
illustrated  in  the  fact  that  it  sometimes  causes  meningeal  tubercu- 
losis to  mimic  opium  poisoning,  with  resultant  coma.         Freema^t- 

212.  ZuR  Katonie-Prage.  Eine  kunische  Studik  (A  Clinicaf 
Study  of  the  Katatonia  Question).  V.  Schiile  (Allgemeine  Zeit- 
schrift  f.  Psychiatric,  54,  1897,  p.  515). 

The  present  communication  presents  an  elaborate  discussion  on 
the  subject  of  katatonia,   first  clinically  set  apart  by  Kahlbaum,  in 

1873. 

The  author  does  not  believe  that  there  is  any  clinical  entity  that 
can  with  justice  be  termed  a  condition  of  katatonia.  The  diagnosis, 
is  purely  then  in  his  opinion  a  verbal  one,  including  a  most  irregular 
collection  of  motor  symptoms.  Jelliffe. 

213.  Katatonia  (Katatonie  of  Kahlbaum-Katatonische  Ver. 
RiJCHTHEiT  OF  Schule)  F.  Peterson  and  Langdon  (Medical  Record » 
52,  1897,  p.  473). 

The  authors  review  the  literature  and  report  four  cases;  their  con- 
clusions are  as  follows: 

1.  Katatonia  is  not  a  distinct  form  of  insanity,  not  a  clinical 
entity. 

2.  There  is  no  true  cyclical  character  in  its  manifestations;  hence 
it  cannot  properly  be  classed  as  a  form  of  circular  insanity. 

3.  It  is  simply  a  type  of  melancholia. 


PERISCOPE.  633 

4.  It  is  not  desirable  to  fetain  the  name  katatonia. 

5.  The  term  ''katatonic  melancholia,''  or  ''katatonic  syndrome," 
may  be  usefully  retained  as  descriptive  of  melancholia  with  cataleptic 
symptOQis,  verbigeration  and  rhythmical  movements,  but  should  be 
strictly  limited  to  this  symptom  complex. 

6.  The  prognosis  in  melancholia  with  katatonia  is  more  grave 
than  in  any  other  form. 

7.  The  treatment  of  the  katatonic  syndrome  is  the  same  as  for 
other  types  of  melancholia.  Jelliffe. 

214.    Al^GUNAS  CONSIDERACIONES  SOBRE  EI*  PRONOSTICA    DB    LA    AI,IE- 

NACION  MENTAi*  (Some  Considerations  on  the  Prognosis  of  Men- 
tal Alienation).  Jose  F.  Borda  (Buenos  Ayres  Baletino  del 
Circulo  Medico  Argentina,  January,  1898,  p.  13). 

Borda  studied  very  carefully  the  prognosis  of  the  various  forms  of 
mental  diseases  as  they  occurred  in  the  Hospital  de  las  Mercedes,  in 
Buenos  Aires,  from  1892  to  1896.  Out  of  2,350  patients  with  mental 
disease,  556  have  been  cured,  451  improved,  88  have  escaped,  and  618 
have  died;  a  percentage  therefore  of  23  of  cures.  In  reality  this  per- 
centage should  be  greater,  because  of  those  escaped  some  undoubtedly 
went  on  to  recovery,  and  of  those  improved  the  author  believes  some 
were  relatively  cured.  The  percentage  of  cures  varies  greatly  in  the 
different  years.  For  instance,  in  1892  it  was  17  per  cent.,  while  in  1894 
it  was  ^i  per  cent.  In  the  five  years  368  maniacs  entered  the  hos- 
pital, and  of  these  112  were  cured,  76  improved,  15  escaped  and  104 
died.  During  the  same  time  ^00  melancholiacs  were  received,  of 
whom  55  were  cured,  66  improved,  10  esca'^ed,  and  59  died.    Krauss. 

THERAPY. 

215.  The  Direct  Transplantation  of  Muscles  in  the  Treat- 
ment OF  Paralytic  Deformities.  Goldthwait  (Boston  Med. 
and  Surg.  Journal,  137,  1897,  p.  489). 

The  author  reports  five  additional  cases  of  implantation  of  the 
lower  end  of  the  sartorius  into  the  quadriceps  extensor,- just  above 
the  patella.  He  says  that  in  acute  poliomyelitis,  involving  the  thigh 
muscles,  the  sartorius  and  tensor  vaginse  femoris  are  frequently 
spared.  The  latter  is  too  small  and  its  range  of  contractility  too  lim- 
ited to  be  of  use  as  a  substitute,  but  the  former  is  long  and  powerful. 
Of  the  five  cases,  three  showed  marked  improvement  after  operation. 
Not  only  could  the  leg  be  extended  with  considerable  vigor,  but  the 
••flinging  gait"  was  largely  mitigated,  this  latter  being  due,  in  great 
part,  the  author  thinks,  to  the  unantagonized  action  of  the  sartorius 
in  its  normal  condition.  Patrick. 

216.  Morphine  Habit  of  Long  Standing  Cured  by  Bromide 
Poisoning.     MacLeod  (British  Medical  Journal,  2,  1897,  p.  76). 

The  author  reports  the  case  of  a  lady,  aged  25,  a  victim  of  the 
morphine  habit  for  seven  years,  who  by  mistake  took  18  drachms 
of  sodium  bromide  in  48  hours.  This  induced  profound  stupor,  but 
five  days  later  the  bromide  was  resumed,  and  continued  for  three 
days  at  tiie  rate  of  2  drachms  per  day.  She  did  not  recover  from  the 
profound  bromism  for  10  days,  but  then  found  her  appetite  for  mor- 
phine entirely  gone.  Profiting  by  the  experience  of  this  case,  "cured 
by  mistake,"  the  author  deliberately  stupefied  his  next  case  of  mor- 
phinomania  with  bromide,  takinj?  about  two  weeks  to  withdraw  the 
morphine  and  increase  the  dose  of  bromide  of  sodium  from  30  grains 
every  six  hours  to  60  grains  every  three  hours.  During  the  third 
week  the  patient  was  very  stupid.    The  drug  was  stopped  on  the  20th 


634 


PERISCOPE, 


day,  after  which  the  patient  practically  slept  for  three  days,  and  was 
unable  to  stand  for  a  week  longer.  Five  weeks  after  the  cessation 
of  the  bromide  he  had  completely  recovered  from  its  effects,  and  had 
lost  all  desire  for  morphine  and  alcohol.  > 

The  following  advantages  are  claimed  for  this  method,  based, 
it  must  be  remembered,  on  only  two  cases: 

1.  It  did  away  with  the  suffering  entailed  by  stopping  the  drag. 

2.  The  patient  could  not  bribe  the  attendants  when  the  drug 
was  withdrawn,  he  could  not  deceive  his  doctor,  nor  could  he  es- 
cape vigilance — he  was  powerless. 

3.  It  acted  equally  well  whether  the  patient  wished  to  be  cured 
or  not. 

4.  No  special  attendants  or  establishment  were  needed;  only 
nurses  who  took  ordinary  care. 

5.  No  violence  or  excitement  is  likely  to  result  from,  nor  a  taste 
to  arise  for,  bromide  given  in  this  way.  Patrick. 

217.  Des  anastomoses  tendinkuses  entre  muscles  sains  et 
muscles  paralyses  pour  la  correction  des  deviations  ou 
DiFFORMiTfes  PARALYTIQUES  (Tendinous  Anastomoses  for  Para- 
lytic Deformities).     Rochet  (Lyon  Medical,  85,  18^,  p.  579). 

The  author  reports  5  examples  of  this  operation,  which  promises 
to  be  of  signal  value  in  certain  qases  of  deformity  and  disability  from 
paralysis  more  or  less  limited  in  distribution.  Four  of  the  cases  were 
old  infantile  spinal  paralyses,  and  one  a  spastic  hemiplegia  from  infan- 
tile cerebral  disease.  Four  operations  were  done  for  paralysis  and 
deformity  involving  the  hand  and  fingers,  and  one  for  pes  equino- 
varus.  The  tendon  of  a  healthy  muscle  after  division  was  either  in- 
serted laterally  into  the  tendon  of  a  paralyzed  muscle,  or  after  section 
of  this  latter  united  to  the  cut  end.  The  results  in  all  of  the  cases 
were  satisfactory,  and  in  some  surprisingly  good. 

For  surgical  details  the  reader  is  referred  to  the  original,  which,  on 
the  whole,  is  an  admirable  paper.  Patrick. 

218.     DE    LA    VALEUR    TH^RAPEUTIQUE    DE     L*ELECTRICITE    DANS    LE 

TRAiTEMBNT  DE  l'h^miplegib  c^r&brale  (The  Therapeutic 
Value  of  Electricity  in  Cerebral  Hemiplegia).  P.  Dignat  ( Bull.  Gen. 
deTh^rap.,  1897.  p.  397). 

In  quite  an  elaborate  discussion  of  the  subject,  the  author  reaches 
the  following  conclusions:  i.  In  no  case  of  cerebral  hemiplegia  should 
electrical  treatment  be  begun  for  several  days  subsequent  to  the  at- 
tack. 2.  At  about  the  end  of  the  third  week,  electrical  interference 
may  be  instituted,  in  which  case  it  should  be  limited  to  faradization 
of  the  affected  muscles  for  a  period  of  two  or  three  weeks.  3.  Then 
the  faradic  should  be  substituted  for  the  constant  current,  applied 
-along  the  vertebral  regions.  The  intensity  of  the  galvanic  current 
should  be  4  to  5  ma.  to  begin  with,  gradually  increased,  during  the 
course  of  treatment,  to  15  ma.,  but  never  higher,  and  the  duration 
of  a  seance  10  to  15  minutes,  changing  the  poles  once  or  twice  dar- 
ing each  application.  4.  If  the  patient  shows  appreciable  evidence 
of  improvement  after  several  days  of  this  treatment,  and  nothing 
points  to  a  secondary  degeneration,  it  may  be  discontinued  .entirely. 
However,  it  is  advisable  to  keep  the  case  under  observation,  applying 
static  electricity  from  time  to  time,  in  order  to  keep  up  the  general 
nutritions,  and  especially  to  ward  off  any  functional  disorder.  5.  In 
case  of  permanent  secondary  contractions,  the  galvanic  current  should 
be  used  for  a  long  time.  6.  No  electrical  treatment  should  be  pre- 
scribed for  patients  in  which  the  development  of  focal  epileosv  is  ap- 
prehended. Macalester. 


Jl^aala  ^jetiijews. 


Atlas  of  Legal  Medicine.  By  Dr.  E.  Von  Hofmann,  Professor  of 
Legal  Medicine  and  Director  of  the  Medico-Legal  Institute  at 
Vienna.  Authorized  translation  from  the  German.  Edited  by 
Frederick  Peterson,  M.  D.,  Clinical  Professor  of  Mental  Diseases 
in  the  Woman's  Medical  College,  New  York;  Chief  of  Clinic, 
Nervous  Department,  College  of  Physicians  and  Surgeons,  New 
York;  assisted  by  Aloysius  O.  J.  Kelly,  M.  D.,  Instructor  in 
Physical  diagnosis,  University  of  Pennsylvania;  Adjunct  Pro- 
fessor of  Pathology,  Philadelphia  Polyclinic;  Visiting  Physician 
to  St.  Mary's  and  St.  Agnes'  Hospitals;  Pathologist  to  the  Ger- 
man Hospital,  Philadelphia.  56  plates  in  colors  and  193  illustra- 
tions.    Philadelphia:  W.  B.  Saunders,  1898.     Price,  $3.50  net. 

This  is  a  valuable  addition  to  the  editions  in  English  of  the  well- 
known  Lehmann's  Medical  Hand  Atlases.  The  author,  the  late  Prof, 
von  Hofmann,  was  eminently  distinguished  in  his  specialty,  and  his 
position  of  Director  of  the  Medico-Legal  Institute  of  Vienna  put  at 
his  disposal  an  almost  limitless  material.  The  book  reflects  the  oppor- 
tunity, as  well  as  the  skill,  of  its  creator.  The  well-chosen  subjects, 
which  are  taken  directly  from  actual  cases,  illustrate  the  appearances 
and  lesions  which  most  frequently  come  to  medico-legal  inquiry. 
Among  others,  the  illustrations  bear  upon  the  legal  questions  which 
may  arise  in  connection  with  malformation  ot  the  genital  organs; 
with  generation;  with  premature  birth  and  the  causes  of  death  in 
infants;  with  fractures  of  the  skull  and  brain  injuries;  with  pistol-shot 
wounds;  with  death  by  hanging,  drowning,  poisoning,  etc.  Both  the 
figures  and  colored  plates  are  accurately  and  artistically  rendered. 
The  explanatory  text  is  ample,  and  has  been  translated  into  excellent 
English.  Altogether,  the  atlas  merits  a  cordial  reception  by  all  who 
are  interested  m  medico-lecal  questions.  Pearce   Bailey. 

A  Manual  of  Legal  Medicine.  For  the  Use  of  Practitioners  and 
Students  of  Medicine  and  Law.  By  Justin  Herold,  A.M.,  M.D., 
formerly  Coroner's  Physician  of  New  York  City  and  County, 
etc.    J.  B.  Lippincott  Company,  Philadelphia,  1898. 

One  of  the  largest  gaps  in  the  collection  of  facts  with  which  the 
average  physician's  mind  is  stored  pertains  to  the  subject  matter  of 
this  volume.  It  is  a  deplorable  fact  that  so  few  medical  men  have  even 
the  faintest  ideas  of  the  important  questions  of  medical  jurisprudence. 
The  present  volume  is  an  excellent  guide  to  make  good  some  of  the 
deficiencies.  The  book  is  divided  in  two  parts.  Part  one  deals  with 
Toxicology,  and  oart  two  is  devoted  to  Forensic  Medicine.  The  princi- 
pal poisons,  their  effects  and  lesions,  methods  of  treatment  and 
methods  of  detecting  the  same  in  the  dead  body  are  carefully  con- 
sidered. One  of  the  best  chapters  is  "On  the  Evidences  of  Death." 
The  medico-legal  aspects  of  some  of  the  recent  poisoning  cases  are 
well  presented. 

In  Part  two  on  Forensic  medicine  most  every  subject  of  import- 
ance to  this  branch  of  science  is  considered,  in  chapter  XX.  some 
■excellent  ideas  relative  to  the  making  of  medico-legal  autopsies  being 
presented.  In  chapter  XXIV.  a  very  good  resume  of  our  knowledge 
of  the  blood  in  its  medico-legal  aspects  is  gfiven.  and  excellent  tables 
of  the  measurements  of  various  bloods  of  various  animals  are  pre- 
pared. The  subject  of  wounds  is  exhaustively  treated,  and  the  discus- 
sion of  death  from  suffocation,  electricity,  drowning,  hanging,  etc., 
carefully  considered. 

The  work  closes  with  an  appendix  in  which  a  number  of  illustrative 


636 


BOOK  REVIEWS. 


cases  is  given.    Taking  it  all  in  all,  the  work  is  a  very  excellent  onc^ 
well  conceived  and  executed.  Ely. 

NORMALB     UND     PATH0I«00ISCHE     AnATOMIE     DER     NERVENZELLEN 

AUF  Grukd  der  neueren  Forschungen  (Normal  and 
Pathological  Anatomy  of  the  Nerve  Cells,  based  on  Recent  In- 
vestigations). By  A.  Goldscheider  and  E.  Flatau.  Berlin,  W. 
35.  Verlag  von  Fischer's  Medicin.  Buchhandlung,  H.  Kornfeld, 
1898. 

The  authors  state  in  their  preface  that  their  work  is  a  critical 
digest.  Our  knowledge  of  the  normal  and  pathological  histology  of 
the  nerve  cells  is  as  yet  very  limited,  and  this  knowledge  has  been 
obtained  by  widely  separated  investigators.  The  value  of  a  digest, 
therefore,  by  men  so  well  known  as  Goldscheider  and  Flateau,  which 
presents  these  scattered  results  within  the  covers  of  one  small  volume,, 
must  be  apparent  to  all.  On  account  of  the  insufficiency  of  the  find- 
ings, the  abstracts  of  many  papers  are  given  without  comment.  A 
short  chapter  is  devoted  to  the  modern  technique,  and  this  is  followed 
by  five  chapters  containing  most  of  what  is  at  present  known  of  the 
normal  and  pathological  conditions  of  the  nerve  cells.  Little  is  said 
regarding  the  so-called  pigments  of  the  cells  and  the  finer  structure  of 
the  nucleus.  Many  questions  remain  unanswered.  We  cannot  de- 
cide from  this  digest,  for  example,  whether  the  chromophilic  bodies 
are  artifacts  or  not,  or  whether  fibrils  exist  within  the  nerve  cells. 
The  changes  which  occur  in  the  nerve  cells  after  division  of  the  peri- 
pheral fibres  are  quite  fully  described,  and  many  pages  are  devoted  to 
the  action  of  poisons  on  the  cells.  We  are  not  quite  sure,  however, 
that  all  neuropathologists  are  prepared  to  ascribe  to  the  Nissl  stain 
the  importance  accorded  by  Goldscheider  and  Flatau.  Spiller. 


ti 


it 


ti] 


BOOKS   RECEIVED. 

"  The  Insanity  Law  of  the  State  of  New  York  Revised  to  April, 
1898,"  by  John  F.  Montignani.     Albany,  1898. 

"Aphasia  and  Other  Speech  Defects,"  by  C.  A.   Bastian. 

"  Die   Bedeutung  der   Reize   fiir   Pathologic  und   Therapie,"   by 
Prof.  A.  Goldscheider.    J.  A.  Barth,  Leipzig. 

"Atlas  of  Legal  Medicine,"  by  E.  von  HoflFman;  edited  by  Fred. 
Peterson  and  O.  A.  J.  Kelly. 

"Atlas  and  Abstract  of  Diseases  of  the  Larynx,"  by  Dr.  L.  Grun- 
wald.     W.  B.  Saunders,  1898. 
Insanity,"  by  Clevenger. 
'Aix-la-Chapelle  as  a  Health  Resort." 

'Die  Sensibilitatsstorungen  der  Haut  bei  Visceralerkrankungen," 
by  Henry  Head,  M.  A.,  M.  D.,  London. 

"  Experimental    Research    upon    Cerebro-cortical    Afferent    and 
Efferent  Tracts,"  by  Ferrier  and  Turner. 

"Zeitschrift  fiir  Geburtshulfe  und  Gynakologie,"  by  Henry  Head, 
M.  A.,  M.  D.,  London. 

"  Ueber  das  Pathologische  bei  Goethe,"  von  P.   F.   Mobius.     J. 
A  Barth,  Leipzig,  1898. 

"St.  Bartholomew's  Hospital  Reports,"  vol.  xxxiii.,  1897. 

"American    System    of    Practical    Medicine,"    vol.    iv.,    Loomis- 
Thompson. 

"  Modern  Surgery,"  Da  Costa. 

"Atlas  of  S3rphilis  and  the  Venereal   Diseases,"  by  Prof.   Franz 
Mracek.    W.  B.  Saunders,  1898. 

"Atlas  and  Epitome  of  Operative  Surgery,"  by  Dr.  Otto  Zucker- 
kandl.    W.  B.  Saunders,  1898. 

"  Mental  Affections  of  Children,"  by  W.  W.  Ireland. 

"  Office  Treatment  of  Hemorrhoids,   Fistula,   etc.,"  by  Chas.   B. 
Kelsey. 


|<TTy'r¥<ri|iii|M|iiri;M|iii;ii;i<tw;w;w;wfiri;ii)ii|ii|ii|ii)iii)ii|iii|ii;ij 

j  Cocaine  Discoids  "Sd^eMs" ; 

I  The  Safest,  Most  Efficient,  and  Conoenient  Means 
\  for  'Produdng  Local  Anaesthesia. 

Coc&iiM  Discoids  cODBist  oi  pura  cocaine  tajrdTochlorate,  withoKt  kdnixtme  of  foreign 
'  material  to  impair  its  Activity,  and  in  quantitieB  accurately  detanninBd  by  weight.  Ovringto 
,  tbcir  mode  of  mannf actnre,  not  being  comprened,  they  diasolTe  readilv  in  one  drop  ot  water. 
',  Instead  of  keeping  on  hand  ready-^Bade  solutions,  which  are  liable  to  detenorate,  the 

I    doctor  has  qov  at  bis  dlspceal  a  nwsnH  of  obtaining 

FrD«iily  PrefMTAd  Cocaiaa  Solntlou  of  Any  Destred  Streagtb 
'     at  a  moment's  notice,  and  the  quantity  of  the  drag  employed  during  ansesthesia  is  always 
I     koown,  and  not  a  matter  of  conjecture. 

Cocaine  Discoids  are  indicated  in  all  conditions  demanding  the  use  of  this  drug,  as  a 
'  local '  aa::-thetic,  as  in  the  treatment  of  diseases  of  the  eyes,  nose  and  throat,  in  general 
\     EBTgeiy,  «f]d  in  dentistry,  especially  for  cataphoresis. 

Discoids  coDtadning  }  gr.  .14  .50 

«  "         I  gr.  .IS  .05 

"  «  j.gr.  .16  .60 

"  "  igr.  .18  .TO 

,     Cocaine  Discoids  are  manufactured  solely  by 

Sdueffelin  &  Co.,  New  York.    \ 

t,L.i..i..i..t..i..4..i..t...i..a..t..a..t..a.....i..i..a.....*..s..i..a..* s..a..a..a....S 


tl|lfl^|i|f|i||Ht|i||ll||i|||i|||i|fP^|i||ll|I^IPW||i|fWfH|HfPI||ii;ii|||i|||il||il|ll|ll|ll|l^^ 

Schieffelin's 

\  (Alkaline  c/lntiseptic  and  Prophylactic. 

f  Bensotyptus  is  an  Agreeable  alkaline  solution  of  various  highly 
f  approved  antiseptics,  so  combined  that  one  sttpplanents  the  action  of 
\   me  other*    Its  ir^redients  are  all  of  recognized  value  in  the  treatment 

f  Catarrhal  c4ffections 

\   because  of  their  cleansing,  soothing,  and  healing  properties.    Benso- 
t   hf^tts  is  highly  recommended  in  all  diseases  of  the  nose  and  throat, 
t   Mb  aatte  am  chronic,  and  as  a  moatk-'wash  and  dentifmx.    It  is 
t   also  btdicated  for  internal  txse  in  affections  of  the  stomach  and  intes- 
tines <where  an  agreeable,  anirritating,  and  efficient  antiseptic  and 
antifermentative  is  required, 
PutifUtis  on  apoUaHon  to 

Schieffelin  &  Co.,  NeatYork.  : 


7«(.  85  j^rptrmbrr  1898  |(#.  9 


XLbc  S^outnal 


of 

l^crvous  anb  fllbcntalS^iseaec 

ZTbe  Bmerican  fleurolodical  Bdeociation 
Zbc  l^cw  l^orft  Vleuroloaical  Society?  ant> 

tTbe  pbila^elpbia  Deurolodical  Society? 

EDITORS 

Or.  CHARLES  L.  DANA  Dr.  HUGH  T.  PATRICK 

V^.  F.  X.  DERCUM  Dr.  JAS.  J.  PUTNAM 

Or.  CHA5.  K.  MILLS  Dr.  B.  SACHS 

Dr.  M.  ALLEN  STARR 

ASSOCiATE  EDITOR 

Dr.  WILLIAM  Q.  5PILLER 

MANAQINQ  EDITOR 

Dr.  CHARLES  HENRY  BROWN 
35  W.  48tta  Street,  New  York 

TABLE  OP  CONTENTS  ON  PAGES  U.  AND  Iv. 

FOREIGN  AND  DOMESTIC  AGENTS 

Bcmbard  Bcmumn,  Tlialefcnisse  «,  I«dpzig,  Germany.   S.  Karg^er,  Charitestr.  3,  Berlin,  Germany 
Trfibner  ft  Co.,  I«ad|^e  Hill,  I«ondon.    E.  Stei^er  Bl  Co.,  as  Park  Place, 
New  York.     B.  Westennann,  8ia  Broadway,  New  York. 
GuitaTC  B.  Stecbert,  9  B.  i6th  Street  New  York. 

ISSUBB   MONTHLY  I3.00  PER  YBAR 

Entered  at  the  Post-Office  in  New  York  as  Second-Class  Matter. 

Copyright,  1898. 


«u>- 


i:;?fc^»;.     '*''^^ 


^<^- 

*^. 


VOL.   XXV. 


September,  1898. 


No  9. 


THE 


Journal 


OF 


Nervous  an^mMental  Disease 


FAMILY  PERIODIC  PARALYSIS.* 

With  a  Report  of  Cases  hitherto  published. 
By  EDWARD  WYLLYS  TAYLOR,  M.D., 

Instructor  in  Keiiropatholog^v.  Harvard  University;  Assistant  in  Neurology,  Massa- 
chusetts General  Hospital;  Visiting  Neurologist,  I^ong  Island 

Hospital,  Boston  Harbor. 

The  condition  which  forms  the  subject  of  this  com- 
munication is  one  of  great  rarity.  In  America  it  has,  with 
two  possible  exceptions,  remained  absolutely  unnoticed 
in  the  form  which  I  shall  later  describe.  In  Europe;  on 
the  other  hand,  and  notably  in  Germany,  a  few  cases  of 
an  identical  sort  have  been  reported  in  detail. 

The  term  "Family.  Periodic  Paralysis"  is  evidently  a 
clinical  one,  and  serves  merely  the  purpose  of  description. 
With  certain  modifications,  this  term  has  been  generally 
used  by  the  German  writers,  and,  in  the  absence  of  definite 
pathological  knowledge  on  the  subject,  serves  its  end  suf- 
ficiently well. 

The  affection  is  charac-terized,  in  its  typical  form,  by 
extensive,  flaccid  motor  paralysis,  associated  with  loss  of 


♦Read  at  the  twentv-fourth  annual  meeting  of  the  American  Neu- 
rological Association,  May,  1898. 


638  EDWARD  WYLLYS  TAYLOR. 

reflex  and  electrical  excitability,  without  sensory  or 
psychic  disturbance  of  any  sort,  and  with  intervals  of  per- 
fect health.  The  disturbance  is  periodic,  and  the  pre- 
disposition to  its  development  is  clearly  hereditary.  It  is 
at  once  evident  that  such  an  affection  has  no  counterpart 
among  the  known  diseases  of  the  nervous  system,  and 
should,  therefore,  command  our  warmest  interest.  Such 
interest  has  by  no  means  been  lacking  in  those  who  have 
had  the  fortune  to  observe  the  condition,  as  a  study  of 
the  literature  amply  demonstrates. 

The  earliest  references  to  a  disturbance  analogous  to 
that  which  we  are  considering  come  from  CavareS  1853. 
and  Romberg,^  1857.  Both  of  these  are  referred  to  by 
Westphal  (5)  in  a  later  article,  and  to  his  paper  we  owe 
the  references,  which  were  not  obtainable  at  first  hand. 
Cavare's  case  occurred  in  a  woman  of  24,  who  had  several 
attacks  of  generalized  paralysis  lasting  from  five  to  eight 
hours;  the  attacks  were  of  the  quotidian  type,  and  were 
relieved  by  quinine,  but  no  definite  statement  is  made  as 
to  their  malarial  nature.  Romberg  describes  similar  at- 
tacks, in  which  the  lower  extremities  were  affected,  and 
which  he  attributed  in  his  case  to  intermittent  fever. 
These  attacks  were  cured  by  quinine. 

Nearly  twenty  years  later  Hartwig  (i),  in  his  in- 
augural dissertation,  again  drew  attention  to  the  subject 
through  the  publication  of  a  carefully  observed  case  of 
what  he  called  intermittent  spinal  paralysis.  The  patient 
was  23  years  old.  He  had  had  malaria  five  years  before 
the  present  attack,  which  came  on  with  weakness  of  the 
legs,  the  arms  and  neck  muscles  being  later  involved, 
somewhat  after  the  manner  of  a  typical  so-called  Landry's 
paralysis,  only  much  more  rapidly.  Speech,  swallowing 
and  breathing  were  hindered.    The  facial  nerve  was  free; 


^Cavare:  Gaz.  des  Hopit.,  1853,  No.  89  (aus  der  Gazett  med.  dc 
Toulouse),  quoted  by  Erb.  Handbuch  d.  Krankheiten  des  Nervcn- 
systems,  I.,  p.  822.  als  Fall  von  Macario. 

'  Romberg:  Lehrbuch  der  Nervenkrankheitcn,  3.  Aufl..  1857,  p.  752. 


FAMILY  PERIODIC  PARALYSIS.  639 

sphincters  uninvolved;  sensibility  and  mental  state  unim- 
paired. Electrical  reactions  were  almost  entirely  lost  dur- 
ing the  attack.  Recovery  took  place  in  24  hours.  Similar 
attacks  followed,  and  this  patient  was  also  much  helped, 
but  not  cured,  by  quinine.  He  was  observed  for  six 
months,  and  the  supposition  of  a  malarial  cause  was  en- 
tertained. This  case,  further  details  of  which  are  given 
in  the  summarj'^  later,  is,  in  its  general  features,  a  type  of 
the  condition  we  are  about  to  study. 

Samuelson  (2),  in  1876,  reported  a  case  of  intermittent 
paraplegia,  with  no  disturbance  of  sensation,  in  a  person 
of  thirty-eight,  in  which  a  suspicion  of  hysteria  was 
aroused,  though  probably  not  justified  by  the  facts. 

In  1882,  Schachnowitsch  (3)  described  a  like  condition 
in  a  patient  whose  father  was  similarly  affected,  and  who 
died  from  increasing  attacks  in  his  fifty-fourth  year.  The 
hereditary  character  of  the  affection  first  appears  in  this 
observation.  In  the  light  of  others'  experience,  death 
from  this  cause  must  be  looked  upon  as  unique;  this  would 
seem  to  throw  a  certain  doubt  upon  the  accuracy  of  the 
diagnosis,  in  spite  of  the  fact  that  in  Goldflam's  opinion 
the  condition  described  is  accurately  classified. 

In  the  same  year  a  paper  was  written  by  V.  P.Gib- 
ney  (4),  on  an  unusual  form  of  paralysis,  which  he  regarded 
as  distinctly  of  malarial  origin.  He  speaks  of  two  cases, 
both  in  children,  in  which,  after  a  malarial  attack,  paralysis 
of  the  extremities  came  on,  associated  with  muscular 
atrophy,  with  certain  sensory  and  constitutional  disturb- 
ances, followed  by  slow  recovery.  The  late  Dr.  Seguin 
diagnosticated  one  at  least  of  the  cases  as  myelitis  of  the 
anterior  horns.  Gibney  regarded  them  as  similar  to  the 
conditions  reported  by  Cavare,  Romberg  and  Hartwig,  to 
which  allusion  has  already  been  made.  In  any  event,  they 
are  so  clearly  unlike  the  typical  condition,  to  which  we 
wish  to  draw  attention,  that  in  our  opinion  they  almost 
certainly  do  not  belong  in  the  same  category,  whether 
malarial  or  not.     They  are  alluded  to  in  this  connection 


640  EDWARD  WYLLVS  TAYLOR, 

because  Westphal,  in  a  subsequent  communication,  fol- 
lowing his  earlier  pai>er,  is  inclined  to  regard  Gibney's 
first  case  as  belonging  to  the  group  of  the  family  periodic 
paralyses,  Westphal  further  thinks  that  aeither  of  Gib- 
ney's  cases  was  due  to  malaria. 

The  first  really  important  consideration  of  the  disease, 
if  w;e  may  so  call  it,  we  owe  to  Westphal  (5),  who,  in  1885, 
described  in  detail  a  typical  case  under  the  heading  "Ueber 
einen  merkwiirdigen  Fall  von  periodischer  Lahmung  aller 
vier  Extremitaten  mit  gleichzeitigem  Erloschen  der  elec- 
trischen  Erregbarkeit,  wahrend  der  Lahmung."  In  the 
study  of  this  case  Westphal  was  assisted  by  Oppenheim. 
to  whom  we  owe  much  careful  work  on  the  electrical 
changes.  The  history,  in  outline,  is  as  follows:  The  pa- 
tient was  a  boy  of  twelve,  with  no  hereditary  predisposi- 
tion, so  far  as  learned.  The  attacks  came  on  by  weakness 
of  the  legs;  three  hours  later  the  boy  could  not  stand,  and 
the  attacks  were  followed  in  a  short  time  by  a  complete 
paralysis  of  arms  and  legs,  of  a  flaccid  character.  Knee 
reflexes  at  times  were  not  obtainable.  Cranial  nerves  were 
free.  Sensation  was  unaffected;  mind  clear.  Electrical 
examination  showed  distinct  quantitative  diminution  to 
both  galvanism  and  faradism,  and  complete  loss  in  certain 
nerve  distributions.  Gradual  improvement  occurred  the 
following  day,  which  soon  became  complete,  with  a  slow 
return  of  electrical  excitability.  He  was  perfectly  normal 
in  all  respects  between  the  attacks.  Repeated  attacks  of 
this  character  occurred,  which  were  carefully  studied  until 
the  patient  passed  from  observation.  The  condition  above 
briefly  described  excited  Westphal's  profoundest  interest. 
His  astonishment  was  chiefly  aroused  by  the  extraordinary 
electrical  and  reflex  changes,  w^hich  at  once  placed  the 
disturbance  without  the  pale  of  the  so-called  functional 
diseases,  notably  hysteria.  Westphal's  since  much-quoted 
words  on  the  subect  are:  "Dieses  relativ  schnelle  Erloschen 
und  Wiederkehren  der  electrischen  Reizbarkeit  in  Nerven 
und  Muskeln  steht  ganz  einzig  in  seiner  Art  da;  wir  ken- 


FAMILY  PERIODIC  PARALYSIS,  64X 

nen  vVedef  eine  Krankheit  des  Riickenmarks  noch  der 
spinalen  Nerven,  in  welcher  jemals  etwas  Aehnliches 
beobachtet  ware;  ebenso  lasst  uns  die  Physiologic  in  Be- 
treff  einer  Erklarung  vollstandig  im  Stich  *  ♦  * 
Wir  stehen  somit  dem  geschilderten  Krankheitsfalle  als 
einemRathsel  gegeniiber,  und  sind  nicht  einmal  im  Stande, 
eine  annehmbare  Hypothese  aufzustellen,  weder  iiber  die 
Natur  der  in  grosseren  Intervallen  (nicht  nach  dem  Wech- 
selfieber  Typus)  auftretenden  Lahmungserscheinung'en, 
geschweige  denn  iiber  die  Ursachen  des  schnellen  Erlo- 
schens  und  der  ebenso  schnellen  Wiederkehr  der  elec- 
trischen  Erregbarkeit  der  Nerven  und  Muskeln."* 

Following  Westphal,  in  the  same  year,  Fischl  (6)  adds 
another  interesting  observation,  which,  although  differing 
in  certain  respects  from  other  reported  cases,  probably  be- 
longs to  the  same  general  group.  The  patient  was  a  girl 
of  eight,  also  without  hereditary  history  of  significance. 
There  was  a  complete  flaccid  paralysis  of  the  legs,  with 
loss  of  knee-jerk,  the  arms  being  very  slightly,  if  at  all,  af- 
fected; recovery  in  twenty-four  hours.  At  a  subsequent 
attack,  faradic  examination  showed  a  complete  loss  of  re- 
action in  muscles  and  nerves  involved.  Condition  be- 
tween the  attacks  perfectly  normal.  Certain  peculiarities 
of  this  case  are  of  special  interest.  These  will  be  here- 
after discussed. 

In  the  following  year,  1886,  Westphal  (7)  published  a 
supplementary  article,  in  which  he  discussed  Gibney's  paper, 
which  he  had  before  overlooked.  Beyond  this,  the  com- 
munication adds  nothing  to  our  knowledge. 

Cousot  (8,  9),  in  1886.  and  again  in  1887,*  gives  his- 
tories of  a  number  of  cases  occurring  in  one  family.  The 
mother  and  four  children  were  affected;  beyond  this  the 
heredity  does  not  go.  The  mother  often  lost  her  motor 
power  once  a  week,  an  affliction  which  lasted  through  life. 


•Westphal:  Ref.  5.  P-  5ii- 

^  We  quote  only  from  the  latter  article.     Ref.  9,  of  bibliography. 


642  EDWARD  WYLLYS  TAYLOR. 

The  children  suffered  from  similar  attacks,  motor  weak- 
ness to  point  of  paralysis,  arms  and  legs  both  affected,  loss 
of  electrical  reactions;  sensation  and  intelligence  undis- 
turbed; normal  between  attacks. 

Griedenberg  (10)  adds  another  case  to  the  list,  that  of 
a  man  of  twenty-two,  who  had  periodic  attacks  of  an 
identical  sort  with  those  already  described. 

In  1890  Goldflam  (11)  first  published  his  investigations 
on  the  subject  with  the  title,  **Ueber  eine  eigenthiimliche 
Form  von  periodischer,  familiarer,  wahrscheinlich  auto- 
intoxicatorischer  Paralyse."  With  the  attention  which 
Westphal  had  already  brought  to  the  matter,  this  and  the 
later  work  of  Goldflam  and  Qppenheim  afford  us  what 
knowledge  we  have  of  this  unique  affection.  To  Goldflam, 
however,  in  particular,  belongs  the  credit  of  working  out 
in  minutest  detail  the  clinical  phenomena,  and  also  of  in- 
stituting various  experimental  researches  in  the  hope  of 
elucidating  the  subtle  problems  of  etiology.  This  first 
complete  description  of  the  disease  covers  eleven  cases 
in  the  patient's  family,  and  affords,  therefore,  an  oppor- 
tunity of  noting  the  remarkable  hereditary  character  of 
the  disturbance.  The  attacks  in  the  best  observed  of 
these  cases  occurred  in  a  boy  of  17,  and  conform  in  all 
essential  regards  with  the  cases  already  briefly  described. 
The  following  year,  1891,  Goldflam  (13)  further  elaborated 
his  paper  in  a  detailed  piece  of  work  under  the  same 
title.  This  second  article  covers  all  the  ground  of  the 
previous  one,  and  adds  considerably  to  it.  These  papers, 
particularly  the  second,  are  monographic  in  their  com- 
pleteness. 

Between  the  publication  of  Goldflam's  two  papers  Pu- 
lawski  (12)  reported  a  perfectly  typical  case,  so  like  others 
that  the  same  general  description  serves  for  all. 

In  the  same  year  that  Goldflam's  later  communication 
appeared  Oppenheim  (14)  had  an  opportunity  to  observe 
again  the  case  described  by  Westphal  in  1885,  ^^^  ^^ 
make  a  much  more  careful  examination  than  had  hitherto 


FAMILY  PERIODIC  PARALYSIS.  643 

6een  done.  The  chief  value  of  this  work  lies  in  the  in- 
vestigation of  the  electrical  changes,  under  varying  con- 
ditions and  in  different  stages  of  the  attacks,  as  well  as 
in  the  free  intervals.  His  conclusions  in  general  are  that 
at  the  height  of  the  attack  nerve-muscle  excitability  is 
completely  lost  in  certain  groups,  but  that  electrical  stimu- 
lation does  not  always  give  uniform  results.  Oppenheim 
also  draws  attention  for  the  first  time  to  a  hardly  less  re- 
markable phenomenon,  viz.,  a  temporary  dilatation  of  the 
heart  during  the  attack,  and  signs  indicative  of  mitral  in- 
sufficiency, which  gave  place  to  perfectly  normal  con- 
ditions between  the  attacks. 

An  interesting  but  cursorily  reported  case  appeared 
in  the  University  Medical  Magazine  for  i892-'93,  ob- 
served by  Burr  (15).  The  patient  was  a  strong  man  of 
thirty,  who  since  his  tenth  year  had  had  periodic  attacks^ 
occurring  about  four  times  yearly,  and  lasting  from  a  day 
to  a  week.  The  long  duration  of  the  attacks,  and  the 
fact  that  but  one  half  of  the  bodv  was  affected  when  seen 
by  Burr  render  the  case  noteworthy.  No  electrical  ex- 
amination was  made. 

In  1894  two  papers  were  published,  by  Hirsch  (16) 
and  Rich  (17),  of  Ogden  City,  Utah.  The  mother  of 
Hirsch's  patient,  who  was  a  man  of  twenty-six,  had  sim- 
ilar attacks;  otherwise  no  hereditary  predisposition. 
Hirsch  verified  Oppenheim's  observation  of  temporary  in- 
sufficiency of  the  mitral  valve  during  the  attacks.  In  other 
respects,  the  case  is  only  noteworthy  from  its  similarity 
to  others. 

Rich's  (17)  communication  is  an  exceedingly  interest- 
ing one,  and  the  subject  is  well  deserving  of  more  study 
than  he  has  devoted  to  it  in  his  published  article.  He  de- 
scribes, without  citing  individual  cases,  a  peculiarity  ex- 
isting in  his  own  family  for  five  generations,  of  a  tem- 
porary motor  paralysis  due  to  cold,  affecting  by  preference 
the  facial  muscles,  without  accompanying  disturbance  of 
the  mind  or  of  sensation.     An  unusual  exposure  to  coUl 


644  EDWARD  WYLLYS  TAYLOR. 

or  dampness  brings  on  almost  immediately  a  more  or  less 
complete  disturbance  of  motion.  He  speaks  of  one  oc- 
casion in  which  a  person  was  completely  paralyzed,  witli 
the  exception  of  the  tongue,  through  sleeping  in  moist 
underclothing.  A  paralysis  of  the  tongue  could  easily  be 
brought  about  by  holding  snow  in  the  mouth,  taste  being 
unaffected.  Complete  recovery  always  takes  place,  pre- 
ceded by  a  feeling  of  exhaustion.  The  paralysis  is  always 
of  the  nature  of  a  tonic  spasm.  No  mention  of  temporary 
electrical  changes  or  of  a  detailed  physical  examination 
is  made  in  his  paper.  Apart  from  the  peculiarity  men- 
tioned, there  was  absolutely  no  neurotic  tendency  in  the 
family,  but  this  one  idiosyncrasy  had  never  skipped  a 
generation,  as  far  back  as  could  be  traced. 

The  analogy  to  the  condition  we  are  considering  is 
so  striking,  and  the  exciting  cause  so  definite  and  yet  so 
different  from  other  reported  cases,  that  this  paper  of  Rich 
must  be  regarded  as  most  significant  and  important,  in 
spite  of  its  brevity. 

In  1895,  Goldflam  (18)  carried  his  researches  still  fur- 
ther, and  attempted  by  various  means  to  arrive  at  definite 
conclusions  of  an  etiologic  sort,  with  what  success  we 
shall  have  occasion  to  see  later.  In  a  footnote  to  this 
elaborate  paper,  he  alludes  to  two  other  cases,  in  addition 
to  those,  eleven  in  number,  which  he  had  previously  de- 
scribed, both  occurring  in  children,  and  he  thinks  of  the 
same  character.  He  does  not  go  beyond  a  very  general 
statement,  pending  further  observation.  It  may  also  be 
said,  in  passing,  that  Goldflam  regards  a  case,  alluded  to 
in  Erb's  monograph  on  Thomsen's  disease,  by  Rothe'  as 
belonging  to  the  family  periodic  paralyses. 

Bernhardt  (19),  in  the  following  year,  writes  on  two 
cases  in  a  father  and  son,  which  correspK)nd  closely,  in 
certain  respects,  to  the  clinical  picture  already  frequently 


'Rothe:  Statistischer  Sanitatsbericht  iiber  die  Konigl.  Prcuss. 
Armee,  u.  s.  w.,  fur  1879-81.  Berlin,  1882,  p.  51  (ref.  taken  from  Gold- 
flam's  paper,  bibliog.  18). 


FAMILY  PERIODIC  PARALYSIS.  645 

outlined.  Bernhardt,  however,  is  chiefly  interested  in  the 
association  of  periodic  paralysis,  with  muscular  distrophy 
and  with  other  forms  of  well  recognized  disease.® 

Goldflam  (20)  contributed  still  a  fourth  paper  to  the 
subject  in  1897.  In  it  he  reports  eight  additional  cases, 
in  a  branch  of  the  family  he  had  already  described,  and 
also  three  other  cases  occurring  in  a  totally  different  fam- 
ily. His  conclusions  from  this  further  study  are  essentially 
confirmatory  of  his  previous  observations,  though  differing 
somewhat  in  detail. 

From  the  foregoing  historical  sketch,  which,  we  be- 
lieve, is  complete  in  its  references,  it  is  evident  that  the 
condition  outlined  is  of  curiously  infrequent  occurrence, 
and  that  when  it  has  been  observed  it  has  aroused  an 
interest  of  the  profoundest  sort.  The  German  cases  have 
been  studied  with  extreme  minuteness  by  Westphal  (7), 
Oppenheim  (14),  Goldflam  (11,  13,  18,  20)  and  others;  in 
America  we  find  but  three  references,  one  of  which,  that 
of  Gibney  (4),  is  doubtful  of  classification.  Of  the  other 
two,  Burr's  (15)  communication  narrates  a  single  case, 
which  is,  no  doubt,  of  the  periodic  type,  but  reported 
with  less  completeness  than  its  importance  warrants;  and, 
finally,  the  extraordinary  condition  described  by  Rich  (17), 
as  due  to  exposure,  presents  a  most  interesting  and  close 
analogy  to  the  matter  under  discussion.  We  have,  there- 
fore, no  excuse  to  offer  for  the  presentation  of  the  follow- 
ing family  history,  and  the  somewhat  detailed  considera- 
tion of  the  affection  as  it  occurred  in  two  of  its  members:'' 

The  affection  in  this  family  first  developed  five  genera- 
tions back.  There  is  a  tradition  that  the  person  afflicted 
was  running  violently,  when  something  seemed  to  give 


*  See  earlier  paper.  Bernhardt:  Muskelsteifigkeit  und  Muskel- 
hypertrophic  (ein  selbststandiger  Symptomencomplex).  Virchow*s 
Archiv,  1897,  Ixxv.^  p.  516. 

*  For  many  of  the  following  facts  and  observations  I  am  indebted 
to  a  member  of  the  family,  a  student  of  medicine,  whose  assistance 
has  been  of  the  greatest  help  in  preparing  the  clinical  side  of  this 
report. 


646 


EDWARD  WYLLYS  TAYLOR. 


way  in  his  back,  and  he  fell  to  the  ground,  2^^^^^^^^^- 
From  that  time  on  he  was  subject  to  attacks  of  a  periodic 
character.  Of  his  three  sons,  only  one  seems  to  have 
had  the  disease.  The  other  two,- with  their  children,  were 
never  afflicted.  The  son  who  was  affected  was  a  judge, 
and  those  who  remember  him  cannot  recall  that  he  was 
ever  kept  from  his  work  by  the  attacks,  but  remember 


Family  Periodic  Paralysis. 


Male,    First  ap- 
I    peaiance  of 
disease. 


Male    Male>    Male 


^ 


I 


(t 


r» 


Female 


3> 


5* 


I- 


Male 


MaU' 


Explanation  of  Chart. 

Italics:  Persons  affected. 

Roman  letters:  Persons  exempt, 

s.  Children  exempt. 

3.  Unmarried. 

3.  Died  younsT* 

4.  Epilepsy. 

5.  Patients  studied. 

that  he  frequently  needed  assistance  in  getting  in  and  out 
of  his  carriage.  In  each  succeeding  generation  the  dis- 
turbance was  transmitted  to  one  or  more  members  down 
to  the  present,  in  which  two  (our  patients)  out  of  three 
are  typically  affected. 

The  genealogy  of  the  family  is  presented  in  the  above 
diagram,  which  makes  a  detailed  description  super- 
fluous: 


fer 


FAMILY  PERIODIC  PARALYSIS,  647 

The  hereditary  tendency  is  transmitted  through  the 
female  as  well  as  through  the  male  line.  Apart  from  this 
affection,  there  is  no  significant  neurotic  tendency  ob- 
servable. One  person,  who  was  exempt,  had  epileptic  con- 
vulsions, and  the  mother  of  our  patient,  and,  possibly,  the 
grandmother,  died  of  tuberculosis  of  the  lungs.  Neither 
of  these  facts  is  significant,  inasmuch  as  the  paralytic  con- 
dition had  already  existed  for  three  generations  in  a  per- 
fectly non-neurotic  family,  so  far  as  ascertainable.  It  is 
to  be  remarked,  further,  that  the  family  is  one  of  rather 
unusual  mental  power. 

Detailed  fact<!  regarding  previous  generations  are  diffi- 
cult to  obtain,  although  certain  members  of  the  second 
generation  are  living.  The  testimony  of  those  members 
of  the  family  with  whom  I  have  been  able  to  talk  is,  how- 
ever, definite,  viz.,  that  the  attacks  in  all  cases,  with  one 
exception,  when  they  began  at  the  eighteenth  year,  have 
come  on  at  about  the  age  of  puberty,  and  persisted,  with 
varying  frequency,  during  the  active  years  of  life,  after 
which,  between  the  fortieth  and  fiftieth  year,  they  have 
gradually  disappeared.  The  character  of  the  individual 
attacks  has  been  in  all  cases  strikingly  similar,  to  such  a 
degree  that  one  description  serves  for  all. 

That  description  we  shall  give  in  the  following  most 
carefully  observed  case  in  the  present  generation: 

Case  I. — ^J.  T.  S.,  19;  schoolboy.  As  a  young  boy  he  was 
perfectly  well,  and  free  from  the  ordinary  diseases  of  child- 
hood; no  malaria  nor  venereal  infection.  During  the  sum- 
mer of  1894,  when  he  was  14  to  15  years  old,  he  first  noticed 
a  certain  slight  feeling  of  weakness  in  the  thighs  and  calves  of 
the  legs.  His  earliest  remembrance  is  that  in  playing  "leap- 
frog^' he  was  weaker  than  usual.  Thiis  condition  continued 
in  intermittent  fashion  during  the  summer,  and  in  the  fall  of 
that  year  be  had  the  first  typical  attack.  It  occurred  at  night, 
as  all  the  succeeding  ones,  practically  without  exception,  have 
dome.  The  attack  was  characterized  by  a  general  weakness 
of  the  body  and  limbs,  without  further  disturbance  of  any  sort. 
From  that  time  the  attacks  followed  eaich  other  rapidly,  on 
an  average  of  one  a  week.  He  would  awake  in  the  morning 
to  find  himself  paralyzed;  he  thinks  he  was  often  awakened 


648  EDWARD  WYLLYS  TAYLOR, 

by  the  paralysis.  His  lielplessness  usually  continued  during 
the  day,  suid  passed  away  gradually  toward  night  His  own 
observation  was  that  the  attacks  were  brought  on  by  excite- 
ment, exercise  or  late  hours.  Between  the  attacks  he  was 
absolutely  well,  with  no  trace  of  muscular  weakness. 

From  that  time  to  this,  a  periiod  of  nearly  four  years,  there 
has  been  no  change,  with  the  possible  exception  that  the  at- 
tacks have  increased  somewhat  in  frequency  and  diminished  in 
intensity.  This  is  the  general  history  of  the  affection,  as  it 
appeared  to  the  patient's  own  observation  of  himself.  Being 
an  active  boy,  with  a  taste  for  athletic  exercise,  it  goes  without 
saying  that  he  has  been  exceedingly  annoyed  by  his  persistent 
periods  of  disability.  So  many  of  his  ancestors,  including  his 
mother,  have,  however,  been  similarly  affected  that  he  has 
developed  a  certaim  philosophical  attitude,  which  helps  him 
over  days  of  enforced  idleness. 

A  typical  attack,  in  detail,  is  as  follows:  After  a  day  usually 
of  somewhat  violent  exercise,  as,  for  example,  bicycle  riding, 
be  goes  to  bed  feeling  perfectly  well  and  strong.  There  are 
no  prodromal  symptoms  whatever,  beyond,  on  occasions,  a 
certain  feeling  of  weakness,  which  usually  is  not  observed, 
since  the  attack  begins  almost  invariably  at  night.  The  por- 
tion of  the  body  first  affected,  whether  legs  or  arms,  is  also 
not  definitely  known  for  the  same  reason,  though  he  thinks  a 
weakness  of  the  legs  is  antecedent.  On  awaking  iti  the  morn- 
ing, he  finds  himself  in  a  pronounced  attack,  completely  par- 
alyzed, with  the  general  exception  of  the  cranial  nerves.  'Vol- 
untary movement  is  absolutely  abolished.  Coughing*  and 
sneezing  are  iimpossible,  but  respiration,  so  far  as  he  has  ob- 
served, remains  normal.  There  is  no  dyspnoea.  The  muscular 
system  is  perfectly  flaccid.  He  has  no  desire  for  food  or  drink 
during;  the  attack,  and  he  often  goes  twenty-four  hours  or  more 
without  urination.  There  is  sometimes  apparent  temporary 
urinary  retention,  which  be  thinks  is  due  rather  to  the  awk- 
ward position  in  which  he  happens  to  be  lying  than  to  any 
actual  disturbance  with  the  sphincters.  He  never  defe- 
cates during  an  attack.  He  has  no  sensory  disturbance  wfiat- 
ever,  and  his  mind  is  perfectly  clear  througfhout.  After  lying 
in  this  helpless  condition  for  hours,  he  gradually  recovers  the 
lost  motor  power,  and  toward  evening  of  the  same  day  is 
able  to  get  up,  the  power  usually  returning  first  in  the  arms, 
after  which  a  complete  return  to  the  normal  takes  place. 
Speech  is  always  unafl^ected ;  there  is  no  difficulty  in  swallowing 
and  never  the  sHIghtest  pain. 

From  this  time  until  the  onset  of  the  next  attack  the  pa- 
tient regards  himself,  and  his  friends  regard  him,  as  a  normal 
individual,  capable  of  the  same  muscular  exertion  as  his  com- 
panions.    He  has  always  noticed  that  afiy  overexertion  tends 


FAMILY  PERIODIC  PARALYSIS.  649 

to  bring  on  an  attack,  whdch  must,  however,  be  preceded  by 
a  period  of  rest.  .  In  this  way  he  has  come  to  predict,  with 
relative  certainty,,  the  occurrence  of  a  "lameness,"  as  he  calls 
it.  He  usually  pays  the  penalty  for  a  partictilarly  enjoyable 
day  of  activity  by  an  enforced  rest  of  many  hours  the  follow- 
ing day,  the  onset  of  the  paralysis  coming  some  time  during 
the  night.  He  is  able  to  abort  a  threatened  attack  temporarily 
during^  the  day  by  increased  muscular  exertion,  but  it  is  merely 
a  postponement  of  the  inevitable  paralysis,  which  follows  with 
all  the  more  certainty  later.  He  is  not  able  to  attribute  the  at- 
tacks to  dietary  errors,  or  to  anything  whatever  beyond  the 
mere  fact  of  exertion. 

Physical  Examination. — I  first  saw  the  patient  April  8th, 
1897,  between  attacks.  He  presented  a  picture  of  perfect 
health,  and  the  examination,  as  made  at  that  time,  showed 
nothing  which  could  be  regarded  as  abnormal.  His  muscular 
system  was  particularly  well  developed;  the  legs  somewhat  out 
of  proportion  to  the  arms  and  body.  His  calves  were  notice- 
ably large.  Measurements  made  at  the  time  were  as  follows: 
Chest  under  the  nlipples,  31^  inches  unexpanded;  33^  ex- 
panded; biceps,  midway  between  shoulder  and  elbow,  right, 
11^;  left,  io|  inches.  Thigh,  a  little  above  patella,  right,  20J; 
left,  20  inches;  calf,  maximum  circumference,  right,  16^;  left, 
16J.  No  pathological  significance  was  to  be  attached  to  these 
measurements. 

June  18th,  1897.  Saw  the  patient  again  at  his  home,  which 
was  some  distance  from  Boston.  The  previous  day  he  had 
ridden  fourteen  miles  on  a  bicycle  and  otherwise  exerted  him- 
self, but  went  to  bed  feeling  well.  He  awoke  at  6  the  follow- 
ing morning,  completely  paralyzed,  except  for  the  slightest 
possible  movements  of  the  hands  and  feet.  The  face  was  un- 
aflFected.  He  remained  in  this  helpless  condition  until  about 
three  in  the  afternoon,  when  a  gradual  improvement  began, 
first  in  the  arms.  Owing  to  the  distance  at  which  he  lived,  I 
was  imable  to  see  him  until  about  five  in  the  afternoon,  after 
improvement  had  begun.  He  was  then  in  a  state  of  partial 
paralysis.  Movements  were  made  with  the  greatest  difficulty 
and  weakness.  The  legs  were  almost  completely  beyond  his 
control:  the  arms  less  so;  neck  muscles  very  weak.  He  could 
raise  himself  in  bed  only  with  the  greatest  difficulty.  His 
eflForts  reminded  me  of  a  person  in  the  last  stages  of  a  pros- 
trating" disease.  His  mind  was  oerfectly  clear,  and  he  made 
no  comolafint  of  pain.  It  was  a  hot  dav,  and  he  was  sweating 
profusely.  His  face  was  somewhat  flushed,  but  his  temperature 
was  normal.    Pulse  88,  and  of  fair  quality.    The  heart*  sounds 

*^*^W^^^^^  —^"^^^^^^-^     IPI-..--  ■■■  ■      »M  ^      ■  ■      ■■.^■^^  ■-  —■■■  II  ■■■■  l^fM 

•In  view  of  Oppenheim's  work,  a  moie  careful  examination  of 
the  heart  is  to  be  desired. 


650  EDWARD  WYLLYS  TAYLOR. 

were  normal;  the  pupils  were  equals  of  normal  size  and  good 
reaction;  swallowing  was  unaffected.  He  was  totally  unable 
to  hold  his  head  up,  unsupported.  All  movements  of  the 
arms  extremdy  weak;  when  he  was  supported  in  a  sitting 
position  he  could  not  raise  his  arm  above  the  horizontal.  The 
legs  were  much  weaker  than  the  amis.  Slight  flexion  at  the 
knees  was  possible,  and  extremely  slight  flexion  at  the  ankle. 
Mexion  and  extension  of  the  toes  possible,  but  very  weak. 
Feet  slightly  adducted.  Muscles  all  felt  normal.  Difficulty 
in  coughing  and  sneezing. 

Reflexes:  Knee-jerks  lost;  no  plantar;  cremaster  very 
slight;  abdominal  and  epigastric,  active. 

Electrical  Examination;  the  faradic  current  alome  available: 
Marked  quantitative  diminution  of  reaction  from  the  facial 
nerve.  Right  arm:  median,  ulnar  and  musculo-spiral  (?) 
nerves  tested.  Slight  reaction  from  very  strong  currents. 
Same  from  Erb's  point.  Muscles:  Deltoid,  sterno-mastoid, 
trapezius,  flexors  and  extensors  of  forearm,  interossei  of  the 
hand,  excited  to  contract  only  by  very  strong  currents.  Right 
leg:  Very  slight  reaction  from  peroneal  nerve;  none  from  the 
posterior  tibial  nerve.  Muscles:  Vastus  extemus,  quadriceps, 
interossei,  slight.  Left  leg:  Even  less  reaction  obtained  from 
the  same  muscles  and  nerves.  The  strength  of  the  current 
used  was  sufficient  to  produce  painful  tetanic  contraction  in  a 
normal  person. 

The  result,  therefore,  of  the  partial  electrical  examination, 
which  was  alone  possible,  was  enormous  quantitative  diminu- 
tion to  both  indirect  and  direct  stimulation.  No  qualitative 
change  to  faradism  was  noted.  There  was  no  disturbance  of 
any  form  of  sensation,  and  the  patient  took  an  intelligent  in- 
terest in  the  examination  throughout,  answering  all  questions 
with  perfect  clearness. 

At  six  in  the  evening,  twelve  hours  after  waking,  he  had 
eaten  nothing  but  a  few  bananas,  and  had  not  had  the  slightest 
desire  for  drink.  He  had  not  passed  urine  for  twenty  hours, 
nor  had  an  operation  of  the  bowels  for  at  least  forty-eight 
hours.  An  hour  later,  at  about  7  o'clock,  he  was  again  ex- 
amined, and  it  was  found  that  an  increase  in  the  weakness  had 
again  come  on,  an  unusual  occurrence.  It  was  probably  to 
be  explained  by  the  effort  of  muscular  exertion,  occasioned 
by  the  preceding  somewhat  prolonged  examination. 

Two  days  later,  June  20th.  patient  wrote  the  following  let- 
ter, which  I  reproduce  in  part:  "I  thought  I  would  write  and 
tell  you  how  I  qame  out  of  my  immovability.  When  you  left 
T  had  grown  somewhat  weaker  than  when  you  came,  as  you 
know,  but  that  was  only  a  warning  of  w^bat  was  to  come. 
Tn  the  night  it  came  back  full  force.  I  was  unable  to  sleep 
\ery  long  at  a  time.    It  is  not  exaggerating  to  say  that  I  was 


FAMILY  PERIODIC  PARALYSIS.  651 

truly  miserable  until  it  kft  me,  about  3  or  4  o'clock  Satur- 
day morning.  I  was  so  weak  and  sore  that  I  did  not  get  up 
until  about  1 1 ;  the  rest  of  the  day  I  took  life  fairly  easy,  but 
was  a  little  tired  when  I  went  to  bed.  This  morning  (forty- 
eight  hours  after  first  onset)  when  I  woke  up,  I  was  a  little 
lame,  but  aft«r  I  got  up  it  worked  off,  and  I  am  feeling  quite 
well  now." 

The  fact  of  his  being  able  to  write  in  a  steady  hand  shows 
the  complete  disappearance  of  the  paralysis  from  the  hand 
muscles. 

Several  months  later,  September  19th,  1897,  his  aunt,  with 
whom  he  lives,  wrote  as  follows:  "I  thought  you  might  be  in- 
terested to  hear  of  J.'s  condition  since  we  were  at  your  office. 
The  following  day,  Wednesday,  he  was  unable  to  dress  until 
3  P.  M.;  Thursday,  not  until  5  o'clock;  Friday,  at  10  o'clock, 
so  went  to  school  at  recess.  Saturday  he  was  all  right;  to-day 
(Sunday),  able  to  get  out  of  bed  at  3:30  P.  M.  He  wished 
very  much  for  me  to  send  for  you  to-day,  etc.  Mrs.  G.[the 
sister  about  to  be  described]  was  also  in  bed  the  greater  part 
of  the  day  yesterday,  only  able  to  sit  up  about  an  Hour  the 
latter  part  of  the  afternoon." 

May  nth,  1898,  the  patient  J.  was  again  seen  during  a  free 
interval.  A  careful  examination  resulted  negatively.  The 
attacks  had  diminished  somewhat  in  frequency  for  the  past 
few  months.    He  is  to-day  feeling  perfectly  well. 

Physical  Examination:  Muscular  system  apparently  normal; 
no  impairment  of  strength  anywhere.  Mechanical  irritability 
-of  muscles,  noonal.  Knee-jerks  present  and  normal.  Peri- 
pheral reflexes  obtainable,  and  sufficiently  active. 

Sensation  undisturbed;  pupillary  reactions  normal;  no  en- 
largement of  the  spleen. 

Heart  perfectly  normal  as  regards  size  and  sounds.  Pulse, 
88,  good  quality. 

Electrical  Examination:  Strong  currents  well  borne.  Con- 
siderable skin  resistence.  Faradism:  Ptx)mpt  and  normal  re- 
action from  nerves  and  muscles  of  arms  examined.  Good  re- 
action also  from  nerves  and  muscles  of  legs,  with  the  possible 
exception  of  the  peroneal  group  in  the  right  leg.  Inasmuch, 
however,  as  the  indirect  stimulation  from  the  peroneal  nerves 
produced  reaction  of  the  muscles  supplied  by  it,  we  would  not 
lay  particular  stress  upon  the  poor  response  of  the  muscles  to 
direct  stimulation.  Galvanism:  Normal  reactions,  with  the 
same  exception  above  noted.  Response  quick;  cathodal  con- 
traction much  greater  than  anodal.  No  polar  changes  nor 
slightest  indication  of  a  reactiion  of  degeneration.  No  ex- 
haustion of  muscular  contraction  through  prolonged  stimula- 
tion. In  greneral,  somewhat  stronger  currents  were  necessary 
than  in  case  of  the  control  used,  but  not  more  than  could  be 


652  EDWARD  WYLLYS  TAYLOR, 

explained  by  a  heightened  skin  resistence. 

Blood:  Examinaticwi  of  the  blood  was  kindly  made  for  me 
by  Dr.  H.  F.  Hewes,  of  the  Harvard  Medical  School. 
His  report  of  a  specimen  taken  between  the  attacks  is  as  fol- 
lows: "Probably  no  increase  in  white  corpuscles.  In  a  dif- 
ferential count  of  200  white  corpuscles,  basophiles  51}^;  poly- 
morphonuclear neutrophiles,  47^;  polymorphonuclear  eosino- 
philes,  2^;  no  myelocytes  nor  other  pathological  forms.  Sum- 
mary: Lymphocytosis,  no  evidence  of  anaemia.  The  large 
proportion  of  basophiles  is  characteristic  of  a  reduced  condi- 
tion of  nutrition.  The  count  would  be  normal  for  ten  years 
of  age." 

In  a  personal  note  Dr.  Hewes  writes:  "The  examination 
of  the  blood  of  Mr.  S.  shows  practically  no  evidence  of  anaemia 
or  of  degenerative  changes  in  the  corpuscles.  The  lymphocy- 
tosis suggests  lack  of  vigor  in  the  metabolic  processes,  that  is, 
if  the  patient  is  over  10  years  of  age.  It  is  a  condition  similar 
to  that  found  in  the  blood  of  rachitis  of  strumous  children," 
etc. 

An  examination  a  few  days  later,  also  in  a  free  iTiterval, 
showed  in  a  differential  count  of  200  white  corpuscles:  Baso- 
philes, 57^;  polymorphonuclear  neutrophiles,  42^;  polymor- 
phonuclear eosinophiJes,  i^;  a  few  endoglobular  poikilocytes 
and  mi:rocytes  were  seen.  No  malarial  Plasmodium.  Very 
slight  suggestion  of  loss  of  corpuscular  substance  in  red  cor- 
puscles, evidently  leucopaenia  plus  lymphocytosis. 

Of  this  specimen  Dr.  Hewes  writes:  "The  relative  increase 
in  the  younger  forms  of  leucocytes  is  more  marked  than  in  the 
other  specimen.  The  form  is  mostly  that  of  the  small  lympho- 
cyte. There  is  evidently  a  very  small  number  of  white  cor- 
puscles, perhaps  four  thousand  per  cm.  of  blood.  This  also  is 
a  sign  of  lowered  vigor." 

Urine  examination  between  attacks,  also  by  Dr.  Hewes; 
I  append  his  report : 

"May  19th,  1898,  mixed  twenty-four-hour  specimen.  Quan- 
tity of  urine  in  twenty-four  hours,  1,170  ccj  color,  normal; 
specific  gravity,  1,022;  reaction,  acid;  amount  of  sediment, 
slight;  urophaen,  normal;  chlorides',  low;  indoxyl,  increased; 
sulphates,  normal;  urea,  1.85^;  earthy  phosphates,  diminished; 
uric  acid,  normal;  alkaline  phosphates,  diminished;  albumin, 
absent;  sugar,  absent;  bile  pigments,  absent;  no  acetone;  total 
chlorine,  8.5  gms.;  total  urea  in  twenty-four  hours,  21  gros.; 
sediment,  centrifugal;  few  small,  round  epithelial  cells;  no 
casts  found;  a  fresh  specimen  examined  one  week  ago  showed 
nothing  abnormal. 

"The  urine  in  this  case  suggests  a  somewhat  low  condition 
of  metabolism.  The  urea  excretion  is  below  normal  for  a 
man  of  this  age  and  weight  upon  ordinary  diet.     It  should 


FAMILY  PERIODIC  PARALYSIS.  653 

approximate  30  grammes  instead  of  20.  The  twenty-four-hour 
amount  of  urine  is  low.  Th^e  chlorine  is  low;  ruyrmal  phos- 
phates are  low;  there  is  no  special  evidence  of  an  excessive 
formation  of  uric  acid  in  place  of  urea,  nor  of  failure  in  carbo- 
hydrate metabolism;  no  sugar  or  acetone.  Proteid  metabolism 
is,  as  I  have  said,  low.  Fat  metabolism  can,  of  course,  be 
judged  by  the  stools  only." 

Owing  to  the  distance  at  which  he  lives  repeated  examina- 
tion of  the  patient  during  the  attacks  has  not  been  possible. 
From  the  foregoing*  it  will  appear  that  the  attack  described 
was  a  severe  one  of  a  typical  sort,  and  that  the  examination 
was  made  toward  its  close,  or  at  least  after  the  most  extreme 
paralysis  had  begun  to  pass  off.  The  signs  observed  were 
characteristic  for  that  period,  the  most  important  being  loss 
of  knee-jerk,  and  great  quantitative  diminution  in  electrical 
excitability. 

Case  II. — Mrs.  G.,  sister  of  previous  patient.  This  pa- 
tient I  have  been  able  to  see  but  once,  and  then  between  at- 
tacks.   She  gives  the  foUowinig  history: 

She  was  at  the  time  .of  the  examination,  September  I4th^ 
1897,  24  years  old;  married;  no  children.  When  she  was 
twelve  years  old,  and  much  worried  about  the  illness  of  her 
mother,  on  rising  one  morning  she  found  it  difficult  to  walk. 
The  calf  muscles  seemed  chiefly  affected;  she  could  not  raise 
her  heels  readily.  She  went  downstairs  and  fell  from  weak- 
ness, or  stumbling,  she  does  not  know  which.  She  made  no 
mention  of  the  feeling  of  weakness,  and  walked  a  considerable 
distance,  experiencing  the  same  difficulty.  This  continued 
during  the  day,  and  passed  off  the  following  day. 

Two  or  three  weeks  later  she  had  a  second  attack,  which 
she  attributed  to  taking  medicine  by  mistake  the  evening 
before.  In  the  morning  she  had  the  same  trouble  in  walk- 
ing. Toward  night  she  could  not  walk  upstairs,  nor  lift  her 
feet.  She  was  carried.  The  arms  and  face  were  unaffected. 
From  this  time  on  she  had  similar  attacks,  varying  in  fre- 
quency from  one  a  week  to  one  a  month,  and  growing  gradu- 
ally more  severe.  A  few  months  later  she  was  completely 
helpless  for  the  first  time,  the  annc  as  well  as  the  legs  being 
affected.  In  the  very  w^orst  attacks,  of  which  she  has  had 
three  or  four,  the  face  has  been  somewhat  involved.  She  de- 
scribes the  disturbance  as  a  drawing  sensation  in  the  lower 
part  of  the  face,  associated  with  a  certain  difficulty  in  opening  * 
the  jaws,  but  not  in  closing  them.  She  has  never  been  unable 
to  close  her  eyes.  When  her  face  was  affected,  she  also  had 
difficulty  in  breathing.  She  could  not  cough  or  sneeze.  There 
was  no  disturbance  with  the  special  senses,  nor  with  sensation 

generally. 

Two  years  ago  she  took  a  "headache  medicine"  of  unknown 


654  EDWARD  WYLLYS  TAYLOR. 

character  in  the  evening.  The  following  morning,  at  9  o'clock,, 
she  suddendy  lost  consciousness  while  lying  on  the  bed.  She 
found  herself  about  ten  minutes  later  in  a  corner  of  the  room. 
She  did  not  bite  her  tongue,  and  had  never  had  a  similar 
attack,  nor  had  she  ever  fainted  in  her  life.  After  recovering 
consciousness  from  this  attack,  whose  character  is,  of  course, 
doubtful,  she  at  once  became  generally  weak,  and  forthwith 
went  through  the  most  severe  paralytic  seizure  she  has  ever 
had.  At  12  o'clock  she  was  helpless.  Her  face  was  involved; 
she  breathed  only  with  the  greatest  difficulty,  and  had  artificial 
respiration  during  the  night.  She  was  also  g^ven  digitalis. 
The  following  day  she  was  somewhat  better,  but  still  helpless. 
The  next  day,  about  forty-eight  hours  afta-  the  onset,  she 
was  able  to  get  up,  but  remained  very  weak.  She  was  not 
entirely  strong  for  seven  days.  She  had  been  married  three 
weeks  before  this  attack.  During  her  wedding  journey  she  had 
been  travelling  and  walking  much  more  than  was  her  custom. 

After  this  violent  seizure  she  seemed  to  improve,  and  had 
milder  attacks  at  longer  intervals.  This  continued  up  to  Feb- 
ruary, 1897.  Then  she  had  tonsillitis,  and  a  serious  attack, 
but  less  so  than  the  one  above  described.  This  was  followed 
by  slight  attacks  up  to  a  week  ago  (September,  1897),  but  for 
a  month  she  has  been  feeling  weak  in  the  characteristic  way. 
In  September,  1897,  a  week  before  I  saw  her,  she  had  another 
severe  attack,  coming  on  after  a  period  of  anxiety.  She  went 
to  bed  well,  and  woke  up  perfectly  helpless,  with  both  face 
and  respiration  affected;  the  attack  lasted  about  twelve  hours; 
four  hours  Mater  she  came  to  Boston.  She  states  that  her 
muscles  always  feel  weak  and  sore  after  an  attack. 

Physically,  she  is  an  exceedingly  strong  and  healthy  look- 
ing woman.  She  has  no  disturbance  in  the  bowel  or  men- 
strual functions,  and,  apart  from  her  family  infirmity,  con- 
siders herself  well.  Owing  to  the  relative  infrequency  of  her 
attacks,  she  never  lost  work  at  school,  and  was  the  valedic- 
torian of  her  class.  She  is  a  woman  of  considerable  general 
culture. 

Her  pulse  was  88;  slightly  irregular.  She  sleeps  fairly,  has 
no  headaches,  and  is  not  of  a  nervous  temperament.  She  has 
noticed  no  difference  in  the  urinary  secretion  during  and  be- 
tween the  attacks. 

This  patient  has  not  been  seen  since  this  visit  in  Septem- 
ber, 1897.  I  have  only  learned  from  other  members  of  the 
family  that  she  is,  on  the  whole,  improving,  but  by  no  means 
free  from  the  attacks.  In  average  they  are  less  severe  than 
in  Case  I.,  although  occasionally  very  much  more  so,  even 
threatening  a  paralysis  of  respiration,  as  already  described. 

The  two  cases  are  evidently  identical  in  their  essential  na- 
ture, though  diiffering  somewhat  in  detail.    The  examination 


FAMILY  PERIODIC  PARALYSIS,  655 

has  been  in  neither  case,  notably  in  the  second,  as  complete 
as  desirable,  but  amply  sufficient  to  establish  the  diagnosis, 
and  add,  we  hope,  some  points  of  interest  to  the  literature  al- 
ready collected. 

In  consideration  of  the  relative  fewness  of  the  cases  re- 
ported, and  extreme  rarity  and  growing  interest  of  conditions 
of  this  character,  w-e  offer  the  following  abstract  of  cases 
hitherto  appearing  in  literature,  in  the  order  of  their  publi- 
cation: 

Case  I.  Cavare :  Woman,  24  years  old,  several  attacks  of  a  general 
paralysis,  lasting  five  to  eight  hours;  quotidian  type;  relieved  by 
quinine;  no  statement  as  to  malaria. 

Case  II.  Romberg:  Case  of  paralysis  of  lower  extremities,  oc- 
curring in  three  attacks  of  the  quotidian  type.  Disappeared  on  ad- 
ministration of  quinine.  Thought  by  Romberg  to  be  due  to  inter- 
mittent fever  (malaria). 

Case  III.  Hartwig  (quoted  by  Westphal):  Male,  23  years  old; 
healthy  family;  five  years  before  had  had  tertian  intermittent  fever. 
Onset;  "tired  feeling"  in  legs;  increased;  spread  to  arms.  On  third 
day  moved  with  great  difficulty.  Following  night,  paralyzed:  legs, 
arms,  body  and  movements  of  head.  Facial  muscles  free.  Speech, 
breathing,  swallowing  somewhat  dif!icult.  No  incontinence.  Sensi- 
bility  unaffected;  general  condition  good;  no  fever;  some  sweating; 
after  twenty-four  hours  improvement  in  following  order:  neck,  fingers, 
arms,  body,  legs.  Similar  attacks  lasting  about  twenty-four  hours. 
Attack  later  observed;  muscles  of  respiration,  except  diaphragm, 
affected;  coughing  and  sneezing  impossible.  Loss  of  reflexes.  Elec- 
trical excitability  almost  abolished;  at  same  time  numbness,  formi- 
cation and  cramp  in  paralyzed  parts.  Temperature  normal.  Paresis 
of  extremities  persisted  and  increased.  Secondary  contractures.  Qui- 
nine merely  temporary  effect.  Paresis  increased  by  rest,  diminished 
by  movement.    Patient  lost  fifteen  pounds.    (Later  history  not  given.) 

Case  IV.  Samuelsohn:  Male,  38  years  old;  affection  began  at 
18.  At  first,  two  attacks  yearly;  later  one  a  week.  Legs,  body  fully 
paralyzed;  upper  extremities  only  partially.  Sensation  undisturbed. 
In  ten  hours  recovery.  Quinine  and  other  drugs  unavailing.  No 
electrical  tests  made,  nor  observations  on.  the  reflexes.  Samuelsohn 
thought  case  of  hysterical  character, 

Case  V.  Schachnowitsch :  Father  of  patient  similarly  affected. 
Said  to  have  died  from  increasing  attacks.  One  brother  epileptic. 
Patient,  a  man;  attacks  for  twenty-five  years;  usually  begin  at  night; 
also  has  abortive  attacks  indicated  by  subjective  sensory  disturbance 
and  weakness;  attacks  could  be  checked  by  energetic  movements; 
muscles  tense. 

Case  VI.  Gibney:  Child  of  7;'  after  malarial  attack,  paralysis 
of  four  extremities.  Sensory  disturbances.  Slow  recovery,  after 
months.     Muscular  atrophy.     (A  doubtful  case.) 

Case  VII.  Gibney:  Child  of  6:  similar  to  preceding;  slowly  re- 
covering paralysis;  much  constitu^tional  disturbance;  malarial.  (A 
doubtful  case.) 

Case  VIII.  Westphal:  Boy  of  12;  strong.  Onset;  weakness 
in  legs  with  a  pricking  sensation.  Great  thirst  and  desire  to  urinate. 
Some  minutes  before  he  could  pass  urine.  Three  hours  later  could 
not  stand.  Slight  movements  of  hips  and  arms  possible;  at  midnight 
complete  paralysis.  Seen  by  Oppenheim  at  4  A.  M.  Mind  clear, 
cranial  nerves  free.     Turning  of  head  difficult.     Coughing,  sneezing 


65^ 


EDWARD  WYLLYS  TAYLOR, 


impossible.  Complete  flaccid  paralysis  of  arms  and  legs;  sensibility 
normal.  Plantar  reflex  lacking;  cremaster  and  abdominal  present; 
knee-jerk  weak  and  not  always  obtainable.     No  dyspnoea. 

Electrical  examination:  Faradism;  strong,  painful  currents,  very 
weak  response  from  nerves.  None  from  left  peroneal  nerve  and  its 
muscles.  At  8  A.  M.  gradual  return  of  reaction  to  G.  and  F.,  direct 
and  indirect.    Quick  contractions  when  present  at  all. 

Improvement:  in  evening  could  walk.  No  enlargement  of  spleen. 
Sweating.  Temperature  y^.y.  Recovery  on  the  following  day,  except 
for  slight  electrical  changes  in  certain  muscles.  Similar  attacks  fol- 
lowed.   Movement  prevents  onset  of  attack. 

Etiology:  No  heredity.  Scarlet  fever  followed  some  years  later 
by  unknown  illness.  Four  weeks  after  exposure  to  draught  sudden 
paralysis.  Well  between  attacks  which  were  at  first  four  to  six  weeks 
apart,  and  lasted  about  twenty-four  hours.  Same  patient  studied  again 
later  by  Oppenheim.  Condition  between  unchanged.  Attacks  usually 
at  night;  awakes  paralyzed,  decreasing  in  intensity  until  following 
evening.  Arms,  legs,  head  paralyzed;  face,  tongue,  larynx  and  eye 
muscles  free.  Thirst,  heat,  sweating.  No  excretion  of  urine.  In- 
tensity of  paralysis  not  always  the  same.  No  pain;  no  disturbance 
of  consciousness;  no  parsesthesia,  except  tickling  in  soles  of  feet. 
Swallowing  practically  unhindered,  knee-jerks  lost.  Heart,  slight 
temporary  enlargement,  and  murmurs  indicative  of  insufficiency. 
Heart  normal  between  attacks.  Electrical  examination;  results  not 
uniform.  In  general,  complete  loss  in  certain  muscle  groups  at  height 
of  attack.  During  attack  often  increased  skin  resistance.  Later  ob- 
servations; slight  atrophy  of  those  muscles,  with  poorest  electrical 
reaction  between  the  attacks.     Permanent  weakness  of  legs. 

Case  IX.  Fischl:  Girl,  8  years  old,  good  heredity.  November, 
1884, scarlatina, nephritis;  complete  recovery.  Following  May,  lassitude, 
headache  and  backache,  appetite  poor.  Somnolence,  difficulty  in 
rousing  her  from  sleep.  One  morning  could  not  stand  or  sit  without 
support.  Examination,  mind  clear;  anxious  expression;  somewhat 
rapid  pulse;  temperature  of  head,  body,  arms  normal;  of  legs  and 
lower  part  of  thighs  ice  cold,  and  remarkably  pale;  movements  of 
head  free.  Cranial  nerves  free,  movements  of  body  good.  Sitting 
up,  or  rising  from  prone  position  not  possible.  Arms  normal  when 
examined.  Said  to  have  been  weak  at  first.  Lower  extremities  com- 
pletely paralyzed;  flaccid.  Sensation,  diminished  in  affected  areas. 
Abdominal  reflexes  present.  Knee-jerks  lost.  Plantar  reduced.  No 
muscle  excitability.  No  splenic  enlargement;  internal  organs  normal; 
urine  and  faeces  normal,  and  normally  passed.  Attack  lasted  three 
hours.  Sudden  and  complete  recovery.  Second  attack,  a  few  days 
later,  also  in  the  morning.  Electrical  examination;  faradism;  arms, 
normal ;  legs,  no  reaction  to  strong  currents,  excepting  some  muscular 
contraction  in  anterior  crural  distribution.  Duration,  five  hours. 
Slower  recovery.  Normal  reactions  between  attacks  to  galvanism. 
Third  attack,  less  than  an  hour's  duration.  Same  otherwise,  as  before. 
Fourth  attack,  length  one  half  hour  during  day  arms  weak,  then 
legs.  Recovery  of  arms  first.  Prodromata:  headache,  pain  in  back 
and  legs,  yawning,  weakness.  Later  attack,  twenty-four  hours*  dura- 
tion, right  foot  only  affected.  Subsequent  attacks  irregular,  character- 
ized by  drowsiness,  one  quarter  to  one  half  hour  long,  usually  in 
afternoon.  Child  slept  normally  except  f6r  occasional  stretching. 
Later,  feeling  of  being  tired.  Subsequently  became  entirely  normal 
•(somewhat  doubtful  case). 

y        Case-X,    Cousot:    Mother  and  four  children:    no  heredity  other- 
wise.    All  strong,  but  smaller  children  of  family  of  ten,  affected.    The 
1  mother  often  lost  motor  power  at  times  twice  weekly,  through  life. 


FAMILY  PERIODIC  PARALYSIS.  657 

Son,  man  now  of  34;  attacks  began  at  14,  increased  tip  to  26, 
then  stationary.  Strong  in  appearance;  perfectly  healthy  on  examin- 
ation between  attacks;  attacks  very  frequent;  usually  began  at  night. 
First,  feebleness  of  articulation;  desire  to  walk;  no  sensory  disturb- 
ance; usually  arms  last  to  lose  power  and  first  to  regain  it.  Emotions 
increase  tendency  to  attacks.  Work  and  fatigue  make  them  more 
violent.  Duration,  eight  to  ten  hours;  most  helpless  at  third  or  fourth 
hour  of  attack.  Muscles  of  face  always  spared.  Deglutition  and 
speech  difficult.  Attacks  deferred  by  exercise.  Intelligence  unim- 
paired. Sweating  during  attacks.  No  urinary  nor  faecal  incontinence. 
Urine:  no  sugar,  no  albumin,  much  uric  acid.  Electrical  reactions 
lost;  galvanic  response  first  appears  on  recovery. 

The  next  Cousot  case,  not  carefully  observed;  boy,  onset  at  ninth 
year,  similar  to  foregoing  but  more  severe. 

The  other  two  cases,  girls,  onset  in  both  about  tenth  year;  pre- 
cisely similar  attacks. 

Case  XI.  Griedenberg:  Soldier;  22  years  old;  healthy;  no  hered- 
ity; similar  attacks  to  foregoing;  occasionally  attacks  limited  to  legs; 
cranial  nerves  free;  certain  muscles  contracted. 

Case  XII.  Pulawski:  Man,  ai  years  old.  Nothing  significant 
in  past  history.  Had  had  two  previous  short  attacks.  Present  attack: 
went  to  bed  well,  at  one  A.  M.  could  not  move.  No  pain,  sphincters 
unaflFected.  Examined  in  hospital;  movements  of  arms  not  possible; 
slight  movements  of  fingers.  Same  condition  in  legs.  Could  not  sit 
up;  lateral  movements  of  head  possible,  not  forward  and  backward. 
Muscles  flaccid;  respiration  free,  but  superficial.  Deep  respirations 
and  coughing  impossible.  Cranial  nerves  free.  Sensation  and  muscle 
sense,  normal.  Knee-ierks  lost.  Cutaneous  reflexes  normal.  Internal 
organs  normal.  Feeble  faradic  reaction.  Hypnotism  failed  twice.  No 
evidence  of  an  antecedent  intoxication.  Urine,  alkaline;  specific  grav- 
ity, 1017;  no  albumin,  no  sugar,  abundant  sediment  of  ammonium 
urate.  Attack  lasted  one  day;  quinine  given;  following  night  much 
sweating,  recovery. 

Case  XIII.  Goldflam:  Eleven  cases  in  patient's  family,  on 
mother's  side.  No  other  neurotic  heredity.  Transmitted  through  both 
males  and  females.  Onset  usually  between  fifteen  and  twenty.  Fre- 
quency varying  from  weeklv  to  yearly  attacks.  Mother  of  patient 
had  one  attack  in  thirty-sixth  year.  Attacks  generally  more  frequent 
in  youth,  but  never  cease  altogether;  in  only  one  case  was  paralysis 
limited  to  legs. 

Case  reported  in  detail:  Boy  of  17.  Previous  history,  typhoid 
fever,  scarlet  fever,  with  ear  involvement,  eczema;  otherwise  well. 
At  thirteen  paralysis  of  body,  head,  and  extremities;  duration  three 
days.  Saliva  could  not  be  swallowed.  Following  summer  two  equally 
severe  attacks;  later  others,  not  so  severe  but  oftener,  lasting  from 
twenty-four  to  forty-eight  hours;  then  more  severe,  followed  again 
by  milder  seizures.  Attacks  usually  Friday,  beginning  at  6  or  7  P.  M. 
First,  weakness  of  legs,  arms  less  affected,  on  well  evenings  much 
trouble  with  itching;  none  on  evening  of  attack.  No  pain,  chill  nor 
fever.  Constipation;  complete  paralysis,  sparing  head;  thirst;  sleepy 
during  attack;  consciousness  otherwise  undisturbed.  Sense  organs, 
speech,  bladder,  normal.  Slight  sweating  during  attack,  more  profuse 
toward  its  end.  This,  with  acute  itching  for  an  hour  ushers  in  end 
of  attack.  Return  of  movement  in  following  order:  Fingers,  arms, 
body,  legs,  within  a  few  hours.  Capricious  as  to  food,  but  no  Symp- 
toms of  intestinal  disturbance.  Drinks  tea  only  on  the  evening  before, 
and  during  attack.  Physical  examination:  Flaccid  paralysis,  knee- 
jerks  absent,  plantar,  abdominal  and  cremaster  present.  Sensation 
normal.    No  pain  on  pressure  over  nerves  or  muscles.    No  diminution 


658 


EDWARD  WYLLYS  TAYLOR. 


in  amount  of  urine  during  attack.  No  enlargement  of  spleen.  Elec- 
trical examination:  faradism;  quantitative  diminution  in  nerves  of 
arm^;  loss  in  legs.  No  reaction  from  muscles  in  either  arms  or  legs. 
Reaction  of  facial  nerve  normal.  Mechanical  muscular  irritability 
lost.  After  attack,  nerve  and  muscle  irritability  normal,  excepting 
small  muscles  of  thumb;  slow  contraction;  An  C=Ca  C;  R.  D.  chiefly 
in  small  muscles  of  hands. 

Further  study  of  above  case  made  four  years  later:  Itching  less 
prominent  than  before.  Prodromata  now;  feeling  of  coldness  in  legs, 
and  then  in  arms.  Occasional  thirst;  attacks  usually  at  night  Abortive 
attacks,  certain  groups  of  muscles  aflFected.  Attacks  occasionally 
aborted  by  active  exercise,  usually  unavailing.  In  irregular  attacks, 
relapses  in  stage  of  improvement.  At  times  arythmic  heart;  systolic 
murmur  at  base.'  Slight  accentuation  of  second  tone;  no  enlargement; 
slow  pulse;  faint  first  tone  in  attacks. 

Cuse  aIV.  Goldflam:  Older  brother  of  the  foregoing;  first  at- 
tack at  eighteen 2  attacks  in  general,  similar;  in  one,  dangerous  as- 
phyxia. :Gpod  muscular  development.  Electrical  examination:  direct 
and  indirect  irritability  markedly  diminished  to  both  streams  between 
attacks.  Rapid  fatigue  of  muscles.  Slow  contractions;  polar  changes. 
Ca  C  Te.  ootained  with  weak  .currents.  Faradic  R.  D.  and  partial 
R.  D.  In  free  intervals  qualitative  changes  prominent:  in  attacks, 
quantitative.  Loss  in  attack  proportional  to  amount  of  paralysis.  Me- 
chanical irritability  lost  in  complete  attack.  These  changes  in  general 
found  in  both  brothers.  Goldflam  mentions  in  a  footnote  to  his  article, 
to  which  reference  has  been  made,  two  other  cases  in  children,  not 
yet  adequately  observed. 

Case  XV.  Burr:  Male  of  30,  no  heredity  whatever;  no  malaria. 
Began  at  10.  One  attack  about  every  four  months  since.  Attacks 
last  from  one  day  to  a  week.  Recovery  gradual.  Cranial  nerves  free. 
Slight  involvement  of  neck  muscles.  Sensation,  sphincters,  mind 
normal.  Attacks  increasing  somewhat  in  frequency.  When  seen  by 
Burr,  hemiparesis.  Knee-jerk  absent  on  left;  present  on  right,  but 
slight.  Spleen  not  enlarged.  No  pain.  Attacks  always  come  at 
night;  at  times  momentarily  weak  in  the  street,  never  at  home.  No 
electrical  examination  made. 

Case  XVI.  Hirsch:  Male  of  26;  no  heredity,  except  mother  had 
similar  attacks,  often  of  very  quick  recovery  and  with  thirst  during  at- 
tacks. Patient  previously  well;  first  attack  at  19th  to  20th  year;  arms  first 
heavy  and  stiff,  then  legs;  obliged  to  go  to  bed.  Paralysis  not  extreme. 
Well  in  twenty-four  hours.  One  such  attack  yearly  thereafter  until 
1892.  Prodromata  of  heavy  and  tired  feelings  in  legs  for  days  before 
actufil  attack.  In  1894  first  decided  paralytic  seizure.  Arms,  legs,  body, 
face,  (ree.  Duration  twenty- four  hours;  sudden  recovery;  thirst. 
Phyjsical  examination  at  hospital;  mind  clear;  intelligence  and  speech 
unaffected.  Facial  «nd  other  cranial  nerves  free.  Neck  muscles 
markedly  affected.  Breathing  superficial.  Paralyses  inspiratory  and 
expiratory  muscles,  excepting  diaphragm.  Lungs  normal.  Heart 
dullness  enlarged;  first  sound  at  apex  impure,  slight  accentuation  of 
secopd- pulmonic.  Insufficiencv  of  mitral  valve.  Pulse  regfular.  78^ 
abdominal  muscles  movable.  Spleen  normal.  Complete  paralysis  of 
.arms  and  legs;-  deep  reflexes  lost,  also  superficial  reflexes,  excepting 
«a;bdon1inal,  which  were  weak.  Idio-muscular  irritability  of  paralyzed 
muscles  weaker- than  normal.  Sensibility  normal;  also  muscle  sense. 
Occasional  sharp  pains  in  left  foot;  no  painful  points.  Bladder  and 
rectal 'functions  nprmaK  No  albumin,  no  sugar,  no  increased  swea*inu:: 
nbrmar temperature*  good  appetite.  No  electrical  examination  made. 
■Rapid  recovery  during  night:  entirely  recovered  following  morning: 
.heart  practically  normal.  -  Attack  twenty-four  hours  coming  on,  forty 


FAMILY  PERIODIC  PARALYSIS.  659 

hours'  duration.  Cause  of  attack  as  given  by  patient,  **drinking  of  tea 
or  grog  the  night  before." 

Case  XVII.  Rich:  22  cases  occurring  in  five  generations,  no 
individual  case  particularly  described.  The  type  is  as  follows:  Family 
affection,  no  other  neuroses  or  psychoses  in  the  family  history.  Cause, 
exposure  to  cold.  Paralysis  of  tonic  character  following  and 
affecting  various  groups  of  muscles,  preferably  the  face.  On  one 
occasion  complete  motor  paralysis,  excepting  tongue,  from  sleeping 
in  moist  underclothing.  Paralysis  of  tongue  may  be  brought  about 
by  holding  snow  in  the  mouth,  taste  remaining  uninvolved.  Sen- 
sation in  general  unaffected,  mind  clear.  Desire  to  urinate;  sphincters 
normal;  complete  temporary  recovery  with  considerable  antecedent 
weakness.  The  affection  has  never  skipped  a  generation.  No  mention 
made  of  electrical  changes,  nor  of  reflexes  during,  or  between  the 
attacks  (doubtful  cases,  belong  rather  to  the  congenital  myotonias). 

Case  XVIII.  Bernhardt:  Man;  affection  began  in  extreme  youth; 
sudden  attack  of  general  weakness.  Difficulty  always  in  walking; 
tendency  to  stumble.  Some  muscles  hypertrophic.  Three  years  later 
general  weakness;  electrical  reactions  diminished;  mind  clear  (doubt- 
ful  case). 

Case  XIX.  Bernhardt:  Son  of  preceding  case;  almost  daily  at- 
tacks. Tendency  often  to  cough,  but  not  possible;  cyanosis,  threat- 
ened suffocation,  sweating.  Father  similarly  affected.  Examination 
three  years  later:  Attacks  on  waking,  going  to  bed  well.  Immovable; 
sweating;  no  loss  of  consciousness.  Speech  at  times  slightly  affected. 
Two  years  later  unstable,  but  special  senses  normal.  Slight  quanti- 
tative diminution  to  electrical  current.  Knee-jerk  present;  walks  with 
great  difficulty.  No  difficulty  in  rising  from  seated  position.  Bladder 
and  rectal  functions  normal.  No  albumin,  no  sugar.  Attacks  similar, 
but  less  frequent  than  formerly.  Never  come  on  when  exercising, 
only  after  rest.  Neck  muscles  affected,  cranial  nerves  free.  Attacks 
last  about  fifteen  minutes  (somewhat  doubtful  case). 

Case  XX.  Goldflam  (reported  in  1897):  Man  of  22;  attacks  be- 
gan in  eighth  year,  and  have  increased  in  frequency.  Attack  usually 
begins  in  the  evening  with  weakness  of  arms  and  general  feeling  of 
exhaustion.  Sleep  usually  follows;  on  waking,  often  complete  paraly- 
sis. Duration,  twenty-four  to  forty-eight  hours.  Mind,  speech,  de- 
deglutition,  sphincters,  free.  Recovery  begins  in  evening.  At 
times  attacks  sudden  in  onset.  Attacks  much  more  frequent  in  sum- 
mer than  in  winter.  Muscles  well  developed  apparently,  but  strength 
diminished  in  free  intervals;  also  changes  in  electrical  excitability, 
including  muscles  of  face.  Examination  during  an  attack  showed 
usual  conditions;  toward  end  of  attack,  urine  had  traces  of  albumin. 

Case  XXI.  Goldflam:  Boy  of  7J^;  brother  of  previous  case. 
First  attack  in  fifth  year,  examination  incomplete;  certain  electrical 
changes  in  free  interval  demonstrated. 

Case  XXII.  Goldflam:  Man  of  28;  first  attack  in  eleventh  year. 
Infrequent  attacks  of  from  twenty-four  to  seventy-two  hours'  dur- 
ation. Attacks  at  night.  Extremities,  body  and  neck  muscles  para- 
lyzed. Coughing  difficult,  appetite  poor,  mind  and  sphincters  unaf- 
fected.    Marked  electrical  changes;   slow  contraction. 

Case  XXIII.  Goldflam:  Woman  of  25,  sister  of  previous  case. 
Onset  of  attacks  at  twenty-four.  Hands,  arms,  legs  affected,  in  order 
named.  Parsesthesia  in  fingers.  At  times  complete  paralysis.  Intelli- 
gence, speech,  sensibility,  sphincters,  unaffected.  Loss  of  appetite; 
recovery  first  in  arms,  followed  by  head  and  legs.  Diminution  to 
complete  loss  of  reflexes  during  attack,  with  marked  quantitative 
diminution  in  faradic  excitability.     Pulse  irregular,  rapid;  heart  mur- 


66o  EDWARD  WYLLYS  TAYLOR, 

mur;  no  enlargement  of  heart.     Trace  of  albumin  in  urine  during 
height  of  attack. 

Cases  XXIV  and  XXV.    Taylor:  Complete  report  already  given. 

(To  be  continued.) 


2x9.  SYia)ROMB  SYRINGOMYBI.IQUB  AVRC    HBMIATROPHIB    FACLAXB  BT 

TROUBi^BS  ocuw>-PUPii,iyAiRBS  (The   Syndrome  of  Syringomyelia 

with  Hemiatrophy  of  the  Face  and  Oculo- Pupillary  Disturbance). 

Queyrat  et  Chretcin  (La*Presse  Medicale,  December  24th,  1897. 

The  patient  had  had  in  infancy  a  series  of  abscesses  of  the  skin. 
He  did  not  walk  until  three  years  of  age,  but  otherwise  appeared 
well,  and  displayed  normal  intelligence.  At  the  age  of  eighteen  years 
he  had  a  very  painful  panaritis  upon  the  index  finger  of  the  right 
hand)  causing  the  loss  of  the  terminal  phalynx.  Three  years  later 
he  had  a  second  panasritis  upon  the  left  thumb,  much  less  painful,  bat 
causing  the  same  mutilation.  At  this  time  there  was  some  loss  of 
power  in  the  left  arm  and  a  succession  of  panaritides,  and  he  was 
treated  by  various  physicians  for  leprosy  without  any  improvement 
His  condition  in  1896  was  as  follows:  There  was  kyphosis  and  slight 
scoliosis  in  the  dorso-cervical  region,  mutilation  of  the  thumb, 
index  and  middle  fingers  of  the  left  and  of  the  thumb  and  index 
finger  of  the  right  hand.  Some  very  large  cicatrices,  representing  the 
situations  of  the  infantile  abscesses  were  found  upon  the  arms.  The 
face  was  markedly  asymmetrical,  the  left  side  being  distinctly  smaller 
than  the  right,  but  there  were  no  motor  disturbances  other  than 
those  produced  by  the  difference  in  size.  The  hair  grew  equally  well 
on  both  sides.  There  was  slight  paresis,  chiefly  in  the  arms.  The 
right  hand  was  somewhat  weaker  than  the  left.  Reactions  of  de- 
generation were  present  in  the  muscles  of  the  hands.  Sensibility  was 
diminished  in  the  left  half  of  the  face,  the  left  shoulder  and  the  left 
arm  and  hand,  most  markedly  in  the  latter  situation,  and  involved 
touch,  pain  and  temperature.  The  tactile  sensibility  was  preserved  in 
the  right  forearm,  but  the  pain  and  heat  senses  were  lost.  Both  the 
pupils  were  myotic,  reacting  well  to  light,  but  poorly  to  accommo- 
dation. The  visual  field  was  normal:  the  patient,  however,  was  color 
blind,  not  being  able  to  perceive  green.  The  case  is  interesting  on 
account  of  the  existence  of  facial  atrophy  and  the  possibility  of  lep- 
rosy, although  a  careful  search  for  the  microorganisms  in  an  excised 
piece  of  skin  was  negative.  Sailer. 


i 


EXPERIMENTAL  RESEARCHES  ON  THE  LO- 
CALIZATION OF  THE  SYMPATHETIC  NERVE 
IN  THE  SPINAS  CORD  AND  BRAIN,  AND 
CONTRIBUTIONS  TO  ITS  PHYSIOLOGY.* 

(abstract.) 

By   B.   ONUF   (ONUFROWICZ),   M.  D., 

Anodate  in  Pathology,  Pathological  Institute  of  the  New  York  State  Hoapitals; 
l,eoUixer  on  Keroouaand  Mental  Dbeasca  in  the  New  York 

Polydinic 

Aim 
JOSEPH  COLLINS,  M.  D., 

ProfeiM>r  of  Oiaeaaes  of  the  Mind  and  Nervooa  System  In  the  N^w  Yoik  Poat-GfaihMite 

Medical  Sdiool:  VisithiR  Physician  to  th«  City  Hospital;  Neurolo|{ist 

to  the  Poat-Gradvate  Hospital,  St.  Mark's  HospiUl, 

and  to  the  St.  John'a   Guild  Hospital. 

The  anatomy  and  physiology  of  the  nervous  system 
have  long  been  favorite  subjects  for  the  study  and  specu- 
lation of  scientists.  In  latter  years  the  method  of  metal 
impregnation,  inaugurated  by  Golgi,  and  the  methylene 
blue  method,  first  successfully  utilized  by  Ehrlich,  have  lent 
themselves  to  the  study  of  this  obscure  part  of  the  body, 
and  many  investigators,  of  whom  we  may  mention  K61- 
liker,  His,  Ramon  y  Cajal,  Van  Gehuchten,  Retzius,  Do- 
giel  and  Sala,  have  illumined  our  knowledge  of  the  mi- 
nute structure  and  of  the  architecture  of  a  large  part  of  the 
nervous  system.  Thus  far,  however,  few  authors  have 
undertaken  to  determine  the  manner  in  which  the  sympa- 
thetic is  connected  with,  or,  better  said,  localized  in,  the 
spinal  cord  and  brain.  Of  these  few,  some  have  specu- 
lated from  clinical  data  alone  regarding  such  localization. 
According  to  Mott,  for  instance,  Ross  was  the  first  to 
suggest  that  in  tabes  the  visceral  crises  and  other  dis- 
turbances of  a  similar  nature  are  due  to  affection  of  the 

*  Read  b«lore  th«  American  Neurological  Assaciation,  May  27tb» 
1898.  From  the  Pathological  Institute  of  the  New  York  State  Hospitals. 


662  B.  ONUF  AND  JOSEPH  COLLINS. 

cells  of  Clarke's  columns.  Sachs  says  "it  is  not  a  great 
stretch  of  imagination  to  suppose  that  tactile  sensation 
and  the  sensory  impulses  by  which  reflex  action  is  excited 
pass  through  the  lateral  series  of  fibres,  whereas  those 
fibres  connecting  with  the  columns  of  Clarke  in  all  prob- 
iibility  have  to  do  with  the  functions  of  coordination  and 
with  the  transmission  of  visceral  sensations."  The 
merit. of  the  first  attempt  to  study  in  a  systematic  manner 
the  distribution  of  the  "visceral"  nerves  in  the  brain  and 
spinal  cord  is  due  decidedly  to  Gaskell.  To  enter  into 
the  details  of  the  highly  ingenious  plan  on  which  his  re- 
searches were  conducted  would  lead  too  far.  We  can 
only  hint  at  some  of  the  principal  points.  Gaskell  had 
demonstrated  that  in  the  nerve  roots  of  the  cerebrospinal 
nerves  certain  medullated  fibres  distinguish  themselves  by 
the  fineness  of  their  calibre.  He  had  shown  in  a  convinc- 
ing manner  that  these  fine  fibres  represented  the  visceral 
fibres  of  the  roots.  Furthermore,  he  had  demonstrated 
the  presence  of  these  fine  medullated  fibres  in  many  of  the 
rami  communicantes.  By  following  the  course  of  these 
fine  fibres  in  the  spinal  cord  he  came  to  definite  conclu- 
sions; the  most  important  of  which  are:  (i)  That  the  vis- 
ceral nerves  become  connected  in  the  spinal  cord  with 
the  large  cells  of  the  lateral  horn,  which  he  considers  to  be 
a  nucleus  for  efferent  fibres  to  striated  splanchnic  muscles; 
(2)  that  the  cells  of  Clarke's  columns  give  origin  to  inhib- 
itory fibres  for  the  splanchnic  glandular  system  and  the 
muscles  of  the  viscera  and  vaiscular  system;  (3)  that  the 
solitary  cells  of  the  posterior  horns  furnish  a  motor  sup- 
ply for  the  muscles  of  the  viscera,  and  finally  (4)  that  the 
small  cells  of  the  lateral  horn  form  a  nucleus  of  katabolic 
(motor)  nerves  to  the  splanchnic  glandular  system  and  to 
the  muscles  of  the  vascular  system. 

There  can  be  no  doubt  that  some  of  the  premises  on 
which  Gaskell  bases  his  conclusions  are,  in  part  at  least, 
erroneous.  It  is  an  erroneous  statement,  for .  instance, 
that  the  vasoconstrictor  nerves  arise  only  in  the  thoracic 


LOCAUZATION  OF  THE  SYMPATHETIC  NERVE,    663 

region  of  the  spinal  cord. .  Yet  we  shall  see  that,  in  the 
ma;in,  Gfiskdl  has  hit  very  near  to  the  mark  in  most  of  his 
final  conclusions,  and  we  can  only  praise  his  ingenious  re- 
searches, and  recommend  them  for  close  study  to  him 
who  wishes  information  of  the  structure  and  central  dis- 
tribution of  the  sympathetic  nervous  system. 

Mott  contends  against  Gaskell's  view  that  the  axis 
cylinder  processes  of  the  cells  of  Clarke's  columns  become 
fibres  of  the  anterior  roots,  claiming  justly  that  these 
axis  cylinders  are  continued  as  fibres  of  the  direct  cere- 
bellar tract.  Mott  considers  the  nuclei  of  the  funiculi  cu- 
neati  and  Deiters*  nucleus  to  be  the  homologue  of  Clarke's 
column  in .  the  medulla  oblongata.  Blumenau  had  pre- 
viously reached  the  conclusion  that  the  large  cells  in  the 
lateral  portions  of  the  funiculus  gracilis  and  (chiefly) 
funiculus  cuneatus  were  the  homologues  of  Clarke's  col- 
umns. Mott's  further  views  regarding  the  connections  of 
the  sympathejtic  nervous  system  with  the  cerebrospinal 
axis  may  be  summed  up  as  follows: 

"The  fine,  centrifugal,  splanchnic  fibres  which  Gaskell 
found  in  the  anterior  roots  originate  from  the  bipolar  cells 
of  the  tractus  intermedio-lateralis  (lateral  horn)  and  from 
the  solitary  cells  of  the  posterior  horn.  The  vago-glosso- 
pharyngeal  nucleus  (the  one  situated  beneath  the  floor  of 
the  4th  ventricle)  is  to  be  considered  as  the  continuation 
of  the  tractus  intermedio-lateralis,  having  the  same  physio-, 
logical  significance  in  the  medulla  oblongata  as  the  latter 
has  in  the  cord.  Other  larger  cells  of  the  tractus  inter- 
medio-lateralis haVe  altogether  other  functions,  and  are, 
perhaps,  related  to  the  antero-lateral  tract." 

Biedl  cut  the  .splanchnic  ,nerves  in  dogs  and  studied 
the  ascending  degeneration  in  the  spinal  cord.  His  con- 
clusions are  formulated  in  a  rather  vague  manner,  so  that 
it  13  diffixrult  tQ  gather  where  he  conceives  the  location 
of  the  centres  of  the  efferent  fibres  to  be,  and  where  he 
believes  the  afferent  fibres  to  end  in  the  spinal  cord.  Yet 
it  would  §eemrthat  he  found  a  splanchnic  motor  centre 


664  ^-   ^^^^  ^^^  JOSEPH  COLUNS. 

in  the  lateral  horn  of  the  lower  cervical  and  upper  dorsal 
regions.  We  must  riot  forget  to  add,  however,  that  the 
purpose  of  Biedl's  researches  was  not  so  much  to  establish 
the  localization  of  the  splanchnic  nerve  in  the  spinal  cord 
as  it  was  to  study  the  histological  character  of  the  spinal 
cell  changes  occurring  after  section  of  the  nerves  men- 
tioned. 

Aside  from  the  investigations  just  discussed  (Gaskell's, 
Mott's  and  Biedl's),  we  have  found  no  literature  relating 
to  the  localization  of  the  sympathetic  or  visceral  nerves 
in  the  spinal  cord  or  brain. 

In  view  of  the  fact,  then,  that  so  few  investigators  have 
attacked  this  subject,  and  particularly  that  the  conclusions 
of  these  are  disharmonious,  it  seemed  to  us  justifiable  to  re- 
take a  new  experimental  and  critical  survey  of  the  subject. 

Notwithstanding  the  liability  to  erroneous  conclusions 
by  homologizing  results  obtained  from  experimentation 
on  animals,  we  decided  to  adopt  the  experimental  method 
for  our  investigations.  It  was  originally  intended  to  con- 
fine our  researches  to  the  allocation  of  the  sympathetic 
nerves  in  the  spinal  cord  and  brain,  but  some  of  the 
physiological  observations  which  the  experiments  per- 
mitted us  to  make  proved  interesting  enough  to  be  em- 
bodied in  the  report  of  our  findings.  In  this  connection  it 
is  necessary  to  state  that  the  results  of  our  investigations 
are  embodied  in  a  monograph  on  the  sympathetic  nervous 
system,  which  will  soon  be  published  in  the  Archives  of 
Neurology  and  Psychopathology.  Here  we  shall  attempt 
to  give  only  a  brief  abstract  of  our  conclusions,  and  to  il- 
lustrate our  principal  findings  by  diagrams  and  drawings. 

Our  mode  of  procedure  consisted  in  extirpating  vari- 
ous parts  of  the  nervous  system,  and  stud)ring  the  con- 
secutive ascending  degeiieration  in  the  sphial  cord  and 
oblongata.  In  all,  eight  cats  wfere  thus  successively  op- 
erated upon.    The  following  operations  were  perforined: 

I.  Extirpation  of  the  stellate  ganglion;  a  ganglion 
that  corresponds  to  the  cervical  and  the  first  thoracic 


LOCAUZATION  OF  THE  SYMPATHETIC  NERVE.    665 


sympathetit  ganglion  of  man  fused  into  one  common 
ganglion.    This  operation  was  done  in  three  young  cats. 

2.  Extirpation  of  a  piece  of  the  thoracic  sympathetic 
nerve  with  three  ganglia  in  two  young  cats. 

3.  Extirpation  of  the  lumbar  sympathetic  nerve  with 
three  ganglia  in  one  young  cat. 

Fig.  I. 

riifer/^    cltiusfon  ^f  SpimU^  fierce. 


4.  In  two  young  cats  the  semilunar  ganglion,  which 
is  known  as  the  abdominal  brain,  was  extirpated. 

Although  it  is  difficult  to  encompass  in  a  few  para- 
graphs the  results  of  our  experiments  and  observations, 
we  shall  endeavor  to  state  the  more  important  conclusions. 
These  can  be  classified  into:  First,  localizatory;  second, 
physiological;  third,  general  physiological  remarks. 

I.  Localizatory:  Our  conclusions  concerning  localiza- 
tion may  be  siimmed  up  as  follows : 

"'    Most  of  the  afferent  (sensory)  fibres  of  the  sympathetic 
nerves  do  not  originate  from  cells  of  the  spinal  ganglia,  as 


666  B,   ONUF  AND  JOSEPH  COUJNS. 

Kolliker  claims;  on  the  contrary,  they  must  have,  in  ac- 
cordance with  Dogiel's  view,  their  cells  of  origin  within 
the  ganglia  or  plexuses  of  the  sympathetic  system. 

We  believe  that  the  efferent  fibres  of  the  sympathetic 
take  their  origin  from  the  cells  of  the  following  groups: 
First,  the  paracentral  group;  second,  the  small  cells  of  the 
lateral  horn,  and  third,  probably  also  the  small  cells  of  the 
intermediate  zone.  By  way  of  explanation,  we  may  say 
that  we  have  designated  as  paracentral  group  that  col- 
lection of  cells  situated  to  both  sides  of  the  central  canal, 
directly  ventrad  of  Clarke's  column,  and  sometimes  con- 
fluent with  the  latter,  especially  in  very  young  animals. 
By  intermediate  zone  we  understand  an  area  lying  between 
the  bases  of  the  posterior  and  anterior  horns. 

The  afferent  fibres  of  the  sympathetic  are  connected  by 
their  terminal  arborizations  with  the  cells  of  Clarke's  col- 
umn, and  it  seems  quite  probable  that  the  large  cells  of 
the  intermediate  zone,  especially  of  Bechterew's  nucleus, 
bear  the  same  relation  to  the  visceral  afferent  fibres  as  the 
cells  of  the  vesicular  column.  We  concede  that  the  whole 
zone  separating  the  anterior  from  the  posterior  homs  has 
relations  to  the  fibres  of  the  sympathetic,  but  we  do  not 
thereby  imply  that  many  of  the  cells  therein  have  not  al- 
together different  functions. 

We  saw  vertical  fibre  bundles  emerge  from  Clarke's 
columns,  and  bend  off  in  horizontal  (dorso-ventral)  di- 
rection ;  part  of  them  seemed  to  lose  themselves  in  what  we 
call  the  paracentral  field.  These  fibres  we  have  much  rea- 
son to  consider  either  as  direct  afferent  fibres  of  the  pos- 
terior roots  or  as  collaterals.  In  our  monograph  we  give 
detailed  arguments  in  favor  of  the  view  that  they  ter- 
minate around  the  small  cells  of  the  paracentral  g^oup 
'perhaps  also  of  the  intermediate  zone),  and  are  thus  des- 

ined  for  the  enactment  of  spinal  reflexes  in  the  domain 

f  the  vegetative  nervous  system. 

In  young  animals  (cats)  Clarke's  column  and  the  para- 

entral  cell  group  coalesce  almost  into  one  group.    Prob- 


LOCAUZATION  OF  THE  SYMPATHETIC  NERVE,    667' 

ably  in  the  adult  the  separation  is  also  incomplete,  so  that 
the  two  may  have  partially  common  functions  in  such 
manner  that  part  of  the  cells  of  Clarke's  column  (the 
larger  ones)  are  concerned  in  afferent,  the  other  (the 
smaller  ones)  in  efferent  functions.  Similarly,  the  large 
sporadic  cells  that  one  meets  in  the  paracentral  group 
may  have  afferent,  while  the  smaller  ones,  which  form 
the  chief  contingent  of  the  group  have  efferent  functions. 

Two  weeks  after  extirpation  of  the  3d,  4th  and  5th 
lumbar  sympathetic  ganglia  we  observed  degenerative 
changes,  both  in  the  cells  of  Clarke's  columns  and  in  the 
fibres  passing  into  them  from  the  posterior  roots.  The 
-degeneration  in  the  fibres  reaches  from  the  3d  lumbar  up 
to  the  13th  dorsal  segment;  on  the  other  hand,  the  in- 
ferior (caudal)  limit  of  the  cell  changes  must  be  looked 
for  in  the  ist  lumbar  segment,  showing  that  the  cell 
changes  occupy,  on  the  whole,  a  higher  level  than  the  fibre 
changes,  that,  accordingly,  the  afferent  fibres  of  the  lum- 
bar sympathetic  nerves,  entering  the  spinal  cord  by  way 
of  the  posterior  roots,  make,  after  having  arrived  at 
Clarke's  columns,  a  longitudinal  course  cephalad  to  ter- 
minate around  cells  of  a  considerably  higher  level. 

From  the  distribution  of  the  secondary  atrophies  ob- 
served in  the  spinal  cord  four  weeks,  and  six  months  after 
extirpation  in  one  case  of  the  7th  (or  6th)  to  9th,  in  the 
other  of  the  7th  to  nth,  thoracic  sympathetic  ganglia  in 
young  cats,  we  conclude  that,  on  the  whole,  the  fibres — 
at  least  the  afferent,  probably  also  the  efferent — coming 
from  the  ganglia  of  the  lower  half  of  the  thoracic  sympa- 
thetic cord,  take  a  rather  horizontal  course  in  the  spinal 
cord,  becoming  connected  with  spinal  cells  of  the  same 

level,  but  that  part  of  these  fibres  descend  through  the 

< 

distance  of  one  or  more  segments  before  reaching  the  cells 
around  which  they  terminate  (or  from  which  they  orig- 
inate if  they  be  efferent  fibres). 

Extirpation  of  the  stellate  ganglion  causes  within  a 
few  months  retrogressive  changes  of  an  atrophic  order 


668  B.   ONUP  AND  JOSEPH  COLUNS. 

in  the  cells  of  both  lateral  horns,  of  both  paracentral 
groups  and  of  both  columns  of  Clarke.  These  changes 
extend  downward  at  least  to  the  9th  dorsal  segment,  show- 
ing that  many  of  the  afferent  and  also  of  the  efferent  fibres 
from  the  stellate  ganglion  make  a  long  descent  in  the 
cord,  or  possibly  in  the  sympathetic  nerve,  becoming  con- 
nected partly  with  the  same  cells  with  which  the  fibres 
from  the  lower  portion  of  the  sympathetic  cord  form  con- 
nections. We  may  conclude  that  the  afferent  fibres  of 
the  sympathetic  system,  after  T-shaped  division,  become 
ascending  and  descending,  and  thus  become  connected 
with  several  levels  of  Clarke's  columns  simultaneously. 

Regarding  the  function  of  the  paracentral  group,  we 
have  adduced  arguments  in  favor  of  the  view  that  it  may 
be  concerned  in  vascular  and  in  visceral  motor  innerva- 
tion. Clarke's  column,  besides  being  a  terminal  station 
for  afferent  fibres  conveying  impulses  from  the  vegetative 
organs,  may  be  instrumental  also  in  conducting  sensory 
stimuli  from  the  muscles,  tendons,  joints  and  bones  to  the 
cerebellum,  being  thus  largely  concerned  in  functions  of 
equilibrium.  StiUing's  sacral  nucleus,  situated  in  the  3d 
sacral  segment,  is  possibly  a  coalesced  Clarke's  column  and 
paracentral  group. 

Regarding  the  representation  of  the  sympathetic  in  the 
oblongata,  we  find  that  it  has  not  yet  been  proven  that 
the  vago-glosso-pharyngeal  nucleus  situated  beneath  the 
floor  of  the  fourth  ventricle  is  a  terminal  nucleus  of  purely 
sensory  or  afferent  function.  We  are  much  inclined  to 
share  Forel's  and  Gaskell's  view  that  the  nucleus  is,  on 
the  contrary,  predominantly  motor  in  such  sense  that  the 
axis  cylinders  of  its  cells  become  efferent  fibres  of  the 
IX.  and  X.,  probably  also  partly  of  the  XI.  nerve.  The  fact, 
however,  that  by  extirpation  of  the  stellate  ganglion — 
aside  from  afferent  fibres — only  insceral  (vegetative)  ef- 
ferent fibres  and  no  somatic  motor  fibres  of  the  vagus 
nerve  (which  give  off  a  strong  communicating  branch  to 
the  ganglion),  become   interrupted,  in  connection   with 


LOCALIZATION  OF  THE  SYMPATHETIC  NERVE,    669 


the  observation  that  as  a  secondary  consequence  of  such 
lesion  the  spinal  division  of  the  vago-glosso-pharyngeal 
nucleus  undergoes  some,  although  very  slight,  atrophy, 
while  the  nucleus  ambiguus  remains  normal,  leads  us  to 
conceive  furthermore  that  the  vago-glosso-pharyngeal  nu- 
cleus gives  origin  only  to  visceral  (vegetative)  efferent 


Fig.  II. 


Ccl{i4f^ru 


pa/fa  con  frciL  cfrt/n, 


fibres  of  the  vago-glosso-pharyngeal,  and  in  part  also  the 
accessory  nerve,  and  that  the  nucleus  ambiguus  gives 
origin  only  to  somatic  efferent  fibres  of  these  nerves,  that 
is,  to  motor  fibres  supplying  striated  muscles.  In  other 
words,  in  relation  to  the  so-called  lateral  mixed  system  of 
nerves  (which  includes  the  IX.,  X.  and  XI.  nerves)  the  so- 
called  vago-glosso-pharyngeal  nucleus  is  probably  the  vis- 
ceral (vegetative),  the  nucleus  ambiguus,  the  somatic  nu- 
cleus. 


670  B,   ONUF  AND  JOSEPH  COLLINS. 

The  so-called  vago-glosso-pharyngeal  nucleus  is,  fur- 
thermore, probably  the  homologue  of  the  paracentral 
group.  The  homologue  of  Clarke's  column  we  believe  to 
be  a  nucleus  accompanying  the  solitary  bundle  at  its  ven- 
tro-lateral  border.  The  relation  of  the  afferent  fibres  of 
the  lateral  mixed  system  (IX.,  X.  and  partly  XI.  nerves) 
to  the  two  nuclei  just  mentioned  is  probably  such  as  we 
have  tried  to  demonstrate  as  existing  between  the  spinal 
visceral  fibres  on  one  side  and  Clarke's  column  and  the 
paracentral  group  on  the  other. 

In  accordance  with  this  view,  the  vagus  fibres  which 
have  been  seen  terminating  in  the  vago-glosso-pharyngeal 
nucleus  by  Van  Gehuchten,  Kolliker,  His  and  others  are 
to  be  considered  as  afferent  reflex  fibres  or  collaterals. 

II.  Physiological  conclusions: 

In  regard  to  the  influence  of  the  sympathetic  upon 
lachrymal  secretion,  our  results  were  rather  contradictory. 
Removal  of  the  stellate  ganglion  in  one  animal  apparently 
prevented  secretion  of  the  lachrymal  gland  of  the  operated 
side  when  pilocarpine  was  instilled,  while  in  two  other  cats, 
on  the  contrary,  the  secretion  was  more  profuse  on  the 
operated  side.  Naturally,  the  lachrymal  secretion  was  an 
artificial  one  caused  by  a  poison,  pilocarpine.  We  con- 
clude, therefore,  that  the  results  were  so  contradictory 
that  further  experimentation  is  necessary  before  positive 
conclusions  can  be  drawn. 

In  reference  to  the  sweat  secretion,  our  experiments 
seemed  to  warrant  the  assertion  that  not  all  sweat  se- 
cretory fibres  of  the  forepaw  pass  though  the  stellate 
ganglion,  and  through  the  main  trunk  of  the  sympathetic 
in  general,  as  Luchsinger  and  Langley  assume,  but  that 
a  good  portion  of  them  follow  other  pathways,  and  that 
these  fibres  develop  a  compensatory  function  so  strongly 
as  to  entirely  mask  the  loss  of  function.  But  yet  we  had 
to  note  the  paradoxical  fact  that  in  a  cat  in  which  the 
stellate  ganglion  was  removed,  there  was  sweating  of 


LOCALIZATION  OF  THE  SYMPATHETIC  NERVE.    6jl 

all  the  paws  except  the  left  forepaw,  as  the  result  of  the 
animars  struggles  during  etherization. 

In  reference  to  the  influence  of  the  sympathetic  sys- 
tem on  the  pupil,  our  experiments  led  us  to  believe  that 
the  cervical  sympathetic  contains  not  only  pupil-dilating 
fibres,  but  very  probably  pupil-contracting  fibres  as  well. 

Regarding  digestion,  we  found  that  disturbance  of 
that  function  followed  invariably  on  removal  of  the  stellate 
ganglion,  of  the  lower  thoracic  portion  of  the  sympathetic 
and  of  a  semilunar  ganglion.  The  digestive  disturbances 
that  ensue  after  removal  of  the  stellate  ganglion  are,  how- 
ever, more  marked  and  more  persistent  than  those  noted 
after  removal  of  the  lower  thoracic  sympathetic.  They 
consisted  of  diarrhoea  and  of  putrefaction  of  the  faeces. 
They  were  more  or  less  remote  symptoms,  and  they 
showed  a  progressive  tendency. 

We  observed  that  removal  of  one  stellate  ganglion,  as 
well  as  defect  of  the  lower  part  of  the  thoracic  sympa- 
thetic (including  the  splanchnic  at  this  level),  gives  rise 
to  attacks  of  sneezing,  to  paroxysms  of  coughing  and  to 
hiccough.  The  cough  occurs  not  only  spontaneously, 
but  a  paroxysm  of  coughing  could  always  be  precipitated 
by  stroking  the  animal's  back,  particularly  the  nuchal 
portion.  Removal  of  the  stellate  ganglion  causes,  in  ad- 
dition, first  a  mucous,  then  a  purulent  discharge  from 
the  nasal  mucous  membrane.  In  one  case  it  produced  a 
chronic  purulent  bronchial  catarrh  with  lobular  infiltration 
of  the  lungs.  The  attacks  of  cough  and  hiccough  gave 
the  impression  of  nervous  symptoms  due  to  defective  in- 
hibitory action.  The  respiratory  disturbances  were  more 
grave  in  a  case  of  removal  of  the  stellate  ganglion  than 
in  a  case  in  which  resection  of  the  thoracic  sympathetic 
in  its  lower  portion  was  done.  We  noted  that  resection 
of  the  lower  part  of  the  sympathetic  was  followed  by  dia- 
betes, and,  considering  the  large  amount  of  sugar  found 
four  months  after  the  operation,  we  are  led  to  the  belief 
that  the  glycosuria  caused  by  such  lesions  is  not  tem- 


672  B.  ONUF  AND  JOSEPH  COLUNS, 

porary,  but  permanent,  and  seems  to  have  a  tendency  to 
increase  rather  than  to  diminish. 

In  reference  to  the  effect  of  extirpation  of  the  stellate 
ganglion  on  the  local  temperature,  we  found  that  there 
was  an  immediate  and  a  remote  increase  of  from  one  to 
two  degrees  Fahrenheit. 

Concerning  the  pilomotor  nerves,  we  concluded  that, 
although  they  have,  on  the  whole,  the  segmental  distribu- 
tion which  Langley  and  Sherrington  attribute  to  them, 
there  must  be  a  collateral  supply,  or  a  direct  cerebrospinal 
supply,  which  can,  in  the  course  of  time,  entirely  replace 
the  functional  loss  which  extirpation  of  three  or  four 
successive  ganglia  causes. 

The  trophic  influences  which  we  observed  in  connec- 
tion with  lesions  of  the  sympathetic  were  most  evident 
after  removal  of  the  stellate  and  the  lower  thoracic  gan- 
glia. They  were  bilateral,  although  quite  irregular  in  dis- 
tribution, and  were  predominantly  cutaneous  (partial 
alopecia).  It  is  probable  that  the  nasal,  bronchial  and 
laryngeal  secretion  already  spoken  of  may  be  on  a  trophic 
basis. 

III.  General  Physiological  Remarks: 

The  essential  influence  which  the  sympathetic  system 
exercises  on  the  vegetative  life  of  the  organism  has  been 
amply  demonstrated  by  numerous  physiological  observa- 
tions. Inasmuch  as  some  vegetative  functions  are  exqui- 
sitely vital,  we  may  say  also  that  the  sympathetic  system 
possesses  in  high  degree  vital  function.  This  is  confirmed 
by  our  observations.  In  very  young  cats  lesions  of  the 
important  parts  of  the  sympathetic  invariably  proved  fatal. 
Even  if  the  animals  outlived  such  operations  as  extirpation 
of  the  semilunar  ganglion,  or  removal  of  the  stellate  gan- 
glion, or  resection  of  the  lower  part  of  the  thoracic  sympa- 
thetic, they  invariably  died,  usually  a  few  hours  or  days, 
afterward.  One  cat  of  four  weeks  of  age  survived  the  re- 
moval of  one  semilunar  ganglion  three  weeks,  being  at 
first  quite  playful  and  apparently  healthy,  but  at  the  end 


LOCALIZATION  OF  THE  SYMPATHETIC  NERVE.     673 

of  two  weeks  he  was  attacked  by  diarrhea,  and  died  in 
a  state  of  collapse.  Even  a  cat  of  five  and  a  half  weeks, 
in  which  we  had  removed  three  lumbar  ganglia,  would 
have  died  from  collapse  two  weeks  after  the  operation, 
had  we  not  preferred  to  kill  it  by  chloroform,  and  in  this 
case  no  tangible  cause  of  the  collapse,  except  the  defect 
of  the  said  three  ganglia,  could  be  found. 


Sytf^n,  f^X .U  4  %'f  r. 


VVe  desire  to  call  attention  to  the  fact  that  the  death 
of  many  animals  during  the  operations  was  caused  by 
pulling  upon  the  sympathetic  nerve  or  bruising  of  a  sym- 
pathetic ganglion.  We  noted  that  this  was  especially  the 
case  in  operating  to  remove  the  stellate  ganglion.  Al- 
though the  animal  would  be  breathing  vigorously  and 
fully  immediately  before,  as  soon  as  the  stellate  ganglion 
was  pulled  upon,  or  as  soon  as  its  connection  with  the 
thoracic  sympathetic  nerve  was  severed,  respiration  be- 
came suddenly  arrested,  and  the  animal  promptly  died. 


674  ^    ONUF  AND  JOSEPH  COLUNS. 

With  older  animals,  that  is,  with  cats  which  had 
reached  the  age  of  five  or  six  weeks,  we  succeeded  much 
better,  and  three  of  them  lived  from  three  to  five  months 
after  the  operation,  when  they  were  killed. 

In  closing,  we  wish  to  call  attention  to  a  method  of 
physiological  research  which  may  serve  to  enlighten  us 
on  points  for  which  the  other  methods  give  us  no  sufficient 
information.  This  method  consists  in  studying,  not  the 
immediate,  but  the  remote  effects  of  injuries  of  certain  lo;i 
of  the  nervous  system;  of  investigating  not  only  the  per- 
version or  loss  of  function,  .vhich  is  the  immediate  result 
of  the  removal  or  section  of  some  ganglion  or  nerve,  but 
also  the  compensation  of  the  functional  defect  that  occurs 
in  the  course  of  time.  In  this  manner  it  is  often  possible 
to  determine  whether  certain  functions  are  performed  ex- 
clusively by  a  definite  nerve  or  ganglion,  or  whether  other 
nerves  or  ganglia  share  in  the  fulfillment  of  this  function. 
Illustrations  of  the  truth  of  this  are  given  in  the  observa- 
tions made  by  us  on  the  pupils  of  cats  in  which  a  stellate 
ganglion  had  been  removed.  The  immediate  consequence 
of  this  operation  was  reduction  of  the  size  of  the  pupil 
of  the  operated  side  to  one-third,  or  less,  of  the  size  of  the 
other  pupil.  Gradually,  however,  the  difference  in  the 
size  of  the  two  pupils  diminished,  until  in  the  course  of 
from  three  to  five  months,  it  had  entirely  disappeared, 
showing  in  the  most  convincing  way,  by  this  compensa- 
tion of  function,  that  not  all  pupil-dilating  fibres  are  de- 
rived from  the  cervical  sympathetic  nerve  and  stellate 
ganglion.  The  method  mentioned  has  given  another  in- 
teresting result  bearing  on  the  same  point.  When,  three 
months  after  the  removal  of  one  stellate  ganglion,  the  gan- 
glion of  the  other  side  was  removed,  a  test  of  the  pupillary 
reaction  showed  that  the  pupil  of  the  side  first  operated 
upon  contracted  much  more  intensely  and  more  rapidly  to 
light  than  the  other  pupil.  This  fact  can  hardly  be  ex- 
plained otherwise  than  by  granting  that  the  cervical  sym- 
pathetic contains  not  only  pupil-dilating  but  also  pupil- 


LOCALIZATION  OF  THE  SYMPATHETIC  NERVE.     675 

contracting  fibres.  Owing  to  this  compensation,  the 
pupil  of  the  side  on  which  the  stellate  ganglion  had  been 
removed  three  months  previously  to  the  test  contracted 
much  more  promptly  than  the  pupil  of  the  other  side,  on 
which  the  ganglion  had  been  extirpated  just  before  the 
test. 

No  less  interesting  were  the  results  which  we  obtained 
regarding  the  sweat  fibres  of  the  forepaw  of  the  cat,  and  re- 
garding the  influence  of  the  cervical  sympathetic  on  lach- 
rymal secretion.  Twenty-five  days  after  extirpation  of  the 
left  stellate  ganglion  injection  of  one  centigramme  of 
pilocarpine  caused  no  perceptible  change  in  the  state  of 
the  left  forepaw,  while  when  an  injection  or  instillation 
of  pilocarpine  was  made  three  or  four  and  a  half  months 
after  this  operation  (in  two  other  cats),  the  forepaw  of 
the  operated  side  sweated  quite  abundantly,  and  in  one 
case  apparently  no  less  than  that  of  the  other  side. 

Moreover,  injection  of  pilocarpine  three  weeks  after  ex- 
tirpation of  the  left  stellate  ganglion  caused  profound 
lachrymal  secretion  on  the  healthy  side,  the  eye  of  the 
operated  side  remaining  dry;  while,  on  the  contrary,  three 
months  after  this  operation  (in  another  cat)  the  eye  of 
the  operated  side  secreted  much  less  than  that  of  the 
healthy  side  when  pilocarpine  was  injected.  In  a  third 
animal,  finally,  four  and  a  half  months  after  the  defect  of 
the  ganglion,  pilocarpine  instillation  produced  lachrymal 
secretion  of  both  eyes  in  an  equal  degree. 

The  contrast  between  the  direct  and  the  remote  con- 
sequences of  the  defect  of  certain  parts  of  the  sympathetic 
system  is  further  shown  in  quite  an  opposite  direction. 
While  such  defects  seem  at  first  not  to  cause  any  dis- 
turbance of  certain  functions,  such  disturbances  often 
make  their  appearance  weeks,  and  even  months,  after  the 
defect  is  created  and  show  a  tendency  to  progression. 
No  legitimate  conclusions  could  be  drawn  as  to  the  ef- 
fect of  the  removal' of  the  stellate  ganglion  upon  the  gas- 
tric and  intestinal  functions  during  the  first  four  weeks 


676  B.   ONUF  AND  JOSEPH   COLLINS. 

after  such  removal,  because  during  this  period  these  func- 
tions appeared  quite  normal.  Nevertheless,  they  became 
markedly  disordered  later.  In  the  same  manner  two  cats 
which  were  deprived  of  the  semilunar  ganglion  showed  no 
symptoms  in  the  first  two  weeks  after  the  operation,  but 
at  the  end  of  that  time  one  of  them  was  taken  with  diar- 
rhoea, and  finally,  three  weeks  after  the  operation,  it  died 
in  a  state  of  collapse.  The  second  cat  did  not  begin  to 
have  vomiting  attacks  until  three  weeks  after  the  injury 
had  been  inflicted. 

In  like  manner  the  disturbances  of  respiration  observed 
after  removal  of  the  stellate  ganglion,  or  the  lower  por- 
tion of  the  thoracic  sympathetic  nerve,  differed  in  their 
immediate  and  remote  consequences.  In  one  case,  for  in- 
stance, pertussis-like  paroxysms  set  in  as  late  as  two 
months  after  resection  of  the  thoracic  sympathetic  nerve 
with  the  adjoining  piece  of  the  splanchnic. 

The  clinical  importance  of  these  facts  needs  no  men- 
tion. 

DISCUSSION. 

Dr.  William  G.  Spiller  said  that  the  paper  read  by  Drs. 
Onuf  and  Collins  contained  so  much  valuable  material,  and 
was  of  such  a  cliaracter,  that  in  discussing  it  one  could  hardly 
do  justice  to  it  after  hearing  it  read  once.  The  importance 
attached  by  the  authors  to  the  columns  of  Clarke  and  the  cells 
in  this  region  seemed  to  be  justified  by  the  investigations  of 
others.  Marinesco  has  advanced  the  view  that  Morvan's  dis- 
ease may  be  due  to  an  affection  of  the  posterior  horns  and 
internicdiate  gray  matter,  and  the  speaker  said  that  about  two 
years  ago  he,  in  connection  with  Dr.  Dercuni,  reported  a  case 
of  syringomyelia  with  arthropathy  of  the  shoulder  joint,  in 
which  the  lesion  in  the  cervical  cord  was  limited  to  the  pos- 
terior horn  on  the  same  side  as  the  arthropathy.  Dr.  Spiller 
said  he  was  inclined  to  believe  that  the  cells  of  the  intermediate 
gray  matter,  between  the  anterior  and  posterior  horns,  may 
be  concerned  with  vasomotor  and  similar  functions. 

Drs.  Onuf  and  Collins  spoke  of  the  presence  of  pupillary 
fibres  in  the  sympathetic;  the  investigations  of  Madame  De- 
jerine,  Oppenheim,  and  others  have  fully  established  the  fact 
that  these  fibres  leave  the  spinal  cord  through  the  upper  tho- 
racic roots.     The  statement  made  bv  Onuf  and  Collins  that 


LOCALIZATION  OF  THE  SYMPATHETIC  NERVE,     677 

canstricting  fibres  of  the  pupdl  are  contained  in  the  sympa- 
thetic is  of  much  interest. 

Marinesco  found  the  posterior  nucleus  of  the  vagus  de- 
generated after  lesions  of  this  nerve,  and  concluded  that  this 
posterior  nucleus  must  be  motor.  Van  Gehuchten  has  sought 
to  explain  this  degeneration  in  another  way.  Dr.  Spiller  said 
that  Dr.  Dercum  and  he  had  just  reported  to  the  association 
a  case  of  amyotrophic  lateral  sclerosis,  in  which  the  posterior 
nucleus  of  the  vagus  was  degenerated,  and  the  anterior  was  ap- 
parently normal.  They  had  found  a  number  of  similar  cases 
in  the  literature.  In  this  disease  the  motor  system  is  chiefly 
affected,  and  it  is  remarkable  that  the  posterior  nucleus  of  the 
vagus  should  present  such  evident  signs  of  degeneration  if 
it  is  a  sensory  nucleus. 

Dr.  Onuf,  in  reply  to  a  question  by  Dr.  Booth,  said  that 
in  their  experiments  the  thoracic  sympathetic  had  been  re- 
moved in  two  cases,  and  in  both  instances  the  animals  de- 
veloped diabetes. 

Dr.  F.  W.  Langdon  was  inclined  to  believe  that  the  paper 
of  Drs.  Onuf  and  Collins  would  prove  of  great  clinical  im- 
portance. In  myelitis,  for  example,  we  are  all  acquainted  with 
the  variability  of  the  symptoms,  and  the  speaker  said  that 
in  locating  such  lesions  he  had  always  laid  considerable  stress 
upon  the  presence  or  absence  of  trophic  symptoms.  He  had 
come  to  look  upon  the  occurrence  of  marked  trophic  disturb- 
ances, bed-sores  and  similar  condition®,  as  an  indication  of  a 
lesion  far  back  in  the  gray  matter,  and  the  investigatiions  of 
Drs.  Onuf  and  Collins  give  us  a  very  satisfactory  reason  for 
this  clinical  fact. 

Dr.  Joseph  Collins  did  not  think  it  necessary  to  speak  fur- 
ther of  the  experimental  conclusions  contained  in  the  paper, 
but  added  a  few  remarks  on  the  clinical  aspect  of  the  subject. 
In  their  experiments  they  had  had  in  mind  that  if  the  sym- 
pathetic could  be  located  in  the  spinal  cord,  certain  symptoms 
of  syrangomyelia  and  tabes,  about  which  we  are  now  in  the 
dark,  could  be  easily  explained.  Not  long  ago  he  saw  a  boy, 
13  years  old,  whose  symptoms  were  diarrhoea,  paroxysmal  in 
character,  which  had  extended  over  a  period  of  several  years ; 
a  condition  of  the  right  eye  commonly  known  as  the  "Schultze 
eye,"  atrophy  of  the  thenar  and  hypothenar  eminences  of  the 
right  hand,  and  cervicodorsal  kyphosis.  No  sensory  symp- 
toms were  noted.  Dr.  Collins  said  he  hazarded  the  diagnosis 
of  syringomyelia,  despite  the  absence  of  sensory  jftienomena, 
and  explained  the  symptoms  in  this  case  by  the  presence  of  a 
lesion  in  the  central  canal,  which,  in  extending,  implicated  the 
paracentral  nuclei  and  the  nuclei  of  the  intermediate  zone, 
without  encroaching  upon  any  of  the  sensory  fibres.  The  alio- 


6/8  B.   ONUF  AND  JOSEPH  COLLINS. 

cation  of  the  sympathetic  to  the  medulla  oblongata,  which 
their  results  showed,  threw  much  light  on  the  interpretation 
of  symptoms  referable  to  the  sympathetic  system,  occurring 
with  bulbar  disease  and  asthenic  bulbar  paralysis. 

Dr.  Onuf,  in  closing,  said  that  several  investigators  have 
shown  that  all  the  dilating  nerve  fibres  of  the  pupil  are  not 
derived  from  the  cervical  sympathetic;  compensatory  fibres 
being  derived  from  the  cranial  nerves,  probably  the  trigeminal. 

He  thought  that  the  more  we  learn  abooit  the  lo- 
calization of  the  sympathetic  nerve,  the  less  shall  we  be  in- 
clined to  diagnose  syringomyelia  in  a  diagrammatic  or  dog- 
matic way,  and  the  more  shsJl  we  be  guided  by  a  knowledge 
of  the  localization  of  the  lesions.  In  syringomyelia  it  is  not 
really  the  disease  that  makes  the  peculiar  combination  of  the 
symptoms;  it  is  the  location  of  the  process. 


220.  Amyotrophic  Laterai,  Sci^hrosis.  Raymond  (La  Presse  Medi- 

cale,  Nos.  41  and  43,  1897). 

After  a  clinical  demonstration  of  two  cases  (one  male,  one  fe- 
male) of  this  disease,  which  began  with  bulbar  symptoms,  and  in 
which  the  arms  and  legs  were  later  aflfected,  the  author  discusses  the 
relationship  existing  between  amyotrophic  lateral  sclerosis,  glosso- 
labial-laryngeal  paralysis  and  progressive  muscular  atrophy  of  the 
Aran-Duchenne  type.  Certain  authorities,  headed  by  Leyden,  hold  that 
there  is  no  spinal  muscular  atrophy  depending  upon  a  lesion  strictly 
limited  to  the  cells  of  the  anterior  horns,  but  that  there  is  always 
more  or  less  involvement  of  the  fibres  of  the  pyramidal  tracts.  Others 
of  the  school  of  Vulpian,  of  whom  Dejerine  is  the  chief  representa- 
tive, deny  the  existence  of  a  glosso-labio-laryngeal  paralysis  due  10 
lesion  of  the  bulbar  nuclei,  without  involvement  of  the  pyramidal 
tracts  in  that  region.  Each  of  these  views  the  author  thinks  incorrect. 
He  cites  an  observation  by  Jean  Charcot  of  a  case  presenting  the 
typical  symptoms  of  spinal  muscular  atroohy  of  the  Aran-Duchenne 
type,  in  which  lesion  of  the  cells  of  the  anterior  horns,  without  in- 
volvement of  the  white  columns,  was  found,  and  one  of  his  own  of 
a  case  of  glosso-labio-laryngeal  paralysis,  in  which  the  lesion  was 
strictly  limited  to  the  nuclei  of  the  bulb  and  concluded  that  while  they 
may  be  closely  related,  the  diseases  in  question  must  be  considered  as 
separate  and  distinct  morbid  entities.  As  to  the  lesion  causing  the 
rigidity  and  spasmodic  phenomena  in  amyotrophic  lateral  sclerosis,  the 
author  expresses  the  opinion  that  it  is  not  the  sclerosis  of  the  lateral 
tracts,  but  is  probably  a  lesion  in  the  gray  matter  of  the  cerebrum. 
As  negative  evidence,  he  mentions  a  case  of  Senator's,  in  which, 
though  the  clinical  picture  of  amyotrophic  lateral  sclerosis,  with  in- 
volvement of  the  bulbar  nuclei,  was  present,  the  atrophy  disclosed  de- 
generation of  the  bulbar  and  spinal  nuclei,  with  diffused  lesions 
throughout  the  cord,  but  no  sclerosis  of  the  lateral  tracts.  Positive 
evidence  supporting  his  view  he  does  not  give.  Allen. 


A  SUMMARY  OF  THE  SYMPTOMS  IN  SIXTY- 
ONE  CASES  OF  LOCOMOTOR  ATAXIA,  WITH 
ADDITIONAL  REMARKS,^ 

By  W.  H.  RILEY,  M.D., 

Superintendent  oi  the  Colorado  Sanitarium,  Boulder,  Col. 

The  sixty-one  cases  of  locomotor  ataxia,  the  most  im- 
portant symptoms  of  which  are  here  given  in  the  order  of 
their  relative  frequency,  have  been  examined  and  treated 
by  the  writer  in  sanitariums  with  which  he  has  been  con- 
nected. These  patients  were  all  males,  which  is  quite  un- 
common for  so  large  a  number  of  cases.  The  percentage 
of  females  suffering  with  this  disease  is,  however,  usually 
small. 

A  history  of  syphilis  was  given  in  thirty-one  cases  out 
of  forty-nine.  Of  the  remaining  eighteen  cases  of  the 
forty-nine,  fourteen  had  had  gonorrhoea,  been  excessive 
in  sexual  indulgence,  or  gave  other  evidence  of  possible 
exi>osure  to  syphilis.  Of  the  remaining  twelve  cases  of 
the  sixty-one,  syphilis  was  either  denied,  or  this  point  was 
not  determined  in  the  history  of  the  case.  In  the  cases 
that  gave  a  history  of  syphilis,  from  two  years  to  thirty 
years  intervened  between  the  primary  venereal  disease 
and  the  initial  symptoms  of  locomotor  ataxia.  In  most 
cases  the  initial  symptoms  of  ataxia  appeared  from  eight 
years  to  fifteen  years  after  syphilis  had  developed.  In 
two  cases  the  disease  followed  soon  after  a  mechanical  in- 
jury. A  history  of  exposure  to  wet  and  cold  was  given 
in  seven  cases.  One  case  developed  immediately  after  an 
attack  of  typhoid  fever.  This  last  case,  however,  differed 
from  cases  usually  seen,  in  that  the  disease  was  not  pro- 
gressive in  character,  and  the  only  prominent  symptoms 


*Read  at  the  twenty-fourth  annual  meeting  of  the  American  Neu- 
rological Association,  May,  1898. 


68o  W.  H.  RILEY. 

present  were  well  marked  ataxia  in  all  four  extremities,  as 
well  as  in  the  muscles  of  speech. 

The  majority  of  these  cases  came  from  the  middle  and 
higher  walks  of  life.  In  twenty-nine  cases,  the  disease 
first  showed  itself  between  the  ages  of  thirty  and  forty 
years;  in  twenty  cases,  between  the  ages  of  forty  and 
fifty  years;  in  six  cases,  between  the  ages  of  fifty  and  sixty 
years.  In  two  cases  the  disease  began  at  the  age  of 
twenty-five,  and  in  one  case,  following  typhoid  fever,  it 
began  at  the  age  of  twenty-two  years.  The  initial  symp- 
tom, as  given  by  patients  in  the  history  of  their  cases, 
was  as  follows: 

In  thirty-seven  cases  the  initial  symptom  was  pain  in 
some  part  of  the  body,  and  was  usually  described  as 
''rheumatic" ;  in  three  cases,  it  was  gastric  crises;  in  three 
cases,  laryngeal  crises;  in  four  cases,  incoordination  of  the 
lower  limbs.  In  the  remaining  cases  the  initial  symptom 
consisted  of  one  or  more  of  the  following:  Various  paraes- 
thesias  in  the  extremities,  diplopia,  partial  blindness,  ver- 
tigo, difficulty  in  emptying  the  bladder,  loss  of  sexual  func- 
tion, general  feeling  of  weakness — ^frequently  without  ex- 
ertion— and  digestive  disturbances. 

The  symptoms  of  the  sixty-one  cases  tabulated  in  the 
order  of  their  frequency  are  as  follows: 

1.  Knee-jerk  absent  in 55  cases. 

2.  Severe  paroxysms  of  pain  in 54  cases. 

In  twenty-one  of  these  cases  severe  pains  were  in  the 
arm,  trunk  and  legs;  in  fifteen,  in  the  legs  alone;  in  thir- 
teen, in  the  trunk  and  legs;  in  one,  in  the  arms  alone;  and 
in  one,  in  the  trunk  alone. 

3.  Ataxia  in  locomotion,  with  eyes  closed  (56 

cases  examined),  present  in 54  cases. 

4.  Various  paraesthesias,  as  numbness,  pricking, 

formication,  etc.,  present  in 53  cases. 

In  thirty  of  these  cases,  paraesthesia  was  confined  to 
the  lower  extremities;  in  twenty-one,  to  both  lower  and 
upper  extremities;  in  two,  there  was  paraesthesia  in  the 
face,  as  well  as  in  the  lower  and  upper  extremities. 


SYMPTOMS   OF   LOCOMOTOR   ATAXIA,  68l 

5.  Static  ataxia,  with  eyes  closed  (56  cases  ex- 

amined), present  in 54  cases. 

6.  Anaesthesia  (referring  to  tactile,  temperature 

and  pain  sense,  one  or  more  being  affected), 
present  in 45  cases. 

In  fourteen  of  these,  the  anaesthesia  was  in  the  upper 
and  lower  extremities;  in  two,  in  the  trunk  and  upi>er  and 
lower  extremities;  in  two,  in  the  face  and  upper  and  lower 
extremities;  in  the  remainder,  in  the  lower  extremities. 

7.  Girdle  sensation  about  trunk  present  in ....  39  cases. 

8.  Constipation  present  in 39  cases. 

9.  Static  ataxia,  with  eyes  open  (56  cases  ex- 

amined), present  in 41  cases. 

10.  Ataxia  in  locomotion,  eyes  open  (56  cases  ex- 

amined), present  in 41  cases. 

11.  Cold  extremities  in 34  cases. 

Loss  of  sexual  power,  partial  or  complete,  in .  35  cases. 
General  feeling  of  weariness,  with  diminished 

motor  power,  in 37  cases. 

12.  Area  of  hyperaesthesia  about  abdomen  and 

lower  part  of  trunk,  with  increased  skin  re- 
flexes in  the  same  area,  in 29  cases. 

13.  Indigestion  and  stomach  disorders  in 33  cases. 

Considerable  loss  of  weight  in 33  cases. 

14.  Myosis  present  in 28  cases. 

Argyll-Robertson  pupil  (that  is,  pupil  con- 
tracted, responding  to  light,  but  not  to  ac- 
commodation), present  in 28  cases. 

15.  Nervous  irritability  and  despondency  in 25  cases. 

16.  Accelerated  pulse  (85  or  above)  in 25  cases. 

17.  Skin  reflexes  (plantar,  cremasteric  and  ab- 

dominal) increased  in 24  cases. 

Incomplete  retention  of  urine  in 27  cases. 

18.  Insomnia  in 20  cases. 

19.  Ataxia  in  arms  in 15  cases. 

20.  Diplopia  usually  present  at  beginning  of  dis- 

ease  in 14  cases. 

Skin  reflexes  absent  in 16  cases. 

21.  Delayed  sensations  in 14  cases. 

Partial  incontinence  of  urine  in 15  cases. 

22.  Ptosis  (transient  or  permanent)  in 13  cases. 

Attacks  of  sudden  vertigo  in 13  cases. 

Partial  iridoplegia  in 11  cases. 


682  .  W,  H,  RILEY. 

23.  Partial  deafness  in 13  cases. 

24.  Plantar  skin  reflexes  absent,  or  very  much  di- 

minished,  with   other   skin   reflexes   nor- 
mally present,  in 10  cases. 

Gastric  crises  in 11   cases. 

25.  Tenderness  along  the  spine  in 7  cases. 

Diminished  faradic  irritability  of  muscles  in . .   6  cases. 

Diminished  galvanic  irritability  in 6  cases. 

Unable  to  walk  with  crutches  or  two  canes  in  6  cases. 

26.  Rise  of  temperature  during  paroxysms   of 

pain  in 6  cases. 

Optic  nerve  atrophy  in 7  cases. 

Laryngeal  crises  in 6  cases. 

Diarrhoea  in 8  cases. 

Pupils  dilated  in 8  cases. 

27.  Unequal  pupils  in . ' 6  cases. 

28.  Polyaesthesia  in 4  cases. 

29.  Complete  retention  of  urine  in 3  cases. 

Complicated  with  marked  muscular  atrophy 

with  the  electrical  reaction  of  degeneration 

in  muscles  in 2  cases. 

Tremor  in  hands  in 2  cases. 

Anaesthesia  in  face  in 2  cases. 

Taste  affected  in 2  cases. 

Area  of  hyperidrosis  about  trunk  in 2  cases. 

Knee-jerk  present  and  normal  in 2  cases. 

Knee-jerk  present,  but  unequal,  right  strong- 
er, in  I   case. 

30.  Knee-jerk  exaggerated  in i   case. 

31.  Hyperidrosis  of  both  legs  in i  case. 

Knee-jerk  present,  but  diminished,  in i   case. 

Knee-jerk  present  in  one  limb  and  absent  in 

the  other i  case. 

Complicated  with  general  paresis  in i  case. 

Traces  of  albumin  in  urine  in i  case. 

Complete  incontinence  of  urine  in i  case. 

Traces  of  sugar  in  urine  in i  case. 

With  reference  to  the  symptomatology  of  tabes,  I  be- 
lieve that  this  is  fairly  well  represented  in  a  report  of  the 
symptoms  found  in  sixty-one  given  herewith.  Many  of 
these  are  seldom  noticed,  or  only  lightly  touched  upon,  by 
the  majority  of  writers  on  this  subject;  and  they  are  even 


SYMPTOMS   OF   LOCOMOTOR    ATAXIA.  683 

more  frequently  overlooked  in  examinations  of  patients 
suffering  with  this  disease. 

The  symptoms  apt  to  be  overlooked  in  connection 
with  this  disease  are  an  exaggeration  of  the  skin  reflexes, 
partial  deafness,  and  accelerated  pulse.  In  addition  to 
these,  there  is  in  many  cases  insomnia,  considerable  loss 
of  weight,  with  more  or  less  disturbance  of  the  digestive 
organs,  and  very  frequently  a  relaxed  condition  of  the  ab- 
dominal muscles,  allowing  the  stomach  and  bowels,  and 
sometimes  other  abdominal  organs,  to  become  prolapsed 
and  displaced.  This  is  often  a  very  marked  condition  in 
locomotor  ataxia. 

Another  fact  that  may  be  noticed  in  this  connection 
is  that  the  knee-jerk  is  not  always  absent  in  locomotor 
ataxia,  as  is  usually  supposed.  Of  these  sixty-one  cases 
reported,  it  was  found  absent  in  fifty-five.  Of  the  six  re- 
maining cases,  it  was  present,  and  apparently  normal,  in 
two;  present  but  unequal,  the  right  being  the  stronger, 
in  one;  present,  but  much  diminished,  in  one;  present  in 
one  limb  and  absent  in  the  other,  in  one  case;  and  in  one 
case  it  was  certainly  exaggerated.  There  is  another  class 
of  cases  of  so-called  ataxic  paraplegia,  in  which  the  knee- 
jerk  is  exaggerated;  but  in  this  class  there  is  an  actual 
paralysis  present  in  the  lower  limbs,  in  addition  to  the 
symptoms  of  locomotor  ataxia,  and  the  lesion  in  the  cord 
occupies  a  larger  and  entirely  different  territory  than  in 
typical  locomotor  ataxia.  The  case  here  referred  to,  in 
which  the  knee-jerk  was  exaggerated,  does  not  belong  to 
this  class.  In  this  particular  instance  there  was  no  pa- 
ralysis of  the  lower  limbs,  and  a  careful  study  of  the  symp- 
toms of  the  case  would  in  no  way  warrant  putting  it  in 
this  class  of  so-called  ataxic  paraplegias. 

Dr.  S.  Weir  Mitchell,  of  Philadelphia,  has  reported  a 
case  in  which  the  knee-jerk  was  exaggerated,  but  the 
symptoms  of  ataxia  were  in  the  upper  extremities  en- 
tirely. 

Where  the  anaesthesia  affects  the  arms  and  hands,  I 


684  ^-  ^-  RILEY, 

have  found  in  several  cases  that  it  was  confined  to  the 
ulnar  nerve.    This  observation  has  been  made  by  others. 

With  reference  to  the  exaggeration  of  the  skin  re- 
flexes, in  my  own  examinations  I  have  found  this  con- 
dition in  many  cases  which  I  have  had  an  opportunity  of 
examining  at  an  early  stage  of  the  disease.  As  the  maJady 
progresses,  the  skin  reflexes  diminish,  and  finally  disappear 
entirely,  so  that  in  most  cases  of  tabes  in  the  second  or 
third  stage  of  the  disease  the  skin  reflexes  are  entirely 
absent.  I  have  found  this  exaggeration  of  the  skin  re- 
flexes of  great  diagnostic  value.  Cases  are  frequently 
seen  where,  in  the  early  stages  of  the  disease,  it  is  some- 
what difficult  to  make  an  accurate  diagnosis.  The  symp- 
toms are  not  prominent,  and,  perhaps,  a  diagnosis  must 
be  formed  upon  only  a  general  history  of  the  case,  to- 
gether with  two  or  three  symptoms.  In  instances  of  this 
kind,  when  I  have  found  the  skin  reflexes  exaggerated,  in 
connection  with  a  few  other  symptoms  pointing  to  this 
disease,  I  have  usually  had  no  trouble  in  making  a  diag- 
nosis of  locomotor  ataxia. 

I  remember  distinctly  one  case  coming  under  my  ob- 
servation, where  the  only  symptom  pointing  to  incipient 
locomotor  ataxia,  with  only  the  very  slightest  suggestion 
of  incoordination,  was  decided  skin  reflexes,  particularly 
plantar.  The  knee-jerk  was  present,  and  all  other  symp- 
toms of  the  disease  were  absent.  The  diagnosis  of  in- 
cipient locomotor  ataxia  was  made.  I  had  an  oppor- 
tunity to  watch  this  case  for  about  two  years,  and,  as  time 
progressed,  nearly  all  the  other  symptoms  of  locomotor 
ataxia  made  their  appearance.  I  do  not  believe  that  in 
the  literature  treating  upon  this  subject  sufficient  im- 
portance has  been  given  to  this  symptom  in  the  earlier 
stages  of  the  disease. 

The  deafness  which  frequently  occurs  in  those  suffer- 
ing with  this  disease  I  believe  to  be  a  part  of  the  disease 
proper,  and  that  it  should  be  considered  as  forming  part 
of  the  symptom-complex  which  characterizes  the  trouble. 


b- 


SYMPTOMS   OF   LOCOMOTOR    ATAXIA.  685 

The  cause  of  the  deafness  is  due  to  a  lesion  of  the  auditory 
nerve  in  some  part  of  its  course,  similar  to  that  which  af- 
fects the  roots  of  the  spinal  nerves.  If  these  cases  in  which 
deafness  is  present  are  carefully  examined,  and  the  cause 
of  the  deafness  sought,  it  will  be  nearly  always  found  to 
be  of  nervous  origin;  at  least,  such  has  been  my  experience. 

An  accelerated  pulse  is  another  symptom  which  is 
usually  overlooked.  I  have  reported  it  present  in  25  of 
the  61  cases  here  reported.  In  these  25  cases  the  pulse 
was  85  per  minute  or  above.  This  is  probably  due  to  an 
irritation  of  the  pneumogastric  nen^e,  similar  to  that 
which  in  the  spinal  nerves  produces  sensory  symptoms. 

Another  unusual  symptom  noted  in  connection  with 
the  study  of  these  sixty-one  cases  was,  in  eight  ca^s,  a 
dilatation  of  the  pupil,  instead  of  a  contraction,  as  is  usu- 
ally the  case.  In  those  cases  in  which  the  pupils  were  di- 
lated, they  did  not  respond  to  the  light,  and  only  very 
sluggishly  to  accommodation.  In  one  of  the  sixty-one 
cases  there  was  a  trace  of  sugar  present  in  the  urine,  which 
has  been  observed  a  few  times  in  other  cases  of  this  dis- 
ease. 

These  cases  were  seen  in  all  stages  of  the  progress  of 
the  disease,  some  in  the  first,  some  in  the  second,  and 
some  in  the  third  stage.  As  the  symptoms  change  as  the 
disease  progresses,  the  comparison  of  the  symptoms  found 
in  any  number  of  cases  which  may  be  made  by  one  ob- 
server cannot  well  be  compared  with  an  equal  number  of 
cases  of  this  disease  made  by  another  observer,  for  the 
reason  that  one  observer  may  see  more  cases  in  a  certain 
stage  of  the  disease  than  another;  and,  secondly,  the  rela- 
tive frequency  of  any  symptom  or  group  of  symptoms 
may  vary. 

The  relative  importance  of  the  different  factors  which 
are  supposed  to  be  the  cause  of  the  disease  is  a  question 
with  reference  to  which  there  is  considerable  difference  of 
opinion.  As  nearly  as  can  be  determined  by  clinical  ob- 
servation, the  factors  which  enter  into  the  causation  of 


686  tV.  H.  RILEY. 

this  disease  may  be  briefly  stated  as  follows:  Neuropathic 
tendencies,  syphilis,  sexual  excesses,  exposure  to  wet  and 
cold,  overexertion,  mechanical  injuries. 

Between  the  opinions  of  Erb,  Mobius,  Strumpell,  Four- 
nier  and  others,  on  the  one  hand,  who  regard  tabes,  in  the 
majority  of  cases,  at  least,  as  purely  a  post-syphilitic  con- 
dition, and  those  of  Leyden,  Charcot,  etc.,  on  the  other 
hand,  who  disregard  syphilis  entirely,  or  give  it  but  a  small 
place  in  the  etiology  of  tabes,  there  are  many  careful  ob- 
servers who  hold  all  grades  of  opinion  between  these  ex- 
tremes. Leyden  claims  that  syphihs  must  be  left  out  of 
the  etiology  entirely;  while  Charcot  strongly  favored  a 
neurotic  heredity,  and  regarded  syphilis-of  minor  etiologi- 
cal importance.  The  doctrine  of  the  syhilitic  origin  of 
tabes  is  mainly  due  to  Fournier,  of  Paris  (in  1876),  and 
Erb,  of  Heidelberg  (1879).  Previous  to  either  of  these 
dates,  however,  Virchow,  Wunderlich  and  Berger  had  al- 
ready expressed  themselves  as  believing  that  many  cases 
of  tabes  were  of  syphiHtic  origin.  In  1883,  Erb  declared 
that  syphilis  was  the  most  important  factor  in  the  causa- 
tion of  tabes  dorsalis,  and  that  persons  not  previously  in- 
cted  with  syphilis  had  but  the  slightest  chance  of  suflfer- 
g  from  this  disease. 

In  the  third  number  of  his  Neurologische  Beitrage 
,  J.  Mobius  called  attention  to  the  changes  of  opinion 
various  authors  since  1880  in  regard  to  the  etiology  of 
bes.  He  claims  that  the  number  of  authors  who  regard 
philis  as  an  etiological  factor  is  constantly  increasing, 
'hile  Erb,  Strumpell  and  other  strong  defenders  of  the 
'philitic  theory  admit  that  a  certain  percentage  of  ta- 
jtics  can  with  certainty  be  excluded,  as  not  having  had 
-evious  syphilitic  infection,  Mobius  holds  the  most  ex- 
■eme  views,  and  considers  such  an  infection  as  the  sine 
aa  non  for  the  development  of  this  disease,  and  believes 
lat  Edinger  overestimates  the  importance  of  excessive 
inction  as  an  etiological  factor. 
In  1892,  Erb  found  that  89  per  cent,  of  the  cases  of 


SYAfPTOMS   OF   LOCOMOTOR   ATAXIA.  ^StJ 

tabes  that  he  had  examined,  which  included  a  large  num- 
ber, had  previously  had  syphilis.  Fpurnier  states  that  over 
90  per  cent,  of  persons  suffering  from  tabes  have  had 
syphilis.  Out  of  247  cases  examined  by  Hirt,  90  per  cent, 
were  syphilitics.  Senator  gives  70  per  cent.,  Mendel  75 
per  cent.  Gowers,  of  London,  found  in  his  private  prac- 
tice that  58  per  cent,  of  his  tabetic  patients  had  previously 
had  syphilis,  and  he  thinks  that,  could  the  facts  be  ob- 
tained, two-thirds  would  be  nearer  the  truth.  In  Fraen- 
kel's  experience,  the  percentage  was  50  7-10;  in  Ger- 
hardt's,  50;  in  Dana's,  50.  In  a  minute  study  of  212 
cases,  Lagondaky  found  42  per  cent,  syphilitics.  Eulen- 
berg  gives  36  4-5  per  cent.  In  sixty-eight  cases  ex- 
amined by  Borgherini,  he  found  that  32  per  cent,  had 
previously  had  syphilis,  and  37  per  cent,  more  had  suf- 
fered from  chancroid.  A  neuropathic  taint  was  found  in 
half  his  cases.  De  Werker  gives  30  per  cent,  as  syphilitics, 
while  Panas  finds  that  one-third  of  his  cases  have  previous- 
ly had  syphilis. 

Minor  shows  from  his  statistics  that  tabes  is  much 
more  rare  in  Russia  among  the  Jews  than  among  other 
Russians,  which  is  undoubtedly  due  to  the  fact  that  the 
latter  are  more  or  less  syphiHtic.  Magel  found  46  per 
cent,  of  syphilitics  in  1,403  cases.  In  the  experience  of 
Westphal,  14  per  cent,  of  his  tabetic  patients  were  syphi- 
litic. In  my  own  experience  I  have  found  that  60  per  cent, 
of  the  cases  suffering  from  tabes  dorsalis  had  previously 
had  syphilis. 

Grimm,  in  the  Berlin  Medical  Gesell.,  April  nth,  1894, 
gives  the  result  of  his  seven  years'  experience  in  Japan, 
syphilis  being  very  prevalent  in  that  country.  Of  the 
13,000  cases  which  came  to  his  hospital,  1,020  were  af- 
fected with  syphilis.  His  expectation  to  find  syphilitic 
tabes  was  not  realized.  He  observed  only  five  undoubted 
cases  of  tabes  in  Japan,  of  which  only  one  had  a  history 
of  syphilis. 

Recently,  Edinger  has  advanced  a  new  theory  as  to 


688  IV.  H.  RILEY. 

the  origin  of  tabes  dorsalis,  as  well  as  some  other  diseases 
of  the  nervous  system.  Edinger's  theory  is  based  upon 
the  following  laws: 

1.  The  healthy  normal  activity  of  every  organ  always 
causes,  or  is  accompanied  by,  certain  molecular  changes 
which  take  place  in  the  organ.  The  organ  consequently 
suffers  certain  damages,  which  must  be  repaired.  When 
the  restitution  in  the  organ  is  equal  to  the  amount  of 
function,  the  organ  is  strengthened  by  functionating;  but 
when  not,  it  undergoes  retrogressive  changes. 

2.  A  diseased,  damaged  or  weakened  tissue  soon  de- 
cays, and  gives  place  to  the  surrounding  healthy  tissue, 
which  grows  into  it  and  takes  its  place. 

Weigert  has  proved  that  so-called  hypertrophy,  pro- 
liferation, interstitial  inflammation,  etc.,  are  no  more  than 
the  ingrowth  of  healthy  tissue  into  the  diseased  tissue. 
In  the  so-called  gray  atrophies  of  the  central  nervous  sys- 
tem the  nerve  tissue  is  always  first  diseased,  after  which  it 
retrogrades,  and  is  finally  destroyed  by  the  ingrowth  of 
neuroglia.  A  degeneration  of  tissue  must  follow  whenever 
there  is  a  disproportion  between  function  and  restitution 
to  such  a  degree  that  the  tissue  does  not  return  to  its  for- 
mer condition.  Edinger  thinks  that,  by  properly  appreci- 
ating these  facts,  many  problems  may  be  explained  which 
heretofore  have  not  been  fully  comprehended.  He  there- 
fore holds  that  excessive  function  is  a  common  cause  of 
tabes,  as  well  as  of  other  diseases  of  the  central  nervous 
system. 

Tabes  is  most  frequently  observed  in  persons  who 
overexert  their  legs,  such  as  military  officers,  railroad  men, 
etc.,  while  it  is  seldom  found  in  women  of  sedentary  habits. 
In  these  cases  the  neuromuscular  mechanism  necessary  for 
the  maintenance  of  the  equilibrium  of  the  body  and  the 
normal  gait  is  excessively  active,  and  under  an  uncom- 
monly high  pressure.  This  also  explains  the  rare  occur- 
rence of  the  disease  in  prostitutes,  nothwithstanding  they 
are  frequently  affected  with  syphilis,  the  etioloe^ical  im- 


SYMPTOMS   OF   LOCOMOTOR    ATAXIA.  689^ 

portance  of  which  Edin^er  does  not  seem  to  underesti- 
mate. 

The  existence  of  tabetic  symptoms  in  diabetes  shows 
the  intimate  relation  between  diseases  of  the  spinal  cord 
and  nutrition. 

Mechanical  injuries  are  usually  considered  by  most 
writers  on  this  subject  as  one  of  the  causes  of  tabes  dor- 
salis.  The  cases  in  which  the  disease  has  followed  a  me- 
chanical injury,  or  in  which  there  seemed  to  be  a  relation 
between  an  injury  and  the  development  of  the  disease,  are 
comparatively  few,  and  the  evidence  that  the  mechanical 
injury  caused  the  disease,  or  was  even  a  factor  in  the 
causation,  is  by  no  means  conclusive. 

Hitzig  has  recently  analyzed  sixty-six  cases  in  which 
the  cause  of  the  disease  was  said  to  be  traumatism.  In 
these  sixty-six  cases,  only  ten  or  eleven  met  the  require- 
ments of  sound  criticism.  Hitzig  concludes  from  his  study 
of  these  cases  that  the  occasional  onset  of  the  disease  in 
the  injured  side,  or  the  preponderance  of  the  symptoms 
of  that  side,  are  not  sufficiently  constant  to  warrant  a 
conclusion  of  the  traumatic  origin  of  the  disease;  but,  not- 
withstanding the  great  importance  of  previous  venereal 
infection  in  most  cases  of  tabes,  Hitzig  thinks  that  there 
are  cases  which  show  a  distinct  relation  between  trau- 
matism and  tabes  dorsalis,  and  which  cannot  be  explained 
in  any  other  way. 

In  the  February  number  of  the  Journal  of  Nervous  and 
Mental  Disease,  1895,  Dr.  Morton  Prince  gives  a  very  in- 
teresting and  valuable  article  on  "Traumatism  as  a  Cause 
of  Locomotor  Ataxia."  In  this  article  Prince  describes 
quite  fully  two  illustrative  cases  which  show  the  liability  to 
error  in  arriving  at  a  conclusion  in  this  matter,  when  the 
statements  of  the  patient  are  taken  as  the  basis  for  an 
opinion.  Dr.  Prince  thinks — and  the  point  is  well  illus- 
trated in  the  two  cases  he  reports — that  a  person  may 
have  locomotor  ataxia  for  some  months,  or  even  several 
years,  without  knowing  it,  or  knowing  that  anything  is 


690  W.  H.  RILEY. 

specially  wrong  with  him.  Especially  is  this  apt  to  be  the 
case  when  the  sensory  symptoms  are  in  abeyance.  In  view 
of  this  fact,  Prince  insists  that  the  following  rules  must  be 
rigidly  adhered  to  in  examining  the  evidence  afforded  by 
alleged  individual  cases: 

"i.  The  subject  must  have  been  proved  free  from  tabes, 
either  immediately  before  or  immediately  after  an  acci- 
dent. 

**2.  The  subject  must  be  shown  not  to  have  been  ex- 
posed to  other  known  causes,  as  syphilis,  for  example. 

"3.  The  traumatism  must  have  been  of  a  nature  to 
produce  a  physical  or  psychical  impression  of  an  appreci- 
able degree,  and  not  such  a  one  as  people  are  frequently 
exposed  to  without  suffering  afterward  from  tabes,  e.  g., 
the  extraction  of  a  tooth  or  a  mild  bruise. 

"4.  The  symptoms  must  have  made  their  appearance 
within  a  reasonable  time  after  the  accident — at  least  within  ! 


a  year. 

"5.  The  diagnosis  must  have  been  established  beyond 
a  reasonable  doubt." 

In  this  article  Prince  analyzes  critically  the  evidence 
which  is  given  in  cases  thus  far  reported,  in  which  trau- 
matism was  the  supposed  cause.  He  divides  these  cases 
into  three  classes. 

The  first  class,  consisting  of  twenty-two  cases,  he  con- 
siders inadmissible  on  account  of  the  triviality  of  the  in- 
jury, the  pre-existence  of  syphilis,  long  interval  between 
injury  and  onset  of  symptoms,  doubtful  diagnoses,  etc. 

The  second  class  of  cases,  consisting  of  six,  are  those 
which  cannot  be  excluded,  but  which,  from  various  cir- 
cumstances,  are  questionable  in  evidence. 

The  third  class  are  those  in  which  the  disease  was  ap- 
parently caused  by  traumatism.  Of  these,  there  are  twelve 
cases.  From  those  studied,  Prince  gives  the  following  as 
the  result  of  his  investigation  of  this  subject : 

'Taking  all  the  facts  above  collated  into  consideration, 
it  would  seem  that  the  current  view  that  locomotor  ataxia 


I 


k 


SYMPTOMS   OF   LOCOMOTOR   ATAXIA.  69 1 

may  be  caused  by  traumatism,  per  se,  irrespective  of  direct 
lesion  of  the  cord,  is  not  sustained  by  the  evidence  thus  far 
adduced.  If  such  a  relation  exists,  further  evidence  is 
required  before  it  can  be  accepted.  It  would  seem  to  be 
more  probable,  aside  from  mere  coincidence,  that  when  a 
sclerosis  of  the  posterior  column  develops  after  a  trau- 
matism, the  subject  was  already  doomed  to  this  condition, 
the  process  having  already  begun,  and  that  the  trau- 
matism, at  most,  but  accelerated  the  symptoms,  and,  pos- 
sibly, the  anatomical  process." 

In  the  writer's  opinion,  there  are  two  things,  or  con- 
ditions, necessary  to  the  development  of  this  disease  in 
any  individual.  One  of  these  is  an  organic  predisposition 
to  the  disease;  that  is,  a  neuropathic  condition — a  low 
resistance  in  the  nerve  elements.  The  other  essential  con- 
dition is  the  presence  in  the  blood  and  tissues  of  a  toxin, 
which,  in  a  very  large  proportion  of  cases,  is  of  syphilitic 
origin.  This  toxin,  in  the  case  of  syphilis,  is  constantly 
formed  in  the  body  after  it  once  becomes  infected,  and 
keeps  up  a  continuous  chronic  intoxication  for  a  number 
of  years,  until  finally  the  vitality  of  the  tissues  is  over- 
come, and  the  symptoms  of  tabes  begin  to  appear. 

Other  infections,  both  acute  and  chronic,  have  been 
known  to  cause  this  disease.  Cases  are  on  record  in  which 
tabes  developed  after  infection  from  tubercular  disease 
and  also  from  leprosy.  These  infections,  like  that  of  syph- 
ilis, are  chronic;  that  is,  the  germs  of  the  disease  remain 
in  the  system  for  a  long  period  of  time,  and,  as  the  result 
of  the  life  and  activity  of  these  germs,  ptomaines  are  con- 
stantly formed,  and  consequently  the  system  is  kept  in  a 
state  of  intoxication  for  a  period  of  months,  or  even  years. 
The  disease  may  also  follow  or  accompany  infections  of 
acute  diseases,  such  as  diphtheria,  typhus  and  typhoid 
fever.  It  is  a  well  known  fact  that  in  many  cases  of  diph- 
theria there  is  a  post-diphtheritic  paralysis.  This  is  quite 
frequently  supposed  to  be  due  to  a  neuritis  which  is  the 
result  of  the  action  of  diphtheria  toxins  upon  the  nerve 


692  IV.  H.  RILEY. 

fibres.  This  same  poison  may,  and  does,  in  some  cases  at 
least,  produce  tabes.  In  my  own  experience  I  have  seen 
one  well  developed  case  of  locomotor  ataxia  (tabes  dor- 
salis)  follow  an  attack  of  typhoid  fever. 

There  is,  however,  an  essential  difference  between 
cases  of  tabes  resulting  from  chronic  infection  like  syphilis 
or  tuberculosis,  and  those  of  an  acute  infection  like  diph- 
theria, typhoid  fever,  etc.  In  the  first  instance,  the  dis- 
ease, in  the  large  number  of  cases  at  least,  is  progressive, 
which  is  a  natural  result  if  the  body  is  kept  constantly  in- 
toxicated by  poisons  that  are  formed  by  the  infection  of 
syphilis  or  tuberculosis.  In  the  second  instance,  that  is. 
where  the  disease  develops  from  an  acute  infection,  it 
becomes,  after  a  period  at  least,  regressive;  it  does  not 
continue  to  progress  as  in  the  first  instance.  The  best 
reason  I  can  give  for  this  difference  is  that  in  these  cases 
poisons  are  formed  in  the  body  only  for  a  limited  period 
of  time.  The  germs  of  diphtheria  and  typhoid  fever  re- 
main in  the  system  but  a  few  weeks,  and  consequently  the 
poisoning  continues  only  for  a  limited  space  of  time. 

The  question  will  naturally  arise  in  the  minds  of  some, 
whether  these  cases  of  so-called  tabes  dorsalis  following 
acute  infections,  such  as  typhoid  fever  and  diphtheria,  are 
really  true  cases  of  tabes  dorsalis,  or  whether  the  ataxic 
symptoms  are  due  to  a  multiple  neuritis,  which  frequently 
follows  these  infectious  diseases.  To  this  point  I  have 
but  to  answer  that  cases  of  tabes  dorsalis  have  been  re- 
ported by  those  of  experience  and  careful  observation. 
In  my  own  personal  experience  I  have  seen  only  two  cases 
of  this  kind,  which  appeared  to  me  to  be  cases  of  tabes 
dorsalis,  and  not  multiple  neuritis. 

It  is  as  unreasonable  as  it  is  unscientific,  in  the  light  of 
modern  pathology,  to  suppose  that  a  man  in  the  prime  of 
life,  thirty  years  of  age,  for  instance,  should  be  attacked 
with  a  disease  like  locomotor  ataxia,  which  constantly 
progresses  and  becomes  more  severe  in  character  and 
wider  in  extent,  causing  the  individual  to  stagger  through 


^ 


SYMPTOMS   OF    LOCOMOTOR    ATAXIA.  693 

life,  and  finally  totter  into  the  grave,  except  there  be  in 
the  body  a  cause  that  is  constantly  present  and  active. 
Certainly  no  good  reason  can  be  given  why  in  a  man  in 
apparently  good  health  there  should  begin  to  be  formed 
on  the  posterior  columns  of  the  spinal  cord  a  strip  of 
sclerosed  tissue,  which  constantly  extends  its  borders,  un- 
less, as  said  before,  there  exists  in  the  body  a  cause  that 
is  constantly  acting.  To  say  that  this  might  be  caused  by 
perverted  action  on  the  part  of  the  tissues — a  sort  of  habit, 
as  it  were — is  a  very  poor  and  unsatisfactory  explanation. 
It  does  not  give  any  reason  why  the  disease  should  con- 
stantly progress  as  it  does. 

Besides  the  infections  above  referred  to,  chemical  poi- 
sons may  cause  this  disease.  It  is  well  known  that  poison- 
ing from  ergot,  also  from  lead  and  mercury,  is  frequently 
followed  by  symptoms  of  tabes  dorsalis.  Besides  these, 
poisoning  from  substances  formed  within  the  body  in 
gouty,  rheumatic  and  diabetic  diatheses  is  sometimes  fol- 
lowed by  symptoms  of  locomotor  ataxia.  Locomotor 
ataxia  may  also  follow  pernicious  anaemia. 

I  do  not  believe  that  mechanical  injury,  exposure  to 
wet  or  cold,  overwork,  or  sexual  excesses  without  infec- 
tion can  be  regarded  as  an  exciting  cause  of  tabes  dor- 
salis,  per  se.  None  of  these  influences,  acting  alone  or  in 
conjunction,  could  cause  a  bundle  of  nerve  fibres  to  de- 
generate, and  the  adjacent  connective  tissue  to  increase 
until  a  well  defined,  triangular  band  of  sclerosed  tissue  is 
formed  for  a  greater  or  less  distance  along  the  posterior 
part  of  the  spinal  cord.  That  these  agents  have  some  in- 
fluence in  exciting  the  disease  in  many  cases  is  granted, 
but  their  action  is  in  lessening  the  vitality  of  the  nerve  ele- 
ments, and  preparing  them  for  another  more  active  agent, 
which  I  believe  is  always  a  poison  from  some  of  the  sources 
previously  mentioned.  The  essential  thing  is  a  toxin  in 
the  blood,  which  may  be  a  ptomaine,  a  leucomaine,  or  a 
chemical  poison,  either  organic  or  inorganic. 

Much  valuable  work  has  been  done  recently  with  ref- 


694  ^-  ^  RILEY, 

erenee  to  the  pathogenesis  of  tabes.  The  old  theory, 
which  considered  the  primary  lesion  in  tabes  as  a  degenera- 
tion of  the  posterior  columns  of  the  spinal  cord,  will,  in 
the  light  of  recent  research,  hardly  hold.  That  there  is  a 
degeneration  of  the  nerve  fibres  of  the  posterior  columns 
of  the  cord  is  a  well  established  fact;  but  is  this  primary? 
Or  is  it  the  result  of  another  lesion,  which,  at  least  in  a 
casual  relation,  antedates  it? 

Rindfleisch  ascribes  the  origin  of  tabes  to  a  slightly 
progressive  inflammation  of  the  pia  mater,  which  by  rea- 
son of  tissue  continuity  gradually  extends  to  the  connec- 
tive tissue  of  the  cord,  and  there  forms  an  interstitial 
myelitis,  which  results  in  a  secondary  degeneration  of  the 
nerve  fibre  of  the  cord.  Obersteiner  and  Redlich  have  re- 
cently advocated  a  modification  of  this  idea.  They  have 
attempted  to  determine  the  exact  starting  point  of  the  de- 
generation. By  making  oblique  sections  of  the  spinal 
roots  in  the  direction  in  which  they  enter  the  cord,  they 
have  found  that,  normally,  the  roots  are  constricted  by  a 
circular  band  of  connective  tissue  of  the  pia  mater. 

In  the  early  stages  of  tabes,  the  roots  of  the  spinal 
side  of  the  restriction  are  found  to  be  degenerated;  the 
cause  of  this  degeneration  is  a  hyperplasia  of  the  connec- 
tive tissue,  which  forms  the  constriction.  This  presses  on 
the  nerve  fibre,  and  leads  to  its  degeneration.  The  rea- 
son that  the  nerve  fibres  in  Lissauer's  boundary  zone  of 
the  spinal  cord  differ  so  in  the  disease  is  that  in  the  spinal 
roots  these  fibres  are  located  in  the  periphery,  and  con- 
sequently suffer  most  from  the  constriction.  Nageotte, 
in  the  Societe  de  Biologic,  November  loth,  1894,  gives 
his  views  of  the  primitive  lesion  of  tabes.  He  believes  that 
the  initial  lesion  of  tabes  is  a  perineuritis,  which  affects  the 
posterior  spinal  roots  between  the  spinal  ganglia  and  the 
point  where  the  roots  enter  the  subarachnoid  space.  The 
perineuritis  at  first  partakes  of  the  nature  of  an  embryonic 
process,  but  later  is  fibrous  in  character.  Following  the 
inflammatory  process  is  a  degeneration  of  the  root  fibres. 


SYMPTOMS   OF  LOCOMOTOR   ATAXIA.  695 

which  extends  into  the  posterior  columns  oi  the  cord. 
The  anterior  as  well  as  the  posterior  spinal  nerve  roots  are 
affected  by  the  inflammation;  but,  as  they  seem  to  have 
greater  resistance,  the  motor  nerve  fibres  are  less  liable  to 
degenerate. 

Prof.  Leyden,  as  early  as  1863,  expressed  the  opinion 
that  the  lesion  in  tabes  begins  in  the  posterior  roots,  and 
that  the  degeneration  in  the  posterior  columns  of  the  cord 
is  secondary.  The  researches  of  Obersteiner,  Redlich  and 
Nageotte,  previously  referred  to,  as  well  as  those  of  the 
French  neurologists,  Marie  and  Dejerine,  concur  in  the 
opinion  expressed  so  long  ago  by  Leyden.  As  to  the 
primary  lesion  in  tabes,  Marie,  however,  holds  that  it  is  in 
the  ganglia  of  the  roots,  and  not  in  the  root  fibres. 

It  seems  quite  well  established,  therefore,  that  the  dis- 
ease begins  in  the  posterior  spinal  roots,  either  in  the  nerve 
fibre  or  the  ganglia,  the  nature  of  the  lesion  being  at  first 
inflammatory,  and  affecting  the  connective  tissue,  and, 
later,  degenerative,  affecting  the  nerve  fibres. 

The  nerve  fibres  which  form  the  posterior  column  of 
the  spinal  cord  are  but  the  extension  of  those  which  make 
up  the  posterior  spinal  roots. 

A  lesion  affecting  the  fibres  of  the  posterior  spinal 
roots  would  likewise  affect  those  of  the  posterior  columns 
of  the  cord.  A  lesion  of  the  posterior  roots  would  inter- 
fere with  the  nutrition  of  the  fibres  of  the  posterior  col- 
umns of  the  cord  by  cutting  them  off  from  their  centre  of 
nutrition,  which  is  the  spinal  ganglia  of  the  posterior  roots. 

With  reference  to  the  treatment  of  this  disease,  space 
will  not  allow  a  minute  description.  I  can  make  only  a 
few  general  suggestions.  My  own  practice  for  some  time 
past  has  been  to  direct  the  treatment  along  two  lines,  viz., 
(i)  to  eliminate  poisons  that  are  in  all  probability  being 
constantly  formed;  (2)  to  improve  the  general  health  and 
nutrition  of  the  patient,  special  treatment  being  directed 
to  the  seat  of  the  lesion. 

The  first  of  these  lines  of  treatment,  that  is,  the  elim- 


696  IV.  H.  RILEY. 

ination  of  the  poisons  froni  the  body,  I  believe  can  be  best 
accomplished  by  the  free  use  of  water  internally.  I  usually 
instruct  my  patients  to  drink  from  five  to  seven  pints  of 
water  daily,  and  to  take  it  in  small  quantities  and  at  short 
intervals  between  meals.  This  flushes  the  tissues,  and 
keeps  the  poisons  that  may  be  in  the  body  in  solution, 
thus  favoring  their  elimination.  It  also  increases  the  ac- 
tivity of  the  eliminative  organs.  In  many  cases  it  is  best 
to  have  the  patient  drink  the  water  hot.  Besides  this,  the 
use  of  warm  baths,  particularly  the  electric  light  bath, 
which  is  usually  very  agreeable  to  these  patients,  is  to  be 
highly  recommended.  This  does  good,  not  only  by  the 
elimination  of  poisons,  but  also  by  relieving  the  distressing 
pains,  which  are  so  troublesome  in  this  disease.  By  cor- 
recting all  bad  habits,  prohibiting  the  use  of  tobacco  and 
alcohol,  and  placing  the  patient  on  an  aseptic  diet,  the 
further  intoxication  of  the  body  from  without  becomes 
almost  impossible. 

The  second  indications  for  treatment  are  best  met  by 
the  proper  use  of  hydrotherapy,  electricity  in  its  various 
forms,  massage  and  other  manual  and  mechanical  move- 
ments, including  suspension  treatment.  I  am  satisfied 
from  the  results  of  the  treatment  in  a  large  number  of  cases 
of  this  kind  that  a  great  deal  more  can  be  done  for  pa- 
tients suffering  with  this  disease  than  is  usually  supposed. 
I  do  not  myself  lay  claim  to  any  superior  wisdom  or  ex- 
traordinary skill  in  managing  these  cases;  but  I  believe 
from  my  own  experience  that  when  they  can  be  put  under 
proper  conditions — the  daily  life  of  the  patient  controlled, 
and  the  treatment  above  indicated  intelligently  applied — 
as  much  can  be  accomplished  in  this  malady  as  in  many 
other  diseases  affecting  other  parts,  which  are  generally 
considered  less  intractable. 

It  is  certainly  unjust  to  tell  a  man  suffering  from  loco- 
motor ataxia,  in  the  first  or  second  stage  of  the  disease, 
that  nothing  can  be  done  for  him;  I  have  had  many  cases 
concerning  which  such  statements  had  been  made  by  phy- 


SYMPTOMS   OF   LOCOMOTOR   ATAXIA.  697 

sicians,  and  yet,  after  taking  the  course  of  treatment  as 
indicated,  they  have  materially  improved,  the  disease  being 
checked  in  its  onward  progress,  and  the  patient  put  in  a 
position  where  he  could  be  of  practical  service  to  himself 
and  to  his  friends.  And  this  is  as  much  as,  or  more  than,  is 
done  in  the  treatment  of  numerous  other  diseases  which 
are  not  supposed  to  be  as  formidable  as  tabes  dorsalis. 


221.    EiN   BEITRAO  ZUR   PATHOWXilB  UND  PATHOI.OGISCHEN  ANATOMIE 
DKR       TRAUMATISCHEN       RUCKENMARKSERKRANKUNGEN      (SOGB- 

NANNTE  HXmatomyewe,  secundXre  H6hi*enbii.dung.  (A  Contri- 
bution to  the  Pathology  and  Pathological  Anatomy  of  the  Traumatic 
Diseases  of  the  Spinal  Cord»  etc.)    Lax  and  Miiller   (Deutsche 
zeitschrift  fiir  Nervenheilkunde,  12,  3  and  4). 
A  man  became  paralyzed  in  all  his  limbs  immediately  after  a  fall. 
Complete  anaesthesia  reached  as  high  as  the  axillae.    The  movements 
of  the  head  and  neck  were  not  interfered  with.     Cerebral  or  bulbar 
symptoms  were  not  noted,  and  consciousness  was  preserved  even  im- 
mediately after  the  accident.     Motion  in  the  shoulders  and  elbows 
gradually  became  possible,  but  the  hands  remained  much  paralyzed. 
The  complete  anaesthesia  gradually  changed  to  analgesia  and  thermo- 
anaesthesia.     Tactile  sensation  was  regained  in  the  entire  body.     A 
gradually   developing   atrophy    of   the    interosseous    muscles    of   the 
hands  and  of  the  extensors  of  the  forearms  was  noted.    The  muscles 
of  the  lower  extremities  became  rigid,  and  all  the  tendon   reflexes 
were  exaggerated.     Death  occurred  three  years  after  the  fall. 

The  vertebral  column  was  intact  A  cavity  was  found  in  the 
posterior  part  of  the  cord,  and  was  limited  to  the  fifth  cervical  seg- 
ment. The  lateral  columns  were  sclerosed.  Bands  of  tissue,  consist- 
ing of  glia  fibres,  vessels  and  medullated  nerve  fibres,  were  found 
within  the  cavity,  and  bore  much  resemblance  to  peripheral  nerves. 
Secondary  ascending  and  descending  degeneration  was  noted.  No 
remains  of  a  former  hemorrhage  could  be  observed,  but  the  cavity 
was  believed  to  be  due  to  the  absorption  of  a  hemorrhage  and  dis- 
organized nerve  tissue.  A  recent  case  of  haematomyelia  resulting 
from  fracture  of  the  vertebrae  is  also  noted.  The  writers  believe  that 
the  lower  cervical  region  is  a  frequent  seat  of  spinal  hemorrhage. 
They  think  that  a  force  which  is  sufficient  to  cause  hemorrhage  causes 
injury  also  of  the  nervous  tissue,  not  depending  directly  on  the 
hemorrhage.  The  case  is  important,  as  showing  the  development 
of  syringomyelia  after  trauma.  Spiller. 


ON  REGENERATION  OF  NERVE  FIBRES  IN  THE 
CENTRAL  NERVOUS  SYSTEM/ 

By  W.  L.  WORCESTER,  M.D. 

Dr.  Worcester  read  a  paper  on  this  subject  and  ex- 
hibited photographs  and  specimens.  The  literature  con- 
tained but  few  observations  countenancing  the  belief  that 
such  regeneration  takes  place.  Brown-Sequard  and  Eich- 
horst  and  Naunyn  had  reported  regeneration  with  partial 
restoration  of  function  in  experimental  sections.  Stroebe 
had  reported  growth  of  nerve  fibres  from  the  posterior 
roots  into  the  cicatrix,  and  also  what  appeared  to  be  newly 
formed  fibres  in  the  anterior  and  lateral  columns  after 
division  of  the  spinal  cord  in  rabbits.  Borst,  in  a  case  of 
fracture  of  the  vertebral  column,  after  three  years  found 
medullated  fibres,  which  he  compared  to  amputation  neu- 
romata, and  which  appeared  to  be  outgrowths  from  the 
anterior  and  posterior  nerve  roots. 

The  case  upon  which  the  paper  was  founded  was  that 
of  a  woman,  presenting  paresis  and  partial  anaesthesia  of 
the  left  side,  in  whom,  at  the  autopsy,  the  right  corpora 
quadrigemina  were  found  to  be  in  a  cicatricial  condition, 
probably  resulting  from  thrombosis.  In  the  middle  of 
the  cicatrix  a  group  of  greatly  contorted  bundles  of  me- 
dullated fibres  was  found,  entirely  different  from  anything 
normally  seen  in  that  situation.  The  only  connection  with 
sound  tissue  that  could  be  discovered  w^as  by  a  number  of 
small  bundles  of  fibres  from  the  tegmentum,  in  the  neigh- 
borhood of  the  red  nucleus.  The  general  appearance  was 
very  similar  to  that  of  an  amputation  neuroma,  to  which 
the  author  believed  it  to  be  analogous,  in  view  of  its  dis- 
similarity to  any  normal  structure,  and  the  improbability 

*Read  at  the  twenty-fourth  annual  meeting  of  the  American  Ncu- 
Tolog^ical  Association,  May,  1898. 


REGENERATION  OF  NERVE  FIBRES.  699 

of  its  being  exempt  from  the  destruction  of  the  surround- 
ing nervous  substance  in  that  situation. 

DISCUSSION. 

Dr.  Joseph  CoUins  said  that,  as  he  understood  the  con- 
dition described  by  Dr.  Worcester,  there  was  a  bundle  of 
nerve  fibres  in  the  degenerated  area,  which  Dr.  Worcester  was 
not  able  to  trace  to  any  particular  destination.  He  would  like 
to  ask  if  serial  sections  were  made  aind,  consequently,  at  dif- 
ferent axial  planes.  If  they  had  all  been  made  on  the  same 
plane,  and  the  author  had  been  able  to  trace  the  fibres  for  a 
long  distance,  then  the  interpretation  he  had  put  upon  the 
condition  would  be  justifiable,  but,  if  they  had  not  been  so 
made,  a  bundle  of  undegenerated  fibres,  coming  from  an  origin 
cephdad  to  the  lesion,  and  unimplicated  by  it,  might  have  been 
encountered  in  certain  sections  cut  in  different  planes  from 
other  sections. 

Dr.  Worcester,  in  reply  to  Dr.  Collins,  said  the  sections 
were  all  made  at  the  same  time,  in  an  uninterrupted  series, 
extending  about  three  mm.;  the  abnormal  group  of  fibres  was 
largest  in  the  centre,  and  grew  gradually  smaller  at  both  ends. 
The  speaker  thought  it  absolutely  certain  that  the  condition 
found  did  not  represent  a  normal  tract  of  fibres.  He  had  never 
seen  anything  like  it  in  the  normal  corpora  quadrigemina.  It 
was  either  an  abnormal  growth  existing  previously  to  the 
lesion,  or  a  new  formatian  developed  subsequently.  On  the 
former  hypothesis,  we  must  assume  that  this  abnormal  bundle 
of  fibres  possessed  greater  vitality  than  the  surrounding  nor- 
mal tissues. 


periscope* 


IVith  the  Assistance  of  the  Following  Collaborators: 

Chas,Lewis  ALLEN,M.D.,Wash.,D.C.R.  K.  Macalester,  M.D.,  N.Y. 
J.  S.  Christison,  M.D.,  Chicago,  111.  J.  K.  Mitchell.  M.D.,  Phila.,  Pa 
A,  Freeman,  M.D.,  New  York.  H.  Patrick,  M.D..  Chicago,  111. 

S.  E.  Jelliffe,  M.D.,  New  York.  Joseph  Sailer,  M.D.,  Phila..  Pa. 
Wm.C.Krauss,M.D.,  Buffalo,  N.Y.  Henry  L.  Shively,  M.D.,  N.  Y. 
W.  M.  Leszynsky,  M.D.,  New  York.  A.  Sterne,  M.D.,  Indianapolis. 


ANATOMY  AND  PHYSIOLOGY. 

222.  Cortical  Localization  in  Animals.    British   Medical  Journal, 

November  20th,  1897. 

Wesley  Mills,  of  Montreal,  after  a  very  full  series  of  experiments, 
reaches  important  conclusions  as  to  differences  of  cerebral  localization 
in  the  lower  animals,  conclusions  that  are  suggestive  not  only  as  to 
the  evolution  of  cortical  representation  of  definite  movements,  but  as 
to  localization  in  the  human  brain.  For  instance,  he  finds  no  defined 
centre  for  the  hind  limbs  of  the  rabbit,  and  in  this  connection  remarks 
that  the  method  of  locomotion  in  rabbits  is  peculiar,  and  not  com- 
parable to  that  of  the  rat,  guinea  pig,  etc. 

He  comes  to  the  following  gejieral  conclusions: 

In  the  dog,  cat,  rabbit,  cavy,  rat  and  mouse  electrical  stimulation 
of  the  cerebral  cortex  over  definite  regions  produces  regularly  certain 
movements.  These  animals  are,  however,  not  on  the  same  physiologi- 
cal plane  with  regard  to  this  subject.  The  dog  and  the  cat  are  more 
closely  related,  and  fall  into  a  physiological  group  by  themselves. 
The  rabbit,  the  cavy,  the  rat  and  the  mouse  constitute  another  grroup. 
There  are  well  defined  differences  for  the  cat  and  the  dog.  The 
same  applies  to  the  members  of  the  other  group.  In  the  cat  and  the 
dog  the  motor  areas  are  better  defined  than  in  the  members  of  the 
other  group. 

In  the  case  of  all  these  animals  it  has  been  clearly  demonstrated 
that  all  motor  centres  are  not  functional  equivalents — some  respond 
more  readily  and  produce  better  defined  results  than  others.  They 
seem  to  be  better  organized.  There  appear  to  be  all  degrees  of 
this  functional  variation  down  to  zero.  The  rabbit  is  an  especially 
good  illustration  of  some  phases  of  this  principle. 

The  cortical  localization  mapped  out  by  Ferrier  for  the  dog,  cat, 
rabbit,  cavy  and  the  rat  is  in  the  main  confirmed  by  the  present  in- 
vestigator, but  considerable  allowance  must  be  made  for  individual 
differences,  and  it  is  important,  as  has  been  just  pointed  out,  to  recog- 
nize that  all  motor  centres  in  the  same  animal  are  not  functionally 
equivalent  in  the  sense  explained  above. 

The  removal  of  motor  centres  in  the  animals  made  the  subject 
of  this  investigation  does  not  lead  to  complete  loss  of  the  correspond- 


PERISCOPE.  JO  I 

ing  movements,  and  in  some  cases  the  difference  between  the  intact 
animal  and  that  operated  on  is.  after  a  few  days,  relatively  slight;  so 
that  it  is  plain  that  motor  centres  in  such  animals  are  not  strictly 
comparable  with  motor  centres  in  the  primates.  In  other  words,  here 
again  the  question  of  degree  of  localization  and  functional  organiza- 
tion (among  others)  must  be  considered. 

The  bird  is  on  a  .wholly  different  plane.  None  of  the  ordinarily 
recognized  movements  on  stimulation  of  the  cerebral  cortex  can  be 
excited  in  the  bird.  On  the  other  hand,  certain  eye  movements,  both 
intrinsic  and  extrinsic,  follow  as  a  result  of  stimulation  of  the  cortex. 

Patrick. 

223.  Rbchbrchbs  cuniques  sur  l'alcai«bscencb  du  sang  et  i«es 
injections  de  soi^utigns  alkaunbs  chez  i,es  epii*eptiques 
(Clinical  Researches  on  the  Alkalinity  of  the  Blood,  etc.).  R. 
Charon  et  E.  Briche  (Arch,  de  Neurologie,  4,  1897,  p.  465). 

The  author  comes  to  the  following  conclusions  as  the  results  of  a 
series  of  experimental  researches: 

1.  In  epileptics  in  the  course  of  each  quotidienne  revolution  the 
degree  of  alkalinity  of  the  blood  is  modified  regularly  with  minimum 
and  maximum  amounts  corresponding  with  the  digestive  operations. 

2.  The  convulsive  attacks  present  nearly  constant  variations, 
isochronous  and  in  inverse  relationship  to  the  variations  of  the  al- 
kalinity of  the  blood. 

3.  Repeated  injections  of  alkaline  solutions  do  not  modify  in 
any  permanent  measure  the  grade  of  alkalinity  of  the  blood.  It 
produces  but  a  temporary  rise  in  this  alkalinity,  which  disappears 
within  an  hour,  and  during  which  no  convulsive  attacks  are.  present. 

4.  Injections  would  seem  to  diminish  isolated  attacks  and  to 
augment  those  which  appear  in  a  series.  The  total  number  of  attacks 
is  not  diminished. 

5.  The  injections  seem  to  augment  the  post-epileptic  psychical 
manifestations,  and  in  certain  cases  provoke  delirious  or  maniacal 
attacks.  Jelliffe. 

224.  Recherches  experimentalhs  sur  la  thyroidine  (Experi- 
mental Investigations  on  Thyroidine).  Barteit  (Sitzungsb.  d. 
Naturf.  Ges.  z.  Inojew,  1896,  p.  123). 

The  author,  exoerimenting  on  himself  and  on  animals  with  prep- 
arations of  thyroidine,  in  powder  form  and  alcoholic  solution,  reports: 

I.  Personal  experiments.  The  ingestion  of  0.006  gr.  of  pure 
thyroidine  gives  rise  to  a  considerable  diuresis,  due  in  all  probability 
to  increased  combustion  of  the  carbohydrates,  fatty  substances,  and 
albuminoids.  There  were  no  abnormal  manifestations,  nor  increase  in 
the  pulse  rate. 

II.  Experiments  on  animals.  Even  in,  large  doses  there  was  no 
evidence  of  toxic  symptoms,  and  the  diuretic  action  was  but  slight. 

III.  Investigations  on  isolated  organs  with  artificial  circulation. 
Thyroidine  has  no  influence  on  the  blood-pressure  in  cats,  nor  on 
the  cardiac  movements  in  frogs.  In  0.006  gr.  doses  there  was  no 
action  on  the  renal  vessels,  and  consequently  no  increase  of  urine  se- 
cretion in  oxen. 

Conclusions.  The  author  considers  thyroidine  as  the  best  toler- 
ated, the  least  noxious,  and  the  most  constant  preparation  of  the  thy- 
roid gland.  It  is  not  a  real  diuretic,  its  action  upon  the  secretion  of 
urine  being  indirect.  It  may  be  prescribed  with  benefit  in  obesity,  in 
which  metabolism  is  sluggish,  and  in  all  cases  in  which  the  function 
of  the  thyroid  gland  is  impaired.  Macalester. 


702 


PERISCOPE. 


CLINICAL  NEUROLOGY. 

225.  On  a  Case  of  Acxtte  Myewtis.    Dr.  Jaccoud  (Medical  Week, 

September  17th,  1897). 

Dr.  Jaccoud  discusses  the  diagnosis  of  hemorrhage  into  the  cord 
in  the  report  of  a  case  in  which  the  mistaken  diag^iosis  was  not  re- 
futed until  the  post-mortem  examination.  The  patient  suffered  a 
sudden  chill  when  perspiring  freely,  and  eighteen  or  twenty-four 
hours  afterward  found  that  he  could  not  pass  water;  no  other  symp- 
toms had  preceded  this  trouble.  On  the  same  day  his  legs  began 
gradually  to  grow  weak,  until  there  was  complete  paraplegia,  twenty- 
four  hours  after  the  retention  began.  On  the  third  day  an  ulcer 
of  small  dimensions  appeared  on  the  sole  of  the  right  foot  Two 
other  ulcers,  one  on  the  trochanter  and  one  on  the  buttock,  followed 
quickly,  both  on  the  right  side.  The  rapidity  of  onset  was  the  point 
upon  which  the  diagnosis  rested,  and  the  immediate  appearance  of 
atrophic  symptoms  only  added  force  to  the  probability  of  the  diag- 
nosis of  haematomyelitis.  The  patient's  history  being  absolutely  good 
in  respect  to  intoxication  or  infection  of  any  kind  rendered  it  probable 
that  the  original  cause  was  the  sudden  chill,  and  that  alone.  He  had 
no  fever,  and  no  symptoms  other  than  those  which  were  due  to 
pressure  in  the  lumbar  portion  of  the  spinal  cord.  There  was  no  dis- 
turbance of  sensation  whatever,  the  skin  reflexes  were  not  affected, 
but  the  tendon  reflexes  were  abolished.  The  preservation  of  sensation 
is  rare  in  such  cases,  and  would  certainly  have  been  very  ex- 
traordinary had  signs  of  hemorrhage  been  found  in  the  cord.  It 
was  only  to  be  explained  by  the  supposition  of  Brown-Sequard  that 
the  posterior  white  tracts  might  convey  sensation  when  the  posterior 
gray  substance  had  been  destroyed.  Dr.  Jaccoud  concluded  the  dis- 
eased regions  were  the  white  anterior  and  lateral  columns  and  the 
anterior  and  posterior  gray  matter.  A  sudden  ascending  degeneration 
carried  off  the  patient  within  a  few  hours  by  implication  of  the  res- 
piratory centre,  and  the  somewhat  unsatisfactory  statement  is  made 
that  the  postmortem  discovered  a  "focus  of  softening  in  the  dorso- 
lumbar  region  of  the  spinal  cord,  measuring  about  seven  centimetres 
in  length."  No  trace  of  hemorrhage  could  be  detected.  Bacteriologi- 
cal examination  showed  the  presence  of  streptococci  and  staphylo- 
cocci, but  no  suggestion  is  made  as  to  the  manner  in  which  the  mi- 
crobes gained  entrance  to  the  organism.  It  is  a  curious  omission 
in  the  report  of  the  case  that  more  details  should  not  be  given  as 
to  the  distribution  of  the  focus  of  softening,  as,  in  view  of  the  ante- 
mortem  statements  of  the  regions  probably  diseased,  comparison 
would  be  interesting.  Mitchell. 


Cocaine  Discoids  "soieffenn's"  i 

The  Safest,  Most  Efficient,  and  Convenient  Means  1 
for  'Producing  Local  Anaesthesia.  i 


material  to  impair  its  activity,  and  In  qnantities  accurately  determined  by  weigbL    Onriogti 

tbeir  mode  of  numnfacture,  not  beiag  campressed,  theydissolTe  readily  in  one  drop  of  water. 
Instead  of  keeping  on  haad  ready^oade  solutions,  wbich  are  liable  to  detenorate,  the 

doctor  has  now  at  his  disposal  a  means  of  obtaining 

Freshly  Prepared  Cocaine  Solutloiu  of  Any  Desired  Strength 

at  a  moment's  notice,  and  the  quantity  of  the  drug  employed  during  ancesthesia  is  always 

known,  and  not  a  matter  of  conjecture- 
Cocaine  Discoids  are  indicated  in  all  conditions  demanding  the  use  of  this  drug,  as  a 

local  antestbetic,  as  in  the  treatment  of  diseases  of  the  eyes,  nose  and  thruat,  in  general 

surgery,  and  in  dentistry,  especially  for  cataphoresiH. 

Diftcoida  containing  |  gr.  .14  .50 

"  "  Igr-  .15  .55 

"  "  1  gr.  .16  .60 

"  "  j  gr.  .18  .70 

Cocaine  Discoids  are  manufactured  steely  by 

Schkffetin  8  Co.,  New  York. 

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i-»'-I"f  •  •»"?'■»  "T"1"f"f"f  "f"f"1"f"    "I  "f  ■'¥'■»'■»■■»'■»"¥"?'■?■■?■ 'ft  "fTy 


Schieffelin's 


cAlkaline  cAntiseptic  and  Prophylactic. 

Bensolyptus  is  an  agreeable  alkaline  solution  of  various  highly 
approved  antiseptics,  so  combined  that  one  sapplements  the  action  of 
the  other.    Its  ingredients  are  all  of  recognized  value  in  the  treatment 

Catarrhal  c4ffections 

because  of  their  cleansing,  soothing,  ami  healing  properties.  Benso- 
lyptus is  highly  reatmmended  in  all  diseases  of  the  nose  and  throat, 
bath  acute  and  chronic,  and  as  a  mouth-wash  and  dentifrice.  It  is 
also  indicated  for  internal  use  in  affections  of  the  stomach  and  intes- 
tates 'ojhere  an  agreeable,  unirrttating,  and  efficient  antiseptic  and 
aniifermentative  is  required. 
Famphlets  on  apoUcaUon  to 

Schieffelin  &  Co.,  New  York. 


PiL  Astiflcptk. 

9  Salphite  Soda,    i  gr. 
Salimic  Acid,     i  gr. 
Ktuc  Vomica,      ^  gr. 
1-3. 


PIL  Airtiseiitic  U. 

Bt  Sntphite  Soda,  i  gr. 
Salicylic  Add,  i  gr. 
Nmc  vomica,  H  gr. 
Fowd.  Capsic  i-io  gr. 
Concen«  Pepsin,  i  gr. 
Doae— 1-3 

Pilt  Antiseptic  and  Pilt  Antiseptic  Ck>. 

For  Indigestioiit  Malassimilation  of  Foodt 

Dyspepsia,  etc. 

Will  produce  marked  improvement  in  cases  of  gastric  debility.  Prescribed  for  those 
patients  who  do  not  appear  to  derive  full  benefit  from  their  food.  Morning  doses  of 
Aperient  Saline  (Warner  &  Co.),  a  pleasant  eflfervescent  salt,  may  be  used  to  advan- 
tage in  connection  with  Pil.  Antiseptic  and  Pil.  Antiseptic  Comp.  for  its  gentle 
aperient  effect. 


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Nutrient  Wine  is  more  of  a  food  than  a  stimu/ 

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1 


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TTbe  View  iporli  Deuroloaical  Sodeti?  ant) 

Zbc  pbiIa^eIpbia  neurological  Sodeti? 


EDITORS 

Dr.  CHARLES  L.  DANA  Dr.  HUGH  T.  PATRICK 

Or.  P.  X.  DERCUM  Dr.  JAS.  J.  PUTNAM 

Dr.  CHAS.  K.  MILLS  Dr.  B.  SACHS 

Dr.  M.  ALLEN  STARR 

ASSOCIATE   EDITOR 

Dr.  WILLIAM  Q.  5PILLER 

MANAQINQ  EDITOR 

Dr.  CHARLES  HENRY  BROWN 
S5  W.  45th  5trMt,  New  York 

TABLE  OP  CONTENTS  ON  PAGES  U.  AND  iv. 

POREIQN  AND  DOMESTIC  AQENTS 

Bmkhmxd  Bcnuna,  TbaMnrnt  s,  JMvU[y  Gennany.   S.  Kjkrger,  Charitestr.  3,  Berlin,  Germany 
Trittmer  &  Gcw,  I«ndgate  Hill,  I^ndon.    B*  Steiger  &  Co.,  35  Park  Place, 
New  York.     B.  Westennann,  Sia  Broadway,  New  York. 
GustaTC  B.  Stechert,  9  B.  x6tb  Street  New  York. 

ISSUBD  MONTHLY  $3.00  PER  YEAR 

Entered  at  the  Post-Office  in  New  York  as  Sccond-Clasi  Matter. 

Copyright,  1898. 


tL  .oJmt^*^  JW-**^^  ****** 


VOL.   XXV.  October,  1898.  No.  10. 


THE 


Journal 


OF 


Nervous  aad-'Mefftal  Disease 

©visual  ^vticlcs. 


.•' 


ON  SCLERODERMA  AND  CHRONIC  RHEUMA- 
TOID ARTHRITIS.* 

By  F.  X.  DERCUM,  M.D., 

Clinical  Professor  of  Nervous  Diseases  in  the  Jefferson  Medical  College, 

Philadelphia. 

Our  knowledge  of  some  of  the  trophic  diseases  is  as 
yet  so  obscure  that  new  observations  concerning  them  can- 
not but  be  of  value.  Several  of  them,  especially  acromegaly 
and  myxcedema,  have  in  the  past  few  years  received  a 
large  share  of  attention.  Scleroderma,  on  the  other  hand, 
has  not  been  studied  to  the  extent  that  its  importance 
deserves.  This  is  also  true  of  that  other  obscure  disease, 
chronic  rheumatoid  arthritis.  Repeated  observations  have 
convinced  me  that  as  regards  scleroderma,  our  conception 
is  as  yet  too  limited.  Our  point  of  view  has  in  the  past 
undergone  several  important  changes.  The  first  was  the 
recognition  that  all  forms  of  local  scleroderma  and  general 
or  diffuse  scleroderma  are  one  and  the  same  affection. 
The  second  consisted  in  the  recognition  of  the  fact  that 
the  disease  process  is  not  necessarily  limited  to  the  skin, 
but  may  include  other  structures  as  well.     In  a  paper,^ 


*Read  at  the  twenty-fourth  annual  meeting  of  the  American  Neu- 
rological Association,  May,  1898. 

•Journal  of  Nervous  and  Mental  Disease,  July,  1896. 


704  ^-   ^'   DERCUM, 

read  some  two  years  ago  before  the  Neurological  Section 
of  the  New  York  Academy  of  Medicine,  I  laid  emphasis 
upon  the  fact  that  tendons,  muscles,  fasciae,  bones  and 
joints  may  also  become  involved.  That  this  involvement 
of  tissues  other  than  the  skin  may,  in  rare  instances,  be 
excessive,  there  can  be  no  doubt.  Indeed,  the  question 
arises  whether  they  may  not  at  times  exceed  those  in 
the  skin.  The  changes  in  the  latter  have  so  long  been 
regarded  as  the  primary  and  all-important  features  of  the 
disease,  that  changes  in  other  structures  have  not  only 
been  looked  upon  as  secondary,  but  even  as  dependent 
upon  the  changes  in  the  skin.  Thus,  most  writers  refer 
the  restricted  movements  of  joints  or  the  atrophy  of  bone, 
as  seen  in  the  fingers  in  sclerodactyle,  to  the  contracture 
of  the  overlying  dermal  structures  and  to  the  interference 
with  nutrition  thus  produced.  For  instance,  the  impair- 
ment of  movement  in  the  fingers,  of  the  wrist  and  of  the 
elbows,  appears  in  many  cases  to  be  directly  dependent 
upon  the  contraction  of  the  skin.  In  sclerodactyle,  again, 
the  fingers  become  for  the  most  part  thin  and  tapering, 
and  when  such  cases  are  skiagraphed,  we  may  find  that 
the  phalanges,  especially  the  distal  phalanges,  have  be- 
come decidedly  pointed  or  sharpened,  as  though  they 
were  undergoing  atrophy.^  In  such  cases  the  atrophy  of 
the  bone  appears  to  be  general,  and  it  does  not  seem  un- 
reasonable to  suppose  that  the  changes  in  the  bones  are 
directly  dependent  upon  the  changes  in  the  skin.  The 
latter  may  be  dense,  hard  and  contracted,  and  may  inter- 
fere greatly  with  the  blood  supply  of  adjacent  structures. 
We  should  bear  in  mind,  however,  that  changes  may  occur 
in  phalanges  when  the  skin  is  not  hard  and  contracted, 
but  merely  thin  and  atrophic.  This  was  true  of  a  case 
studied  by  me  several  years  ago,  and  which  I  have  already 
reported.^  In  this  case  the  proximal  and  middle  phalanges 


*  Loc.  cit.  Addendum. 

*  Loc.  cit. 


CHRONIC  RHEUMATOID  ARTHRITIS. 


705 


of  the  little  finger  of  the  left  hand  had  almost  entirely  dis- 
appeared, while  the  skin  was  much  wasted  but  not  infil- 
trated, the  finger  being  abnormally  mobile  because  of 
the  loss  of  bone.  Many  of  the  phalangeal  joints  also  were 
ankylosed,  the  ankylosis  being  evidently  due  to  fixation 
of  the  joints  independently  of  the  changes  in  the  atrophic 
skin.  Again,  that  changes  occur  in  the  bones  of  the  fingers, 
independent  of  contracture  and  atrophy  of  the  skin,  is 
proven  beyond  all  doubt  by  the  following  case. 

Case  I. — A.  G.;  female;  married;  aged  44  years;  house- 
keeper. 

Family  history,  negative;  father,  mother,  several  brothers 
and  sisters  all  living  and  well;  no  history  of  nervous  or  skin 
affections. 

Personal  History.— -Was  perfectly  well  as  a  child  and 
young  girl;  lived  out  as  a  servant;  was  compelled  to  do  a 
great  deal  of  washing,  and  frequently  worked  in  the  open  air 
with  her  hands  and  face  exposed,  while  wet,  to  intense  cold; 
menstruated  at  fourteen;  married  at  thirty  years,  but  never 
became  pregnant. 

When  twenty-six  years  of  age,  she  noticed  that  the  middle 
and  ring  fingers  of  the  right  hand  were  becoming  stiff  .and 
swollen,  and  that  this  condition*  was  more  marked  at  times. 
A  little  later  the  affection  made  its  appearance  in  the  corre- 
sponding fingers  of  the  opposite  hand,  and,  finally,  all  the 
fingers  and  both  thumbs  became  involved.  Very  soon  the 
stiffness  and  swelling  became  decided,  and  the  fingers  became 
chronically  swollen  and  thickened,  so  that  it  was  impossible 
to  flex  or  extend  them  in  the  normal  manner.  About  this 
time  also  the  face  became  hardened  and  stiffened.  Distinct 
swelling  does  not  appear  to  have  been  present.  There  ap- 
peared to  be  merely  an  infiltration,  followed  by  a  gradual 
shrinking  of  the  skin.  The  lips  became  much  thinner,  while 
the  skin  of  the  cheeks  and  forehead  was  tense.  Gradually, 
also,  infiltration  of  the  skin  of  the  back  of  the  feet,  and  slightly 
of  the  toes,  became  noticeable.  This,  however,  has  never  been 
as  marked  as  in  the  hands. 

At  various  times  small  trophic  ulcers  made  their  appear- 
ance upon  the  first  phalangeal  joint  of  the  little  finger,  and, 
after  having  existed  for  some  time,  slowly  healed.  Gradually 
the  finger  ends  became  more  swollen  than  the  rest  of  the 
finger,  so  that  the  latter  became  club-shaped.  At  the  same 
time  the  tips  of  the  fingers  became  shorter.    Ulcerations 


706  F-   X.   DERCUM. 

frequently  occurred  about  the  root  of  the  nails.  The  nails 
became  shortened  and  flattened.  Upon  one  digit,  the 
right  forefinger,  the  nail  was  lost  altogether.  These  ul- 
cerations, the  patient  states,  were  always  very  painful. 

Some  time  ago  the  teeth  of  the  upper  jaw  gradually 
loosened,  one  by  one.  and  had  to  be  removed. 

In  other  respects  her  health  has  been  fairly  good.  She 
has  suffered  at  times  from  mental  depression,  ami  quite  fre- 
quently from  heaclache.  \'ertigo  and  tinnitus  were  not  at  any 
time  present. 

Menstruation,  which  had  been  regular  and  normal  up  to 


two  years  ago,  had  ceased  at  that  time,  and  had  not  since 
returned. 

Status  Praesens. — Patient  presents  the  facies  of  sclero- 
derma. The  skiji  of  the  cheeks,  forehead  and  lips  is  tensely 
drawn.  The  forehead  presents  an  erythematous  flush.  Per- 
sistent pressure  produces  marked  pitting  over  the  forehead- 
No  pitting  can  be  elicited  over  the  rest  of  the  face.  When 
the  patient  talks  or  smiles,  it  is  readily  seen  that  the  mouth 
is  much  contracted:  the  lips  become  tense  ai»d  thin.  TTiere 
is  decided  palor  of  the  tongue,  roof  of  the  mouth  and  fauces. 

There  are  no  changes  in  the  tnmk  or  limbs  other  than 


CHRONIC  RHEUMATOID  ARTHRITIS. 


707 


chose  described,  save  in  the  skin  over  both  shoulders,  which 
is  somewhat  infihrated  and  hard.  There  is  everywhere  an 
absence  or  diminution  of  the  superficial  fat.  In  the  hands 
there  is  slig^ht  infihration  of  the  dorsum  and  very  marked  in- 
filtration of  the  fingers  and  thumbs.  The  fingers  are  more  or 
less  fixed  in  the  semi-flexed  position,  and  are  thick,  sausage- 
shaped  or  club-shaped.  The  distal  phalanges  are  evidently 
shortened  by  atrophy.    .All  of  the  fingers  reveal  traces  of  pre- 


FiG.  11.     Skiagraph  of  the  fingers  of  the  right  hand  showing  chaagea 
in  the  distal  phalanges. 

vions  ulceration  in  the  matrix  of  the  nail,  save  the  little  fingers, 
the  nails  of  which  are  apparently  normal.  On  the  forefinger 
of  the  right  hand  the  nail  has  been  entirely  lost,  a  scar  of  the 
matrix  only  being  left.  An  ulceration  is  at  present  active  at 
the  root  of  the  nail  of  the  left  thumb.  This  ulcer  is  exceed- 
ingly painful.  Tactile,  thermal  and  pain  senses  are  every- 
where preserved.    Knee-jerks  arc  not  changed.    An  examina- 


7o8  ^   X.   DERCUM. 

tion  of  Che  blood  failed  to  reveal  any  evidences  of  leucocy- 
tosis.    Examination  of  the  urine,  negative. 

Some  two  months  after  the  first  examination  the  patient 
again  presented  herself  with  an  ulcer  over  the  left  olecranon, 
while  extreme  ulceration  had  recurred  on  the  fingers.  Ulcers 
were  present  on  all  of  the  fingers,  the  little  fingers  being  this 
time  also  affected.  The  ulcers  involved  the  matrix  of  the 
nails  and  also  the  tips  of  the  fingers.  They  were  all  very 
painful. 

Seen  again  four  months  later,  the  ulcers  were  evidently  in 
process  of  healing.  The  little  fingers  had  become  much  con- 
tracted, and  the  mouth  was  also  more  drawn.  Backache  was 
also  complained  of,  and  the  general  health  had  evidently  be- 
come much  impaired.  The  patient  complained  also  of  cold 
sensations  and  occasional  flushes. 


Ftc.  III.    Skiagraph  of  the  left  thumb  and  forefiDger. 

In  this  case  the  changes  in  the  face  were  so  typical  that 
there  could  be  no  doubt  as  to  the  nature  of  the  affection.  The 
face  was  drawn,  the  cheeks  flattened,  the  angles  of  the  mcuth 
slightly  drooping  and  the  lips  contracted.  The  hands  were 
also  in  a  condition  of  sclerodactyle.  All  of  the  digits  were 
fixed  and  rigid,  but  instead  of  being  pointed  and  showing  ex- 
cessive contracture  and  atrophy  of  the  skin,  they  were,  as  is 
seen  in  the  photograph  (Fig.  I.),  enlarged,  bulbous  and  sausage- 
shaped.  Ulceration,  as  has  already  been  described,  had  taken 
place  in  the  tips  of  the  digits  and  thumbs,  with  loss  of  the  soft 
tissue  and  also  with  loss  of  some  of  the  nails.  When  these 
fingers  were  skiagraphed  (Figs.  II.  and  HI,),  a  most  interest- 
ing condition  of  the  l>ones  was  revealed.  The  changes  were 
limited  to  the  distal  phalanges.  There  was  not  the  general 
sharpening  and  wasting  shown  in  the  first  case  skiagraphed 


CHRONIC  RHE  UMA  TO  ID  A  R  THRITIS.  709 

by  me*,  but,  instead,  there  had  ensued  a  g^oss  and  very  de- 
cided loss  of  bony  tissue,  and  in  several  of  the  digits,  for  ex- 
ample  the  thumbs,  in  which  the  nails  had  been  fairly  well 
preserved,  and  in  which  there  had  been  no  wasting  of  the  pulp 
of  the  tip,  very  striking  changes  were  revealed  in  the  bones. 
The  changes  were  of  such  a  character  as  to  justify  no  other 
inference  than  that  they  were  trophic  in  character.     In  this 
cofmection  it  is  interesting  to  recall  the  fact  that  Wolters  de- 
scribed, in  a  case  of  sclerodactyk,  which  he  examined  micro- 
scopically, an  interstitial  inflammaition  of  the  phalangeal  bones. 
As  is  well  known,  symptoms  suggesting  Raynaud's  disease  are 
every  now  and  then  observed  in  sclerodactyle.     In  this  case, 
however,  no  such  symptoms  were  present,  and  there  was  no 
History  suggesting  vascular  crises.     The  case  is  further  in- 
teresting because  the  trophic  changes  in  the  fingers  strongly 
call  to  mind  those  of  Morvan's  disease.     From  the  latter  af- 
fection, however,  it  is  sharply  defined  by  the  absence  of  all 
sensory  losses,  all  forms  of  cutaneous  sensibility  being  pre- 
served, and  by  the  presence  of  pain  in  the  ulcers. 

The  following  case  which  must  be  placed  under  the 
caption  of  rheumatoid  arthritis — whatever  that  may  be^ — 
presents  a  number  of  features  pointing  strongly  to  sclero- 
derma,  and  suggesting  a  similarity  in  the  pathological 
changes  at  work.  The  case  is  specially  interesting  when 
"vre  reflect  that  it  is  not  improbable  that  under  chronic 
rheumatoid  arthritis,  two  or  more  clinical  entities  may 
"be  confused. 

Case  II. — E.  McG.,  male;  aged  28;  born  in  this  coun- 
try; inmate  of  nervous  wards,  Philadelphia  Hospital. 

Family  History. — Father  died  of  pneumonia  at  46;  mother 
living  and  well ;  one  brother  and  three  sisters  living  and  well ; 
one  brother  and'  two  sisters  died  in  infancy;  no  history  of 
rheumatic,  skin  or  nervous  affections  in  the  family. 

Previous  History. — Was  well  during  childhood,  save  that 
he  frequently  had  attacks  of  croup;  also  had  measles;  fre- 
quently suffered  from  headache;  had  good  health  otherwise 
up  to  fifteen  years.  At  that  time  had  a  swelling  of  the  right 
knee,  which  confined  him  to  bed  for  one  week ;  the  attack  was 
not  accompanied  by  pain.  It  was  pronounced,  according  to 
patient's  statement,  to  be  "rheumatism  and  white  swelling.*' 
One  year  later  the  swelling  recurred,  and  he  was  confined  to 


•  Loc.  cit.  Addendum. 


7IO  /•'.   X.   DERCUM. 

bed  two  weeks.  One  and  a  half  years  later  tlie  attack  again 
recurred:  this  time  it  lasteti  three  months,  and  was  accom- 
panied by  pain.  Seven  months  later,  in  June,  1887,  he  suf- 
fered frcMii  another  attack.  The  right  ankle  began  to  swell, 
and  became  painful,  so  that  lie  could  not  walk.  This  time  the 
attack  lasted  three  weeks,  but  subsequently  he  became,  as  he 
thought,  entirely  well.  Some  time  later,  however,  he  began 
to  feel  stif!  all  over;  had  (xrcasional  "catching"  of  the  muscles 
of  the  left  tiiigli.  Iialf  way  between  hip  and  krvee.  He  would 
be  so  stiff  at  times  that  he  could  not  walk.  His  general 
strength  also  suffered  severely ;  weakness  became  marked.  In 
about  a  year — 1888 — he  was  able  to  use  his  legs  bnt  little  on 
account  of  stiffness,  though  this  stiffness  varied  considerably 
from  dav  to  dav.     licith  feet  also  became  somewhat  swollen 


Flu.  IV.    (Case  i.)    Showing  general  position  of  limbs. 

in  the  daytime,  the  swelling  disappearing  on  going  to  bed. 
His  arms,  neck  and  back  also  began  to  get  stiff  about  this 
time,  and  these  symptoms  gradually  grew  worse.  He  was 
treated  at  various  times  with  massage,  but  passive  movements 
gave  him  pain.  I'"or  a  time,  in  1894.  his  hands  were  swollen, 
bnt  this  swelling  subsef]uently  disappeared.  About  this  time, 
also,  he  suffered  severely  from  neuralgic  pains  in  the  head. 
Little  by  little  the  stiffness  increase<l,  until  his  limbs,  hands 
and  feet  became  more  or  less  fixed  in  ]X)sition.  About  three 
years  ago  the  skin  of  tlie  legs  became  smooth  and  shiny,  and 
subsequently  the  skin  in  other  situations  assumed  a  similar 
character.  About  this  time,  also,  the  jaw  became  quite  stiff. 
He  has  not  been  able  to  feed  himself  for  five  years.  He  has 
been  unable  to  walk  cr  even  stand  tip  for  eight  years. 


CHRONIC  RHEUMAWIU  ARTHBITJS.  711 

Status  Pnesens. — Patient  lies  extended  upon  his  back  in 
bed.  Some  diffuse  muscular  wasting,  with  loss  of  superficial 
fat,  has  evidently  taken  place.  No  local  muscular  atrophies 
are,  however,  apparent.  Both  legs  are  in  a  position  of  ex- 
tension, the  feet  in  extreme  extension.  The  amount  of  volun- 
tary movement  in  the  legs  is  extremely  limited.  The  patient 
is  able,  by  the  action  of  the  thigh  muscles,  to  move  legs  up- 
ward to  an  extremely  limited  degree — a  mere  fraction  of  an 
inch.  On  attempting  to  make  passive  movements  with  either 
leg,  it  is  found  that  the  ankle  joint,  tarsal  and  metatarsal  and 


F[o.  V.     Right  hand  in  Case  3. 

knee  joints  are  absolutely  fixed.  There  is  also  fixation  of 
both  hip  joints,  though  here  the  fixation  is  not  absolute.  Very 
slight  movement  in  antero-posterior  direction,  as  just  stated, 
can  still  be  made.  On  attempting  lateral  movement,  however, 
the  limbs  cannot  be  moved  without  moving  the  entire  pelvis. 
The  right  knee  joint  is  decidedly  enlarged,  the  patella  quite 
prominent.  The  circumference  of  the  right  knee  joint  is  12S 
inches,  of  the  left  knee  joint  i  if  inches.  The  right  leg  is  not  so 
completely  extended  as  the  left;  it  is  very  slightly  flexed  at  the 
knee.  The  right  foot  is  fixed  in  extension;  its  toes  are  in  a 
position  of  marked  abduction  and  slight  flexion.     The  right 


712 


F.   X.   DERCUM. 


tarsus  is  thickened.  The  left  foot  is  also  fixed  in  extension;  its 
great  toe  is  extremely  flexed,  but  not  abducted  or  adducted;  its 
second  toe  is  markedly  adducted  and  crossed  over  the  great 
toe;  the  remaining  toes  of  the  left  foot  are  slightly  adducted, 
and  neither  flexed  nor  extended. 

The  arms  are  extended,  but  not  completely  so.  There  is 
absolutely  no  movement  at  the  elbows  or  at  the  wrists. 
There  is  very  slight  voluntary  movement  at  the  shoulders  in 
all  directions.  Upon  passive  movement,  it  is  found  that  the 
excursion  of  the  arm  is  considerably  greater  than  by  voluntarj- 
movement,  and  also  that  there  is  more  movement  in  the 
right  shoulder  than  in  the  left.  The  movement  does  not, 
however,  take  place  in  the  shoulder  joint,  or,  at  least, 
only  to  a  very  small  extent,  for,  on  attempting  to  ab- 


FiG.  VI.     Left  hand  in  Case  i. 

duct  or  adduct  the  right  arm,  the  scapula  at  once  moves 
with  the  humerus;  this  is  even  more  marked  in  the  left 
shoulder.  The  patient  is  able-  to  perform  very  feeble 
movements  of  flexion  and  extension  in  the  fingers  of  the 
right  hand.  The  fingers  are  much  distorted.  The  proxi- 
mal phalanges  of  the  fingers  of  the  right  hand  are  in  a  posi- 
tion of  overextension,  while  the  middle  and  distal  pha- 
langes are  in  marked  flexion;  these  peculiarities  are  most 
marked  in  the  little  and  ring  fingers;  the  middle  and  fore- 
finger are  also  extended,  but  to  a  less  degree.  The  middle 
phalanges  are  flexed  at  a  right  angle,  while  the  distal  phalanges 
are  again  in  a  position  of  extension.    The  fingers  are  spread 


CHRONIC  RHEUM  A  TO  ID  AR  THRITIS.  713 

apart  at  their  metacarpal  articulations,  the  Kttle  finger  being 
much  abducted,  while  the  forefinger  is  decidedly  adducted,  as 
are  also  the  middle  and  distal  phalanges  of  the  fore  and  middle 
fingers.  The  thumb  is  extended,  adducted  and  displaced,  so 
as  to  occupy  almost  the  same  plane  as  the  palm  of  the  hand. 
Passive  movements  about  equal  the  small  voluntary  move- 
ments described.  In  the  left  hand  the  fingers  are  likewise 
much  distorted;  the  thumb  is  extended  aiui  adducted;  the 
proximal  phalanges  of  the  ring,  middle  and  fore  finger  are 
flexed,  especially  the  latter;  the  middle  and  distal  phalanges 
are  also  flexed  in  varying  degrees;  the  middle  finger  is  ad- 
ducted so  as  to  cross  the  tip  of  the  thumb;  the  little  finger  is 
in  the  position  of  moderate  flexion  at  the  middle  phalanx. 
The  palmar  surfaces  of  both  hands  are  much  indurated,  and 
hard  to  the  touch.    Both  wrists  are  thickened. 

The  head  and  the  entire  trunk  are  rigid  in  extension.  The 
head  can  be  slightly  raised  from  the  pillow;  slight  extension 
of  the  head  backward  is  also  possible.  Movement  of  the 
entire  head  is,  however,  so  limited  that  when  the  pillow  is 
withdrawn  the  head  remains  fixed  and  extended  upon  the 
trunk.  There  are  almost  no  lateral  movements  of  head,  and 
very  slight  rotary  movement.  The  jaw  is  so  firmly  fixed 
that  the  teeth  can  only  be  separated  for  a  quarter  of  an  inch. 

The  trunk  is  so  fixed  that  it  is  impossible  to  obtain  any 
movement  in  any  direction.  The  ribs  are  almost  completely 
fixed  in  position;  no  movement  is  perceptible  in  any  but  the 
false  ribs,  and  in  these  only  upon  forced  respiration.  The 
thorax  everywhere  feels  firm  and  resistant  to  touch,  the  inter- 
costal spaces  oflfering  almost  as  much  resistance  to  touch  as 
the  ribs. 

Respiration  is  almost  exclusively  abdominal.  The  abdom- 
inal muscles  move  freely  only  upon  forced  inspiratibn.  They 
feel  firm,  hard  and  resistant  to  the  touch,  suggesting  almost 
the  board-like  feel  met  with  in  tetanus.  The  abdominal  re- 
flexes are  much  exaggerated. 

The  muscles  of  the  neck  feel  excessively  firm  and  hard, 
with  the  exception  of  the  right  sterno-mastoid,  which  is  soft 
and  flaccid.  The  right  deltoid,  even  in  a  flaccid  condition, 
seems  to  have  its  density  increased,  and  on  efforts  to  move 
the  arm  it  becomes  excessively  hard.  The  biceps  and  triceps 
are  flaccid,  yet  likewise  present  a  firm,  fibrous  feel.  This  is 
true  also  of  all  the  muscles  of  the  forearm.  In  the  muscles 
of  the  left  arm  the  same  condition  is  noted  as  in  the  right. 
The  right  deltoid,  biceps  and  triceps,  even  in  the  relaxed  con- 
dition, feel  firm  and  fibrous  to  the  touch.  The  belly  of  the 
biceps  feels. as  though  it  were  made  up  of  a  bundle  of  coarse. 


714  ^-   ^-   DERCUM, 

hard  cords  (giving  a  rope-like  feel).  The  condition  of  the 
forearm  is  similar  to  the  right.  The  muscles  of  the  right  thigh 
feel  firm  and  fibrous.  This  is  also  true  of  the  muscles  of  the 
leg,  the  sensation  which  is  given  to  the  finger  being  similar 
to  that  given  by  the  arms.  The  condition  of  the  left  thigh  and 
calf  is  practically  identical  with  that  of  the  right.  The  ad- 
ductor and  calf  muscles,  though  relaxed,  are,  nevertheless, 
dense  to  touch,  giving  here  and  there  the  fibrous  feel  noticed 
in  the  biceps. 

The  face  is  smooth,  the  normal  folds  and  wrinkles  being 
somewhat  obliterated;  fche  surface  of  the  forehead,  nose,  an- 
terior aspect  of  cheek,  temples  and  ear  is  smooth  and  glisten- 
ing. The  ears  present  a  wax-like  hue  or  gloss;  indeed,  they 
might  pass  as  artificial  models  of  the  human  ear  in  wkx;  this 
is  especially  true  of  the  right  ear.  The  lips  are  purple-pink  in 
color.  The  vessels  of  the  eyelids  are  much  increased  in  num- 
ber, so  as  to  suggest  a  telangiectatic  condition.  Both  cheeks 
are  tinted  a  purple-pink  hue,  and,  upon  close  examination, 
minute  vessels  are  seen.  The  ears  are  tinted  with  the  same 
hue,  save  in  the  prominent  portions  of  the  cartilage,  such  as 
the  tip  of  the  tragus  and  antitragus  and  the  edges  of  the  helix 
and  antihelix,  which  are  dead  white. 

The  scalp  and  the  neck,  especially  the  back  of  the  neck, 
reveal  copious  masses  of  epithelial  scales  or  encrustaticwis. 
These  scales,  the  patient  tells  us,  accumulate  rapidly.  They 
can,  as  a  rule,  be  removed  with  difficulty  both  by  washing 
and  by  gentle  scraping,  leaving  a  raw  and  slightly  sensitive 
surface,  probably  the  sensitive  layer  of  epithelium,  exposed. 
These  patches  are  observed  also  back  of  the  ears  and  at 
various  parts  of  the  chest  and  abdomen.  The  hands  also  pre- 
sent yellowish  stains  on  palms  and  flexures  of  fingers,  due  to 
similar  epithelial  deposits.  The  backs  of  the  hands  and  fingers 
reveal  much  pigmentation.  The  skin  of  the  face  is  everywhere 
movable,  though  this  mobility  is  restricted;  this  restriction  is 
especially  noticeable  on  the  forehead.  The  scalp  also  is  very 
restricted  in  movement,  the  loss  of  mobility  being  such  as  to 
suggest  a  very  tightly  drawn  skull-cap.  The  fibro-cartilage 
of  the  ears  seems  denser,  more  resistant,  and  less  flexible  than 
normal.  The  cheeks  are  somewhait  flattened.  There  is  evident 
loss  of  superficial  fat  above  and  below  the  zygoma.  The  mo- 
bility of  the  facial  muscles  is  well  preserved.  The  skin  of  the 
eyelids,  both  upper  and  lower,  seems  somewhat  thinner  than 
normal.  The  eyelids  and  the  sides  of  the  nose  at  the  root  are 
slightly  bluish  in  tint. 

The  neck  and  shoulders  also  present  a  glossy  appearance. 
A  number  of  telangiectatic  patches  are  Observed  upon  the 


CHRONIC  RHEUMATOID  ARTHRITIS. 


715 


neck,  shoulders,  sc^ula  and  chest.  The  skin  of  the  trunk  is 
less  smooth  and  more  normal  to  the  touch  than  that  of  the 
face  and  neck.  Its  mobility,  however,  is  much  diminished,  and 
it  is  much  firmer  to  the  feel  than  normal  skin.  It  is  slightly 
more  movable  over  the  lower  portions  of  the  chest  and  ab- 
domen than  over  upper  portions  of  the  chest.  Tache  cerebrale 
is  noted  freely  over  chest  and  abdomen. 

The  skin  of  the  left  thig^h,  especially  in  the  middle  third, 
appears  to  be  slightly  less  mobile  and  more  tense  than  normal. 
The  middle  and  lower  third  of  the  thigh  present  the  same 
yellowish  et*crustation  of  epithelium  noted  elsewhere.     These 


F[G.  VII.     Feetincaaei. 

having  been  partially  removed,  the  underlying  skin  presents 
numerous  pink  punctuate  markings.  The  skin  of  the  left 
knee,  anterior  aspect  of  the  leg  and  foot,  is  also  very  much 
thinned  and  atrophied,  and  is  highly  glazed  and  shining.  The 
skin  over  the  foot  is  so  thin  that  it  permits  the  muscles  and 
tendons  beneath  it  to  be  plainly  seen.  The  skin  of  the  middle 
and  lower  third  of  the  leg  and  of  the  dorsum  of  the  foot  pre- 
sents a  marked  veining  (the  veins  are  apparently  readily  seen 
owing  to  the  atrophied  condition  of  the  skin).  The  skin  of 
the  leg,  especially  in  the  lower  portions,  is  much  less  movable 
than  the  skin  of  the  thigh;  it  is  especially  tense  over  the  dorsum 


7l6  F.   X.   DERCUM, 

of  the  foot.  The  skin  is  especially  thin  over  the  first  phalangeal 
articulation.  The  nails  are  much  thickened,  yellow,  opaque 
and  distorted;  the  matrix  of  the  great  toe  is  especially  thick. 

The  right  thigh  is  in  every  way  similar  to  the  left.  Over 
the  knee  the  skin  is  very  tense,  shining  and  thin.  On  the  outer 
aspect  of  the  leg  and  dorsum  of  the  foot,  the  skin  has  the  same 
appearance  as  in  the  left  limb.  The  toes  are  glazed,  and  the 
nails  are  in  the  -same  condition  as  in  the  left.  The  atrophied 
changes  of  the  skin  also  appear  to  be  equally  marked  over 
the  right  foot,  so  that  the  tendons,  veins  and  other  structures 
can  be  readily  seen  tnrough  it. 

The  skin  of  the  back  of  the  neck,  trunk  and  buttocks  pre- 
sents similar  changes  to  those  noted  elsewhere,  save  that  they 
are  less  marked.  Its  mobility  seems  lessened,  and  it  seems 
denser  to  the  feel  than  normal,  but  these  factors  are  far  less 
marked  than  in  the  skin  over  the  anterior  portion  of  the  trunk. 
The  soles  of  the  feet  are  distinctly  indurated,  though  less  so 
than  the  palmar  surfaces  of  the  hands.  There  is  no  special 
loss  of  the  plantar  fat.  An  occasional  fibrillary  twitch,  or 
twitch  of  a  tendon,  is  noted  in  the  hands.  The  palms  of  the 
hands  present  an  indurated  feel. 

Pain  is  caused  by  attempts  at  passive  movement  or  by  turn- 
ing the  patient  in  bed,  but  this  pain  seems  to  be  due  to  the 
strain  placed  upon  the  fibrous  tissues  and  muscles,  rather  than 
to  a  strain  upon  the  joints. 

No  sensory  loss  can  be  discovered,  and,  according  to  the 
patient's  statement,  none  ever  existed.  The  special  senses  are 
also  normal.  The  growth  of  hair  over  the  scalp,  pubis  and 
axilla  and  over  the  general  surface  of  the  body  appears  normal. 
The  growth  of  beard  is  scanty.  The  patient  swallows  without 
difficulty  liquid  and  semi-fluid  food.  No  decided  changes  are 
noted  in  the  vessels.  The  sound  of  the  heart,  however,  is 
somewhat  accentuated,  while  the  pulmonary  valves  are  dis- 
tinctly roughened.  No  other  visceral  changes  are  observed. 
Bowels  are  constipated.  Anal  sphincter  normal.  The  control 
over  the  bladder  is  slightly  diminished;  sometimes  soils  his  bed 
before  the  urinal  can  be  brought.  The  urine  is  normal  in  quan- 
tity. The  solids  are  somewhat  diminished,  the  urea,  for  ex- 
ample, varying  from  230  to  270  grains  daily.  One  specimen 
of  urine  revealed  also  the  presence  of  peptone,  though  this 
observation  was  not  repeated. 

A  blood  examination  by  Dr.  A.  E.  Taylor  failed  to  reveal 
any  evidence  of  leucocytic  degeneration  or  karyokinesis. 

The  patient  has  never  had  sexual  intercourse,  has  never 
had  any  seminal  emissions ;  has  occasional  erections.  Pubis  is 
covered  with  a  dense  epithelial  covering,  similar  to  that  noted 
on  scalp  and  elsewhere. 


CHRONIC  RHE  UMA  TO  ID  A  R  THRITIS.  717 

When  we  analyze  this  case,  we  find  that  its  clinical 
history,  especially  the  mode  of  onset,  accords  closely  with 
that  frequently  met  with  in  chronic  rheumatoid  arthritis. 
The  recurrent  attacks  of  paia  in  the  right  knee,  which 
appeared  to  be  the  starting  point  of  the  case,  are  exceed- 
ingly suggestive.  Further,  while  trophic  changes,  in- 
volving the  skin,  nails  and  muscles,  are  not  common  in 
rheumatoid  arthritis,  they  may  odcur.  The  case  before 
us,  however,  is  distinctly  unusual  in  the  extent  to  which 
these  changes  are  present.  We  need  only  point  to  the 
tissues  of  the  scalp,  the  fibro-cartilage  of  the  ears,  the 
tissues  of  the  plantar,  and  especially  of  the  palmar  surfaces, 
all  of  which  are  indurated,  much  denser  and  less  mobile 
than  normal,  and  are  evidently  the  seat  of  some  diffuse 
sclerotic  change.  When  we  examine  the  muscles,  the 
same  fact  is  again  apparent.  As  regards  the  muscles  of 
the  extremities,  which  are,  of  course,  related  to  joints,  it 
is  conceivable  that  the  changes  found  in  them  are  arthritic 
in  character.  However,  it  is  somewhat  striking  that  the 
usual  disproportion  in  the  involvexnent  of  the  flexors  and 
extensors  is  not  present.  In  purely  arthritic  muscular 
atrophy,  the  extensors  suffer  so  greatly  as  to  lead  to 
marked  flexion  and  contraction  of  the  legs  and  arms;  and, 
indeed,  this  is  the  usual  position  assumed  in  typical 
rheumatoid  arthritis.  Again,  the  diffuse  induration  of 
the  muscles,  very  marked  in  certain  situations,  is  a  feature 
of  the  present  case  which  must  not  be  lost  sight  of;  and 
even  if  we  assume  an  arthritic  origin  for  the  muscular 
changes,  how  are  we  to  explain  the  induration  of  the 
muscles  which  are  not  related  to  joints,  such  as  the  inter- 
costals  and  the  muscles  of  the  abdomen?  These,  as  pointed 
out,  have  an  induration  that  is  boardlike. 

The  deformity  of  the  hands  in  this  case  also  departs 
from  that  usually  met  with  in  rheumatoid  arthritis.  The 
so-called  ulnar  deflection  is  entirely  absent.  It  is  only  in 
^the  toes  of  the  right  foot  that  abduction  is  seen.  In  the 
condition  of  the  skin  and  nails,  the  hands  and  feet  strongly 


7l8  F.   X.   DERCUAf. 

call  to  mind  the  sclerodactyle  of  scleroderma.  Rigidity 
of  the  spine,  so  marked  in  this  case,  may  also  be  met  with 
in  scleroderma,  though  much  less  pronounced.  It  was 
markedly  present  in  a  case  of  scleroderma  described  by 
me  and  rei>orted  in  a  former  paper.  In  this  instance  the 
rigidity  of  the  spine  was  not  related  to  the  skin  of  the 
back  or  of  the  neck,  and  appeared  to  be  dependent  upon 
involvement  of  the  articular  joints.  In  the  same  case, 
also,  there  was  undoubted  involvement  of  one  shoulder 
joint  without  any  involvement  of  the  surrounding  skin. 
Further,  Legrange  observed  in  sclerodactyle,  loss  of  ar- 
ticular cartilage  and  calcareous  deposits  in  the  fibrous  tis- 
sues, while  Verneuil  and  Mirault  observed  short  fibrous 
bands  extending  between  the  apposed  joint  surfaces  in 
which  there  had  also  been  destruction  of  the  synovial  mem- 
brane. While  bone  and  joint  changes  do  undoubtedly 
occur  in  scleroderma,  and  independently  at  times  of  the 
changes  in  the  skin,  such  extensive  joint  changes  as  ob- 
served in  the  present  instance,  have  not  been  obser\'ed 
in  cases  described  as  scleroderma.  However,  the  case  is 
extremely  interesting  as  suggesting  a  general  sclerotic 
process  bringing  about  extensive  changes  in  bones,  joints, 
muscles,  tendons  and  skin,  similar  in  character  to  those 
seen  in  scleroderma.  It  would  almost  seem  as  though  in 
scleroderma  the  process  expended  itself  primarily  upon 
other  structures,  while  in  this  case,  call  it  rheumatoid  ar- 
thritis, if  we  may,  the  process  had  expended  itself  prim- 
arily upon  the  deeper  structures.  The  study  of  this  case 
suggests  the  further  thought  that  under  the  name,  chronic 
rheumatoid  arthritis,  are  properly  included  two,  if  not 
more,  clinical  entities;  one  a  disease  in  which  a  sclerotic 
process,  similar  to  that  which  occurs  in  scleroderma,  is 
active,  and  another  in  which  the  joint  changes  are  attended 
by  absorption  of  cartilage,  eburnation  of  bone,  osteophy tic 
deposits,  and  secondary  arthritic  muscular  atrophy. 


FAMILY  PERIODIC  PARALYSIS. 

With  a  Report  of  Cases  Hitherto  Published. 
By  EDWARD  WYLLYS  TAYLOR,  M.D., 

Instructor  in  Neuropathology,  Harvard  University;  Assistant  in  Neurology,  Massa- 
chusetts General  Hospital;  Visiting  Neurologist,  I«ong  Island 

Hospital,  Boston  Harbor. 

(Continued  from  page  660.) 

I  find  no  reference  since  Goldflam's  publication  in  1897 
bearing  directly  on  this  subject.  The  series  of  cases  above 
outlined,  which  I  believe  to  be  complete,  is  extremely  in- 
teresting from  several  points  of  view,  and  especially  in 
this  connection,  first,  because  of  the  fewness  of  all  cases, 
and,  secondly,  because  of  the  relatively  frequent  occur- 
rence of  the  affection  in  certain  families.  C^ses  inade- 
quately reported  I  have  not,  in  general,  included  in  the 
foregoing  summarv,  except  to  allude  to  them  under  the 
case  or  cases  to  which  the  individual  author  pays  particular 
attention.  For  example,  Cousot  mentions  five  cases,  and 
reports  one  completely;  Goldflam  mentions  twenty-two, 
and  reports  six  in  detail. 

A  critical  examination  of  all  the  cases  included  in  the 
list  given  permits  us,  with  reasonable  certainty,  to  ex- 
clude a  certain  number  from  the  typical  form  of  paralysis 
already  outlined. 

The  early  cases  of  Cavare,  Romberg  and  Gibney  may 
rightly  be  questioned,  chiefly  on  account  of  their  associa- 
tion with  malaria.  The  very  slow  recovery  in  Gibney's 
cases  would  seem  to  place  them  in  a  distinct,  though  pos- 
sibly allied,  category.  Fischl's  case  is  anomalous,  but 
probably  belongs  to  the  clinical  group  of  the  periodic 
family  paralysis.  The  extremely  interesting  family  his- 
tory, as  reported  by  Rich,  must  also  be  regarded  as  doubt- 
ful on  account  of  the  etiology,  viz.,  exposure,  the  tonic 


720  EDWARD    WYLLYS   TAYLOR, 

conditions  of  the  muscles  during  the  attacks,  and  the  lack 
of  information  as  to  the  reflexes  and  electrical  conditions. 
Finally,  Bernhardt's  cases  are,  as  he  states,  complicated 
by  certain  muscle  changes  of  the  dystrophic  type.  His 
patients  suffered  at  all  times  from  a  distinct  muscular 
weakness,  although  notably  increased  during  the  so-called 
attacks;  otherwise,  his  cases  are  similar.  We  are  justified 
in  regarding  the  observations  of  Hartwig,  Samuelsohn, 
Schachnowitsch,  Westphal,  Oppenheim,  Fischl  (doubtful), 
Cousot,  Griedenberg,  Pulawski,  Goldflam,  Burr,  Hirsch, 
Bernhardt  (w4th  the  above  modification),  and  Taylor  as 
the  definite  type  of  the  condition  under  discussion.  The 
number  of  cases  reported  by  these  observers  is  in  all  fifty- 
three.  Of  these,  only  sixteen  have  been  described  in  any 
detail,  the  others  occurring  either  in  past  generations,  or 
in  persons  who  were  unavailable  for  a  careful  personal 
examination. 

The  second  point  is  also  of  interest — that  of  the  fifty- 
three  cases,  thirty-five  occurred  in  three  families,  Cousot 
five,  Goldflam  nineteen,  and  Taylor  eleven,  the  remaining 
eighteen  being  either  sporadic,  or  associated  with  one 
other  in  the  same  family.  From  this  fact  alone  the  family 
character  of  the  affection  is  sufficiently  demonstrated. 

Before  entering  upon  a  detailed  analysis  of  this  re- 
markable affection,  it  is  as  well  to  forestall  a  possible 
criticism  in  the  use  of  terms  by  saying  that  in  the  present 
state  of  our  knowledge,  the  word  "disease"  should  be  used 
with  much  caution  as  applied  to  this  periodic  paralysis. 
The  tendency  to  dignify  a  symptom  or  a  group  of  symp- 
toms by  calling  it  a  disease  entity  has  already  been  pro- 
ductive of  much  confusion  of  nomenclature  in  relation  to 
affections  of  the  nervous  system  whose  pathology  is  ob- 
scure. As  stated  at  the  outset,  the  term  "family  periodic 
paralysis"  is  purely  clinical  and  descriptive,  and  should  be 
definitely  so  understood.  If  through  a  certain  poverty  of 
words  we  occasionally  speak  of  the  symptom-complex 
under  consideration  as  a  disease,  it  is  merely  as  a  matter 


FAMILY  PERIODIC  PARALYSIS,  72 1 

of  convenience,  and  in  no  way  as  indicative  of  a  dogmatic 
belief  that  a  periodic  paralysis,  as  such,  can  in  itself  rep- 
resent a  pathological  entity.  Our  feeling,  rather,  is  that 
we  are  dealing  here  merely  with  a  symptom,  or  symptoms, 
of  extraordinary  constancy,  whose  etiology  and  patho- 
logical anatomy  are  as  yet  wholly  obscure.  This  being 
understood,  we  may  profitably  attempt  an  analysis  of  the 
condition  in  the  light  of  the  reported  cases  and  of  our 
own,  leaving  the  most  subtle  problems,  viz.,  those  of  eti- 
ology and  pathological  anatomy  to  the  end. 

The  first  striking  feature  of  the  condition  is  that  it  has 
certain  constant  and  cardinal  peculiarities.  Itjs  charac- 
terized in  its  typical  manifestation  by  its  heredity,  by  its 
periodicity,  by  its  confinement  to  the  motor  portion  of 
the  nervous  system,  by  the  electrical  changes,  and,  finally, 
negatively  by  the  practically  perfect  health  of  the  indi- 
vidual in  the  free  intervals.  We  shall,  consider  each  of 
these  cardinal  symptoms  in  detail. 

Heredity:.  The  affection  is  distinctly  of  a  family  type. 
In  Cousot's  cases  five  members  of  one  family  were  af- 
fected; in  Goldflam's  nineteen,  and  in  ours  eleven.  Schach- 
nowitsch  and  Hirsch  each  report  two  cases  as  occurring 
in  parent  and  child,  and  Goldflam  again  three  in  one  gen- 
eration. The  other  few  cases  are  sporadic.  In  the  con- 
dition described  by  Rich,  twenty-two  members  of  the 
family  were  affected,  of  whom  fourteen  were  still  living 
when  his  paper  appeared.  The  two  family  histories  of 
statistical  interest  are  those  described  by  Goldflam  and 
Taylor.  In  Goldflam's  family  the  predisposition  was  trans- 
mitted on  the  mother's  side,  through  both  male  and  fe- 
male lines.  It  was  not  associated  with  other  neuroses 
of  any  sort.  Many  of  the  family  were  entirely  free.  In 
my  cases,  also,'  the  affection  is  on  the  mother's  side,  be- 
ginning with  a  male  five  generations  back;  from  him  trans- 
mitted to  a  son,  thence  to  two  daughters,  one  of  whom  had 
six  children,  three  sons  and  one  daughter,  all  but  two  be- 
ing affected.     Several  of  this  generation  are  now  living. 


722 


EDWARD    WYLLYS   TAYLOR. 


but  I  have  been  unable  to  secure  any  definite  data.  The 
other  daughter  of  the  previous  generation  had  three  chil- 
dren, one  of  whom,  the  mother  of  our  patients,  was  af- 
fected. She,  again,  had  three  children,  two  of  whom,  a 
son  and  daughter  (our  patients),  are  sufferers  from  the 
condition,  the  other  son  having  no  trace  of  it  whatever.  It 
is,  therefore,  seen  that  in  our  cases  the  transmission  has 
been  absolutely  direct  through  two  females  and  two  males. 
Those  who  have  been  exempt  from  the  condition  them- 
selves have  in  no  case  transmitted  it  to  their  children. 
(Vide  chart.)  As  regards  other  possible  hereditary  taint 
in  the  family,  we  find  none  of  significance.  One  member 
in  the  second  generation  had  epileptiform  convulsions, 
but  was  not  afflicted  with  periodic  paralysis.  The  mother 
of  our  patients  died  of  tuberculosis,  and,  possibly,  their 
grandmother.  To  this  fact  we  can  attach  no  importance, 
as  already  stated. .  No  other  significant  heredity  appears. 

In  general  it  may  be  said  that  these  cases  have  oc- 
curred in  families  of  unusual  nervous  stability  (See  ab- 
stracts of  histories);  in  no  case  do  we  find  any  evidence 
whatever  of  a  degenerative  family  history.  If  a  neurosis 
at  all,  it  is  distinctly  not  one  of  a  degenerative  type.  The 
mental  superiority  of  our  family  and  its  freedom  from 
other  nervous  derangement  is  noteworthy. 

Periodicity:  A  characteristic  of  the  condition  is  its  re- 
currence. The  alternation  of  attacks  of  loss  of  motor 
power,  with  intervals  of  perfect  health,  is  the  peculiar 
feature  which  lends  to  the  affection  one  of  its  chief  in- 
terests. This  periodicity  is  governed  by  no  discoverable 
law,  and  varies  greatly  in  different  cases.  From  a  con- 
dition of  health,  so  far  as  the  patient  knows,  he  is  more 
or  less  suddenly  plunged  into  a  state  of  helplessness,  which, 
again,  lasts  a  varying  time,  to  give  place  in  turn  to  a  period 
of  normal  activity.  Details  of  individual  cases  are  not 
here  necessary,  inasmuch  as  the  fact  of  periodicity  applies 
to  all,  and  is  to  be  regarded  as  a  fundamental  charac- 
teristic. 


I'AMILY  PERIODIC  PARALYSIS. 


723 


Motor  Paralysis:  Another  equally  important  and  fun- 
damental peculiarity  is  the  absolute  confinement  of  the 
affection  to  the  motor  sphere.  Apart  from  certain  doubt- 
ful subjective  sensory  disturbances,  there  is  no  evidence 
whatever  to  show  that  the  sensory  side  of  the  nervous 
system  is  ever  involved  in  the  process.  In  our  most  care- 
fully studied  case  there  is  no  indication  during  the  attack 
of  the  slightest  sensory  involvement.  Tests  for  various 
sorts  of  disturbed  sensation  were  wholly  negfative  in  re- 
sult, nor  was  there  ever  any  subjective  complaint  of  pain 
or  paraesthesia.  It  was  noted  at  the  examination  made 
during  an  attack  that  strong  faradic  currents  were  borne 
without  complaint,  but  this,  we  believe,  was  due  rather 
to  the  failure  of  muscles  to  respond  adequately  than  to 
an  actual  blunting  of  the  feeling.  This  is  so  common  in 
observation  that  further  com-ment  is  unnecessary.  It  was 
furthermore  observed  that  between  the  attacks  there  was 
small  complaint  of  pain  from  strong  currents.  He  is, 
perhaps,  unusually  tolerant  of  the  peculiar  sensations  pro- 
duced by  electricity,  as  one  frequently  sees  in  non-neurotic 
persons. 

In  Case  II.,  the  sister,  there  is  also  no  sensory  dis- 
turbance, beyond  a  dull  pain,  following  a  severe  attack,  in 
the  muscles  affected.  J.  also  complains  at  times  of  a  feel- 
ing of  soreness,  which  is  evidently  due  to  a  natural  local 
disturbance  in  the  muscles  themselves,  following  the  para- 
lytic stage. 

The  following  vague  disturbances  of  sensation  have 
been  described  by  previous  observers:  Hartwig  speaks  of  a 
sense  of  numbness  and  formication  in  the  paralyzed  part, 
while  finding  objective  sensibility  unaffected.  In  Schach- 
nowitsch's  second  case  there  were  subjective  sensory  dis- 
turbances as  precursors  of  the  actual  attack.  In  the 
Westphal-Oppenheim  case  there  was  an  antecedent  prick- 
ling sensation  in  the  legs,  and  Oppenheim  also  noted  a 
sense  of  prickling  in  the  soles  of  the  feet  in  the  course 
of  an  attack,  with  otherwise  perfectly  normal  sensibility. 


724 


EDWARD    WYLLYS  TAYLOR, 


Fischl,  on  the  other  hand,  found  in  his  case  a.  distinct 
blunting  of  sensation  in  the  aflfected  areas,  with,  at  times, 
an  ice-cold  surface  temperature.  This  fact,  in  conjunction 
with  the  generally  anomalous  course  of  the  case,  a  certain 
mental  involvement,  with  lack  of  heredity,  would  seem 
to  render  it  doubtful  of  classification,  and  we  have  so  re- 
garded it.  Goldflam  alludes  to  an  annoying  itching, 
chiefly  between  attacks,  and  also  just  previous  to  recovery 
from  an  attack.  In  Hirsch's  case  there  were  occasional 
sharp  pains  in  one  foot.  In  no  case,  excepting  that  of 
Fischl,  was  any  objective  change  found,  and  the  foregoing 
slight  subjective  disturbances  we  must  regard  as  incon- 
stant and  unimportant. 

The  mind  has  in  all  cases  remained  unaffected,  whether 
during  or  between  the  attacks.  An  occasional  drowsiness 
has  been  observed,  which  in  Fischl's  anomalous  case  came 
to  be  practically  an  equivalent  of  the  typical  attack.  The 
disturbance  of  the  nervous  system  in  these  cases  may, 
therefore,  be  regarded  as  essentially  motor  in  its  mani- 
festation. This  is  a  constant  symptom.  The  distribution 
of  the  paralysis,  however,  varies  in  different  cases,  and  at 
different  times  in  the  same  patient.  This  will  be  con- 
sidered in  detail  later.  The  paralysis  is  in  all  cases  flaccid 
in  type. 

Electrical  Changes:  In  general  it  may  be  said  that  there 
is  a  loss  of  direct  and  indirect  electrical  excitability,  vary- 
ing from  absolute  loss  to  both  currents,  to  slight  quanti- 
tative diminution,  depending  upon  the  completeness  of  the 
paralysis.  Between  the  attacks  the  conditions  have  usu- 
ally been  normal  or  only  very  slightly  abnormal.  Ex- 
haustive examinations  have  been  made  into  the  electrical 
peculiarities,  chiefly  by  Oppenheim  and  Goldflam.  Op- 
penheim  found  that  at  the  height  of  the  attack  there  was 
complete  loss  of  reaction  in  certain  groups  of  muscles,  with 
an  increased  skin  resistance.  The  return  of  reaction  to 
faradism  and  galvanism  was  gradual,  like  the  return  of 
motor  power.    There  was  always  quantitative  diminution 


FAMILY  PERIODIC  PARALYSIS.  725 

during  attacks.  Response,  when  obtainable  at  all,  was 
quick.  No  R.  D.  The  results  of  Oppenheim's  electrical 
examinations  were  not  entirely  uniform.  Later  observa- 
tions on  the  same  patient  showed  a  slight  atrophy  of  those 
muscles  which  had  the  poorest  reactions  between  the  at- 
tacks. 

Goldflam  also  has  examined  his  cases  with  extreme 
thoroughness,  and  with  interesting  results.  In  addition 
to  the  quantitative  changes,  up  to  complete  loss,  ob- 
served during  attacks,  Goldflam  describes  certain  changes 
in  the  free  intervals,  which  he  regards  as  of  the  utmost 
significance  and  importance.  In  two  of  his  cases,  brothers, 
he  found  the  direct  and  indirect  irritability  markedly  di- 
minished to  both  currents  between  the  attacks,  associated 
with  rapid  fatigue.  The  character  of  the  contraction  was 
also  changed;  it  w^as  slow,  and  there  were,  in  addition, 
various  polar  changes.  Partial  R.  D.  was  obtained  and 
both  Ca.  C.  Te.  and  An.  C.  Te.  with  weak  currents.  He 
found  qualitative  changes  more  prominent  in  the  free 
intervals,  and  quantitative,  often  up  to  complete  loss,  in 
the  actual  attacks.  Other  observers  have  all  noted  the 
quantitative  diminution  of  electrical  excitability  during 
the  attacks,  but  have  in  general  found  the  condition  be- 
tween normal  in  this,  as  in  other  respects.  With  the 
possible  exception  of  Oppenheim,  however,  no  one  has 
so  thoroughly  investigated  the  matter  as  Goldflam.  In 
our  own  case  a  quantitative  diminution  to  faradism,  which 
it  was  alone  possible  to  use,  during  the  attack  was  pro- 
nounced. Noteworthy  in  our  case  was  a  quantitative  di- 
minution in  the  facial  nerve  and  its  distribution.  Be- 
tween the  attacks  we  could  demonstrate  absolutely  no 
polar  changes  whatever.  Response  was  also  quick  and 
normal  to  faradic  and  galvanic  currents.  There  was  an 
apparently  increased  skin  resistance,  alluded  to  by  Oppen- 
heim as  occurring  during  the  attacks.  The  only  note- 
worthy peculiarity  in  our  case  was  the  failure  of  reaction 
of  the  right  peroneal  group  of  muscles.     In  the  light  of 


726  EDWARD    WYLLYS  TAYLOR, 

Goldflam*s  researches,  this  fact  may  be  of  more  significance 
than  we  are  at  present  disposed  to  grant.  Future  ex- 
amination will  demonstrate  its  importance,  if  it  have  any. 
Considering  the  fact  that  all  other  muscles  and  nerves 
tested  responded  normally,  we  would  reserve  judgment 
of  the  unexplained  failure  of  this  one  group. 

The  general  changes  regarding  the  electrical  changes 
may  be  summed  up  by  saying  that  there  is  a  loss  or 
marked  quantitative  diminution  during  attacks,  and  con- 
siderable evidence  of  a  disturbed  neuromuscular  excit- 
ability in  the  free  intervals,  not  yet  demonstrated  as  con- 
stant. 

Reflexes:  Hardly  less  noteworthy  than  the  electrical 
changes  is  the  behavior  of  the  reflexes.  In  all  cases,  when 
any  mention  is  made  of  the  matter,  the  deep  reflexes,  of 
which  the  knee-jerk  is  the  type,  have  been  reported  lost 
during  the  height  of  the  attack,  and  present  in  the  inter- 
vals. This  was  verified  in  my  case.  The  same  holds  true, 
in  general,  of  the  peripheral  reflexes,  though  not  to  the 
same  degree.  Oppenheim  reports:  Plantar,  lacking;  cre- 
master  and  abdominal,  present;  Hirsch:  Peripheral  re- 
flexes lost,  excepting  abdominal,  which  were  weak;  Tay- 
lor: No  plantar;  cremaster,  slight;  abdominal  and  epi- 
gastric, active.  Pulawski  and  Goldflam,  on  the  other 
hand,  report  cutaneous  reflexes  present.  The  disturbance 
of  the  reflexes  depends  apparently  wholly  upon  the  ex- 
tent of  the  paralysis.  Inasmuch  as  the  legs  are  most 
often  and  most  completely  involved,  we  find  an  explana- 
tion of  the  constant  loss  of  knee-jerks,  and  the  greater 
frequency  of  the  loss  of  the  plantar  than  the  other  cu- 
taneous reflexes.  With  our  relative  lack  of  knowledge 
of  the  peripheral  reflexes,  nothing  further  is  to  be  said. 
Our  chief  interest  centres  in  the  knee-jerk. 

The  Free  Intervals:  We  have  maintained  that  the  pa- 
tients suffering  from  this  affection  are  normal  be- 
tween the  attacks.  This  is,  in  general,  true,  but  the  rigid 
examinations  to  which  certain  of  the  cases  have  been 


k 


FAMILY  PERIODIC   PARALYSIS,  727 

subjected  would  seem  to  throw  doubt  upon  its  absolute 

acceptance.     In  our  cases  nothing  abnormal  was  found; 

the  patients  themselves  feel  and,  so  far  as  they  know,  are 

perfectly  well  and  strong,  excepting  at  the  time  of  the 
attack.     This  has  been  the  usual  verdict.     Oppenheim, 

however,  found  slight  atrophy  of  the  hand  muscles  in  his 
case,  and  later  weakness  of  the  legs,  associated  with  con- 
stant defect  in  electrical  reaction.  Goldflam  describes  in 
detail  electrical  abnormalities  between  the  attacks,  and 
definite  changes  in  the  muscular  system,  upon  which  he 
bases  his  theory  of  the  affection.  Bernhardt,  whose  cases 
we  have  considered  somewhat  atypical,  found  muscle 
changes,  which  he  regards  as  allied  to  the  dystrophies, 
from  the  beginning  of  the  affection  or  even  before.  With 
these  exceptions,  the  general  statement  stands. 

In  the  foregoing  discussion  we  have  pointed  out  what 
may  be  looked  upon  as  the  cardinal  symptoms  of  the 
family  periodic  paralysis.  These  symptoms  are  so  con- 
stant that  their  absence  would  rightly  throw  doubt  upon 
the  diagnosis.  They  are:  Periodicity,  flaccid  motor  pa- 
ralysis, loss  of  electrical  excitability,  loss  of  deep  reflexes, 
and,  between  attacks,  relatively  perfect  health. 

Other  symptoms  vary  somewhat  in  different  cases,  and 
for  this  reason  demand  a  painstaking  analysis.  We  shall 
attempt  to  describe  them  in  as  systematic  a  manner  as 
possible,  omitting  for  the  time  being  any  discussion  of 
possible  causes. 

Attack;  Prodromata:  Various  symptoms  have  been  de- 
scribed as  occurring  immediately  antecedent  to  an  attack, 
though  none  of  them  are  constant  in  all  cases.  Hartwig's 
patient  had  a  feeling  of  weariness,  with  some  sweating  and 
considerable  numbness  and  formication.  Westphal-Op- 
penheim  noted  heat  and  sweating,  with  a  desire  to  urin- 
ate, which  could  not  at  once  be  satisfied.  Fischl's  (doubt- 
ful) patient  had  headache,  backache,  poor  appetite,  somno- 
lence, rapid  pulse,  with  a  normal  surface  temperature  of 
the  head,  body  and  arms,  and  an  icy-cold  temperature  of 


728  EDWARD    WYLLYS   TAYLOR. 

the  l^s,  associated  with  great  pallor,  suggesting  a  vaso- 
motor disturbance  of  a  violent  sort.  Cousot  found  feeble- 
ness of  articulation  and  a  desire  to  walk.  Goldfiam,  in 
his  best  observed  case,  alludes  to  the  fact  that  the  attacks 
usually  came  on  Friday,  no  doubt  a  coincidence;  that  the 
patient  had  itchings  on  the  well  evenings,  but  none  on  the 
evenings  preceding  the  attack;  that  he  was  capricious 
as  to  food,  and  was  later  annoyed  by  a  feeling  of  coldness 
in  the  legs  and  by  occasional  thirst.  In  my  best  observed 
case  there  are  no  prodomata  whatever,  excepting  a  feel- 
ing of  weakness,  which  is  rather  a  part  of  the  actual  at- 
tack than  a  warning  of  its  onset. 

Evidently,  then,  these  prodromal  symptoms  are  ex- 
ceedingly inconstant.  Sweating  and  thirst  are  most  fre- 
quent, but  they  are  much  more  often  absent  than  present. 
The  fact  that  the  attacks  come  on  so  frequently  at  night 
may  explain  the  fewness  of  the  prodromal  symptoms. 

Age  of  Onset:  The  age  at  which  the  attacks  usually  be- 
gin varies  within  somewhat  narrow  limits.  The  data  on 
this  point,  so  far  as  obtainable,  are  as  follows:  Cavare,  be- 
fore twenty-one;  Hartwig,  at  twenty-three;  Samuelsohn, 
at  eighteen;  Westphal,  at  twelve;  Fischl,  at  eight;  Cousot, 
four  cases  at  fourteen,  nine,  ten  and  ten,  respectively; 
Griedenberg,  before  twenty-one;  Pulawski  before  tw-enty- 
one;  Goldflam,  case  chiefly  studied,  at  thirteen.  The 
mother  of  Goldflam's  case  had  but  one  attack,  at  thirtv- 
six.  Goldflam  also  refers  to  a  number  of  young  children 
similarly  affected,*  who  are  said  to  have  died  during  at- 
tacks. Burr's  case  began  at  ten,  Hirschs  at  the  nineteenth 
or  twentieth  year,  and  Taylor's  first  case  at  fourteen  or 
fifteen;  the  second  at  twelve.  Of  the  other  nine  cases  in 
the  family,  the  tradition  is  that  the  attacks  began  always 
at  or  about  the  time  of  puberty.  The  latest  case  was  at 
eighteen. 

From  these  statistics,  it  will  appear  that  the  affec- 
tion is  evidently  one  that  owes  its  origin  to  certain  con- 


r 


FAMILY  PERIODIC  PARALYSIS,  729 

ditions  prevailing  in  youth  and  the  developmental  period 
of  life.  With  the  exception  of  a  few  cases  mentioned  by 
Goldflam,  the  onset  has  always  been  before  the  twenty- 
fourth  year,  and,  in  the  great  majority  of  best  reported 
cases,  it  has  been  between  the  tenth  and  twentieth  years 
of  life.  Of  those  reported  under  the  tenth  year,  Fischl's 
is  very  doubtful,  as  before  stated.  Cousot's  was  imper- 
fectly reported,  as  also  Goldflam's  cases  occurring  in  child- 
hood. 

Sex:  In  general  there  seems  to  be  no  discrimination  as 
to  sex,  though  it  happens  that  in  the  carefully  reported 
cases  there  are  but  three  females — reported  by  Fischl, 
Goldflam  and  Taylor.  The  affection  is  transmitted,  how- 
ever, equally  through  the  female  line.  Of  the  eleven  cases 
in  Taylor's  family,  five  were  women. 

Muscles  Involved:  The  most  constant  feature  in  this  re- 
gard is  the  paralysis  of  the  lower  extremities.  In  the 
typical  cases  the  legs  are  always  affected,  usually  first  and 
most  severely.  Body  and  arms  are  later  involved  in  the 
severe  attacks,  as  are  also  the  neck  muscles.  Very  unusual 
is  an  involvement  of  any  of  the  cranial  nerves.  An  analysis 
of  the  observed  cases  shows  certain  variations  from  the 
general  rule.  Burr,  for  example,  found  in  his  case  a  hemi- 
paresis,  not,  however,  involving  the  cranial  nerves;  or- 
dinarily, the  paralysis  was  bilateral.  Hirsch,  in  one  at- 
tack of  his  patient,  speaks  of  the  weakness  beginning  in 
the  arms.  In  Romberg's  case  and  Fischl's  cases  the  at- 
tacks were  practically  limited  to  the  legs,  as  they  were  at 
times  in  Griedenberg's  case.  Cousot  noted  feebleness  of 
articulation  as  an  early  symptom,  with  difficulty  later  both 
in  speech  and  deglutition.  The  usual  description,  how- 
ever, is:  Legs,  arms,  body,  head  involved;  cranial  nerves 
free,  coughing  and  sneezing  often  impossible;  at  times 
superficial  respiration.  With  slight  variations  these  were 
the  conditions  found  by  Hartwig,  Samuelsohn,  Westphal- 
Oppenheim,  Pulawski,  Goldflam,  Hirsch  and  Bernhardt. 
In  our  own  case  the  paralysis  is  unusually  complete.    Legs, 


730 


EDWARD    WYLLYS  TAYLOR. 


body,  arms,  neck  muscles  are  always  involved  in  these 
severe  attacks.  Most  noteworthy,  however,  is  the  ob- 
servation that  the  facial  nerves  are  occasionally  included, 
to  a  less  degree,  and  in  the  case  of  Mrs.  G.  (Case  11.)  the 
motor  branches  of  the  trigeminal  nerves  are  slightly  af- 
fected in  the  most  serious  attacks.  In  her  case,  also,  a 
threatening  dyspnoea,  alluded  to  also  in  Goldflam's  second 
case,  has  occurred  in  her  worst  attacks. 

The  distribution  of  the  paralysis  is  sufficiently  constant 
to  justify  the  general  statement  that  its  greatest  severity 
is  in  the  leg  muscles,  and  that  it  gradually  grows  less  the 
higher  on  the  body  we  go,  the  ocular  nerves,  for  example, 
never  being  involved,  and,  so  far  as  we  know,  the  fifth 
only  in  our  one  case.  The  involuntary  muscles  are  not 
affected. 

Order  of  Involvement  of  Muscles  in  Attack:  We  have  al- 
ready, in  a  preceding  paragraph,  indicated  that  the  legs 
are  first  affected,  and  later  the  other  portions  of  the  body 
in  a  somewhat  regular  sequence.  The  exact  determina- 
tion of  this  point  in  our  case  and  in  others  is  difficult,  ow- 
ing to  the  fact  that  the  paralysis  usually  comes  on  during 
sleep,  and  the  patient  finds  himself  on  waking  completely 
paralyzed.  My  patient  J.,  for  example,  could  give  me  no 
definite  information  as  to  which  muscles  were  first  af- 
fected. His  general  impression,  however,  is  that  the  legs 
first  grow  weak. 

Mechanical  Irritability  of  Muscle  and  Nerve:  Goldflam 
lays  stress  upon  the  fact  that  the  mechanical  nerve-muscle 
irritability  is  markedly  changed  during  an  attack.  Ir- 
ritabihty  of  the  muscles  through  tapping  or  pressing  a 
nerve,  in  his  case,  was  often  totally  lost.  The  idiomuscular 
irritability  was  altered  in  such  a  way  that  the  fascicular 
contractions  in  the  muscles  were  lost,  and  later  the  trans- 
verse swellings  occasioned  by  the  blow  also  disappeared. 
The  return  of  the  mechanical  irritability  of  the  muscles 
and  nerves  he  found  antedated  somewhat  the  return  of 
electrical  excitability.     Goldflam  regards  this  observation 


FAMILY  PERIODIC  PARALYSIS,  731 

as  of  great  importance,  though,  naturally,  secondary  to 
the  still  more  remarkable  electrical  changes.  Hirsch 
speaks  of  the  idiomuscular  irritability  being  less  than  the 
normal  in  his  case. 

Order  of  Recovery:  It  appears  from  a  study  of  the  cases 
that  the  order  of  return  of  power  is  the  inverse  of  the 
onset.  As  a  rule,  recovery  begins  in  the  upper  extremi- 
ties, and  extends  later  to  the  legs. 

Rapidity  of  Onset  and  Recovery:  The  usual  rule  is,  so  far 
as  it  is  possible  to  observe,  a  gradual  onset,  usually  of  several 
hours,  at  times  of  several  days,  before  the  height  of  the 
paralysis  is  reached;  a  stationary  stage  of  varying  length, 
and  an  equally  gradual  recover}'  in  the  order  named.  A 
sudden  loss  of  power  and  a  sudden  recovery  are  exceed- 
ingly rare.  Hirsch  reports  a  sudden  recovery,  and  also 
Fischl,  from  one  attack,  and  Goldflam  a  sudden  onset. 

Time  of  Onset:  It  is  usually  at  night.  Schachnowitsch, 
Westphal-Oppenheim,  Cousot,  Pulawski,  Bernhardt  and 
Taylor  report  cases  in  which  the  patient  wakes  paralyzed. 
This  is  always  so  in  my  best  reported  case.  The  other 
case,  Mrs.  G.,  has  attacks  not  infrequently  which  begin 
during  the  day. 

Length  of  Attack:  This  varies  within  very  wide  limits, 
from  less  than  an  hour  (Fischl)  to  a  week  (Burr).  The 
usual  duration  of  a  well-pronounced  attack  is  from  ten  to 
forty-eight  hours.  The  length  varies  greatly  in  the  same 
patient  at  different  times.  It  is  a  common  experience  for 
my  patient  J.  to  be  unable  to  leave  his  bed  before  11  or 
12  o'clock,  and  hardly  less  common  for  him  to  be  helpless 
until  evening.  (Vide  letter).  He  also  has  frequent 
feelings  6l  weakness,  which  may  hardly  be  called 
actual  attacks.  These  feelingsare  rather  precursors  of  the 
most  serious  ones,  which  are  sure  to  come.  In  general, 
the  longer  the  attack,  the  more  complete  the  helplessness 
and  the  more  profound  the  reflex  and  electrical  changes. 

Frequency  of  Attacks:  Nothing  definite  is  to  be  said  on 
this  point.     Goldflam  speaks  of  a  case  in  which  but  one 


732. 


EDWARD    WYLLYS  TAYLOR. 


attack  occurred  during  life,  and  that  in  the  thirty-sixth 
year.  In  one  of  my  cases  the  attacks  occur  at  times  daily, 
and  frequently  several  times  weekly,  with  intermissions. 
Cavare  and  Romberg  spoke  of  a  quotidian  type,  which 
they  associated  with  malaria.  Samuelsohn's  case  had  two 
attacks  a  year  for  a  while;  Hirsch's,  one  yearly  for  a  certain 
period;  Westphal's,  one  every  four  and  six  weeks;  Gold- 
flam's,  weekly  to  yearly.  There  is  in  this  absolutely  no 
constancy.  It  is  to  be  observed,  however,  that  each  in- 
vidual  has  a  certain  type  of  attack,  which  may  vary  greatly 
in  degree,  but  not  markedly  in  kind.  Since  the  onset  of 
the  affection  in  my  case  J.,  scarcely  a  week  has  passed 
without  some  intimation  of  its  presence.  His  sister,  on 
the  other  hand,  is  entirely  free  for  months  at  a  time. 

Total  Length  of  the  Affection:  Although,  for  obvious 
reasons,  definite  information  is  somewhat  uncertain  on 
this  point,  yet  the  stated  or  implied  belief  of  the  various 
writers  on  the  subject  is  that  the  attacks  continue  un- 
changed and  unchecked  through  life.  There  is  no  intima- 
tion that  they  grow  less  or  cease.  Of  very  particular  in- 
terest, then,  is  the  statement  made  in  regard  to  my  family, 
that  in  all  the  cases  the  attacks  have  tended  to  grow  less 
with  advancing  years,  and  finally  to  disappear  entirely 
between  forty  and  fifty.  There  are  at  present  members  of 
the  second  generation  living  who  have  had,  but  are  now 
practically  free  from  the  attacks.  In  view  of  Goldflam's 
and  Bemhardt's  theories,  later  to  be  discussed,  this  fact 
must  be  of  great  importance. 

Abortive  Attacks:  There  is  no  adequate  evidence  to 
show  that  an  attack  is  ever  actually  aborted.  Schach- 
nowitsch,  Goldflam  and  Taylor  found  that  active  muscular 
exercise  had  the  effect  of  postponing  an  attack.  This  is 
very  striking  in  my  case.  A  feeling  of  weakness  may  be 
dispelled  by  walking,  for  example,  but  he  is  sure  that  it  is 
merely  temporary,  and  that  he  pays  all  the  more  dearly, 
perhaps  the  next  day,  for  his  temporary  escape.  A  re- 
lapse before  recovery  has  entirely  taken  place  may  occur, 


FAMILY  PERIODIC  PARALYSIS, 


733 


as  shown  in  my  case,  described  in  detail  under  his  personal 
history.    This  is  unusual. 

Equivalents:  The  only  instance  we  have  been  able  to 
find  of  what  may  properly  be  called  an  equivalent  is  that 
described  by  Fischl.  In  place  of  the  paralytic  attack,  his 
patient,  a  child  of  eight,  developed  a  peculiar  drowsiness, 
which  came  on  in  paroxysms,  from  which  he  finally  fully 
recovered.  The  case  is  in  general  too  uncertain  to  render 
the  observation,  in  this  connection,  of  value. 

Heart:  Oppenheim  was  the  first  to  call  attention  to  a 
remarkable  temporary  affection  of  the  heart.  His  observa- 
tions were  later  verified  by  Hirsch.  Oppenheim  found  a 
slight  but  definite  enlargement,  with  murmurs  indicative 
of  mitral  insufficiency,  during  the  attack,  which  quickly 
gave  place  to  normal  conditions  when  the  paralysis  dis- 
appeared. Goldflam  describes  the  heart  as  arythmic  in 
action  at  times,  with  a  weak,  blowing  systolic  murmur  at 
the  base  and  a  slight  accentuation  of  the  second  sound, 
combined  with  a  slow  pulse,  and  no  other  evidence  of  cir- 
culatory disturbance.  This  condition,  however,  excepting 
the  arythmia,  persisted  in  the  free  intervals;  there  was 
no  enlargement  of  the  heart,  and,  in  general,  the  dis- 
turbance could  not  be  attributed  to  the  direct  influence 
of  the  attack,  unlike  Oppenheim's  case.  In  view  of 
a  later  case,  Goldflam  has  somewhat  modified  his  view. 
Hirsch  found  almost  precisely  the  same  condition  that 
Oppenheim  had — area  of  dullness  enlarged,  first  sound  at 
apex  impure,  slight  accentuation  of  the  second  pulmonic, 
insufficiency  of  the  mitral  valve;  pulse  regular,  78.  The 
morning  following  the  attack,  the  heart  was  practically 
normal.  Up  to  this  time  I  have  not  been  able  to  find 
any  temporary  heart  abnormality  in  my  case.  To  de- 
termine the  point  positively,  however,  repeated  examina- 
tions in  a  large  number  of  attacks  should  be  made. 

The  pulse  shows  no  noteworthy  change  during  the 
attacks,  and,  in  genei'al,  it  may  be  said  that,  apart  from  a 
temporary  heart  dilatation  noted  in  two  cases,  not  much 


731-  EDWARD    WYLLYS  TAYLOR. 

is  to  be  learned  from  a  study  of  the  circulatory  apparatus. 

Temperature:  Nothing  noteworthy.  Changes  in  su- 
perficial temperature  were  observed  in  Fischl's  doubtful 
case. 

Bladder  and  Rectal  Fuftctions:  It  is  an  interesting  ob- 
servation that  in  my  case  the  desire  to  pass  urine  or  faeces 
is  abolished  during  the  attack,  even  if  of  thirty-six  hours' 
duration.  This  is  never  due  to  a  true  retention,  but  to  a 
lack  of  desire.  The  patient  himself  explains  it  on  the 
ground  of  his  helplessness,  and  the  consequent  discomforts 
of  either  act.  This  evidently  is  hardly  a  sufficient  ex- 
planation. Probably  somewhat  less  urine  is  secreted  than 
under  normal  conditions,  and  certainly  much  less  water 
and  food  are  ingested.  (See  previous  remarks  on  appetite 
and  thirst.)  This,  with  the  general  atony  of  the  muscles, 
no  doubt  brings  about  the  condition;  it  is  not  incapacity, 
but,  rather,  lack  of  necessity.  Westphal  speaks  of  a  desire 
to  urinate  as  a  preUminary  symptom,  with  a  temporary 
inability  to  do  so.  With  this  trifling  exception,  we  find 
no  mention  of  disturbance  of  the  rectal  and  bladder 
functions.  When  the  matter  is  mentioned  at  all,  the 
writers  speak  of  the  condition  as  normal  and  the  sphinc- 
ters as  uninvolved. 

Other  symptoms  alluded  to  in  the  reported  cases  are 
too  infrequent  and  inconstant  to  require  individual  con- 
sideration. 

It  will  be  impossible  and  undesirable  to  draw  a  sharp 
line  between  the  pathological  anatomy  and  the  etiology 
of  this  affection.  For  the  sake  of  clearness  of  exposition, 
however,  we  shall  attempt  to  consider  these  two  final 
matters  under  separate  headings. 

Pathological  Anatomy:  There  are  no  constant  changes 
in  any  of  the  internal  organs;  the  only  temporary  change 
as  yet  described  is  a  dilatation  of  the  heart  during  an  at- 
tack (Oppenheim,  Hirsch).  The  spleen  has  shown  no  al- 
teration between  or  during  attacks.  Inasmuch  as  death 
from  this  cause  is  practically  unknown,  no  minute  post- 


FAMILY  PERIODIC  PARALYSIS.  735 

mortem  examination  of  the  nervous  system  has  been  made. 
Nor  can  we  suppose  any  constant  lesion  of  the  nervous 
mechanism,  demonstrable  by  the  microscope,  could,  under 
most  favorable  conditions,  be  found,  since  intervals  of 
health,  certainly  so  far  as  the  nerve  mechanism  is  con- 
cerned, alternate  with  the  typical  attacks.  Leaving  aside 
for  the  moment  the  etiology,  it  is  evident  that  the  chief 
interest  of  the  affection,  from  the  point  of  view  of  patho- 
logical anatomy,  must  centre  in  the  muscular  system,  al- 
though certainly  no  adequate  explanation  of  the  origin 
or  nature  of  the  attacks  is  to  be  sought  in  the  muscles 
themselves.  Excision  of  a  small  bit  of  muscle  has  been 
practiced  both  by  Oppenheim  and  Goldflam,  who  have 
arrived  at  quite  contrary  opinions  as  to  the  significance 
of  their  findings.  Oppenheim  describes  a  bit  of  muscle,  ex- 
cised from  the  deltoid,  as  showing  a  waxy  degeneration, 
which  he  regards,  however,  of  most  doubtful  pathological 
significance.  He  attaches,  in  fact,  no  weight  whatever 
to  the  observation.  Goldflam,  on  the  other  hand,  from 
a  study  of  muscles  from  several  of  his  cases,  using  muscle 
from  a  cadaver  as  control,  comes  to  the  conclusion  that 
the  pathological  changes  in  the  muscle  are  of  extreme 
importance,  and  offer  at  least  a  partial  explanation  of  the 
clinical  picture.  He  found  an  increased  diameter  of  the 
individual  muscle  fibres,  a  general  hypertrophy  of  the 
fibres,  a  rarefaction  of  the  primitive  fabrillcC  and  vacuole 
formation.  To  these  muscle  changes  Goldflam  attributes 
the  persistent  electrical  anomalies,  which  he  alone  has 
found  constant  between  the  attacks.  Such  changes,  or 
any  permanent  changes  whatever,  manifestly  do  not  ex- 
plain the  periodic  paralysis.  Oppenheim's  and  Siemer- 
ling^s®  investigations  would  indicate  that  in  so  far  as 
Goldflam  drew  conclusions  by  comparison  with  muscle 
from  the  cadaver  he  was  in  error.  This  point  Goldflam,  in 
general,  admits,  but  feels  none  the  less  confident  that 

•  Oppenheim-Siemerling:   Centralbl.    f.  rned.  Wissenschaften,  1889^ 
PP-  705,  7^7' 


736  EDWARD    IVYLLYS   TAYLOR, 

definite  pathological  changes  were  present.  In  his  last 
article  Goldflam  reiterates  the  ideas  previously  expressed. 
Beyond  this  we  have  no  knowledge  as  to  the  con- 
dition of  the  muscles.  Bernhardt's  cases  are  interesting 
in  this  connection,  inasmuch  as  his  patients  from  their 
earliest  years  had  constant  difficulty  in  the  use  of  certain 
rtiuscles,  entirely  apart  from  the  periodic  attacks.  For 
this  reason,  because  of  the  almost  undoubted  muscle 
changes  in  Bemhardt*s  cases,  as  he  supposed  of  an  allied 
sort  to  the  various  dystrophies,  we  have  hesitated  to  in- 
clude them  among  the  uncomplicated  forms  of  so-called 
family  periodic  paralysis.  The  justification  for  this  may 
seem  doubtful  in  the  light  of  Goldflam's  researches,  but 
we  have  been  led  to  this  standpoint  for  the  reason  that  in 
our  family  recovery  from  the  attacks  always  occurs  at 
about  the  fiftieth  year.  If  a  dystrophy,  which  both  Gold- 
flam  and  Bernhardt  supposed,  were  at  the  bottom  of  the 
difficulty,  it  is  not  easy  to  explain  this  fact,  which  appears 
absolutely  undoubted  in  our  family.  As  before  stated,  the 
changes  described  by  Goldflam  may  be  an  accompaniment 
but  can  in  no  way  be  regarded  as  causative  of  the  periodic 
attacks,  which,  after  all,  constitute  the  so-called  disease. 
It  will  be  remembered,  also,  that  Oppenheim  found  a 
slight  muscular  atrophy  in  the  hand  muscles,  but  ap- 
parently does  not  take  the  ix)sition  that  the  affection 
is  to  be  classed  with  the  muscular  atrophies  or  dystrophies, 
Goldflam  does  not  hesitate,  however,  to  say  that  through 
his  researches  on  the  muscle  he  has  placed  the  aflfection 
in  the  category  of  the  organic  diseases.  His  own  words 
are:  "Durch  diesen  Muskelbefund  ist  die  paroxysmale 
Lahmung  aus  der  Reihe  der  Neurosen  geschieden,  sie  tritt 
in  das  immer  sich  erweiternde  Gebiet  der  auf  organischen 
Storungen  beruhenden  Erkrankungen,  speciell  muss  sie 
in  die  grosse  Kategorie  der  bereits  bekannten  famili  ren 
(mit  gleichartiger  Vererbung)  Erkrankungen  eingereiht 
werden,  als  welche  die  Dystrophia  muscularis  progressiva, 
die    neurotische    Muskelatrophie    Hoffman's,    die  Fried- 


FAMILY  PERIODIC  PARALYSIS,  737 

reichsche  Krankheit,  die  Myotonia  congenita  z\x  nennen 
sind/'^^ 

Bernhardt  is  inclined  to  the  same  opinion;  others 
would,  as  yet,  not  be  so  dogmatic. 

As  to  the  location  of  the  process,  whatever  it  may  be, 
which  produces  the  paralytic  attacks,  we  may  certainly 
limit  it  to  the  spinal  motor  neuron  and  its  associated 
muscles.  Westphal  suggested,  as  an  explanation,  a 
periodic  disturbance  of  circulation  in  the  cord.  Were 
such  a  circulatory  disturbance  the  cause,  we  should  have 
to  suppose  a  limitation  of  its  action  to  the  anterior  hor*ns, 
since  sensation  is  not  affected.  This  is  evidently  a  mere 
assumption,  and  also,  in  the  light  of  later  researches,  does 
not  explain  the  observed  facts.  Oppenheim  has  suggested 
a  similar  circulator)^  disorder  in  the  periphery,  which  cer- 
tainly may  exist,  but  is  difficult  to  prove.  What  evidence 
we  have  goes  to  show  that  the  periodic  disturbance  is  peri- 
pheral, and  probably  associated  with  the  terminal  distnbu- 
tions  of  the  nerves  in  the  muscles,  and  almost  undoubtedly 
with  the  muscles  themselves,  as  shown  by  the  loss  of 
myotatic,  as  well  as  nerve,  irritability.  Were  it  necessary 
to  find  a  single  point  of  disturbance,  we  should  locate  it 
in  the  muscle  rather  than  in  the  nerve  or  its  endings.  It 
is,  however,  altogether  possible,  and  incapable  of  refuta- 
tion, that  it  may  be  the  result  of  a  temporary  lesion  in 
both  muscle  and  nerve. 

The  blood  shows  certain  changes  of  interest  in  the 
few  cases  in  which  it  has  been  examined.  In  mv  case 
Dr.  H.  F.  Hew-es  has  twice  studied  the  blood,  both  speci- 
mens being  taken  during  the  free  interval.^^  The  details 
of  his  reports  have  already  been  given  under  the  clinical 
history.  In  general,  he  found  a  lymphocytosis,  with  no 
evidence  of  anaemia;  a  large  percentage  of  basophiles, 
which  he  regards  as  characteristic  of  a  reduced  condition 

'**  Goldflam:  Loc.  cit.  Ret.  18,  p.  27. 

"  Unfortunately  it  has,  as  yet,  been  impossible  to  make  an  ex- 
amination of  the  blood  and  urine  taken  during  the  attack. 


738  EDWARD    WVLLYS   TAYLOR, 

of  nutrition.    The  count,  he  states,   would  be  normal  for 
a  child  of  ten,  but  not  for  a  man  of  twenty.     Dr.  Hewes 
finds  also  a  relatively  small  number  of  white  corpuscles. 

Goldflam  alone  of  the  other  observers  reports  a  blood 
examination.  Klein,  who  made  the  examinaiion  found  a 
constant  but  varying  leucocytosis  during  the  attack,  which 
was  normal  in  the  intervals.  Noteworthy  is  the  fact  that 
Klein  also  found  a  definite  lymphocytosis,  40  per  cent.,  in 
the  free  intervals,  which  is  identical  with  Hewes'  observa- 
tion. In  the  free  interval  eosinophiles  often  show  an  in- 
crease to  5  per  cent.  In  the  attack  there  was  a  marked 
neutrophile  leucocytosis,  with  a  reduction  in  the  number 
of  eosinophiles.  The  blood,  therefore,  in  both  Goldflam's 
case  and  mine  shows  distinct  pathological  qualities.  We 
may  not,  however,  draw  deductions  from  this  fact;  it  is 
quite  impossible  for  us  to  say  in  what  relation  the  blood 
changes  stand  to  the  paralytic  attacks.  It  is,  however, 
probable  that  both  are  due  to  a  common  cause,  of  which 
we  have  as  yet  absolutely  no  definite  knowledge. 

The  ordinary  routine  examination  of  the  urine  in 
the  various  cases  has  shown  nothing,  excepting  in  Gold- 
flam's  later  cases,  in  which  traces  of  albumin  and  patho- 
logical cells  were  found  during  an  attack.  Goldflam  again 
was  the  first  to  make  a  detailed  study  in  order  to  deter- 
mine, if  possible,  the  presence  of  a  toxic  substance,  to 
which  might  be  attributed  the  periodic  attacks.  His  ef- 
forts were,  in  part,  successful.  The  analysis  was  made  by 
Knaster,  and  resulted  in  the  isolation  of  certain  substances 
whose  toxic  effect,  however,  could  not  be  demonstrated 
on  animals.  A  rabbit,  for  example,  injected  with  the  sup- 
posed ptomaine,  died,  but  with  none  of  the  symptoms  of 
the  periodic  paralysis,  as  seen  in  man.  The  injection  of 
the  urine  itself  seemed  more  toxic  when  the  urine  was 
taken  during  an  attack  than  in  the  interval.  These  in- 
vestigations must  be  regarded  as,  in  general,  negative,  and 
certainly  show  nothing  as  to  the  pathology  of  the  affec- 
tion.    The  examination  of  a  twenty-four-hour  specimen 


i 


FAMILY  PERIODIC  PARALYSIS,  739 

of  urine  in  the  free  interval  in  my  case  suggested  a  some- 
what low  condition  of  metabolism.  The  excretion  of  urea 
was  below  normal  for  a  person  of  his  age.  The  twenty- 
four-hour  amount  was  also  low.  Otherwise,  the  urine  was 
essentially  normal.  (Details  are  given  under  clinical  his- 
tory.) 

Examination  of  the  stools  has  thrown  no  light  on  the 
question.  It  has  not  been  made  in  my  case,  and  there  is 
no  evidence  that  it  has  been  done  by  any  observer  with 
anything  approaching  adequate  thoroughness. 

Etiology:  The  exciting  cause  of  these  periodic  attacks 
has  been  up  to  this  time  absolutely  elusive,  and  no  doubt 
will  remain  so  until  our  methods  of  investigation  are 
much  more  highly  perfected  than  now,  and  until  we  are 
able  to  distinguish  clearly  causes  from  effects,  and  con- 
comitant conditions  from  both.  There  is  evidently  a 
striking  hereditary  predisposition  in  the  affection,  which, 
naturally,  in  no  way  helps  to  explain  the  exciting  cause. 
The  association  of  the  attacks  with  malaria  led  several 
of  the  earlier  writers  (Hartwig,  Cavare,  Gibney)  to  bring 
the  two  conditions  into  casual  relationship.  Apart  from 
the  doubt  which  attaches  to  the  classification  of  certain 
of  the  cases,  notably  Gibney's,  it  would  appear  that  the 
mere  fact  of  periodicity  possibly  led  to  the  idea  of  malaria 
as  a  cause,  an  error  from  which  we  are  not  yet  wholly  free. 
Now  that  we  are  able  to  demonstrate  the  malarial  or- 
ganism, there  is  no  possibility  of  the  perpetuation  of  this 
error.  The  organism  has  never  been  found  in  cases  of 
periodic  paralysis,  and  as  our  clinical  knowledge  has 
grown,  it  has  become  more  and  more  evident  that  the  con- 
dition has  no  affinity  to  malaria  beyond  the  superficial 
fact  of  its  periodicity. 

An  observation  which  we  have  made  in  common  with 
others  is  that  the  attacks  almost  invariably  occur  at  night, 
and,  what  is  more  important  in  this  connection,  that  they 
are  usually  preceded  by  a  day  of  exceptional  muscular  ac- 
tivity.    My  patient  is  able,  with  a  certain  degree  of  as- 


740 


EDWARD    JVVLLVS   TAYLOR. 


surance,  to  predict  an  attack  from  his  previous  day's  em- 
ployment. A  long  bicycle  ride  on  a  tandem,  in  which  he 
was  obliged  to  do  most  of  the  work,  led  to  one  of  the  worst 
attacks  the  following  night  and  day  he  has  ever  had.  Such 
experiences  are  common  with  him,  though  not  absolutely 
invariable.  Not  less  interesting  is  the  fact  that  the  at- 
tacks never  come  on  while  he  is  exercising,  a  common  ob- 
servation of  others  as  well,  but  only  after  he  has  rested 
and,  preferably,  slept.  Our  conclusions  from  these  rela- 
tively constant  facts  must  simply  be  that  muscular  exer- 
tion, followed  by  muscular  rest,  is  the  condition  of  an 
attack. 

This  statement  of  the  fact,  however,  brings  us  no 
nearer  the  actual  exciting  cause.  Bernhardt,  Oppenheim, 
and  especially  Goldflam  have  urged  the  probability  of  an 
autointoxication  of  some  kind,  the  conditions  of  whose 
activity  are  given  by  exercise,  followed  by  rest.  V^an 
Gieson^^  in  his  recent  paper  expresses  a  like  opinion,  and 
certainly,  to  us,  no  other  cause  seems  adequate.  In  this 
case  we  must  suppose  that,  depending  upon  a  family  pe- 
culiarity in  certain  stages  of  metabolism  a  poison  is  gen- 
erated within  the  system,  whose  action  is  paralyzant  to 
peripheral  motor  nerves  and  muscles.  The  analogy  to 
curare  has  been  suggested  by  Bernhardt.  It  is  interest- 
ing, but  not  altogether  apt,  inasmuch  as  the  effect  of  cu- 
rare is  confined  to  the  nerve,  whereas  in  the  periodic  pa- 
ralysis the  toxic  agent,  whatever  it  may  be,  leads  to  a  loss 
of  myotatic  irritability  as  well.  Further  speculation  on 
this  point  is  unprofitable.  We,  as  yet,  have  no  demon- 
strative evidence  of  the  theory  of  autointoxication.  Nev- 
ertheless, it  remains  by  all  means  the  most  plausible  work- 
ing hypothesis.  The  source  of  origin  of  the  problematic 
poison  is  wholly  obscure.  In  the  hope  of  finding  some 
light,  careful  investigation  as  to  the  digestive  functions 
has  been  made,  with  no  result.     It  is  quite  impossible  in 


u 


Van  Gieson:   The  Toxic  Basis  of  Neural  Diseases,  State  Hospi- 
tals Bulletin,  1896,  I.,  No.  4,  p.  470. 


FAMILY  PERIODIC  PARALYSIS.  741 

my  case  or  others  to  logically  trace  an  attack  to  a  dietary 
error,  or  to  a  possible  retention  in  the  body  of  faecal  mat- 
ter. The  lack  of  appetite  during  attacks  cannot  be  looked 
upon  as  of  the  slightest  significance  in  this  connection. 

For  obvious  reasons  syphilis,  neuritis  and  hysteria  play 
no  part  in  the  etiology.  Emotions  have,  in  certain  cases, 
seemed  to  have  some  effect  in  the  production  or  checking 
of  an  attack,  but  not  to  a  significant  extent. 

The  results  of  pathological  and  etiological  investiga- 
tions hitherto  made  are,  therefore,  positive  as  regards  ac- 
tual muscular  changes  (Goldflam,  Bernhardt)  in  certain 
cases,  and  entirely  negative  as  regards  the  nature  of  the 
substance,  if  such  it  be,  which  causes  the  periodic  attack. 
The  pathological  changes  in  muscle  and,  possibly,  in  blood 
and  urine  are  interesting  as  facts,  but  not  as  explanation. 

Diagnosis  and  Classification:  The  affection  presents  no 
difficulty  in  diagnosis  when  occurring  in  a  typical  form. 
The  combination  of  symptoms  is  imique  and  unmistak- 
able. Goldflam  has  in  one  case  of  Landry's  paralysis  tem- 
porarily made  a  diagnosis  of  paroxysmal  paralysis. 

The  classification  of  the  disturbance  offers  much 
greater  difficulty.  As  already  indicated,  Goldflam  and 
Bernhardt  are  strong  in  their  belief  that  the  affection 
should  be  classed  among  the  dystrophies  as  an  organic 
disease  of  the  nervous  system,  giving  as  an  argument  that 
changes  (Goldflam)  are  found  in  the  muscles.  Admitting 
this  fact,  however,  the  periodic  paralytic  attacks,  which 
alone  are  significant,  remain  totally  unexplained,  inasmuch 
as  most  dystrophies  occur  without  such  attacks.  Goldflam 
admits  to  a  certain  extent  the  inconsistency,  but  retains 
his  somewhat  dogmatic  position.  In  our  opinion,  and  par- 
ticularly in  our  family,  we  feel  altogether  justified  in  sub- 
ordinating any  possible  muscular  changes,  and  fixing  our 
attention  solely  on  the  attacks,  which  are  the  disease,  as 
clinically  observed. 

To  our  mind,  a  more  interesting  and  instructive 
analogy  is  that  between  this  affection  and  the  so-called 


742  EDWARD    WYLLYS   TAYLOR, 

congenital  myotonias.  Although  differing  widely  in  mani- 
festation, the  two  affections  at  least  have  this  in  common, 
that  they  occur  paroxysmally. 

In  this  connection  a  reference  to  Rich's  cases  is  of  in- 
terest. It  will  be  remembered  that  in  his  cases  cold  was 
invariably  the  exciting  cause  of  the  attack,  but  that  the 
attack  was  always  of  the  character  of  a  tonic  spasm.  In 
this  cjirious  family  history  we  no  doubt  have  to  do  with 
what  Eulenburg  has  described  as  Paramyotonia  Congen- 
ita, a  disturbance  allied  to  myotonia  of  the  ordinary  type. 
Further  study  of  these  spasmodic  affections  of  the  neuro- 
muscular system  in  relation  to  the  flaccid  periodic  pa- 
ralvsis  will  no  doubt  vield  much  of  interest.  To  allv  the 
conditions  under  consideration  with  the  muscular  dys- 
trophies is  surely  a  begging  of  the  real  question  at  issue. 
Goldflam,  however,  states  that  the  periodic  paralysis  has 
the  closest  analogy  with  congenital  myotonia,  but  our 
knowledge  of  the  pathology  of  myotonia  is  evidently  too 
vague  to  admit  of  dogmatic  statement.  That  periodic 
paralysis  is  to  be  included  in  the  general  etiology  of  the 
hereditary  affections  goes  almost  without  saying,  but  we 
are  overstepping  our  knowledge  when  we  attempt  too 
closely  to  force  its  relationship  to  any  one. 

Prognosis:  It  is  usually  good  so  far  as  life  is  concerned. 
Apart  from  young  children,  but  two  deaths  have  been  re- 
ported, one  of  doubtful  significance,  the  other  apparently 
induced  by  a  therapeutic  attempt.  My  family  has  the  pe- 
culiarity of  showing  a  tendency  to  recover  in  middle  life. 
Others  repK)rted  have  remained  unchanged  through  life,  so 
far  as  observed. 

Treatment:  Absolutely  unavailing.  It  is  evident  that 
a  successful  treatment  is  not  likely  to  be  instituted  until 
a  cause  is  found;  drugs,  including  quinine,  in  the  un- 
doubted cases  have  been  entirely  inefficient. 

The  affection  discussed  in  the  foregoing  pages  evi- 
dently offers  one  of  the  most  subtle  problems  with  which 
medicine  has  to  deal.     The  clinical  phenomena  are  ex- 


FAMILY  PERIODIC  PARALYSIS,  743 

traordinarily  well  defined;  the  pathological  anatomy  is 
vague;  the  etiology  is  absolutely  obscure.  The  solution  of 
the  problem  already  reaches  far  beyond  the  field  ordinarily 
occupied  by  the  neurologist;  a  laborious  investigation 
into  the  chemistry  of  the  metaboHsm  of  so  peculiarly  pre- 
disposed a  series  of  individuals  may  finally  bring  the  de- 
sired solution.  At  present,  excepting  that  the  problem  is 
more  definitely  stated,  we  are  not  further  advanced  than 
was  Westphal,  more  than  ten  years  ago,  when  he  said: 
"Wir  stehen  somit  dem  geschilderten  Krankheitsfalle  als 
einem  Rathsel  gegeniiber.'* 

BIBLIOGRAPHY. 

(i)  Hartwig:  Ueber  einen  Fall  intermittirender  Paralysis  spinalis. 
Inaug.  Dissertation,  Halle,  1874,  Ref.  by  Bernhardt,  Centralbl.  f.  d. 
med.  Wissensch.,  1875,  No.  26,  p.  428. 

(2)  Samuelsohn:  Fall  von  intermittirender  Paraplegie.  Verein 
fur  wissenschaftliche  Heilkunde  zu  Konigsberg,  i.  Pr.,  Oct.  13,  1876. 
Berl.  kl.  Wochenschr.,  1877,  xiv.,  No.  41,  p.  607. 

(3)  Schachnowitsch:  Wratsch.  Russisch.,  1882,  p.  537.  Ref.  in 
Goldflam's  paper,  13,  of  Bibliography. 

(4)  Gibney:  Intermittent  Spmal  Paralysis  of  Malarial  Origin. 
Am.  Jour,  of  Neurology  and  Psychiatry,  1882,  vol.  i.,  p.  i. 

(5)  Westphal:  Ueber  einen  merkwiirdigen  Fall  von  periodischer 
Lahmung  aller  vicr  Extremitaten,  mit  gleichzeitigem  Erloschen  der 
electrischen  Erregbarkeit  wahrend  der  Lahmung.  Berl.  kl.  Wochen- 
schr., 1885,  No.  31,  32,  p.  489. 

(6)  Fischl:  Ueber  einen  Fall  von  periodischer  auftretender  Lah- 
mung der  unteren  Extremitaten.  Prag.  med.  Wochenschr.,  1885,  No. 
42,  p.  401. 

(7)  Nachtrag  zu  dem  Aufsatze  "  Ueber  einen  merkwiirdigen  Fall 
von  periodischer  Lahmung  aller  vier  Extremitaten,"  u.  s.  w.  Berl.  kl. 
Wochenschr.,  1886,  No.  11,  p.  165, 

(8)  Cousot:  Cas  de  paralysie  p^riodique.  Bui.  d'Acad.  de  M6d. 
de  Belgique,  1886,  No.  7. 

(9)  Cousot:  Paralysie  periodique.    Rev.  de  Med.,  1887,  vii.,  p.  190. 

(10)  Griedenberg:  Wratsch.  Russisch.,  1887,  P- 930.  Ref.  in  Gold- 
flames  paper,  13,  of  Bibliography. 

(11)  Goldflam:  Ueber  eine  eip^enthiimliche  Form  von  periodischer, 
familiarer,  wahrscheinlich  auto-intoxicatorischer  Paralyse.  Wien. 
med.  Presse,  1890,  No.  36,  yj,  38,  39,  p.  1418. 

(12)  Pulawski:  La  paralysie  totale  des  quatre  extremites  et  du 
tronc  durant  48  heures.    Gaz.  hebd.  de  med.  et  de  chir.,  1890,  No.  48, 

P-  570. 

(13)  Goldflam:  Ueber  cine  eigenthtimliche  Form  von  periodischer, 
familiarer,  wahrscheinlich  auto-intoxicatorischer  Paralyse.  Zeitschr. 
f.  klin.  Med.,  1891,  xix;  Supplementary  vol.,  p.  240. 

(14)  Oppenheim:  Neue  Mittheilungen  tibcr  den  von  Prof.  West- 
phal beschriebencn  Fall  von*  periodischer  Lahmung  aller  vier  Extremi- 
taten.   Charite  Annalen,  1891,  xvi.,  p.  350. 

(15)  Burr:  Periodic  Paralysis  with  the  Report  of  a  Case.  Univ. 
Med.  Mag.,  Phila.,  i892-'3,  p.  836. 


744  EDWARD    IVYLLYS   TAYLOR, 

(i6)  Hirsch:  Ueber  einen  Fall  von  periodischer,  familiarer  Para- 
lyse.    Deutsche  med.  Wochenschr.,  1894.     No.  52,  p.  646. 

(17)  Rich:  A  Unique  Form  of  Motor  Paralysis  due  to  Cold. 
Med.  Nevrs,  Phila.,  1894,  Ixv.,  p.  210. 

(18)  Goldflam:  Weitere  Mittheilung  tiber  die  paroxysmale,  fa- 
miliare  Lahmung:.    Deutsche  Zeitschr.  f.  N  erven  he  ilk.,  1895,  vii.,  p.  i. 

(19)  Bernhardt:  Notiz  iiber  die  familiare  Form  der  Dystrophia 
muscularis  progressiva*  und  deren  Combination  mit  periodisch  aut- 
tretender,  paroxysmaler  Lahmung.  Deutsche  Zeitschr.  f.  Nervenheilk.. 
1896,  viii.,  p.  III. 

(20)  Goldflam:  Dritte  Mittheilung  iiber  die  paroxysmale,  familiare 
Lahmung.     Deutsche  Zeitschr.,  f.  Nervenheilk.,  1897,  xi.,  p.  242. 


DISCUSSION. 

Dr.  Wharton  Sinkler,  in  connection  with  the  paper  of  Dr. 
Taylor,  wished  to  place  on  record  a  case  which  came  under 
his  observation  last  summer.  The  patient  w^as  a  man  with 
facial  paralysis,  who  gave  a  history  of  five  previous  attacks 
in  the  course  of  about  ten  years.  Each  of  these  lasted  several 
weeks,  and  ended  in  complete  recovery.  No  satisfactory  cause 
for  the  attacks  could  be  elicited. 

Dr.  C.  L.  Dana  had  seen  a  number  of  cases  of  periodic 
paralysis;  none,  however,  of  the  family  type.  From  his  ob- 
servation of  these  cases,  including  the  one  reported  by  Dr. 
Gibney,  he  had  come  to  the  conclusion  that,  while  some  of 
them  were  cases  of  recurrent  poliomyelitis,  the  majority  were 
purely  hysterical  in  character.  The  speaker  expressed  the 
opinion  that  the  question  of  periodical  paralysis  due  to  ma- 
laria was  still  unsettled.  He  had  never  seen  anv  cases  of 
that  kind,  and  in  several  instances  where  patients  were  sent 
to  him  with  that  diagnosis,  the  paralysis  proved  to  be  simply 
functional  or  hysterical. 

The  fanniily  type  of  the  disorder  reported  by  Dr.  Taylor 
was  extremely  interesting.  It  was  certainly  rare,  and,  per- 
haps, a  little  light  might  be  thrown  upon  the  subject  by  study- 
ing allied  conditions.  Dr.  Dana  said  he  had  seen  a  number 
of  patients  who  had  informed  him  that  when  first  waking  in 
the  morning  they  were  unable  to  move  for  half  an  hour,  or 
even  longer.  They  suflfered  from  waking  palsy  and  a  certain 
amount  of  waking  numbness.  Cases  of  ptosis  are  not  un- 
common, and  the  same  is  true  of  cases  of  morning  sweating, 
where  the  patients  become  bathed  in  profuse  perspiration  just 
as  they  awaken.  Other  peculiar  morning  disorders  are  known, 
and  perhaps  these  palsies  may  be  in  the  same  category.  Dr. 
Dana  said  he  had  always  regarded  them  as  the  result  of  dia- 
thetic (fisturbances.  They  usually  occur  in  persons  of  the 
neurasthenic  or  lithaemic  type,  and  in  the  former  they  are 
probably  associated  with  a  congenital  disturbance  or  defect 
of  the  nervous  system.     The  ordinary  types  of  morning  pa- 


FAMILY  PERIODIC  PARALYSIS.  745 

ralysis  seem  to  be  the  result  of  some  toxic  condition,  associ- 
ated with  an  asthenic  condition  of  the  nervous  system. 

Dr.  Joseph  Collins  had  observed  three  cases  of  periodic 
paralysis;  none,  however,  of  tlie  family  type.  One  of  the  cases 
had  been  reported  by  him  under  the  title  of  asthenic  bulbar 
paralysis,  and  it  was  a  typical  example  of  that  affection.  When 
Dr.  Collins  first  saw  her,  her  symptoms  were  those  of  profound 
neurasthenia.  About  two  years  after  the  commencement  of 
her  illness  she  had  double  ptosis,  double  facial  paralysis,  pa- 
ralysis of  the  extremities,  more  marked  in  the  upper,  and 
ballooning  of  the  abdomen;  her  general  condition  being  very 
similar  to  that  of  surgical  shock,  and  indicating  an  overwhelm- 
ing disorder  of  the  sympathetic  nervous  system.  After  a  few 
days'  duration  the  paralytic  manifestations  disappeared.  Sen- 
sory disturbances  were  never  noted.  In  the  course  of  two 
or  three  years  she  had  had  abofut  five  attacks  similar  to  this 
one,  and  in  the  interval  the  symptoms  of  asthenic  bulbar  pa- 
ralysis persisted. 

The  second  case  was  a  woman  who  had  been  referred 
to  him  by  Dr.  Fordyce.  She  had  complete  motor  and  sen- 
sory paralysis  on  one  side,  and  the  hand  and  forearm,  as  well 
as  the  foot,  of  the  same  side  showed  the  manifestations  of 
Raynaud's  disease  and  erythromelalgia.  The  symptoms  came 
on  in  attacks,  and  had  so  far  recurred  three  times. 

The  third  case  was  one  seen  in  Dr.  Dana's  clinic  some 
years  ago.  The  patient  was  a  boy  of  fourteen,,  with  a  pro- 
foundly neuropathic  family  history,  who  had  had  about  half  a 
dozen  attacks  of  periodic  paralysis.  At  the  time  Dr.  Dana 
suggested  that  maJaria  might  be  at  the  bottom  of  his  trouble. 
Some  of  the  clinical  aspects  of  the  case  simulated  a  low  grade 
of  poliomyeliitis,  but  it  was  subsequently  decided  that  the 
apparent  atrophy  of  the  muscles  was  the  result  of  emaciation. 
The  vasomotor  symptoms  predominated,  and  no  sensory  dis- 
turbances were  present. 

Dr.  Taylor,  in  closing,  said  he  thought  the  cases  which 
had  been  mentioned  by  the  various  speakers  were  not  ab- 
solutely analogous  to-  those  reported  in  his  paper.  In  reply  to 
a  question,  the  speaker  said  that  the  sphincters  in  his  case 
were  not  affected.  In  some  of  the  cases  the  muscles  of  res- 
piration were  involved;  in  others  not.  In  one  case  there  was 
dangerous  dyspnoea.  No  sensory  changes  could  be  found. 
The  clinical  aspects  of  the  condition  were  so  absolutely  unique 
and  characteristic  that  an  error  in  diagnosis  was  hardly  pos- 
sible, viz.,  periodic  paralysis  of  the  muscles  of  the  trunk  and 
extremities,  associated  with  loss  of  reflex  and  electrical  ex- 
citability during  the  attack,  and  occurring  as  a  family  affec- 
tion, with  normal  conditions  between.    The  cases  cited  bv  the 


746  EDWARD    IVYLLYS  TAYLOR, 

various  speakers  evidently  did  not  belong  to  this  type,  al- 
though possibly,  they  \vere  related.  Hysteria  was  evidently 
not  to  be  considered,  and  malaria  had  no  constant  place  in 
the  etiology,  nor  was  there  sufficient  evidence  to  show  that 
the  vasomotor  system  played  any  prominent  part  in  its 
production.  A  temporary  autointoxication  seemed  the 
most  probable  cause,  the  nature  of  which  remains  wholly 
unknown. 


226.  Remarks   on   Spinal   Irritation.    Hugh   T.    Patrick,    M.D., 
(Medicine,  3,  1897,  P-  535). 

The  term  "spinal  irritation"  should  be  banished  from  medical 
nomenclature.  The  pain  and  tenderness  along  the  spine  commonly 
known  by  this  name  have  nothing  to  do  with  the  spinal  cord  or  its 
membranes,  or  with  the  spinal  column.  The  condition  is  not  due  to 
congestion  of  anaemia  of  the  cord,  or  altered  nutrition,  or  a  neurosis 
of  the  spinal  arteries,  or  thickening  of  the  membranes,  or  exhaustion 
of  the  gray  matter  of  the  cord,  or  an  affection  of  the  nerve  roots  or 
trunks,  or  irritation  of  vertebrae  or  spinal  ganglia,  or  any  other  perma- 
nent condition  in  the  back  whatsoever.  In  so-called  spinal  irritation 
there  are  tender  points  along  the  spine.  It  can,  however,  be  shown 
that  these  points  shift  rapidly,  absolutely  changing  their  position 
within  five  or  ten  minutes.  The  sore  points  are  notoriously  inconstant 
in  degree  of  tenderness  and  in  location,  but  it  seems  to  be  not  gen- 
erally known  that  the  r^atient  can  locate  them  only  about  as  accurately 
as  a  well  person  can  locate  a  spot  on  his  back  previously  touched. 
The  tenderness  cannot  be  due  to  anything  abnormal  at  the  tender  spot, 
else  the  pressure  the  second  time  on  the  same  spot  would  be  just  as 
painful  as  the  first  time,  and,  furthermore,  we  cannot  suppose  a  pa- 
thological condition  to  have  developed  within  five  or  ten  minutes. 
This  shifting  corresponds  just  about  to  that  in  the  healthy  individual. 
If  a  normal  person  have  any  given  spot  on  the  baick  pressed,  after 
five  or  ten  minutes  he  will  be  unable  to  indicate  exactly  where  the 
spot  is.  It  seems  reasonable  to  conclude  that  there  is  a  lack  of  ab- 
solute accuracy  of  th€  sensorium.  In  the  pathological  case  the  shift- 
ing involves  the  sudden  disappearance  of  pain  from  one  place  and 
its  appearance  in  another.  The  inference  is  that  the  pain  or  pressure 
is  itself  due  to  the  perverted  mechanism  of  sensory  reception  and 
registration  in  the  brain,  or  to  a  perverted  reaction  of  still  higher 
centres,  constituting  a  vicious  consciousness.  A  proclaimed  diag- 
nosis of  spinal  iritation  may  have  an  exceedingly  bad  effect  upon  a 
nervous  patient.  The  presence  of  tenderness  of  the  back  with  shift- 
ing sensitive  spots,  although  indicating  a  functional  nervous  affec- 
tion located  entirely  in  the  cerebrum,  does  not  in  any  way  preclude  the 
presence,  in  addition,  of  organic  disease  of  the  brain,  cord,  or  any 
other  viscus.  The  almost  ihstantaneous  disappearance  of  tenderness 
from  one  point  and  its  simultaneous  appearance  at  another  is  not  of 
itself  proof  of  simulation,  malingering,  or  nervous  nonsense  on  the 
part  of  the  patient.  Freeman. 


Cltuicat  Cases. 


A  CASE  OF  KATATONIC  MELANCHOLIA. 
By  J.  E.  COURTNEY,  M.D.. 

First  AuIbUdI  PhrflcUn  o(  the  Hudson  River  State  Hospital,  PongbkeepBie,  N.Y. 

The  case  described  and  illustrated  is  typical  o!  that 
grade  of  melancholia  which  has  been  called  "katatonic," 


The  attack,  which  has  lasted  three  years,  was  caused  by  a 
miscarriage.  The  patient  is  38  years  old.  The  trouble 
began  with  the  symptoms  of  simple  melancholia,  depres- 
sion, the  delusion  that  she  was  in  the  way  of  her  family, 
was  ignored,  hated  and  would  be  poisoned  or  killed  in 
some  way.     She  finally  became  violently  agitated,  and 


748  /.    K.    COURTNEY. 

her  family  could  not  care  for  her.  When  she  came  under 
the  writer's  care  she  was  quiet  and  morose,  stubborn  and 
resistive,  and  kept  her  face  covered  with  her  hands;  her 
only  expression  was:  "I  want  to  go  home  to  Mamaro- 
neck."  She  had  to  be  fed  with  a  spoon,  and  was  greatly 
irritated  by  all  attentions.  She  soon  settled  into  her 
present  condition.  She  sits  nearly  all  day*  with  her  face 
resting  so  firmly  against  her  knees  that  impressions  are 


made  upon  the  temples  from  pressure.  The  arms  are 
placed  by  the  side  of  the  legs,  the  hands  resting  in  the 
popliteal  spaces.  This  attitude  is  rigidly  maintained  for 
hours,  and  there  is  passive  but  rigid  resistance  to  attempts 
to  alter  it.  If  the  head  is  forcibly  raised  the  eyes  remain 
tightly  closed,  the  head  is  turned  slightly  to  the  right 
and  the  cheeks  are  drawn  in  closely  to  the  gums.  If  the 
patient  is  touched  or  spoken  to  or  stimulated  in  any 
way,  she  says  in  a  recitative  manner  the  formula  here  il- 


A    CASE  OF  K ATA  TO  NIC  MELANCHOLIA. 


749 


lustrated,  the  wording  and  tone  of  which  are  quite  con- 
stant. Repetition  of  this  can  be  induced  any  number  of 
times  by  even  slight  stimuli.  Beyond  this  she  is  abso- 
lutely mute.  When  called  to  meals,  she  gets  up  suddenly, 
rushes  to  the  table  with  head  lowered  and  little  regard 
for  intervening  objects,  eats  rapidly  with  her  fingers,  and 
when  excused  resumes  her  usual  pose.  She  sometimes 
voids  urine  in  bed  at  night.  There  is  considerable  anaes- 
thesia of  the  surface.    She  is  much  more  manageable  than 

m 


when  admitted,  but  otherwise  her  condition  has  not  im- 
proved under  treatment. 


L9S  Hbmatemeses  DBS  NBURA.STHBNIQUES  (Hsetnatemesis  in  Neuras- 
thenic Subjects).  (Journal  des  Conn.  M^d.,  Dec.  3d,  '96.) 
Hemorrhages  from  the  mucous  membranes  of  neurasthenic  sub- 
jects are  not  of  rare  occurrence,  but  haematemesis,  though  less  fre- 
quent, has  also  been  observed  in  quite  a  number  of  cases.  Thus  Mes- 
nard,  of  Bordeaux,  was  the  first  to  describe  a  case  in  a  woman  52  years 
of  age;  M.  F.  Gallard  reported  two  observations,  and  Dr.  Ausset  pub- 
lishes a  new  case.  This  last  observation  presented  a  typical  clinical 
picture  of  the  disorder,  the  salient  features  of  which  were:  Man,  Z7 
years  old,  had  first  attack  of  haematemesis  when  25,  while  preparing 
for  an  examination.  Was  subsequently  well  until  March,  1896,  when, 
after  a  violent  emotion,  he  vomited  blood  again.  The  patient  was  in 
perfect  health  up  to  the  time  of  the  haematemesis,  and  on  examination 
nothing  abnormal  was  found  in  any  part  of  his  body,  excepting  a  slight 
dilatation  of  the  stomach.  However,  the  patient  was  subject  to  severe 
cephalalgia,  and  was  prostrated  by  the  slightest  exertion,  besides  being 
a  confirmed  neurasthenic.  Dr.  Gallard,  having  studied  the  symptoms 
of  (specific)  haematemesis  in  two  neurasthenic  subjects,^'Considers  it  an 
easy  matter  to  establish  the  diagnosis  in  such  cases,  the  occurrence  of 
vomiting  blood  in  conjunction  with  the  neuropathic  symptoms,  pre- 
senting a  well-defined  clinical  entity.  Macalester. 


J^ociietg  fj^tpavts. 


PHILADELPHIA  NEUROLOGICAL  SOCIETY. 

April  25th,  1898. 
The  President,  Dr.  F.  X  Dercum,  in  the  chair. 

(Continued  from  page  622.) 

Dr.  F.  X.  Dercum  presented  the  specimen  from 

A  CASE  OF  CEREBELLAR  TUMOR. 

The  patient  was  a  man,  39  years  of  age,  who  presented 
the  following  clinical  history.  His  family  history  was  un- 
important. He  had  had  no  diseases  of  moment,  save 
scarlet  fever  at  seven  years  of  age.  This  was  accompanied 
by  destructive  inflammation  of  the  left  middle  ear,  rup- 
ture of  the  drum  membrane,  and  permanent  impairment  of 
hearing.  Otorrhoea  persisted  for  a  year  or  more,  and 
subsequently  ceased.  When  he  was  about  28  or  29  he 
contracted  syphilis,  for  which  he  was  very  thoroughly 
treated.  Some  six  years  ago  he  began  to  suffer  from 
pains  referred  to  the  left  brow^  and  left  temple.  This  pain 
was  at  first  regarded  and  treated  as  a  neuralgia.  It  was 
quite  persistent  for  about  a  year.  Occasionally  exacerba- 
tions of  the  pain  occurred  at  night,  and  at  times  the  pain 
was  referred  to  the  teeth.  Subsequently  the  pain  became 
less  marked,  but  never  entirely  disappeared,  and  in  1893 
it  recurred  with  full  force.  It  was  referred  at  this  time 
to  the  back  of  the  eye,  and  was  made  much  worse  by  jars 
and  sudden  movements  of  the  head.  He  suffered  oc- 
casionally also  from  double  vision,  but  this  symptom  sub- 
sequently disappeared.  The  pain  in  the  head  subsided 
somewhat,  and,  with  the  exception  of  occasional  recur- 
rences in  the  left  temple,  he  presented  few  symptoms,  save 
that  he  w-as  very  much  indisposed  to  exertion,  either  physi- 
cal or  mental.  He  noticed  in  the  summer  of  1896  that  he 
began  to  be  unsteady  when  riding  his  bicycle,  and  later 
on  unsteadiness  was  also  noticed  in  walking. 


PHILADELPHIA  NEUROLOGICAL  SOCIETY.  751 

When  he  was  first  seen  by  Dr.  Dercum,  in  the  spring 
of  1897,  the  sway  was  decidedly  plus,  and  the  gait  quite 
ataxic,  and  at  times  titubating.  No  local  palsies  and  no 
ataxia  of  the  hands  or  arms  were  present.  The  knee-jerks 
were  plus,  but  the  legs  were  flaccid.  No  sensory  disturb- 
ances and  no  rectal  or  vesical  symptoms  were  noted. 
Tremor  also  was  absent.  The  tongue  was  protruded  in 
the  median  line.  The  pupils  were  equal  and  responsive 
to  light.  The  movements  of  the  globes  appeared  to  be 
normal.  An  examination  of  the  eyegrounds  revealed  a 
beginning  optic  neuritis.  Speech  was  at  this  time  some- 
what slow;  at  times  drawling.  Little  change  was  noted 
in  the  case  from  time  to  time,  save  that  during  the  fol- 
lowing summer  he  became  decidedly  more  ataxic,  while 
a  slight  weakness  of  the  left  arm  and  leg  also  made  its 
appearance.  By  November  the  optic  neuritis  had  become 
quite  pronounced.  Headache  was  again  quite  severe,  and 
about  this  time  he  began  to  suffer  from  epileptiform  seiz- 
ures, general  in  character  and  exceedingly  brief  in  duration. 
They  generally  occurred  during  the  night.  When  occur- 
ring during  the  day  they  most  frequently  assumed  the 
form  of  a  slight  petit  mal.  Subsequently  the  optic  neuritis 
attained  a  very  high  grade,  and  in  January  of  1898  begin- 
ning loss  of  vision  was  noted.  The  tongue  now  deviated 
slightly  to  the  right.  The  left  side  of  the  face  and  the 
left  eyelid  drooped  slightly.  The  paresis  of  the  left  arm 
and  leg  also  became  a  little  more  marked,  and  speech 
more  distinctly  drawling  in  character.  Loss  of  vision 
gradually  became  more  pronounced,  and  epileptiform  seiz- 
ures more  frequent.  The  patient  subsequently  was  bed- 
ridden, and  progressive  mental  failure,  coma,  and  death 
finally  ended  the  scene. 

The  autopsy  revealed  a  large,  caseous,  friable  tumor, 
involving  the  base  of  the  left  lateral  lobe  of  the  cerebellum 
anteriorly.  The  adjacent  portions  of  the  pons  and  me- 
dulla oblongata  had  evidently  been  somewhat  pressed 
upon,  and  to  this  fact  the  cranial  nerve  symptoms  present, 
namely,  the  deviation  of  the  tongue  and  the  slight  facial 
palsy,  are  to  be  ascribed.  The  growth  appeared  to  be 
tuberculous,  and  special  interest  is  derived  from  the  fact 
that  the  adjacent  portion  of  the  temporal  bone  w-as  ne- 
crosed. The  query  naturally  suggests  itself  whether  this 
large  tuberculous  deposit  may  not  have  had  its  origin  in 


752  PHILADELPHIA  NEUROLOGICAL  SOCIETY. 

tuberculous  necrosis  of  the  temporal  bone,  the  latter  itself 
being  a  result  of  the  chronic  otitis  media. 

Dr.  James  Hendrie  Lloyd  exhibited 

A  TUMOR  OF  THE  CEREBELLUM. 

The  patient  had  been  entirely  blind  and  deaf,  and  had 
suffered  from  intense  headache  and  occasional  vomiting. 
He  had  been  unable  to  stand.  No  involvement  of  the 
cranial  nerves  had  been  noticed.  There  was  a  tendency  to 
pitch  forward.  At  the  necropsy  a  tumor,  fully  as  larg^e 
as  a  hen's  egg,  was  found  in  the  superior  part  of  the 
vermis.  The  corpora  quadrigemina  had  been  destroyed 
by  pressure.  The  attachments  of  the  tumor  were  slig"ht, 
and  it  could  easily  have  been  removed. 

Dr.  Judson  Daland  reported 

A  CASE  OF  MENINGOMYELITIS. 

The  patient  was  a  female,  aged  19.  The  present  illness 
began  June  ist,  1896.  Several  days  previous  to  this  the 
patient  went  to  the  cemetery,  and  was  on  the  damp 
ground  for  some  time.  The  day  before  she  became  very 
much  overheated  from  dancing,  and  was  exposed  to  a 
draft. 

On  rising  on  the  morning  of  June  ist  she  experienced 
considerable  pain  in  the  back,  about  the  last  lumbar  ver- 
tebra, which  she  compared  to  a  toothache.  This  remained 
localized,  but  was  not  severe  enough  to  prevent  her  being 
up  and  about  all  day  until  evening,  when  it  became  very 
severe.  She  was  unable  to  sleep  that  night  on  account 
of  the  pain. 

The  next  day  she  arose  with  a  very  severe  headache, 
which  continued  throughout  the  night.  She  had  consid- 
erable fever,  varying  between  100  and  105  degrees  F.,  but 
was  able  to  walk  about  all  the  day.  The  lumbar  pain  was 
somewhat  less,  but  the  headache  continued.  She  did  not 
sleep  that  night  on  account  of  aching  in  the  lower  ex- 
tremities. The  following  morning,  the  third  day,  at  i 
A.  M.,  she  attempted  to  get  out  of  bed,  but  fell  and  was 
unable  to  rise.  She  could  raise  the  left  leg  with  great 
effort,  but  the  paralysis  of  the  right  leg  was  complete. 
The  bladder  and  rectum  were  also  paralyzed.  Pain  and 
fever  continued  to  be  constant  symptoms,  but  the  head- 


PHILADELPHIA  NEUROLOGICAL  SOCIETY.  753 

ache  disappeared.  The  night  of  June  3d,  the  lumbar  pain 
was  considerably  decreased,  and  the  pain  disappeared  from 
the  legs.  Sleep  was  secured  by  the  use  of  opiates.  Dur- 
ing the  following  two  days,  Thursday  and  Friday,  her  con- 
dition remained  unchanged.  Friday  evening  the  paralysis 
became  complete  in  the  left  leg.  She  noticed  that  she  had 
lost  all  power  to  use  the  left  arm,  that  the  fingers  were 
flexed  and  the  hand  flexed  on  the  forearm,  but  she  could 
move  the  fingers  and  toes.  The  reflexes  were  not  noted. 
The  fever  disappeared,  and  on  the  fifth  day  a  marked 
tendency  to  drawing  backward  of  the  head  was  noted. 
Lifting  the  head  or  turning  it  to  either  side  caused  pain. 
She  was  quite  excitable.  Her  sight  and  hearing  were  not 
affected.  Although  the  pain  had  disappeared,  the  hyper- 
aesthesia  was  marked. 

Her  condition  remained  unchanged  for  90  days,  when 
improvement  began.  She  became  able  to  sit  up  in  bed, 
and  later  in  a  chair,  and  to  move  the  left  leg  sufficiently 
to  rock  the  chair  in  which  she  was  sitting.  The  improve- 
ment in  the  arms  continued,  and,  to  a  slight  extent,  in  the 
legs.  Her  general  health  was  unusually  good;  thevital 
functions  of  the  body  being  normally  performed,  with  the 
exception  of  the  bowels,  which  were  obstinately  consti- 
pated. Several  analyses  of  the  urine  showed  the  secretion 
to  be  normal. 

The  muscles  of  the  neck,  head  and  upper  extremities 
are  at  present  well  developed,  and  well  covered  with  adi- 
pose, except  those  of  the  left  forearm,  arm  and  shoulder 
region.  The  left  deltoid  and  supraspinous  muscles  are  con- 
siderably atrophied.  The  left  biceps  and  triceps,  although 
smaller  than  the  right,  are  in  good  condition.  The  muscles 
of  the  left  forearm  are  smaller  than  those  of  the  right. 
The  thenar  and  hypothenar  groups  of  muscles  of  the  left 
hand  are  almost  completely  atrophied,  and  the  entire 
hand  seems  smaller.  The  grip  of  the  left  hand  is  dimin- 
ished in  force  about  one  half.  The  muscles  of  the  right 
arm  are  unusually  strong.  The  left  arm  is  strong  also,  but 
is  weaker  than  the  right.  The  left  arm  is  brought  to  a 
right  angle  with  the  body  with  difficulty,  and  the  move- 
ment is  with  pronation.  It  is  exceedingly  difficult  to  raise 
the  left  arm  above  this  point,  and  it  is  impossible  to  carry 
it  backward  beyond  the  midline  of  the  body.  The  lower 
extremities  are  in  extension.     The  feet  can  be  slightly 


754  PHILADELPHIA  NEUROLOGICAL  SOCIETY. 

moved.  Resting  on  her  right  side,  with  leg  partially 
flexed,  she  flexes  and  extends  the  left  leg  on  the  thigh 
well,  but  these  movements  are  overcome  by  a  weight  of  a 
few  ounces.  The  same  is  true  of  the  right  leg,  to  some 
extent,  but  motion  is  considerably  more  restricted  than  in 
the  left  leg,  and  it  is  also  necessary  to  support  the  weight 
of  the  leg  by  the  hand.  When  lying  on  her  face  she  can 
raise  her  left  foot  about  an  inch  from  the  bed.  When  the 
leg  is  flexed  at  the  knee  she  can  hold  it  fixed  at  a  right 
angle  with  the  thigh.  On  examination  the  spine  shows 
considerable  left  lateral  curvature,  which  extends  about 
an  inch  and  a  quarter  from  the  perpendicular. 

Dr.  Daland  spoke  of  the  large  daily  amount  of  iodide 
of  ammonium  (6  1-3  drachms)  and  of  bichloride  of  mer- 
cury (f  grain)  the  patient  had  been  taking. 

DISCUSSIOX. 

Dr.  Wharton  Sinkler  did  not  believe  that  any  special  sig- 
nificance regarding  the  nature  of  a  disease  could  be  drawn 
from  the  amount  of  iodide  a  person  is  able  to  take.  Some 
syphilitic  persons  will  tolerate  only  a  small  amount,  while 
others,  not  syphilitic,  can  take  the  drug  in  large  doses. 

Dr.  F.  Savary  Pearce  reported 

A  CASE  OF  ATAXIC  PARAPLEGIA,  WITH  SEVERE  PAIN 
AND  MUSCULAR  SPASMS.  FOLLOWED  BY  BLOOD 
EXTRAVASATIONS. 

Reference  was  made  to  the  raritv  of  ecchvmoses  follow- 
ing  muscular  spasms,  and  to  the  paper  by  Weir  Mitchell,^ 
in  1869,  in  which  five  cases  were  reported. 

J.  I.  T.,  male,  an  American,  33  years  of  age,  of  a  gouty 
ancestry,  had  always  been  a  healthy,  active  ranchman,  liv- 
ing at  an  altitude  of  6,000  feet  for  the  past  nine  years.  He 
suffered  from  gravel  at  so  early  an  age  as  five  years.  This 
is  mentioned  on  account  of  the  uric  acid  heredity.  Seven 
years  ago  he  had  a  small  chancre,  was  insufficiently  treated 
for  four  months,  and,  considering  himself  well,  continued 
actively  at  ranching  in  the  apparent  vigor  that  is  so  com- 
mon in  those  living  at  such  an  altitude.  Six  years  ago, 
while  again  on  his  annual  visit  to  the  coast  line,  he  began 


*  Transactions  of  the  College  of  Physicians  of  Philadelphia,  vol 
iv.,  N.  S.,  pp.  282-288. 


PHILADELPHIA  NEUROLOGICAL  SOCIETY.  755 

to  suffer  from  **catching  cold"  easily,  and  one  day  he  was 
suddenly  taken  with  anorexia,  headache  and  chill,  which 
were  soon  followed  by  unconsciousness,  without  convul- 
sions. He  remained  generally  paretic,  with  flaccidity  of 
the  muscles,  and  continued  delirious  for  about  a  fortnight. 
He  gradually  recovered,  after  a  month,  sufficiently 
to  be  about ;  but  convalescence  was  unsatisfactory.  After 
another  month  he  returned  to  the  mountains.  Four  years 
ago  he  descended  to  the  coast  a  second  time,  and  had  a  re- 
newal of  his  spinal  meningeal  symptoms.  He  soon  began 
to  suffer  from  numbness  and  increasing  stab-like  pains 
in  the  thighs  and  calves.  All  four  extremities  became  stiff, 
and  he  was  somewhat  relieved  by  moving  about  or  stretch- 
ing himself.  Recurrences  of  pain-spells  in  the  calves  of 
the  legs  gradually  became  unbearable.  He  became  de- 
cidedly spastic  and  ataxic.  Two  years  ago  he  began  to 
have  firm  contractions  of  the  thigh  and  calf  muscles,  with 
the  attacks  of  algesia  described  as  atrocious,  and  occurring 
mostly  in  the  early  morning  or  in  the  evening. 

After  the  severest  attacks  of  pain  he  has  found  "black 
and  blue  marks''  at  the  site  of  the  most  painful  areas,  and 
distal  to  them,  not  resulting  from  any  pressure  on  the 
parts.  This  would  exclude  trauma  as  the  etiological  fac- 
tor. The  extravasations  were  not  seen  until  some  three 
to  five  hours  after  the  painful  seizures,  and  were  rather 
deep,  and  disappeared  slowly,  as  after  a  bruise.  They  oc- 
curred only  half  a  dozen  times,  and  at  the  height  of  the 
pain.  The  extravasations  were  from  one  half  to  one  inch 
in  circumference,  and  with  diminishing  pain  the  tendency 
to  extravasular  leakage  also  ceased.  One  year  ago  the 
bladder  became  involved. 

On  examination  he  presented  the  typical  syndrome 
of  marked  ataxic-spastic  paraplegia.  The  arms  were  some- 
what involved.  Argyll  Robertson  symptom  was  not  noted, 
although  in  the  past  a  transient  diplopia  had  existed. 
Romberg's  symptom  was  marked.  The  urine  showed  a 
trace  of  albumin  from  pus,  but  no  indican  or  uric  acid  ex- 
cess and  no  glycosuria.  An  important  feature  of  the  case 
was  the  very  great  improvement  in  the  ataxia,  the  spastici- 
ty and  the  general  health  of  the  patient,  brought  about  by 
the  combination  of  **rest"  treatment  with  head  extension, 
followed  by  potassium  iodide  up  to  gr.  cccl.  daily,  and 
later  coordinated  voluntary  movement  of  arms  and  legs. 


756  PHILADELPHIA  NEUROLOGICAL  SOCIETY. 

DISCUSSION. 

Dr.  John  K.  Mitchell  said  he  had  instructed  this  patient 
for'  some  time  in  graduated  movements.  From  being  so 
ataxic  that  he  could  not  stand,  he  became  able  to  walk  across 
the  room,  putting  one  foot  directly  in  front  ot  the  other,  and 
to  walk  backward  in  the  same  way,  which  is  not  axi  easy  feat 
for  even  a  normal  individual. 

Dr.  Spiller  reported  a 

CASE  OF  MERALGIA  PARESTHETICA. 

A  man  of  middle  age  had  disturbance  of  sensation, 
closely  confined  to  the  distribution  of  the  external  cu- 
taneous nerve  of  the  right  thigh.  When  in  bed  or  sitting 
in  a  chair,  or  immediately  after  standing  upon  his  feet,  no 
unpleasant  symptom  was  noted;  but  after  standing  for  a 
short  time,  or  walking,  a  distinct  burning  and  drawing 
sensation,  attended  with  severe  pain,  was  experienced  in 
the  distribution  of  the  nerve  named.  Sensation  otherwise 
and  the  condition  of  the  muscles  were  normal.  The  af- 
fection had  existed  for  one  year,  but  had  become  more 
marked  during  the  past  few  months.  Dr.  Spiller  thought 
that  if  other  means  failed  to  produce  relief,  stretching,  or 
later  even  cutting  the  external  cutaneous  nerve,  might 
be  advisable,  inasmuch  as  no  muscular  paralysis  would  re- 
sult, and  the  nerve  could  be  easily  reached  at  the  anterior 
superior  spine  of  the  ilium,  and,  at  the  most,  loss  of  sen- 
sation in  a  limited  portion  of  the  thigh  would  probably 
be  the  only  unpleasant  result.  He  preferred  the  name 
of  meralgia  paraesthetica  to  the  rather  cumbersome  one  of 
Bernhardt's  disturbance  of  sensation  in  the  thigh. 

DISCUSSION. 

Dr.  Wharton  Sinkler  had  seen  two  cases  of  the  disease  de- 
scribed by  Dr.  Spiller.  One  patient,  a  woman,  had  had  the 
symptoms  in  the  distribution  of  the  external  cutaneous  nerve 
referred  to.  After  several  months  she  recovered.  The  second 
case,  now  under  observation,  was  in  a  patient  who  suffered 
injury  in  a  railroad  collision.  Intense  burning  pain  was  ex- 
perienced in  the  distribution  described. 

Dr.  F.  Savary  Pearce  had  seen  the  same  condition  in  a 
case  where  the  middle  cutaneous  nerve  of  the  thigh  appeared 
to  be  alone  involved.  This  was  a  gynaecological  case.  The 
patient  had  had  sepsis,  and  had  been  subjected  to  operation 
upon  the  bladder  and  womb,  and  it  was  a  question  whether 
the  irritation  had  not  extended  from  this  source. 


f^txlscope. 


IVUh  the  Assistance  of  the  Following  Collaborators: 

CrasXewis  Ai.LSN,M.D.,Wash.,D.C.R.  K.  Macalestbr,  M.D„  N.Y. 
J.  S.  Christison,  M.D..  Chicago,  111.  J.  K.  Mitchell.  M.D..  Phila.,  Pa 
A.  KREBMiiM,  M.D.,  New  York.  H.  Patrick,  M.D.,  Chicago,  IlL 

S.  E.  Jblliffb,  M.D.,  New  York.  Joseph  Sailer,  M.D.,  Phila..  Pa. 
WM.C.KRATJSS.M.D.,  Buffalo,  N.Y.  Henry  L.  Shively.  M.D.,  N.  Y. 
W.  M.  Leszynsky,  M.D.,  New  York.  A.  Sterne,  M.D.,  Indianapolis. 

ANATOMY  AND  PHYSIOLOGY. 

227.  ZuR  HXrtung  DBS  Cbntralnbrvrnsvstbms  in  situ  (On  the 
Hardening  of  tbeCmtral  Nervous  System  in  Situ).  Pfister  (Neuro- 
i^giscfties  Centralblatt,  17,  1898,  p  643). 

The  author  uses  a  five  to  ten  per  cent,  solution  of  formaldehyde 
and  injects  it  directly  into  the  vertebral  canal  through  the  third  and 
fourth  intervertebral  spaces.  For  the  brain  a  like  procedure  through 
the  superior  orbital  fissure  is  adopted.  Jelliffe. 

228*       CONTRIBDTION    A    L*:^UDB    DBS     LOCALISATIONS     DBS    NOYAUX 

MOTBUR8  i>ANS  LA  MOBLLB  ^PiNl^RB  i  Contributions  to  the  Study 
of  the  Localization  of  the  Motor  Nerves  in  the  Spinal  Cord).  G. 
Marineaco  (Revue  Neurologique,  6,  1898,  p.  463). 

Marinesco,  by  complete  or  partial  destruction  of  the  motor  nerves 
in  cats  and  dogs  and  guinea  pigs,  presents  the  results  of  his  studies  in 
the  following  brief  rteum^: 

(i)  The  cutting  off  of  a  spinal  nerve  from  the  spinal  axis  pro- 
duces a  condition  of  chromatolysis  which  is  characteristic. 

(2)  Such  a  reaction  can  be  utilized  in  order  to  determine  the 
topographical  position  of  the  nucleus  of  origin  of  a  motor  nerve  or  set 
of  nerves. 

(3)  As  a  rule  each  motor  nerve  arises  from  a  main  nucleus  and 
an  accessory  nucleus,  the  main  nucleus  being  plainly  localized  in  the 
majority  of  cases.  The  median  and  cubital  nerves  prove  exceptions 
to  this  general  rule. 

(4)  Each  motor  spinal  nerve  arises  from  more  than  one  medul- 
lary segment;  two,  three  or  even  more  nerve  segments  may  contribute 
to  its  formation.  Jelliffe. 

229.  On  thb  Structural  Alterations  Observed  in  Nbrvb  Cells. 
W.  B.  Warrington  (Journal  of  Physiology,  23,  1898,  p.  112). 

Using  Held's  method  of  staining  the  author  experimented  with 
cats  and  rabbits  and  comes  to  the  following  general  summary  in  this 
excellent  paper. 


758 


PERlSCOl'li. 


(i)  Distinct  and  easily  recog^nizable  changes  in  nearly  all  the 
cells  of  a  segment  of  the  spinal  cord  are  found  on  the  tide  of  the 
lesion  after  section  of  an  anterior  root. 

(2)  Similar  but  less  marked  changes  follow  division  of  the  facial 
nerve,  and  still  less  distinct  alteration  after  division  of  the  oculo- 
motorius  nerve. 

(3)  The  fate  of  such  altered  cells  and  the  ultimate  condition  of 
the  nucleus  of  origin  are  not  yet  definitely  ascertained. 

(4)  The  age  and  nature  of  the  animal  experimented  on  is  a  fac- 
tor in  determining  the  rapidity  and  degree  of  alteration  met  with  in 
nerve  cells.  Jelliffe, 

PATHOLOGY. 

230.  ZuR   Lehrk  von  der  Syringomyeuk      (On    Syringomyelia). 

L.  Minor  (Zeitschft.  f.  Klin.  Med.  34,  1898,  p.  373). 

The  author  presents  a  study  of  two  cases  of  syringomyeha.  The 
first  case  occurred  in  a  one-year-old  child,  who  from  birth  pre- 
sented a  number  of  anomalies  of  the  nervous  canal.  It  had  spina 
bifida,  meningocoele  and  hydrocephalus.  Microscopic  examination 
showed  hydromyelia,  syringomyelia  with  duplication  of  the  central 
canal  with  well  marked  continuity  of  the  two  cavities.  In  the  second 
case  similar  teratological  developments  were  noted.  This  second  case 
was  in  a  twelve-year-old  girl,  who  died  of  a  compression  myelitis  due 
to  an  endothelioma.  Microscopically  there  was  found  in  the  upper 
segments  of  the  dorsal  cord  a  marked  dilatation  of  the  central  canal. 
In  this  case  the  syringomyelia  could  be  demonstrated,  by  a  study 
of  the  serial  sections,  to  have  originated  from  a  cut-off  portion  of  the 
central  canal.  The  author,  as  a  result  of  his  studies  on  these  two  cases, 
emphasizes  the  Leyden  cmbryological  view  as  to  the  origin  of 
syringomyelia.  Jelliffe. 

231.      SurXE     I.HSIONI     DEL   SrSTEMA    NERVOSA    CENTRALE   PRODOTTE 

DAL   BACiLLO  ICTEROIDE.     Dolt.  A.  Cesaris-Demel,    Torino  (Gior- 
nale  della  R.  accedemia  di  niedicina  di  Torino,  Mnrzo.  1898). 

In  the  pathological  laboratory  of  Professor  Foa,  of  Turin,  Dr. 
Cesaris-Demel  experimented  on  the  action  of  the  bacillus  of  yellow 
fever  as  described  by  Sanarelli.  on  the  central,  nervous  system  of  dogs 
and  rabbits,  and  came  to  the  following  conclusions: 

(i)  The  icteroid  bacillus  produces  in  animals  (dog  and  rabbit) 
important  lesions  in  the  cells  of  the  central  nervous  system. 

(2)  These  lesions  aflPect  principally:  (a),  the  large  and  middle 
pyramidal  cells  of  the  cortex,  which  become  swollen,  lose  their  col- 
oration and  continuity  of  the  chromophilic  elements,  arriving  at  a 
complete  destruction  of  the  cell:  (b),  the  large  cells  of  Purkinje  which 
lose  the  coloration  of  the  prolongations,  and  present  a  swelling  of 
the  basal  part  with  intense  chromatolysis  and  destruction  of  the  cel- 
lular membrane:  (c),  the  pyramidal  cells  of  the  anterior  horns  and  of 
the  oblongata,  which  present  a  conspicuous  chromatolysis  of  a  periph- 
eral type. 

(3)  These  lesions  stand  in  relation  to  the  gravity  and  extension 
and  more  or  less  susceptibility  of  the  animal  to  the  icteroid  bacillus 
and  the  infection.  Krauss. 

232.  ZuR  Pathologie  der  Epilepsie  (The  Pathology  of  Epilepsy). 
N.  Krainsky  (Allg.  Zeitsch.  f.  Psychiatric,  54,  1897,  p.  612). 

From  an  extended  series  of  examinations  of  the  blood  and  urine 
the  author  comes  to  the  general  conclusion  that  the  epileptic  poison 


PERISCOPE.  759 

is  to  be  found  in  the  blood.  The  chemical  nature  of  this  poison  is 
similar  to  carbamic  acid,  and  a  detailed  report  is  given  of  a  series  of 
experimental  researches.  Jelliffe. 

CLINICAL   NEUROLOGY. 

233.   EiN  WEITBRER  FALL  VON  SOUTARBR  TUBERCULOSE  DES  RUCKEN- 
MARKS*  ZUGLEICH    EIN    BEITRAG    ZUR    LEHRE    VON     DER    BROWN- 

Sequard'schen  ^albseitenlXhmung.  (Another  Case  of  Solitary 
Tuberculosis  of  the  Spinal  Cord,  at  the  Same  Time  a  Contribution 
to  the  Brown-S6quard  Paralysis).  L.  R.  Miiller  (Deutsche 
Zeitschrift  fiir  Nervenheilkunde,  vol.  12.  1898,  p.  288). 

A  man,  46  years  old,  who  had  phthisis,  became  very  weak  in  the 
right  lower  limb,  while  the  power  in  the  left  was  retained.  He  had 
retention  of  urine,  exaggerated  knee-jerk,  especially  on  the  right  side, 
and  disturbed  sensation  on  the  left  side.  The  upper  extremities  were 
not  affected.  The  senses  of  pain  and  temperature  were  completely  lost 
on  the  left  side  below  the  ribs.  The  senses  of  touch,  pressure  and  lo- 
cation were  not  disturbed  anywhere.  Sensation  was  somewhat  im- 
paired in  a  small  area  over  the  right  nipple.  A  solitary  tubercle  was 
found  in  the  right  side  of  the  second  thoracic  segment  of  the  spinal 
cord.  The  left  half  of  the  cord  was  compressed  by  the  growth,  but 
otherwise  very  little  altered.  Although  the  clinical  signs  of  spinal 
disease  had  lasted  five  weeks,  secondary  degeneration  was  not  very 
important.  A  slight  degeneration  was  noted  in  the  left  antero- 
lateral column,  beginning  a  little  above  the  tubercle.  This,  the  writer 
believes,  was  due  to  destruction  of  the  gray  matter,  especially  of  the 
posterior  horn,  on  the  right  side.  It  is  only  in  rare  cases  that  the 
existence  of  this  tract  in  the  anterolateral  column,  arising  in  the  con- 
tralateral gray  matter,  has  been  indicated  by  pathological  findings. 
The  vertebrae  and  membranes  were  normal.  A  slight  degeneration  of 
the  posterior  columns  in  the  lower  thoracic  and  lumbar  regions  was 
supposed  to  be  similar  to  that  seen  in  pernicious  an:cmia  and  maras- 
mus. The  diagnosis  of  a  solitary  intramedullary  tumor  in  the  right 
half  of  the  cord  was  made  before  death,  and  was.  founded  on  clinical 
phenomena,  in  a  phthisical  patient,  indicating  a  partial  transverse 
lesion.  The  free  movement  of  the  vertebral  column,  the  absence 
of  painful  areas  along  the  spine,  the  painless  development  of  the 
hemiplegia,  were  regarded  as  indicative  of  the  integrity  of  the  spinal 
vertebrae  and  membranes.  Miiller  agrees  with  Bruns  that  in  spinal 
paraplegia  the  lesion  is  usually  located  too  low  in  the  cord. 

Although  only  one-half  of  the  cord  was  destroyed,  the  paralysis 
was  not  truly  of  the  Brown-Sequard  type.  The  weakness  of  the 
right  lower  limb  did  not  amount  to  paralysis,  and  the  disturbance  of 
sensation  on  the  left  side  was  syringomyelic  in  type.  The  existence 
of  naked  axis  cylinders,  which  escaped  detection  within  the  tubercle, 
may  possibly  explain  the  partial  paralysis,  but  not  the  disturbed  sen- 
sation. The  views  concerning  Brown-Sequard  paralysis  are  correct 
as  regards  pain  and  temperature  senses,  but  not  as  to  tactile  sense; 
the  former  senses,  the  author  thinks,  are  altered  by  lesion  of  the 
posterior  horn  of  the  side  on  which  the  fibres  enter  the  cord,  and 
by   lesions   of  the  anterolateral   column   of  the   opposite   side. 

Spiller. 
234.  sur  un    cas    de    myeute    subaigue    norso-lombaire     [sub- 

Acute  Dorso-Iumbar  Myelitis  (due  probably  to  infection  by  way  of 

the  uterus)].     Mongorer  et  Cariere  (La  Presse  Medicale,  Vol.  55, 

1897,  p.  8). 

The  authors  describe  a  case  of  myelitis  aflfecting  the  portion  of 
the  c6rd  below  the  seventh  dorsal  segment,  and  give  a  very  complete 


76o  PER/SCOPE. 

account  of  the  changes  found  both  in  the  cells  and  fibre  tracts  ana  in 
the  vessels  of  the  cord  on  examination  by  recent  staining  methods. 
They  suggest  that  the  disease  may  have  been  the  result  of  an  infection 
from  the  uterus,  as  the  patient  had  had  for  some  time  an  unhealthy 
condition  of  the  endometrium,  and  had  been  subjected  to  the  op- 
eration of  curettage  about  a  month  before  the  onset  of  the  myelitis, 

Allen. 

235.  PATHOGISNIR  DE  la  RiClDITfe  MUSCULAIRB  ET  DA  LA  COITTRACTURE 
DANS  LBS  AFPBCTIOKS  ORGANIQUBS  DU  SYSTJ^ME  NBRVEUX  (Pa- 
thogenesis  of   Muscular    Rigidity   and    Contractures   in    Organic 

Disorders   of  the   Nervous   System).     A.    Van    Gehuchten    (La 
France  Med.,  44,  1897,  p.  629). 

The  physiological  mechanism  of  muscular  rigidity  and  contrac- 
tion, which  are  constant  symptoms  in  organic  hemiplegia  and  spas- 
modic paraplegia,  are  discussed  by  the  author.  The  theories  advo- 
cated by  Follin,  Hitzig,  Straus,  Marie,  Freud,  Jackson  and  others, 
according  to  which  these  phenomena  are  of  muscular,  spinal  or  cere- 
bellar origin,  prove  to  be  inadequaft  in  explaining  the  clinical  and 
anatomical  facts.  Besides,  it  would  be  difficult  to  find  a  sohition  ap- 
plicable to  both  hemiplegic  and  spasmodic  contractures,  the  under- 
lying cause  not  necessarily  being  the  same.  The  author  maintains 
that  spasmodic  contraction  is  an  active  process,  that  is,  an  exaggera- 
tion of  normal  muscular  tonus,  of  c^^rftm/  origin,  due  to  interruption 
in  the  course  of  the  cortico-spinal  fibres,  with  preservation  of  corto- 
ponto-cerebello-spinal  nerves,  which  latter  keep  the  cells  of  the 
spinal  cord  under  the  control  of  the  motor  cells  of  the  cortex.  On 
the  other  hand,  hemiplegic  contracture  has  quite  a  different  genesis, 
the  influence  of  the  cerebral  cortex  upon  the  motor  spinal  cells  and 
the  corresponding  paralysed  muscles  being  cut  off  by  the  lesions,  and 
if  contractures  develop  in  this  case,  they  are  of  peripheral  origin,  due 
to  a  difference  in  degree  of  paralysis  between  the  flexor  and  extensor 
muscles.  The  former  are  usually  less  involved  than  the  latter,  there- 
fore the  frequency  of  post-hemiplegic  flexion  contractures.  If,  on 
the  other  Ttatid,  the  paralysis  is  of  equal  intensity  in  all  the  muscles 
of  the  extremity,  no  contractions  will  result,  and  there  will  be  a  flaccid 
condition.  Mac.\lester. 

236.  DES  PARALYSIES  POST-ANBSTHfesiQUES  ( Post- Anaesthetic  Pa- 
ralysis).   Ed.  Schwartz  (Gazette  des  Hopitaux,  70,  1897,  p.  1,248). 

Following  operations  performed  under  general  anaesthesia  there 
are  sometimes  observed  paralyses  which  have  no  pathological  con- 
nection with  the  seat  of  operation,  and  surprise  both  patient  and 
surgeon  by  their  unexpected  appearance.  The  following  belongs  to 
this  class  of  cases: 

A  man,  aet.  45,  was  operated  on  for  a  small  inguinal  hernia. 
During  the  operation,  which  was  performed  under  chloroform  an- 
aesthesia, there  was  a  slight  attack  of  cardiac  and  respiratory  syncope, 
which  was  easily  and  promptly  overcome  by  artificial  respiration. 
On  emerging  from  the  chloroform  narcosis  the  patient  observed  a 
feeling  of  formication  in  the  right  hand,  especially  in  the  thumb  and 
index  finger,  and  he  conld  not  readily  move  the  two  affected  fingers. 
The  next  day  there  was  a  complete  paralysis  of  the  flexor  longus 
pollicis  and  the  flexors  of  the  index  finger.  All  the  other  muscles 
of  the  upper  extremity  were  intact.  There  was  no  anaesthesia  or 
hyperaesthesia.  When  he  tried  to  move  his  lower  limbs  there  was 
observed  a  well-defined  paralysis  of  the  right  quadriceps  extensor 
femoris.     The  paralysis  was  thus  limited  to  the  right  side,  involving 


PERISCOPE.  76 1 

a  single  muscle  below  and  two  above.  These  symptoms  gradually 
disappeared  under  massage  and  electricity,  and  at  the  expiration  of 
seven  months  there  was  complete  cessation  of  the  paralysis. 

When  the  paralysis  of  the  thumb  and  index  finger  was  observed 
the  first  impression  was  that  the  case  was  one  of  peripheral  paralysis 
due  to  stretching  of  the  brachial  plexus,  and  y«t  there  had  been  no 
violence  used  in  applying  artificial  respiration,  which  had  lasted  barely 
two  minutes.  Moreover,  it  was  no  longer  possible  to  consider  this 
origin  of  the  trouble  after  th^  development  of  the  quadriceps  ex- 
tensor paralysis,  which  could  only  be  assigned  to  a  central  origin, 
functional  or  otherwise.  Upon  carefully  questioning  the  patient,  it 
was  learned  that  for  some  time  he  had  noticed  a  little  clumsiness  in 
using  his  right  hand,  and  that  in  writing  it  had  become  necessary 
for  him  to  use  a  thicker  penholder.  This  fact  strengthened  the  as- 
sumption of  a  central  paralysis.  The  possibility  of  hysteria  in  this  case 
could  be  ignored. 

Post-anaesthetic  paralyses,  as  they  are  usually  classified,  show  two 
distinct  types.  Sometimes  they  are  true  peripheral  paralyses,  especially 
of  the  brachial  plexus  and  its  branches,  occurring  thus  more  com- 
monly in  the  upper  extremity.  These  cases  have  been  observed  by 
many  surgeons,  and  present  the  clinical  features  described  by  Erb, 
involving  usually  the  deltoid,  brachialis  anticus,  biceps  and  supinator 
longus.  More  rarely  other  muscles  are  paralyzed.  These  cases  are 
true  traumatic  paralyses,  caused  by  compression  or  stretching  in  long- 
continued  or  strained  faulty  positions,  or  to  the  circular  compression 
of  limbs  by  tight  elastic  bands.  They  may,  and  should,  be  avoided  by 
carefully  watching  the  patient  during  the  administration  of  chloro- 
form or  ether.  This  first  class  of  cases  then  is  not  true  postanesthetic 
paralysis,  if  this  term  is  intended  to  have  any  etiological  significance, 
for  they  have  no  other  relation  to  the  anaesthesia  than  to  appear  con- 
secutive to  it,  and  to  have  been  produced  by  a  vicious  attitude  during 
the  continuance  of  the  narcosis. 

Much  more  rare  and  much  less  studied  is  another  class  of  cases, 
which  cannot  be  explained  in  the  same  manner,  and  which  presents 
a  different  clinical  picture.  Without  being  committed  to  any  particu- 
lar theory  as  to  their  nature,  they  may  be  called,  as  the  writers  who 
have  studied  them  have  done,  true  postanaesthetic  or  central  paralyses. 
The  case  here  reported  is  such  a  one,  and  there  have  been  collected  in 
all  ten  cases,  the  clinical  appearances  of  which  are  variable,  but  which 
may  be  arranged  in  three  classes: 

1.  Cases  in  which  the  paralysis  is  limited  to  a  single  limb,  mono- 
plegias resembling  the  cases  described  by  Budinger  and  Franke,  the 
first,  with  autopsy,  showing  a  zone  of  softening  in  the  cerebral  cortex, 
the  second  occurring  in  a  hysterical  woman  with  the  symptoms  of 
hysterical  paralysis. 

2.  Cases  in  which  are  observed  paralyses  of  a  cranial  nerve  (the 
facial)  alone  or  associated  with  paralysis  of  the  limbs  or  of  other 
cranial  nerves. 

3.  Cases  in  which  true  hemiplegia  occurs,  cither  observed  im- 
mediately upon  emerging  from  the  sleep  of  anaesthesia,  or  developing 
a  short  time  after. 

The  pathological  question  which  is  presented  is  difficult  of  solu- 
tion. Is  there  here  a  toxic  paralysis,  as  believe  Btidinger  and  Burn- 
heim,  comparab4e  to  alcoholic  paralyses,  and  depending  on  a  special 
action  of  chloroform,  causing  a  degeneration  of  nerve  tissue  when  the 
latter  constitutes  a  locus  minoris  resistentiaef  Such  would  not  seem  to 
be  the  case  owing  to  the  rarity  of  its  occurrence,  and  to  the  fact 
that  it  is  observed  in  cases  where  the  anaesthesia  has  been  of  very 


762 


PERISCOPE. 


short  duration  or  incomplete.  May  it  be  accounted  for  as  a  simple 
coincidence?  It  is  possible,  but  not  demonstrable.  On  the  other 
hand,  it  may  well  be  believed  that  where  endarteritis  exists  that  pa- 
tients with  diseased  arteries  may  during  the  period  of  excitement, 
while  crying  out,  struggling  or  vomiting,  rupture  a  vessel  and  pre- 
sent variable  symptoms,  depending  upon  the  site  and  extent  of  the 
lesion.  The  cases  of  Depoge,  Gross  and  Biidinger  harmonize  with 
this  view.  Finally,  hysteria  may  account  for  a  certain  number  of  these 
cases,  and  in  the  present  day  it  may  be  well  to  explore  this  field 
further. 

From  the  practical  standpoint  it  is  impossible  to  foresee  its  oc- 
currence, but  it  may  be  suspected  where  arterial  or  cardiac  disease 
is  present.  Recovery  often  takes  place  when  there  is  not  total  hemi- 
plegia. Shivelv. 

237.  Von  der  Verwachsung  oder  Steifigkeit  der  Wirbei^Xule 
(Concerning  Ankylosis  or  Rigidity  of  the  Spinal  Column).  W. 
v.  Bechterew  (Deutsche  Zeitschrift  fiir  Nervenheilkunde,  11,  18^, 

p.  327). 

In  a  previous  communication  v.  Bechterew  described  an  affection 
consisting  of  (i)  immobility  or  rigidity  of  a  part  or  the  whole  of  the 
spinal  column,  without  distinct  tenderness  on  percussion  or  on  bend- 
ing the  body;  (2)  of  kyphosis,  especially  in  the  upper  thoracic  regfion, 
causing  the  head  to  project  forward;  (3)  of  paresis  of  the  muscles  of 
the  trunk,  neck  and  extremities,  with  unimportant  atrophy  of  the 
muscles  of  the  back  and  scapulae;  (4)  of  diminished  sensation,  es- 
pecially in  the  areas  of  the  cutaneous  branches  of  the  thoracic,  lower 
cervical,  and  sometimes  of  the  lumbar  nerves;  (5)  of  irritation  symp- 
toms (paraesthesia,  nain)  in  the  distribution  of  these  nerves;  (6)  oc- 
casionally of  spasmodic  twitching  or  contracture  (irritation  of  motor 
nerves)  of  the  muscles  in  the  extremities;  (7)  of  reaction  of  degenera- 
tion in  advanced  cases. 

On  account  of  the  paresis  of  the  muscles  the  erect  position  of  the 
head  is  rendered  difficult.  The  breathing  is  abdominal.  Heredity  and 
trauma  seem  to  play  a  role,  at  times,  in  the  development  of  the  dis- 
ease. The  affection  is  progressive,  and  is  little  known.  The  "arthritis 
deformans  of  the  vertebral  column,"  described  by  Oppenheim,  does 
not  correspond  in  every  respect  with  the  rigidity  of  the  vertebral 
column  described  by  v.  Bechterew.  A  new  case  of  this  uncommon 
affection  is  described  at  length. 

As  yet  no  necropsies  have  been  obtained,  but  it  is  probable  that 
the  vertebrae  become  united,  that  the  spinal  nerves  are  thereby  com- 
pressed, and  that  the  inflammation  extends  to  the  spinal  dura. 

Spiller. 

238.  Bemerkung  uber  die  chronische  ankyi^osirende  Entzun- 
DUNG  DER  WiRBEi*SAULE  UND  DER  HuFTGELENKE  (Remarks  on 
the  Chronic  Inflammation  of  the  Vertebral  Column  and  Hip 
Joints).  A.  Striimpell  (Deutsche  Zeitschrift  fiir  Nervenheilkunde, 
II,  1897,  p.  338). 

The  above  paper  by  v.  Bechterew  has  called  forth  the  statement 
from  Striimpell  that  he  has  been  acquainted  for  a  long  time  with  this 
peculiar  form  of  chronic  arthritis,  which  affects  the  vertebral  column 
and  hip  joints,  and  causes  complete  ankylosis  of  these  parts.  He 
publishes  the  third  case  of  this  peculiar  disease  observed  by  him.  He 
is  somewhat  in  doubt  as  to  whether  the  disease  which  he  describes  is 
exactly  the  same  as  v.  Bechterew's  affection  or  Oppenheim's  "ar- 
thritis deformans  of  the  vertebral  column."  Spiller. 


PERISCOPE.  763 

239.  Lectures  on  Aphasia.     Bramwell    (Edinburgh  Medical  Jour- 
nal, July  to  December,  1897). 

These  lectures  are  an  elaboration  of  those  given  by  the  author  in 
his  course  on  medicine.  He  makes  the  usual  divisions  of  aphasia 
into  (a)  word  deafness,  (b)  word  blindness,  (c)  motor  vocal  aphasia 
(aphemia),  (d)  motor  writing  aphasia  (agraphia),  and  proceeds  to 
describe  the  chief  characteristics  of  each  variety.  The  close  connec- 
tion between  the  centre  of  auditory  word  memories  and  the  speech 
centre  and  that  between  the  centre  for  visual  word  memories  and  the 
writing  centre  is  emphasized.  Speakinjr  of  word  deafness,  he  sug- 
gests that  the  character  of  the  lesion,  whether  irritative  or  destructive, 
is  of  importance,  as  where  it  is  only  irritative  there  may  be  para- 
graphia or  paraphasia,  instead  of  complete  loss  of  power  to  write  and 
to  speak.  When  the  centre  for  visual  word  memories  is  destroyed, 
there  may  be  still  ability  to  write  through  the  revival  of  memories 
of  movements  presented  in  the  kinesthetic  centre  for  writing  move- 
ments, but  this  power  can  hardly  extend  further  than  to  the  produc- 
tion of  syllables  and  short  words,  not  to  complete  sentences.  It  is 
certain  that  destruction  of  the  visual  speech  centre  does  not  produce 
paralysis  of  the  movement  of  the  hand  and  arm,  but  it  is  a  question 
whether  or  not,  under  the  circumstances,  the  finer  movements,  such 
as  piano  playing,  etc.,  do  not  suflfer  to  some  extent,  and  observations 
on  this  point  are  needed. 

The  author  is  of  the  opinion  that  a  separate  writing  speech 
centre  does  not  exist,  but  that  the  centre  for  writing  movements  is 
included  in  the  psychomotor  centre  for  movements  of  the  hand  and 
arm.  Whether  the  kinsesthetic  memories  of  the  movements  made  use 
of  in  writing  are  stored  up  in  the  same  region  from  which  the  motor 
impulses  emanate,  or  elsewhere,  is  uncertain,  Speaking  of  other 
varieties  of  sensory  aphasia,  it  is  suggested  that  in  the  blind,  who 
read  by  sense  of  touch,  as  the  result  of  a  lesion  "tactile  aphasia"  may 
be  produced,  and  it  is  urged  that  physicians  to  blind  asylums  investi- 
gfate  the  matter. 

The  aphasic  symptoms  due  to  interruotion  of  the  connecting  and 
commissural  fibres  passing  between  the  different  speech  centres  are 
next  considered,  and  after  this  follows  a  discussion  as  to  the  relative 
activity  of  the  corresponding  speech  centres  in  the  two  hemispheres 
of  the  brain.  While  one  side  of  the  brain  (the  left  in  right-handed 
people)  contains  the  leading  or  "driving"  centres,  the  action  of  the 
centres  upon  the  opposite  side  should  not  be  underestimated,  as  it  is 
doubtless  important.  In  support  of  this  point,  a  number  of  facts  are 
mentioned,  aiid  interesting  suggestions  are  made.  The  question  of 
blood  supply  to  the  different  centres  is  taken  up,  and  it  Is  pointed  out 
that  most  of  them  are  situated  about  the  boundary  lines  of  regions 
supplied  by  different  centres,  and  as  these  boundaries  vary  somewhat 
in  different  brains,  we  may  have  here  an  explanation  of  the  different 
symptoms  resulting  from  the  plugging  of  a  certain  artery  in  different 
cases.  Lastly  follows  a  discussion  of  the  physiology  of  speaking  and 
writing,  and  the  development  and  education  of  the  different  centres 
concerned  in  these  processes.  Tljis  is  one  of  the  most  interesting  and 
instructive  parts  of  the  course.  The  lectures  are  clearly  and  pleasantly 
written,  and  give  an  excellent  r^sumd  of  the  subject.  Allen. 

240.   ZUR-  LEHRE  von    DER    GLHICHSEITIGEN    HEMIPLEGIE    BEI    CERE- 

BRALEN  Erkrankungen  (A  Contribution  to  the  Study  of  Col- 
lateral Hemiplegia  in  Cerebral  Diseases).  N.  Ortner  (Deutsche 
med.  Wochenschrift,  23,  1897.  p.  Z72). 

Ortner  mentions  a  valuable  diagnostic  sign  in  cases  of  collateral 
hemiplegia,  i.  e.,  those  in  which  the  paralysis  is  oh  the  same  side 


764  PERISCOPE. 

as  the  cerebral  lesion.  He  reports  two  cases  of  left-sided  hemiplegia, 
in  each  of  which  he  correctly  made  the  diagnosis  of  a  left-sided  cere- 
bral lesion,  because  the  degree  of  the  respiratory  movements  of  the 
right  side  of  the  thorax  was  much  below  normal,  while  on  the  left 
side  the  movements  were  not  affected.  He  acknowledges  that  in  rare 
cases  of  contralateral  cerebral  hemiplegia  differences  in  the  respiratory 
movements  of  the  two  sides  of  the  thorax  are  not  found.  It  is  not  the 
condition  of  the  extremities,  but  that  of  the  respiratory  muscles  which 
is  of  decisive  moment  for  the  localization  of  the  lesion  in  cerebral 
hemiplegia. 

After  mentioning  and  rejecting  the  various  theories  advanced  to 
explain  hemiplegia  existing  on  the  side  of  the  cerebral  lesion,  Ortner 
accepts  the  views  of  Pinneles.  There  is  not  a  true  paralysis  of  the 
limbs  on  the  same  side  as  the  lesion  in  these  cases,  but  a  relaxation 
of  the  muscJes,  and  in  the  limbs  of  the  side  opposite  to  the  lesion 
there  are  manifestations  of  cerebral  irritation,  such  as  apparently 
voluntary  movements  of  defense.  As  such  symptoms  of  irritation 
are  absent  in  the  limbs'  on  the  same  side  as  the  lesion,  the  appearance 
of  paralysis  is  produced.  In  none  of  thirty-eight  cases  of  collateral 
hemiplegia,  with  autopsies,  taken  from  the  literature  was  there  any 
statement  of  a  lesion  of  the  internal  capsule,  and  in  all  thesfi  cases 
the  lesion,  from  its  location,  was  well  adapted  to  cause  signs  of  irri- 
tation in  the  opposite  half  t>f  the  body. 

Collateral  hemiplegia  is  comparatively  frequent  in  haematoma  of 
the  meninges  or  in  internal  hemorrhagic  pachymeningitis,  and  the 
diagnosis  of  these  conditions  becomes  possible  in  cases  in  which  ap- 
parent paralysis  of  the  limbs,  and,  possibly,  also  of  the  face,  of  one 
side  offers  a  striking  contrast  to  the  normal  movements  of  the  res- 
piratory muscles  of  the  same  side.  Trephining  in  such  cases  should 
be  done  on  the  side  on  which  the  hemiplegia  is  noted. 

The  observation  of  imperfect  respiratory  movements  on  one  side 
will  lead  to  a  correct  diagnosis  of  the  side  of  the  brain  affected  in 
cases  in  which  bilateral  symptoms  of  irritation  or  flaccid  paralysis  of 
the  extremities  are  present.  Spiller. 

PSYCHOLOGY  AND  PSYCHIATRY. 

241.  A  Study  xn  Apperception.      W.  B.  Pillsbury  (American  Jour. 
of  Psychology,  8.  1897,  p.  315). 

The  author  presents  Wundt*s  views.  In  normal  consciousness,  at 
any  time,  some  ideas  will  be  found  to  be  prominent  and  distinct^  while 
others  are  vague  and  indefinite,  gradually  shading  down  to  obscurity 
from  "the  point  of  clearest  vision."  Clearness  of  ideas  is  not  the  same 
as  intensity  of  sensation,  but  intensity  favors  clearness,  and  clearness 
favors  intensity.  Degree  of  clearness  varies  inversely  with  the  number 
of  ideas  simultaneously  contained  in  the  point  of  clearest  mental  vision. 
Preceding,  accompanying  and  succeeding  increase  in  the  clearness  of 
ideas  there  is  a  varying  complex  of  sensational  and  affective  phenom- 
ena, viz.,  (i)  increase  of  clearness  in  the  idea  directly  before  the  mind, 
accompanied  by  the  immediate  feeling  of  activity;  (2)  inhibition  of 
other  ideas;  (3)  muscular  strain  sensations  with  the  feelings  con- 
nected with  them,  intensifying  the  primary  feeling  of  activity;  (4) 
the  reflex  of  these  strain  sensations  intensifying  the  idea  apperceived. 
An  idea  never  undergoes  the  peculiar  increase  in  clearness  when  these 
phenomena  are  not  present.  The  change  of  clearness  is  not  like  quality 
or  extent  and  other  attributes  of  sensation.  It  takes  place  while  all 
external  conditions  remain  the  same.  The  whole  circle  of  subjective 
processes  connected  with  apperception  Wundt  calls  "attention". 

Passive  apperception  is  present  (i)  at  certain  times  when  an  idea 


PERISCOPE. 


765 


enters  consciousness  under  the  most  favorable  conditions,  and  (2)  it 
sometimes  precedes  active  perception.  It  is  never  so  complete  or  full 
as  active  apperception,  and  in  the  typical  form  it  is  determined  im- 
mediately and  without  choice.  In  active  apperception  the  incentives 
are  more  numerous  and  more  evenly  balanced,  and  the  decision  re- 
^^arding  the  merits  of  ideas  is  equivocal,  and  often  delayed.  Apper- 
ception of  any  sensation  is  rendered  easy  by  its  separate  and  isolated 
appearance  shortly  before  in  consciousness.  No  sensation  comes  to 
its  full  rights  in  consciousness  unless  apperceived.         Christison. 

242.  Involuntary  Motor  Reaction  to  Pleasant  and  Unpleasant 
Stimuli.  G.  V.  Dearborn  and  F.  N.  Spindlcr  (Psychological 
Review,  4,  1897,  p.  453). 

The  authors  experimented  with  reference  to  the  hypothesis  of 
Prof.  Munsterberg,  that  stimuli,  which  cause  action  of  the  extension 
muscles,  are  as  a  rule,  agreeable,  while  stimuli  which  cause  action  of 
the  flexor  muscles  are,  as  a  rule,  disagreeable.  According  to  this 
theory,  the  hands  should  relax  and  the  head  drop  back  under  agreeable 
stimuli,  while  under  disagreeable  stimuli,  the  reverse  should  take  place. 

The  hands  and  the  head  were,  therefore,  chosen  as  the  reacting 
organs  of  the  experiments.  The  stimuli  used  were  odors,  sounds  and 
Colored  light.  It  was  much  more  difficult  to  find  for  each  subject  a 
positively  disagreeable  odor,  than  it  was  to  find  a  positively  pleasant 
one.  The  most  emphatic  were:  bergamot,  cologne  water,  heliotrope, 
methyl  acetate,  oil  of  cloves,  tincture  of  musk,  ethyl  iodide,  spirit  of 
turpentine,  xylol,  eugenol,  oil  of  eucalyptus,  iodoform,  cider  vinegar, 
bisulphide  of  carbon,  ethyl  bromol  and  camphor,  sulphuric  ether, 
toluidin,  ally!  alcohol,  tincture  of  asafetida,  diamylamine,  acetic  acid, 
ammonium  valerianate. 

It  was  expected  that  as  the  lower  animals,  savages  and  children 
are  very  responsive  to  sensory  stimuli,  the  effects  of  civilization  or 
education  would  reduce  motor  manifestations  as  responses  to  sensory 
stimuli.  It  was  found,  however,  that  some  subjects  did  not  react  at 
all,  except  to  pronounce  the  stimulus  pleasant  or  unpleasant,  and 
other  subjects  would  give  a  motor  reaction  while  they  pronounced 
the  stimuli  indifferent.  Others,  again,  were  so  sensitive  that  "they 
seemed  to  go  all  to  pieces**  by  any  disagreeable  stimulus,  and  would 
"show  most  surprising  and  seemingly  contradictory  reactions." 

The  subjects  cover  mostly  seniors  and  juniors  of  the  Harvard 
and  Radcliff  colleges  and  graduates  working  in  the  laboratory.  They 
were  nineteen  in  all.  They  were  each  comfortably  seated  in  an  arm- 
chair, and  their  heads  and  hands  ingeniously  connected  with  registers. 
The  summary  is  as  follows.  It  includes  only  actual  reactions  to  stimuli, 
764  reactions  in  all.  The  cases  where  stimuli  were  applied  without  re- 
sulting reactions  numbered  253. 


Under  Unpleasant    Under  Pleasant 
Stimulf.  1  Stimuli. 


Plexion.  . 
Extension 
Proportion 


66.6 

33.3 
2  to  I 


32.2 

67.8 

I  to  2  -h 


Under  Indifferent 
Stimuli. 


49 

51 
Nearly  equal. 


These  experiments  afford  a  striking  confirmation  of  Professor 
Munsterberg's  theory  that  there  is  a  strong  tendency  to  expansion 


766  PERISCOPE. 

under  agreeable  and  contraction  under  disagreeable  stimuli.  Other 
tendencies  are  present,  however,  some  of  which  conflict  with  this  one, 
such,  for  example,  as  the  tendency  to  move  toward  an  object  which 
attracts  attention;  the  tendency  lo  move  away  from  a  disagreeable 
object;  the  tendency  lo  make  particular  movements  of  adaptation  to 
stimuli,  etc.  A  further  influence  of  great  interest  is  revealed  upon 
examination  of  the  records  of  the  separate  individuals  who  as  subjects 
took  part  in  these  experiments.  If  their  reaction  to  stimuli  what  they 
pronounced  indifTerent  be  examined,  it  will  be  seen  thai  some  show 
a  temperamental  tendency  to  make  movements  of  flexion  more  often 
than  of  extension;  others,  the  opposite,  and  others  still  to  make  both 
in  nearly  equal  proportion. 

The  "flexion"  temperament  shows  through  the  greater  predomin- 
ance of  flexions  a  greater  difference  in  the  proportion  of  the  two  move- 
ments under  pleasant  stimuli  and  a  nearer  approach  to  equality  under 
unpleasant  stimuli.  The  "extension"  temperament  shows  the  opposite 
results,  and  the  indifferent  temperament  exhibits  proportions  more 
nearly  those  given  in  the  above  table. 

Temperamental  differences  then  work  together  with  the  other 
special  tendencies  mentioned  above  in  modifying  the  tendency  to 
contract  under  disagreeable  and  expand  under  agreeable  stimuli. 
While,  therefore,  this  latter  is  clearly  shown  by  this  research  as  a  real 
and  strong  tendency.  It  is  at  the  same  time  shown  to  be  only  one 
tendency  acting  among  many.  Curistison. 

THERAPY. 

343.      Partiai,    Thvroidkctomv    in  Graves'  Disease.     J,   .\rihur 

Booth,  M.D.  (Medical  Record,  54,  1898,  p.  217}. 

The  author  reports  eight  cases  of  Graves'  disease  operated  upon 
with  five  cures — one  died,  in  one  no  change  occurred,  one  has  been 
improved,  and  in  this  case  the  operation  was  performed  only  six 
months  ago,  so  that  the  author  expects  further  improvement  and  per- 
haps a  cure,  for  the  longer  the  period  of  observation  after  operation 
the  better  appear  the  results.  The  order  of  improvement  was  as  fol- 
lows: First  the  goitre  diminishes;  next  the  nervous  symptoms  dis- 
appear; then  the  pulse-rate  and  vasomotor  phenomena  improve,  and 
the  exophthalmos  last  of  all.  In  fatal  cases  the  deaths  occur  suddenly 
either  at  the  time  of  operation  or  soon  afterwards,  and  the  rapid  onset 
of  acute  symptoms,  with  death  following  in  a  few  hours,  has  caused 
much  speculation  as  to  their  cause.  The  author  believes  that  cases 
of  Graves'  disease  may  be  entirely  cured  by  operative  measures,  anil 
states  that  pathological  and  clinical  evidence  is  in  support  of  the  view- 
that  the  symptom  complex  is  the  expression  of  a  primary  neurosis 
multiplied  by  a  secondary  glandular  intoxication.  While  the  ultimate 
cause  of  the  disease  of  the  gland  is  still  a  matter  of  speculation,  and  a 
mortality  of  seven  per  cent,  after  operation  Is  reported,  he  admits  wo 
cannot  justly  recommend  it  as  a  routine  plan  of  treatment. 

Free  MAS, 


f^ool3i  ll^tniews. 


Bbitrag  zur  Ki«inik  dbr  Ruckbnmarks-  und  Wirbbltumorbn 
(Contributions  to  the  Clinic  of  Tumors  of  the  Spinal  Cord  and 
Vertebrae).  By  Hermann  Schlesinger,  M.D.,  Private  Docent  in 
the  University  of  Vienna.     Gustav  Fischer,  June,  1898. 

It  was  the  intention  of  the  author  to  write  a  monograph  on  spinal 
tumors,  but  the  work  of  Bruns,  which  appeared  before  this  plan  could 
be  carried  into  effect,  rendered  such  an  undertaking  unnecessary. 
Schlesinger,  however,  has  had  at  his  command  the  records  of 
necropsies  performed  in  the  great  hospital  in  Vienna,  and  his  conclu- 
sions are  based  on  the  examination  of  a  material  which  in  value  and 
extent  can  hardly  be  excelled.  Thirty-five  thousand  necropsies,  of 
which  151  were  in  cases  of  tumor  of  the  cord  or  its  envelopes,  re- 
ported during  the  last  eighteen  years,  afford  an  immense  field  of  re- 
search. The  volume  of  209  pages  contains  a  brief  introduction,  which 
is  followed  by  chapters  devoted  to  the  pathological  anatomy,  etiology 
and  clinical  signs  of  tumors  of  the  vertebrae  and  spinal  cord.  Fifty- 
six  new  cases  are  reported  and  589  references  to  the  literature  are 
given.  The  book  is  well  illustrated.  Those  who  are  familiar  with 
Schlesinger's  monograph  on  syringomyelia  will  expect  to  find  a  vol- 
ume on  spinal  tumors  equally  well  written,  and  we  believe  they  will 
not  be  disappointed. 

A  tumor  may  arise  externally  to  the  vertebrae  and  grow  into  the 
canal  through  the  intervertebral  foramina,  or  it  may  develop  within 
the  bodies  of  the  vertebrae,  or  within  the  canal  and  external  to  the 
dura,  or  within  the  membranes,  or  within  the  cord  itself.  Schlesinger 
finds  that  the  vertebral  tumors  with  consecutive  involvement  of  the 
spinal  cord  are  by  far  the  most  numerous,  whereas  tumors  within  the 
cord  substance  occur  about  as  frequently  as  those  within  the  meninges. 
In  400  cases  of  "intervertebral"  tumors  taken  from  the  literature  (by 
which  we  suppose  tumors  within  the  vertebral  canal  are  meant)  sur- 
gical interference  could  have  been  of  benefit  only  in  about  150,  and  if 
the  vertebral  tumors  are  added  the  percentage  of  operable  cases  is 
much  lessened.  Unusual  forms  of  tumor  are  most  common  in  the 
conus  terminalis. 

Tuberculosis  of  the  spinal  cord  is  treated  quite  fully,  and  we  are 
informed  that  primary  tuberculosis  of  the  spinal  cord  has  never  been 
observed.  The  tuberculous  growths  resemble  the  syphilitic  very 
closely,  and  the  absence  of  the  bacillus  is  by  no  means  proof  of  the 
syphilitic  nature  of  the  process.  Schlesinger  has  collected  the  reports 
of  nineteen  cases — including  two  new  ones  of  his  own  and  four  rather 
doubtful  cases — of  gumma  of  the  cord.  He  calls  attention  to  the  fact 
that  in  a  number  of  cases  in  which  the  gumma  was  large  secondary 
degeneration  was  almost  entirely  absent. 

Considerable  space  is  devoted  to  glioma,  but  the  author's  opin- 
ions on  this  subject  are  already  well  known. 

Diffuse  sarcomatous  infiltration  of  the  meninges,  and  even  of  the 
spinal  cord,  extending  a  considerable  distance,  is  a  recognized  and 
interesting  form  of  new  growth.  Schlesinger  has  collected  the  reports 
of  thirteen  cases  of  primary  sarcoma  of  the  cord  without  involvement 


768 


BOOK  REVIEWS. 


of  the  membranes;  it  is  therefore  a  rare  condition,  whereas  the  pri- 
mary sarcoma  of  the  meninges  and  nerve  roots  is  apparently  the 
most  common  of  the  tumors  arising  in  the  meninges.  Attention  is 
paid  to  a  number  of  rarer  forms  of  tumor. 

Primary  carcinoma  of  the  cord  or  its  membranes  is  unknown,  and 
metastatic  carcinoma  within  the  vertebral  canal,  not  growing  from 
a  vertebra,  is  exceedingly  uncommon.  Even  when  the  vertebrae  are 
the  seat  of  carcinoma  the  growth  very  rarely  goes  beyond  the  dura, 
and  in  those  rare  instances  in  which  the  dura  fails  to  offer  a  barrier 
the  Cauda  equina  is  the  portion  more  often  attacked.  In  the  35,000 
necropsies  the  dura  of  the  cervical  and  thoriacic  regions  in  every  case 
prevented  the  further  extension  of  the  carcinomatous  process.  Pri- 
mary carcinoma  of  the  vertebrae  probably  does  not  occur.  Kolisko 
has  repeatedly  shown  that  the  primary  lesion  is  elsewhere,  and  may  be 
so  small  as  to  be  easily  overlooked.  Schlesinger  believes  that  carci- 
noma of  the  vertebrae  cannot  be  considered  especially  common,  and 
he  speaks  of  a  fact  not  generally  known,  viz.,  that  primary  bronchial 
carcinoma,  itself  rare,  relatively  often  gives  metastasis  to  the  ver- 
tebrae. The  most  common  primary  seat  of  vertebral  carcinoma  is  the 
mammary  gland. 

Schlesinger  emphasizes  the  fact  that  cavity  formation  is  found  not 
only  in  the  gliomatous,  but  also  in  the  sarcomatous  and  tuberculous 
tumors  of  the  spinal  cord. 

The  cord  may  suffer  a  slight  change  in  its  form,  from  the  pressure 
of  a  tumor,  and  this  alteration  is  not  always  persistent  when  the  tumor 
is  removed.  The  cord  is,  therefore,  compressible  to  a  certain  degree 
without  being  permanently  injured.  Circumscribed,  even  large,  ex- 
tramedullary  tumors  involve  comparatively  slightly  the  spinal  roots, 
and  this  Schlesinger  considers  a  clinical  fact  of  great  importance;  ver- 
tebral tumors,  on  the  other  hand,  do  much  damage  to  the  nerve  roots. 

Schlesinger  has  not  been  able  to  confirm  the  statement  of  Char- 
cot that  arterial  thrombosis  is  common  when  vertebral  carcinoma  ex- 
ists, but  he  has  found  that  thrombosis  of  the  large  veins  of  the  lower 
extremities  is  not  rare  in  cases  of  vertebral  neoplasm.  This  explains 
why  sudden  death  occurs  frequently  in  vertebral  carcinoma  with  em- 
bolus of  the  pulmonary  artery  as  the  direct  cause. 

The  35,000  necropsies  show  that  the  brain  and  its  membranes  are 
more  than  six  times  more  liable  to  tumor  formation  than  the  cord  and 
its  membranes.  Tuberculosis  and  glioma  are  relatively  frequent  in 
the  different  parts  of  the  central  nervous  system,  but  gumma  of  the 
cord  is  much  more  uncommon  than  gumma  of  the  brain.  Secondary- 
sarcoma  is  not  uncommon  in  the  brain,  but  is  rare  in  the  cord.  A 
vertebral  tumor  involving  the  spinal  canal  and  producing  symptoms 
of  nervous  disease  is  thirty  times  more  likely  to  be  malignant  than 
benign. 

Spontaneous  and  intense  pains  are  among  the  earliest,  most  per- 
sistent and  distressing  of  the  symptoms  of  vertebral  carcinoma.  Sci- 
atica may  be  the  only  sign  for  a  long  time,  as  in  one  of  Schlesinger's 
cases  where  it  existed  alone  for  two  and  a  half  years,  or  in  another 
where  it  existed  for  two  years. 

The  differential  diagnosis  of  vertebral  tumor  may  be  most  dif- 
ficult, and  caries  of  the  vertebra  may  produce  symptoms  closely  re- 
sembling those  of  carcinoma. 

The  indications  and  contraindications  for  surgical  interference  in 
neoplasms  of  the  vertebrae  and  cord  are  given.  We  find  that  Schles- 
inger is  not  entirly  pessimistic  as  regards  the  results  of  attempts  at 
relief  by  surgical  means.  The  mere  opening  of  the  vertebral  canal,, 
however,  may  be  fatal.  Spiller. 


wti<ww;wfWfi;w|w;w|H;i<viii|»i||ii|>i)iii|iii|iii|iii|iii|iii|iii|iii)iii)>i|.ii|ii,,|ii)>i;>i 

Cocaine  Discoids  "Schkffeiin's"  \ 

■   The  Safest,  Most  Efficient,  and  Convenient  Means 
for  'Producing  Local  Anaesthesia. 

Cocaine  Discoids  consist  of  pare  cocaine  hydrochlorate,  without  admixture  of  foreign 
material  to  impair  its  activity,  end  in  quantities  accurately  determined  by  weight.  Oiringto 
their  mode  of  mannfacture,  not  being  compressed.  theydissoWereadilyin  one  drop  o£  water. 

Instead  of  keeping  on  hasd  ready-made  solutions,  which  are  tiaole  to  deteriorate,  the 
doctor  hAS  UDW  at  his  disposal  a  means  of  obtaining 

Freshly  Pr^Mred  Cocaine  Solutions  of  Any  Desired  Strength 
at  a  moment'a  notice,  and  the  quantity  of  the  drug  employed  during  anwsthesia  is  always 
koowD,  and  not  a  matter  of  conjecture. 

Cocaine  Discoids  are  indicated  in  all  conditions  demanding  the  nse  of  this  drug,  as  a 
local  anesthetic,  as  in  tbe  treatment  of  diseases  of  the  eyes,  nose  and  throat,  in  general 
sttTgery,  and  in  dentistry,  especially  for  cataphoresis, 

Discoids  containing  ^  gr.  .14  .60 

"                «         ^gt.  .15  .55 

"                "          IgT.  .16  .60 

"                «         -igr.  .18  .70 

Cocaine  Discoida  are  manufactured  solely  by 

Schieffelin  8  Co.,  New  YotL   j 

h'itfMWKilm>M^tolM>i''"'w''f'"''ii'iiiiitii-'iritMti''ii'"*'i'"'"'"N'M'r'' 


iii>iHiiiiritiiniiniiiintiii>iM'ni'ii'H'i>i'i'ii>iitii|iiiii>"»'i|i'i>ii|i'i>i"ti'<">nii'i»i';i 

Schieffelin's   i 

I  (Alkaline  (Antiseptic  and  Prophylactic,  \ 

Bensolyptus  is  an  agreeable  alkaline  solution  of  various  highly 
approved  antiseptics,  so  combined  that  one  supplements  the  action  of 
the  other.    Its  ingredients  are  all  of  recognised  value  in  the  treatment 

Catarrhal  c4ffedions 

hecause  of  their  cleansing,  soothing,  and  healing  properties.  Benso- 
lyptus  is  highly  recommended  in  all  diseases  of  the  nose  and  throat, 
both  acate  and  chronic,  and  as  a  mouth-wash  and  dentifrice.  It  is 
also  indicated  for  internal  use  in  affections  of  the  stomach  and  intes- 
tines zuhere  an  agreeable,  unirritating,  and  efficient  antiseptic  and 
antifermentative  is  required. 

Ptmpbkts  on  apvUcation  to 

Schieffelin  &  Co.,  New  York 

y...t,.t..t,.t..t..t..i,.i.,..,l,,i^n|.|^,,it|,.|^....^..^.i,....*..»..»..»..i..«-.»..»...»Mt.-' 


ra.  Antiseptk. 

fl  Sulphite  Soda,  i  gr. 
Salicylic  Acid,  x  gr. 
Nuz^omica,      J^  gr. 


PiL  Antiseptic  Co. 

fk  Sulphite  Soda,  i  gc 
Salicylic  Acid,  i  gt. 
Ntix  vomica,  H  V' 
Powd.Capsic.  i^iogr. 
Conoen.  Pepsi  a,  x  gr, 
Doae— 1-3 

Pilt  Antiseptic  and  Pil.  Antiseptic  Co» 

For  Indigestion,  Malassimilation  of  Food, 

Dyspepsia,  etc. 

Will  produce  marked  improvement  in  cases  of  gastric  debility.  Prescribed  for  tbose 
patients  who  do  not  appear  to  derive  full  benefit  from  their  food.  Morning  doses  of 
Aperient  Saline  (Warner  &  Co.),  a  pleasant  eflfervescent  salt,  may  be  used  to  advan- 
tage in  connection  with  Pil.  Antiseptic  and  Pil.  Antiseptic  Comp.  for  its  gentle 
aperient  eflfect. 


SUPERIOR  TO  PEPSIN  OF  THE  HOG 

INGLUVIN  'S^S:- 


A  SPBAIFIO  FOB  TOHITIHO  IS  flESTATiaS  IH  DOBBS  OF  10  «•  •• 


WM.  R.  WA.RNER  &  CO.  Philadelphia,  new  york.  chicaqo. 


Extract   of 


Bone -Marrow 


(Medullary  Glyceride.) 

Stimulates  the  appetite  and  aids  digestion. 

Increases  the  production  of  haemoglobin  and 
red  corpuscles. 

Promotes  cell  proliferation  and  supplies  the 
new  born  cells  with  nutrition. 

Restores  the  blood  to  the  normal  standard. 

Is  the  ideal  remedy  in  all  diseases  character- 
ized by  defective  haemogenesis. 

NOTE — Physicians  who  wish  results  from  the  Bone-Marrow 
treatment  should  specify  ARMOUR'S  and  get  a  preparation 
that  contains  BONE-MARROW. 


Armour  &  Company,  Chicago. 


7<C.  25  i^obrmber  1898  |(«.  ll 


Uhc  Journal 


y  of 


ITbe  Bmerican  fleuroli/m^^ 
tTbe  1^€W  l^rft  Deurolodical  Society?  anD 

^be  pbUa^elpbia  Deuroloaical  Society? 


EDITORS 

Or,  CHARLES  L.  DANA  Dr.  HUGH  T.  PATRICK 

Or.  P.  X.  DBRCUM  Dn  JAS.  J.  PUTNAM 

Or.  CnA5.  K.  MILL5  Dr.  B.  SACHS 

Dr.  M.  ALLEN  STARR 

ASSOCIATE  EDITOR 

Dr.  WILLIAM  Q.  5PILLER 

MANAQINQ  EDITOR 

Dr.  CHARLES  HENRY  BROWN 
»5  W.  48th  Street,  New  York 

TABLE  OP  CONTENTS  ON  PAGES  U.  AND  iv. 

FOREIGN  AND  DOMESTIC  AGENTS 

Bcmliasd  Hcmumfi,  Thalstraase  s,  l^pxig,  Genuany.   S.  ELarger,  Charitestr.  3,  Berlia,  Qermaay 
TrObner  &  Co.,  Ludgate  Hill,  I/>ndon.    9.  Steiger  &  Co.,  35  Park  Place, 
New  York.     B.  Westermann,  812  Broadway,  New  York. 
Gustave  E.  Stecbert,  9  S.  i6tta  Street  Vew  York. 


PRINTED  BY  W.  N.  JENNINGS,  162  LEONARD  ST.,  NEW  YORK 


I88UKI>  MONTHI^Y  fe.oo  PER  YEAR 

Batered  at  the  Post-Office  in  New  York  as  Second-Class  Matter. 

Copyright,  1898. 


VOL.   XXV. 


November,  1898. 


No.  II. 


THE 


Journa 


OF 


Nervous  and  Mental  Disease 


©viflitial  Articles* 


ON  THE  ETIOLOGY  AND  PATHOGENESIS  OF 
THE  POST-TRAUMATIC  PSYCHOSES  AND 
NEUROSES.* 

By  JAMES  J.  PUTNAM,  M.D., 

Professor  of  Diseases  of  the  Nervous  System  in  Harvard  Medical  School. 

In  spite  of  all  that  has  been  written  about  the  post- 
traumatic psychoses  and  neuroses,  the  subject  still  pre- 
sents to  the  searcher  many  fascinating  problems  for  study 
and  speculation,  and  others  of  highly  practical  signifi- 
cance, which  need  all  the  light  that  a  careful  scrutiny  of 
our  experience  and  a  comparison  of  our  observations  can 
furnish. 

What  are  the  factors — for  they  are  obviously  multiple 
— that  make  these  apparently  trivial  accidents  the  start- 
ing point  of  grave  disease  for  some  persons,  while  others 
pass  through  them  unscathed;  what  part  do  the  actual 
injuries  of  the  brain  and  spinal  cord  play — the  minute 
hemorrhages  and  necroses  of  which  we  so  often  hear — in 
shaping  the  future  of  the  case;  to  what  extent  does  the 
law  create  or  increase  the  troubles  for  which  it  was  meant 
to  compensate,  and  what  can  the  doctors  do  in  this  direc- 

♦Read  in  part  before  the  Philadelphia  Neurological  Society^ 
March,  1898.    For  discussion  on  this  paper,  see  page  485* 


770  JAMES  /.   PUTNAM. 

tion,  general  practitioners  or  experts,  to  smooth  the  path 
of  true  justice  and  promote  the  real  interests  of  the  com- 
munity and  the  dignity  of  their  profession;  what  is 
the  nature  of  these  affections. and  what  their  proper  treat- 
ment, and  how^  far  does  ignorance,  as  regards  these  points, 
on  the  part  of  the  profession  and  the  community,  tend  to 
make  a  needless  supply  of  nervous  invalids,  and  what  shall 
we  do  to  improve  the  existing  conditions? 

These  are  a  few  of  the  practical  problems  that  con- 
front us,  while  problems  of  more  purely  scientific  nature 
throng  to  the  mind  of  every  close  inquirer. 

A  friend  to  w^hom  I  casually  mentioned  that  I  was 
writing  on  the  traumatic  phychoses  said,  "They  don't  ex- 
ist. The  cases  are  all  manufactured  by  the  doctors,  w^ho 
persuade  their  patients  that  they  are  ill,  and  thus  make 
them  so.**  Without  fully  sharing  this  drastic  opinion,  1 
do  believe  that  in  many  of  their  features  these  cases  be- 
long largely  to  the  preventable  class,  preventable  by  suf- 
ficiently judicious  treatment  on  the  part  of  physicians, 
and  likely  to  grow  less  numerous  as  the  community  be- 
comes better  educated,  and,  as  lawyers  learn  more  and 
more  to  see  and  seek  the  best  interests  of  their  clients. 

Let  me  say,  however,  at  once,  that  while  these  diseases 
are  obviously  prolonged  and  made  worse  by  the  various 
baneful  influences  that  cluster  round  the  effort  to  obtain 
redress  by  suits  at  law,  yet  that  would  be  a  narrow  judg- 
ment which  should  refer  to  this  cause  alone  the  fact  that  so 
many  more  bad  cases  of  traumatic  hysteria  are  seen  in 
the  law  courts  than  on  the  football  grounds. 

That  this  fact  is  true  I  believe,  but  the  "legal"  causes, 
important  as  they  may  be,  are  by  no  means  the  only  ones 
that  can  be  adduced  in  explanation. 

My  personal  experience  is  based  on  the  examination 
of  one  hundred  and  eighty-two  cases  of  patients  who  have 
consulted  me  for  illnesses  which,  it  was  claimed,  had  re- 
sulted wholly  or  in  part  from  accidents  or  injuries.  Be- 
sides the  record  of  these  examinations,  I  have  used  the 


POST-TRAUMATIC  PSYCHOSES.  771 

notes  of  twenty-four  additional  cases  of  hospital  patients, 
choosing  the  more  striking  ^and  best  reported  ca&es  of 
recent  years.  Many  of  these  reports  leave  much  to  be 
desired  as  regards  fullness,  but  they  can  be  safely  utilized 
for  certain  purposes.  Of  the  private  patients,  one  hun- 
dred and  fifty-three  consulted  me  with  reference  to  claims 
for  damages,  while  only  twenty-nine  came  for  advice  as  to 
treatment.  All  of  the  twenty-four  hospital  patients  came 
for  treatment  alone,  but  five  were  prosecuting  claims,  or 
had  prosecuted  them  in  the  past,  and  about  the  same 
number  had,  perhaps,  made  some  sort  of  settlement,  gen- 
erally with  an  employer.  Thirteen  of  the  hospital  patients 
had  no  legal  claims  to  make.  Of  the  two  hundred  and 
six  cases,  one  hundred  and  thirteen  were  males;  ninety- 
three  females.  The  preponderance  of  males  is,  of  course, 
due  to  their  greater  exposure^  and  no  one  can  read  over 
the  histories  without  becoming  convinced  that  the  pro- 
portion of  females  would  probably  not  have  reached  45 
per  cent,  but  for  a  greater  predisposition  on  their  part  of 
one  or  another  sort. 

In  the  interests  of  an  analysis  of  predisposing  causes, 
which  will  be  giyen  later,  I  have  tried  to  divide  the  pa- 
tients into  four  classes  as  regards  their  "social  status." 
Had  I  been  sufficiently  intimate  with  them,  I  should  have 
made  the  degree  of  cultivation  and  mental  balance  the  basis 
for  this  division,  but  where,  as  was  often  the  case,  I  could 
not  form  a  satisfactory  opinion  on  these  points,  I  have 
divided  the  patients  according  as  they  earned  their  sup- 
port by  wages  (Class  I.);  by  small  salaries  (Class  II.);  by 
professional  income,  higher  salaries,  or  established  busi- 
ness (Class  III.),  or  as  they  belonged  distinctly  to  the 
leisure  class  (Class  IV.).  In  Class  I.  there  were  sixty-two 
patients;  in  Class  II.,  one  hundred  and  seventeen  patients; 
in  Class  III.,  twenty-five  patients,  and  in  Class  IV.,  two 
patients.  It  would,  perhaps,  be  better  to  group  together 
Classes  I.  and  II.,  as  representing  the  patients  who,  in 
my  opinion,  based  on  such  information  as  was  at  my  dis- 


772  JAMES  y.  PUTNAM. 

posal,  had  had  a  relatively  small  amount  of  "social  train- 
ing/' in  the  widest  sense,  and  Classes  III.  and  IV.  as  rep- 
resenting those  who  had  had  better  opportunities  in  this 
respect.  We  should  then  have  a  Class  A  (I.  and  11. ),  com- 
prising one  hundred  and  seventy-nine  patients,  and  Class 
B  (III.  and  IV.),  comprising  twenty-seven  patients. 

For  reasons  which  are  partly  obvious,  but  which  will 
be  discussed  later  at  some  length,  the  "medico-legal" 
cases  fall  mainly  under  Class  A,  the  non-legal  mainly 
under  Class  B.  On  the  other  hand,  a  division  of  the  cases 
as  regards  indications  of  typical  neuropathic  predispo- 
sition, in  the  usual  clinical  sense  of  the  term,  shows  that 
Class  A  contains,  of  neuropathic  cases,28  (i8  per  cent.),  of 
non-neuropathic,  122  (80  per  cent.);  Class  B  contains, 
of  neuropathic  cases,  19  (73  per  cent.),  of  non-neuro- 
pathic, 7  (36  per  cent.).  Here,  again,  the  data  are  lacking 
in  accuracy,  but  the  general  conclusion  is  probably  fairly 
correct.  Thirty  cases  were  excluded  from  this  latter 
estimation,  leaving  one  hundred  and  seventy-six  as  a  basis 
for  the  statement  above  given. 

To  classify  as  simply  as  possible  the  causes  of  the  post- 
traumatic psychoses  and  neuroses,  it  may  be  said  that  the 
various  agencies  unchained  by  a  sudden  accident — 
whether  they  be  nerve  storms  that  are  set  up  by  a  great 
fright,  and  go,  as  it  were,  crashing  through  the  brain,  or 
the  emotions  associated  with  memories  and  reflections 
after  the  event,  or  the  impressions  made  without  the  in- 
tervention of  consciousness,  or,  on  the  other  hand,  actual 
injuries,  small  or  great — all  resemble  each  other  in  that 
they  all  disturb,  more  or  less  profoundly,  the  normal 
hierarchy  of  the  central  nervous  system. 

This  disruption  of  the  old  order  may  be  followed  either 
by  a  satisfactory  establishment  of  the  mental  and  nervous 
balance  on  the  former  lines,  or  by  the  formation  of  a  new 
and  necessarily  unstable  and  unsatisfactory  equilibrium  on 
some  other  basis.  The  post-traumatic  diseases  may  be 
defined  from  this  point  of  view  as  expressions  of  the 


POST' TRA  UMA TIC  PS YC HOSES.  JJ^ 

various  modes  by  which  such  a  new  equilibrium  is  reached. 
It  is  the  expert's  task  to  discover  the  laws  that  control 
this  process  of  readjustment,  and  the  recent  studies  into 
the  psychology  of  the  subconscious  life  furnish  a  valuable 
torch  to  light  us  in  the  search. 

A  long  step  was  already  taken  when  Dr.  Hughlings 
Jackson,  for  a  long  time  the  foremost  of  medical  psy- 
chologists, with  keen  instinct  recognized,  and  with  skill 
expressed  the  principle  to  which  I  have  just  referred — 
that  in  proportion  as  the  nervous  system,  under  the  in- 
fluence of  disease,  loses  its  power  of  working  on  its  former 
basis,  as  indicated  by  symptoms  of  defect  (or  "negative 
symptoms"),  it  inevitably  seeks  to  readjust  itself  to  the 
changed  conditions,  and  it  is  only  the  fact  that  the  re- 
adjustment is  often  defective  in  practical  efficiency  which 
leads  us  to  define  its  manifestations  as  disease  ("positive 
symptoms").  What  Dr.  Jackson  could  not  then  realize 
for  lack  of  sufficient  data,  was  that,  in  this  readjustment, 
subconscious  processes  of  a  high  order  and  susceptible  of 
study  and  classification  greatly  complicate  the  situation, 
making  our  analysis  at  once  more  difficult  and  more  satis- 
factory. 

In  searching  for  the  causes  of  post-traumatic  psy- 
choses we  ought  to  include,  on  the  one  hand,  all  the  in- 
fluences that  tend  toward  a  disarrangement  of  the  normal 
coordination  of  functions  of  the  nervous  system,  and,  on 
the  other,  all  those  that  determine  the  form  of  the  re- 
organization. 

From  this  point  of  view  I  propose  the  following  ar- 
rangement of  causes  in  the  order  of  their  importance: 

(A).  Predisposing  causes: — 

1.  Of  social  character. 

2.  Of  neuropathic  character. 

3.  Of  toxic  character  (alcohol,  syphilis,  etc.). 

(B).  Causes  operative  from  the  time  of  the  accident: — 
I.  Emotional  shock. 


774|  JAMES  J.  PUTNAM. 

2.  The  mental  strain — not  of  emotional  character — 
attendant  on  intense  voluntary  effort. 

3.  Painful  or  disabling  injuries,  such  as  sprains  of  the 
back  or  blows  upon  the  head,  not  sufficient  to  cause  deep 
loss  of  consciousness,  yet  sufficient  to  inhibit  the  volun- 
tary control  in  some  measure. 

4.  Injuries  sufficient  to  cause  deep  loss  of  conscious- 
ness, such  as  powerful  electric  shocks  or  severe  blows  on 
the  head,  or  severe  concussions,  such  as  presumably  inter- 
fere with  the  intimate  nutrition  of  the  nervous  system; 

5.  Slighter  bodily  injuries,  even  down  to  physical  con- 
tact, if  of  a  kind  to  excite  or  increase  apprehension  of 
danger. 

6.  Injuries  of  a  kind  to  cause  actual  lesions  within  the 
central  nervous  system. 

(C).  The  principal  disorganizing  causes  operative  after 
an  accident  are : — 

1.  Excitements  and  anxieties  of  diverse  sorts. 

2.  The  emotional  excitements  due  to  reproduction  in 
memory  of  a  past  danger. 

3.  The  continuance  of  pain,  and  the  depressing  effect 
of  internal  disorders,  such  as  sprains,  uterine  displace- 
ments, etc.  It  is  to  be  noted  that  the  fact  that  such  affec- 
tions as  these  arise  as  the  result  of  an  accident  often 
clothes  them  with  a  power  to  cause  and  perpetuate  ner- 
vous symptoms  infinitely  greater  than  they  would  or- 
dinarily possess.  They  become  centres  of  widely  reaching 
"association  neuroses." 

(D).  The  influences  that  seem  to  me  to  take  the  prin- 
cipal part  in  re-establishing,  on  new  lines,  some  substitute 
for  the  normal  equilibrium  disturbed  by  the  accident 
are: — 

I.  Influences  made  possible  by  the  impairment  of  in- 
nervation and  vasomotor  action  due  to  the  accident. 
Such  are  the  causes  of  the  various  skin,  vascular  and  organ 
affections  and  those  of  bacterial  origin,  and  also  of  the 


POST-TRAUMATIC   PSYCHOSES.  775 

typical  psychoses  and  neuroses.    It  is  only  the  latter  dis- 
eases that  I  shall  discuss  here. 

2.  Influences  analogous  to  hypnotic  "suggestion." 

3.  Influences  equivalent  to  the  formation  of  habit,  ^^ir- 
radiation'' symptoms,  ** association'*  symptoms,  etc. 

4.  The  emotional  tendencies  referable  to  the  direct 
and  indirect  influence  of  lawsuits. 

Some  of  these  influences  ar^  imj>ortant  enough  to  jus- 
tify further  study  of  their  mode  of  action.  Those  enum- 
erated under  A,  B,  C  can  be  grouped  primarily  as  (a)  the 
influences  associated  with  actual  lesions  and  bodily  in- 
juries, and  (b)  those  acting  through  the  intermediary  of 
the  mind.  I  will  begin  with  the  first  of  these  groups,  but 
before  going  further  with  them  I  wish  to  point  out  that 
in  the  study  of  the  traumatic  psychoses  hitherto  the  ten- 
dency has  been  to  treat  the  strictly  "traumatic"  cases  far 
too  exclusively,  though  it  is  true  that  of  late  the  reaction 
against  this  tendency  has  made  itself  felt,  in  some  quar- 
ters, perhaps,  too  strongly.  There  is  no  radical  difference 
between  the  hysteroid  and  neurasthenic  conditions  in- 
duced by  a  misfortune,  or  a  surgical  operation,  and  many  of 
those  induced  by  the  mental  and  physical  shock  of  an  acci- 
dent, and  had  this  been  borne  in  mind  we  should  have 
heard  less  of  the  mistrust  of  the  genuineness  of  all  post- 
traumatic cases,  and  should  have  witnessed  a  more  un- 
biassed and  systematic  effort  on  the  part  of  experts  to 
sift  the  different  etiological  elements.  Dr.  S.  A. 
Lord  has  reported,  for  example  (The  Boston  Medical 
and  Surgical  Journal,  June  23rd,  1898),  two  interesting 
cases  from  the  records  of  our  clinic  at  the  Massachusetts 
General  HosptiaK  as  indicating  how  trifling  operations 
may  plant  the  seeds  of  very  troublesome  symptoms  of  just 
such  a  kind  as  follow  accidents. 

It  often  happens  that  exacerbations  of  neurasthenic 
conditions,  or  the  outbreak  of  special  symptoms  of  hys- 
tero-neurasthenic  character  follow  special  acute  causes, 
the  action  of  which  is  closely  analogous  to  those  of  acci- 


1 


776  JAMES  /.   PUTNAM. 

dent.  This,  indeed,  every  one  knows;  but  it  is  not  so  well 
realized,  I  think,  that  slight  degrees  of  hemianaesthesia 
and  the  like  are  fairly  common  in  such  cases,  and  that,  al- 
together, their  study  may  throw  much  light  on  the  sub- 
ject of  the  traumatic  psychoses.  For  instance,  a  gentle- 
man of  my  acquaintance  had,  after  a  severe  attack  of  in- 
fluenzal character,  which  eventuallv  involved  the  frontal 
sinuses,  an  intense  right-sided  supraorbital  neuralgia,  for 
which  he  stayed  a  couple  of  days  in  bed.  During  this  at- 
tack he  observed  that  the  sole  of  the  right  foot  was  moist, 
and  tests  showed  a  slight  diminution  of  sensibility  of  the 
right  foot  and  the  right  hand,  while,  the  surface  tempera- 
ture of  the  right  foot  was  slightly  greater  than  that  of 
the  left.  This  moisture  lasted  a  few  days,  gradually  fad- 
ing away.  There  was  no  obvious  difference  of  sensibility 
between  the  two  sides  of  the  face,  though  during  the 
presence  of  the  pain  the  right  side  sweated  quite  profusely, 
especially  about  the  nose.  No  other  signs  of  hysteria  were 
present. 

I  have  seen  this  same  slight  general  hemianaesthesia 
in  another  case  of  facial  neuralgia  occurring  in  an  ap- 
parently non-hysterical  young  woman,  and  in  the  cases 
of  two  men  suffering  from  amputation  neuralgia.  Only 
by  courtesy  could  these  cases  be  called  hysterical. 

Since  I  began  to  look  for  them,  I  have  seen  several 
cases  analogous  to  these  which  would  ordinarily  be  called 
neurasthenic. 

One  case  of  this  sort  was  that  of  a  Jewish  lady  of 
middle  life,  seen  in  consultation  a  month  ago.  Although 
she  looked  in  blooming  condition  and  gave  a  history  of 
past  good  health  and  gay  spirits,  yet,  as  a  result  of  a 
series  of  slight  domestic  troubles,  she  complained  of  a 
variety  of  annoying  symptoms,  evidently  based  in  part  on 
hysteroid  instability.  Only  by  close  questioning  did  she 
admit  a  slight  motor  difference  between  the  arms,  but 
on  careful  examination  exactly  the  same  conditions 
were  found  that  characterize  the  light  cases  of  traumatic 


POST-  TRA  UMA  TIC  PS  Y GNOSES,  777 

hysteria,  a  trifling  but  well  marked  difference  in  surface 
temperature  and  slight  degrees  of  anaesthesia  and  anal- 
gesia, which  I  took  great  care  not  to  produce  by  "sug- 
gestion," and  which  had  obviously  been  imnoticed  by  the 
patient. 

Sanger  has  shown,  by  his  valuable  study  into  the  cu- 
taneous sensibility  of  German  workmen  of  the  class  that 
apply  with  especial  frequency  for  pensions  after  injury, 
that  such  sensory  disorders  are  not  uncommon,  due  usually 
to  alcohol,  syphilis,  previous  injuries  and  similar  causes. 

Whatever  opinion  we  may  hold  as  to  the  relation  be- 
tween actual  lesions  of  the  central  nervous  system  and 
the  post-traumatic  neuroses  and  psychoses,  there  can  be 
no  question  but  that  accidents,  even  of  moderate  severity, 
such,  for  example,  as  often  usher  in  the  psychoses  of  hys- 
terical type,  are  capable  also  of  causing  these  actual  lesions, 
presumably,  as  a  rule,  minute  hemorrhages,  but  also 
vascular  disorders  and  subtle  nutritive  changes.  A  good 
many  such  cases  are  on  record,  and  I  have  myself  seen  a 
number,  of  which  the  following  may  serve  as  examples: 

A  lady,  38  years  old,  was  riding  in  a  buggy  which 
was  run  into  by  a  grocery  wagon.  The  wheels  of  the  two 
teams  locked  and  the  jar  threw  her  out,  although  the 
buggy  was  not  tipped  over.  She  struck  the  ground  with 
the  left  side  of  her  face  and  head,  but  was  not  stunned,  or 
only  for  a  moment  at  most.  On  trying  to  rise,  her  arms 
and  legs  felt  "numb"  and  powerless,  and  she  could  not 
stand  alone  or  raise  her  hand  to  her  head.  The  next 
morning  the  feet  and  legs  seemed  to  be  much  better,  but 
the  hands  were  very  painful,  numb  and  prickly,  and  con- 
tinued in  this  wav  for  two  weeks.  She  was  not  able  to 
walk  well  for  the  first  month  after  the  accident,  but  the 
numb,  prickling  sensation  left  the  feet  in  the  course  of 
the  night  following  the  accident.  The  micturition  was  all 
right  from  the  beginning.  Tlie  only  indication  of  a  girdle 
sensation  was  that  on  taking  a  long  breath  there  was  a 
sort  of  catch  in  the  left  side.     She  was  unable  to  feed 


778  JAMES  J.   PUTNAM, 

herself  for  some  weeks,  and  during  the  period  that  the 
hands  were  painful  the  flexor  muscles  of  the  fingers  were 
the  seat  of  cramps.  The  neck  muscles  were  also  slightly 
stiff.  She  was  then  able  to  walk  pretty  well  and  to  use 
her  hands,  although  slowly  and  awkwardly.  All  the  ten- 
don reflexes  were  exaggerated,  and  there  was  some  in- 
coordination of  all  four  extremities,  both  static  and  mo- 
tive, and  a  high  degree  of  impairment  of  sensibility  in  the  ' 
fingers. 

No  "hysterical"  nervous  symptoms  were  present  at 
any  time,  and  I  take  the  case  to  be  undoubtedly  one  of 
hemorrhage  into  the  cervical  enlargement  of  the  spinal 
cord,  induced  without  fracture  of  the  vertebral  column. 
I  could  cite  three  or  four  other  cases  of  a  closely  similar 
sort,  but  pass  to  two  where  acute  myelitis  came  on  after 
injury. 

One  of  these  was  that  of  a  stalwart  young  man,  who 
dove  from  a  moderate  height  and  became  completely 
paralyzed,  from  the  arms  down,  immediately  after  striking 
the  water,  though  he  did  not  strike  his  head  upon  the 
bottom    so  far  as  could  be  ascertained. 

Neither  of  these  cases  was  complicated  by  lawsuits. 

The  next  case  is  that  of  a  man  of  fifty-seven,  who  was 
thrown  out  of  his  buggy,  in  an  electric  car  collision  in  a 
city  street,  so  that  he  fell  with  some  violence  on  to  the 
sidewalk,  and  struck  also  upon  the  brick  wall  of  an  ad- 
joining building.  His  knees  were  badly  bruised,  and  for 
the  first  few  days  his  legs  felt  numb  and  helpless.  He 
then  recovered  his  power  of  locomotion,  but  the  **numb- 
ness'*  still  remained,  being  especially  severe  along  the 
under  side  of  thethighs  of  both  legs,  the  right  being 
somewhat  more  affected  than  the  left. 

For  two  months  after  this  he  went  about,  but  had  con- 
siderable difficulty  in  getting  up  the  stairs,  and  suffered 
continually  from  a  soreness  along  the  under  surface  of 
the  thighs,  so  that  the  pressure  of  an  edge  of  a  chair 
caused  him  great  discomfort.     His  feet  felt  as  if  resting 


POST-TRAUMATIC  PSYCHOSES,  779 

against  a  hot  steam  pipe.  A  week  before  I  saw  him,  which 
was  about  three  months  after  the  accident,  he  had  been 
attacked  with  a  severe  pain  in  the  back,  and  this  was 
followed  by  rapidly  progressing  paralysis  of  the  legs  and 
of  the  bladder,  the  loss  of  power  becoming  complete  at 
the  end  of  three  days. 

There  was  absolute  immobility  of  both  legs,  including 
the  motions  at  the  hip  joints,  except  that  the  motions 
of  the  left  foot  and  toes  were  almost  perfectly  free.  The 
knee-jerks  were  present,  but  not  exaggerated;  but  the 
attempt  to  provoke  them  excited  general  twitching  oi 
the  whole  body.  The  sense  of  touch  was  slightly  dimin- 
ished, more  so  on  the  right  side  than  on  the  left.  A  slight 
motion  of  the  finger  on  the  skin  was  felt  at  once  and  well 
localized.  In  proceeding  up  the  leg  I  found  that  as  soon  as 
the  knee  was  passed  both  contact  and  pressure  were 
painfully  felt.  This  hyperaesthesia  was  much  greater  on 
the  inner  side  of  the  thigh  than  elsewhere,  but  was  pro- 
voked by  deep  .pressure  all  the  way  down  to  the  foot. 
There  was  diminished  sensibility  to  pricking,  except  where 

hyperaesthesia  was  present.  The  nutrition  of  the  muscles 
at  my  first  examination  was  normal.    From  this  time  the 

patient  continued  to  grow  worse,  and  the  case  developed 
rapidly  into  one  of  complete  dorsal  myelitis.  After  an 
illness  of  one  year  without  improvement,  he  died,  and  I 
made  a  post-mortem  examination.  This  showed  exten- 
sive disorganization  of  the  spinal  cord,  which  was  most 
severe  at  the  level  of  the  ninth  dorsal  nerve  root,  where 
the  whole  section  presented  a  brownish  yellow  tint.  The 
membranes  were  somewhat  adherent,  and  covered  with 
exudation,  even  as  high  as  the  cervical  enlargement. 
The  posterior  and  median  columns  showed  evidences  of 
secondary  degeneration  as  high  as  in  the  cervical  region, 
and  some  degeneration  of  the  lateral  column  was  seen  at 
the  fourth  dorsal  root  and  from  there  downward. 

My  object  in  reporting  these  cases  is  not  so  much  that 
of  adding  to  the  clinical  literature,  as  to  show  that  in  of- 


78o  JAMES  /.   PUTNAM, 

fering  the  opinion,  which  I  hold  to  be  correct,  that  such 
lesions  play  only  a  relatively  small  part  in  causing  the 
typical  symptoms  of  the  post-traumatic  psychoses,  I  am 
not  actuated  by  any  disbelief  in  the  power  of  moderate 
jars  and  blows  to  produce  actual  lesions  as  one  of  their 
results.  Both  the  American  and  German  periodicals  of 
the  past  two  years  contain  the  records  of  carefully  studied 
cases,  showing  the  variety  of  the  lesions  producible  by  in- 
jury to  be  greater  than  would  have  been  supposed.  The 
list  embraces  not  only  hemorrhages  and  necroses,  but  dif- 
fuse alteration  of  blood  vessels  with  the  symptom-complex 
of  progressive  paralytic  dementia — perhaps  of  vasomotor 
origin — and  also  lesions  analogous  to  those  of  poliomye- 
litis. Injury  may  also  give  a  strong  impulse  to  the  de- 
velopment of  syringomyelia,  and,  perhaps,  to  that  of  all 
the  degenerative  affections.  Can  such  lesions,  however, 
be  legitimately  considered  as  a  true  cause  of  the  psychoses 
and  neuroses? 

In  the  light  of  our  present  knowledge  I  think  we  may 

« 

say  that  the  only  way  in  which  this  could  happen  would 
be  through  an  inhibiting  and  deranging  influence  which 
the  lesions  might  exert  as  centres  of  irritation.  If  it  is 
true  that  profound  derangement  of  nerve  function  may 
be  excited  in  this  way,  then,  in  the  course  of  the  re- 
establishment  of  equilibrium,  hysteroid  psychoses  and  neu- 
roses might  readily  emerge,  just  as  in  the  case  of  the  post- 
traumatic affections  of  emotional  origin.  It  is  indeed 
probable  that  irritations  which  cause  pain,  as,  for  example, 
strains  of  the  back,  which  make  every  motion,  even  of  the 
arms,  an  event  to  be  dreaded  and  avoided,  do  act  in  this 
way,  and  that,  as  a  result  of  the  pain,  the  nerve  functions 
of  sensitive  patients  may  suffer  a  widespread  disturbance 
and  inhibition,  both  locally  and  in  a  general  sense.  It  is 
also  theoretically  possible  that  the  same  sort  of  inhibition 
should  occur  without  the  intervention  of  conscious  pain 
or  of  any  consciousness  at  all,  and  this  view  is  strengthened 
bv  what  we  know  of  the  relation  of  the  subconscious  to 


POST-TRAUMATIC  PSYCHOSES.  78 1 

the  conscious  processes,  as  underlying,  for  example,  the 
outbreaks  of  hysterical  convulsion.  It  is  also  true  that 
hysteroid  or  neurasthenic  groups  of  symptoms  may  be 
practically  the  sole  manifestation  of  serious  gross  lesions, 
such  as  tumors  of  the  brain,  or  may  accompany  such  dis- 
eases as  syphilis  or  the  spinal  scleroses. 

Again,  it  is  reasonable  to  suppose  that  the  action  of 
disorders  of  general  nutrition,  such  as  those  which  attend 
and  follow  infectious  diseases,  and  which  are  well  known 
to  cause  or  accentuate  the  psychoses  and  neuroses,  find 
their  analogue,  in  some  measure,  in  the  disorders  of  nutri- 
tion, due  in  part  to  actual  lesions  of  the  nervous  system. 
This  must  at  least  be  true  in  so  far  as  such  lesions  inter- 
fere with  circulation  and  digestion,  and  that  which  is  true 
of  these  functions  must  be  true  of  others  which  stand  on 
the  same  plane. 

These  considerations  make  it  appear  probable  that,  to 
a  high  degree  in  exceptional  cases  and  to  a  slight  degree 
in  many  cases,  actual  lesions,  even  if  minute  and  diffuse, 
do  contribute  to  the  occurrence  of  the  post-traumatic 
neuro-psychoses.  But,  after  all  is  said,  it  must,  I  think, 
be  admitted  that  for  the  majority  of  accident  cases  this 
action  makes  itself  but  little  felt,  and  is  wholly  subor- 
dinate to  other  etiological  factors.  Gross  lesions,  small  or 
great,  and  whatever  be  their  nature,  usually  fail  to  cause 
these  hysteroid  symptoms,  and,  in  the  great  mass  of  cases 
— traumatic  and  non-traumatic — where  such  symptoms 
do  occur,  the  main  causes  are  psychical  influences  of  one 
or  another  sort,  acting  on  a  nervous  system  which  is,  if  the 
term  be  correctly  understood,  predisposed  to  such  affec- 
tions. 

To  be  sure,  cases  are  sometimes  met  with  where  the 
differential  diagnosis  as  to  the  presence  or  absence  of 
actual  lesions  is  difficult  or  impossible,  but  with  an  op- 
portunity to  watch  the  patient  we  can  at  least  soon  tell 
whether,  lesions  or  no  lesions,  the  case  is  to  have  the  rela- 
tively favorable  issue  that  characterizes  the  traumatic  hys- 


782  JAMES  J.   PUTNAM, 

terias,  or  the  relatively  unfavorable  issue  that  characterizes 
the  progressive  degenerative  processes.  Even  when  the 
latter  result  occurs,  however,  we  cannot  be  sure  that  actual 
lesions  were  the  cause.  A  case  with  regard  to  which  this 
doubt  as  to  the  existence  of  actual  lesions  arose  is  the 
following,  which  was,  fortunately,  not  of  medico-legal  in- 
terest: A  roofer,  of  good  previous  health,  fell  from  the 
top  of  a  building  to  the  ground,  40  feet  below.  He  was 
dazed,  but  not  wholly  unconscious.  For  three  weeks  he 
stayed  in  bed,  suffering  mainly  from  pain  and  soreness  in 
the  back  and  head.  He  then  went  back  to  work,  but  felt 
poorly,  and  had  to  give  it  up  for  a  time  every  week  or  two. 
A  few  months  later  he  had  to  give  up  entirely,  the  sense 
of  soreness  having  spread  all  over  the  body. 

I  saw  him  first,  at  my  office,  two  years  after  the  acci- 
dent, and  found  him  weak,  emotional  and  demoralized. 

What  especially  attracted  my  attention,  as  possibly  of 
spinal  origin  and  due  to  actual  lesions,  were  a  prickling 
of  the  hands,  which  came  on  whenever  they  were  placed 
in  a  constrained  position,  and  at  times  spontaneously,  and 
a  gait  slow  and  stiff,  with  scuffling  of  the  feet  at  times  on 
the  ground. 

Five  years  after  the  accident  I  received  the  following 
note: 

"Dear  Sir:  In  answer  to  your  inquiry  as  to  the  state  of  my 
health,  I  will  say  that  I  feel  very  well,  thank  you. 

"While  I  experience  some  of  the  symptoms  of  which  I  com- 
plained to  you,  especially  at  this  time  of  the  year,  I  am  able  to  work 
at  the  roofing  business.  When  springtime  comes  I  feel  like  going  to 
some  place  in  the  country  and  taking  a  rest. 

"I  attribute  my  improvement  to  regular  living  chiefly.  It  was 
since  your  treatment,  and  particularly  your  advice,  namely,  not  to 
scrutinize  myself  so  closely,  and  to  make  a  firm  endeavor  to  do  a  little 
work  every  day,  that  my  greatest  improvement  is  noticeable.*' 

It  should  not  be  forgotten  that  the  capacity  of  hysteria 
to  produce    symptom    groups    which    would  have  been' 
thought  to  occur  only  on  the  basis  of  gross  organic  change 
is  being  continually  rated  as  higher  and  higher. 

We  have  the  "hysterical  intention  tremor"  and  the 
"hysterical    paralysis    agitans,"    and,    according    to    Dr. 


POS  T'  TRA  UMA  TIC  PS  Y GNOSES.  783 

Prince's  opinion,  with  which  I  fully  sympathize,  there  is  a 
hysterical  form  of  neurasthenia. 

Nonne  has  described  a  "pseudo-spastic  paraplegia," 
with  exaggerated  tendon  reflexes  and  ankle  clonus,  and 
Schuster  has  recently  given  his  opinion  that  the  kindred 
group  of  symptoms,  associated  with  extreme  rigidity  of 
the  back  muscles,  referred  by  Kiimmel  to  disease  of  the 
vertebrae  due  to  injury  (a  condition  which  certainly  may 
occur)  may  be  a  form  of  hysteria. 

I  have  recently  seen  a  case  of  this  sort,  where  the 
trotting  of  one  or  the  other  of  the  knees  was  so  severe  as 
to  positively  shake  the  floor  of  the  room.  The  stiffness 
of  the  erector  spinae  was  so  great  in  this  case  that  the  pa- 
tient rose  from  his  chair  with  great  difficulty.  Neverthe- 
less, although  this  rigidity  of  the  back  muscles  was  so 
great,  and  the  pain  on  forced  movements  so  severe,  lead- 
ing one  to  believe  that  a  serious  strain  must  have  been  re- 
ceived, the  patient  asserted  that  his  back  had  not  troubled 
him  much  until  after  ten  or  twelve  hours  from  the  time  of 
the  injury,  and  the  consideration  of  the  case  as  a  whole 
made  the  diagnosis  of  hysteria,  or  one  of  the  many  and 
varying  affections  which  we  cover  by  that  name,  highly 
probable,  as  covering  the  major  part  of  the  symptoms,  at 
least. 

But  if  it  can  be  shown,  even  as  a  matter  of  presump- 
tion, that  actual  nerve  lesions  are  rarely  to  be  counted  as 
direct  causes  of  traumatic  hysteria,  let  me  not  be  under- 
stood as  denying  the  indirect  influence  of  physical  violence, 
even  in  those  apparently  insignificant  forms  to  which  only 
in  the  technical  dictionary  of  the  law  the  name  of  violence 
could  be  accorded. 

This  question  has  become  one  of  especial  practical 
significance  in  Massachusetts  since  the  recent  decision  of 
the  Supreme  Court,  reaffirming  a  principle,  which,  though 
at  first  sight  unjust  and  out  of  keeping  with  scientific  doc- 
trine, yet  is  doubtless  based  on  practical  wisdom;  namely. 


784  JAMES  /.   PUTNAM. 

that  one  cannot  recover  damages  for  illness  due  to  pure 
fright,  unattended  by  personal  violence. 

If,  however,  a  personal  violence,  no  matter  how  slight, 
can  be  proved,  even  one  which  does  not  go  beyond  the 
degree  of  personal  contact,  then  it  is  possible  for  the  claim- 
ant to  recover,  not  only  for  the  effects  of  the  violence  or 
contact,  but  also  for  those  of  the  concomitant  emotion  or 
other  factors,  provided,  of  course,  it  can  be  shown  that 
the  contact  was  a  real  cause  of  at  least  a  part  of  the  sub- 
sequent symptoms.  In  this  state  of  affairs  it  is  obviously 
important  for  experts  to  form  their  opinion  as  to  how 
far  trifling  injuries,  received  under  such  circumstances  as 
those  assumed,  may  be  real  causes  of  subsequent  symp- 
toms. 

The  bodily  injuries  which  tend  to  cause  or  increase 
emotion,  in  case  of  accident,  are  rather  those  of  moderate 
severity  than  those  which  are  surgically  very  serious.  It 
sometimes  happens,  no  doubt,  that  patients  who  have 
met  with  serious  injuries  are  subsequently  overcome  by 
strong  emotion,  on  looking  back  at  the  circumstances 
under  which  they  were  received,  but  serious  surgical  in- 
juries in  general,  such,  for  example,  as  cause  acute  surgical 
shock,  are  not  likely  to  increase  the  emotional  tendencies 
of  an  accident.  The  case  is  different  for  moderate  in- 
juries, such  as  sudden  jars  or  blows,  and  obviously  for  the 
reason  that  they  disconcert  the  patient's  will,  impair  his 
sense  of  confidence,  diminish  his  power  of  self-control,  and 
increase  the  apprehension  of  more  harm  to  come,  while 
they  are  not  severe  enough  to  induce  the  anaesthesia  and 
indifference  wdiich  attend  prostrating  wounds,  fractures 
and  dislocations. 

These,  then,  are  the  conditions  which  make  slight 
bodily  injuries  productive  of  harm,  that  they  are  received 
under  such  circumstances  as  render  them  capable  of  dis- 
concerting the  reason  and  the  will,  and  creating  an  ap- 
prehension of  greater  harm  to  come. 

The  decision  above  alluded  to  was  given  in  connection 


POST-TRAUMATIC  PSYCHOSES.  785 

with  a  case  where  a  woman  had  claimed  damages  for  ner- 
vous shock  which  was  received  while  a  drunken  passenger 
was  being  put  off  an  electric  car  and  lurched  slightly  upon 
her  during  the  process.  The  case  was  retried  after  this 
decision,  and  damages  were  awarded  and  allowed. 

There  is  a  subtle  influence  in  a  physical  contact  under 
certain  circumstances  that  raises  it  to  a  high  rank  among 
the  causes  of  nervous  shock.  It  is  easy  enough  to  tell  a 
rattlesnake  from  a  carrot  if  it's  by  daylight  and  you're  not 
in  a  hurry,  but  one  would  like  to  recover  damages  from 
the  man  who  for  joke's  sake  obliged  one  to  make  the 

diagnosis  all  of  a  sudden,  in  the  darkness  of  the  nighty 
when  he  had  just  waked  up  from  sleep,  in  a  pitched  tent 
on  the  banks  of  a  Southern  river.  Of  course,  a  trifling  jar 
or  a  personal  contact,  even  if  experienced  in  connection 
with  a  railway  accident,  may  remain  a  trifling  matter;  but 
this  is  not  always  the  case. 

In  the  instances  just  referred  to  the  physical  violence 
in  itself  was  merely  nominal.  There  are,  however,  other 
cases  where,  although  slight,  it  has  a  definite  effect  of  its 
own,  though  one  which  it  is  difficult  to  classify  in  terms  of 
actual  lesions  of  the  nervous  svstem.  Instances  of  this 
sort  are  the  jars  and  concussions  received  during  railway 
accidents,  where  something  occurs  which  is  more  or  less 
analogous  to  what  we  class  as  concussion  of  the  brain. 
Even  here  it  is  probable  that  in  fact  we  have  to  do  with 
a  mainly  psychical  injury.  To  take  a  homelv  example,  let 
one  imagine  himself  given  a  violent  shake  by  the  collar 
while  crossing  a  crowded  street,  where  it  was  necessary 
to  be  on  the  lookout  for  rapidly  moving  teams.  Such  a 
shake,  even  if  administered  on  the  sidewalk,  would  have 
been  disconcerting,  but  under  the  actual  circumstances 
the  effect  might  have  been  actuallv  paralyzing. 

Mental  influences  attending  accidents,  which  tend  to  de- 
range the  normal  equilibrium  of  the  nervous  system.  These 
may  be  divided  into  (t)  the  predisposing,  and  (2)  the  ex- 
citing influences. 


786  JAMES  /.    PUTNAM. 

I.  What  is  it  that  constitutes  predisposition  to  the 
traumatic  psychoses,  and  why  is  it  that  of  two  people 
fitting  on  the  same  car  seat  one  is  severely  affected  and 
the  other  not  at  all? 

In  some  degree  it  is  doubtless  a  constitutional  neuro- 
pathic tendency,  of  hereditary  origin,  that  causes  this  sus- 
ceptibility, and  many  of  the  patients  who  become  chronic 
hysterics  and  neurasthenics  are  obviously  only  working 
out  their  **manifest  destiny."  It  is,  however,  distinctly 
my  experience,  and  the  same  observation  was,  I  believe, 
made  long  ago  by  Oppenheim,  and  more  recently  by 
Sanger,  that  in  the  great  majority  of  the  cases,  including 
those  where  apparently  trivial  accidents  have  been  fol- 
lowed by  very  serious  results,  no  neuropathic  tendency,  in 
the  usual  sense  of  the  term,  can  be  detected.  This  is  indi- 
cated by  the  analysis  of  my  cases  given  at  the  beginning 
of  the  paper.  In  this  estimation  the  diagnosis  of  **neuro- 
pathic''  was  admitted  quite  liberally,  although  the  data 
were  incomplete. 

The  best  way  to  approach  this  problem  of  predispo- 
sition may,  perhaps,  be  to  consider  what  sorts  of  persons 
are  relatively  exempt  from  the  severer  forms  of  the  post- 
traumatic hysteria  and  typical  neuroses. 

I  choose  out  hysteria  and  acute  forms  of  the  typical 
neuroses  because  the  arguments  which  I  shall  adduce  do 
not  apply  equally  well  to  some  of  the  other  post-traumatic 
affections.  There  are,  for  example,  many  persons  of  the 
relatively  exempted  classes  who  suffer  from  neurasthenic 
troubles,  or  from  ill  health  in  one  or  another  form,  which 
is  often  attributable  to  a  combination  of  causes,  of  which 
an  accident  is  one.  Sometimes,  indeed,  the  accident  may 
have  been  the  essential  cause  of  the  subsequent  symptoms, 
but  the  fact  that  the  patient  struggled  against  the  gradu- 
ally rising  illness  with  resolution  and  temporary  success 
postponed  the  result,  and  made  it  impossible  to  assert 
positively  that  it  arose  from  this  cause  alone.  In  most  of 
these  cases,  however,  occurring  among  the  usually  ex- 


POST-TRAUMATIC  PSYCHOSES.  787 

€mpted  classes,  the  resulting  symptom-complex  is  not 
that  of  typical  acute  hysteria  or  of  mental  affections  bear- 
ing the  hysteric  stamp,  but  rather  of  neurasthenia  or  "as- 
sociation neuroses,"  or  one  of  the  types  described  so  well 
by  Prince  in  the  Boston  Medical  and  Surgical  Journal, 
June,  1898. 

Foremost  among  the  exempted  classes,  in  the  sense 
thus  defined,  are  those  who  meet  with  accidents  in  the 
way  of  sport,  or  of  business  of  which  accidents  of  a  certain 
sort  form  a  legitimate  outcome,  or  of  war.  There  are 
various  good  reasons  why  this  should  be  the  case.  One 
is  that  the  emotions  which  accompany  such  accidents  are 
usually  not  of  the  depressive  sort.  These  mischances  are 
not  associated,  as  a  rule,  with  any  sense  of  personal  griev- 
ance, and  do  not  fall  with  the  heavy  weight  or  startling 
terror  of  a  misfortune  wholly  \inexpected  or  unprepared 
for.  The  football  player,  or  the  artisan,  discounts  his 
injuries  in  advance.  He  knows  that  by  watchful  care  he 
may  prevent  them,  and  that  if  he  receives  them  he  does  but 
pay  the  price  for  his  pleasure  or  profit;  that  he  has  no 
grudge  to  bear,  no  lazvsuit  to  bring.  Such  injuries  are. 
moreover,  not  associated  in  his  mind  with  any  exaggerated 
feeling  of  terror,  of  "social"  origin.  He  has  not  grown  up 
in  an  atmosphere  of  sentiment,  shadowy  and  unnamed  in- 
deed, but  intensified  by  hundredfold  reflection,  that  such 
mischances  are  events  to  be  deeply  dreaded.  He  looks  for- 
ward to  recovery  and  more  play  or  more  work.  Finally, 
the  members  of  some  of  these  exempted  classes  are  young 
and  spirited  men.  Yet  it  must  be  admitted,  in  view  of  the 
severity  of  some  of  the  injuries  which  they  receive,  that  if 
nerve  lesions  of  small  amount  led  often,  of  themselves,  to 
hysteria,  we  should  hear  more  of  such  results  than  we  do 
hear. 

Another  relatively  exempted  class  is  certainly  that  of 
the  men  and  women  with  highly  trained  self-control  and 
cultivated  intelligences.  Whether  from  familiarity  with 
the  risks  of  travel  or  from  the  possession  of  a  character 


788  JAMES  /.   PUTNAM, 

trained  to  accept  philosophically  the  mischances  of  the 
world,  or  from  habits  of  self-discipline  inculcated  by  social 
training,  they  are  little  likely  to  let  their  reason  and  their 
will  remain  long  dethroned. 

Persons  of  this  stamp  are  more  likely  to  be  found 
among  the  professional,  the  leisured  and  the  higher  busi- 
ness classes  than  among  wage-earners  and  people  of  con- 
fined lives  and  small  incomes.  I  do  not,  of  course,  maintain 
that  this  rule  is  an  absolute  one,  or  that  fine  and  strong 
character  is  not  as  common  among  the  poor  as  among  the 
rich.  Neither  can  I  undertake  to  bring  any  great  amount 
of  statistical  evidence  in  support  of  the  opinion  which  I 
advance,  since  cases  vary  so  widely  that  the  numbers  of 
any  one  sort,  the  severe  hysterias  for  example,  available 
for  comparison  as  regards  the  social  status  or  tempera- 
mental and  intellectual  training  of  the  patients,  are  too 
small  to  be  convincing. 

I  believe,  however,  that  every  physician  of  large  ex- 
perience, not  to  say  every  observant  layman,  must  have 
gained  the  strong  impression  that,  on  the  one  hand,  the 
ability  to  withstand  the  demoralizing  effects  of  accidents 
and  injuries  is  an  indication  of  a  good  nervous  system,  and, 
on  the  other  hand,  that  the  sort  of  vigor  thus  implied  is 
not  incompatible  with  an  excitable,  even  highly  neuro- 
pathic, temperament,  provided  the  social  training  has 
been  of  the  appropriate  sort. 

The  man  who  lives  by  his  wits,  the  philosopher,  the  ad- 
venturer, the  person  who  can  look  on  an  accident  as  a 
joke  or  a  new  excitement,  or  as  a  means  of  extending  his 
experience;  even  the  correct  society  man,  whose  rules  of 
caste  do  not  sanction  a  confession  of  weakness,  and  whom 
poverty  is  not  staring  in  the  face,  are  likely  to  pass  un- 
scathed through  a  railroad  disaster  which  might  seem  an 
irreparable  disaster  to  many  a  robust,  hard  working  man 
of  narrow  experience  and  slender  reading,  spending  to  the 
limit  of  his  earnings,  and  figuring,  to  be  sure,  on  a  life 


POST'  TRA  UMA  TIC  PS  YCHOSES,  789 

of  labor,  but  one  free  from  cataclasms  of  such  sorts  as 
these. 

If  the  people  of  the  wider  training  do  fall  victims,  I 
think,  as  I  have  said,  that  it  is  toward  neurasthenic  states 
rather  than  toward  hysteria,  that  their  symptoms  tend. 

I  cannot  trace  out  in  proper  order  all  the  mental  char* 

acteristics  that  impart  such  powers  of  resistance  as  I  have 

I  in  mind,  or,  on  the  other  hand,  all  those  which  tend  in  the 

direction  of  diminished  resistance.  But  I  feel  convinced 
that  one  good  criterion  is  the  degree  of  liability  to  be 
carried  away  by  the  contagion  of  "mob-madness,"  which 
has  been  studied  so  much  of  late.  And  here  I  feel  sure 
that  "Cultur-Menschen,"  be  they  never  so  neuropathic, 
have  a  distinct  advantage.  Of  some  of  them  it  may  be  said 
that  society  has  trained  them  into  an  army,  giving  them 
the  power  to  resist  panic  that  belongs  to  the  disciplined 
soldier;  of  others  that,  in  full  knowledge  of  social  laws 
and  traditions  they  have  chosen  to  disregard  them,  and 
so  have  gained  in  personal  independence.  Obvious  illus- 
trations of  mob-contagion  are  sometimes  seen  in  connec- 
tion with  accidents,  and,  as  a  matter  of  fact,  a  phenomenon 
of  similar  sort  is  verv  common.  For  everv  member  of  so- 
ciety  is  to  a  greater  or  less  degree  under  the  influence  of 
the  ^'social''  opinion  that  an  "accident**,  and  perhaps  es- 
pecially a  "railroad  accident"  or  an  "electrical  accident" 
is  an  event  to  be  greatly  feared,  and  the  ready  yielding 
to  this  opinion  is  equivalent  to  a  ready  yielding  to  mob- 
influence. 

It  may  appear  incorrect  to  say  that  the  poorer  mem- 
bers of  society  are  relatively  unfamiliar  with  accidents,  and, 
therefore,  suffer  from  them  unduly,  since  in  many  cases 
the  very  nature  of  their  occupation  exposes  them  to  injury. 
But  it  is  my  belief  that  the  chains  of  mental  association 
are  very  closely  drawn,  and  distinctions  are  felt  at  once 
by  the  instincts  which  the  reason  is  often  slow  to  define. 
The  accidents  which  come  to  a  man  in  the  way  of  his  busi- 
ness affect  him  as  the  injuries  received  in  war  affect  the 


79q  JAMES  /.   PUTNAM. 

soldier.  In  both  cases  a  certain  nervousness  and  timidity 
are  apt  to  be  induced  for  a  time,  but,  as  a  rule,  the  power 
of  resistance  as  regards  that  special  form  of  danger  im- 
pr6ves  a^  time  goes  on,  while  it  takes  a  training  of  a  more 
real  character  to  make  a  person  -  indifferent  to  danger? 
which  have  hitherto  been  unknown  quantities. 

.   I  have  tried,  in  these  remarks  on  character  and  train- 
ing as  related  to  predisposition,  to  keep  in  mind  the  in- 
fluences which  could  be  exerted  in  cases  not  complicated 
by  lawsuits,  but  one  object  was,  of  course,  to  point  out 
that  because  we  find,  as  we  do,  a  larger  number  of  severe 
hysterias  among  law-court  cases  than  elsewhere,  we  should 
not  jump  at  once  to  the  conclusion  that  desire  for  gain 
is'  the  main  cause  of  this  difference.    It  is  a  partial  cause, 
no  doubt,  and  it  is  possible  to  conceive  of  circumstances 
under  which  "football  hysteria"  should  become  more  com- 
mon than  it  now  is,  but  it  is  also  certain  that  the  majority 
of  the  claimants  for  personal  damages  on  account  of  per- 
sonal injuries  belong  to  a  class  of  persons  who  are  relative- 
ly predisposed  to  hysteria  from  injury,  in  the  sense  that  I 
have  mentioned,  while,  at  the  same  time,  their  lack  of 
fixed  income,  intensified  by  the  '^social*'  traditions  which 
their  dread  of  poverty  has  helped  to  engender,  constitutes 
ample  reason  why  they  should  feel  obliged  to  go  to  law. 
It  is  easy,  in  view  of  these  facts,  to  see  why  we  find  our 
traumatic  hysterias  in  court,  and  why  we  do  not  find  them 
in  greater  numbers  in  private  practice,  or  even  in  hospital 
practice.    I  say  "in  greater  numbers,'*  because,  of  course, 
highly  interesting  cases,  free  from  legal  complications,  are 
to  be  seen  occasionally  both  in  private  and  in  hospital  prac- 
tice.   The  hospital  list  is  the  longer  of  the  two,  and  there 
can  be  no  question  but  that  it  would  be  longer  still  were  it 
not  that  a  stern  fate  supplies  the  vigorous  tonic  of  forced 
work  to  the  few  of  the  hospital  out-patient  class  who  can 
find  no  one  to  go  to  law  against,  and  that  with  this  im- 
pulse they  get  relatively  well,  within  reasonable  periods 
of  time. 


POS  r-  TRA  UMA  TIC  PS  YC HOSES. 


791 


It  is  a  matter  of  practical  importance,  and  at  the  same 
time  a  fact  in  confirmation  of  the  importance  of  '^social" 
causes,  that  not  only  does  severe  hysteria  occur  oftener 
among  the  classes  of  persons  to  whom  I  have  alluded,  but 
it  is  correspondingly  slow  to  pass  away,  lasting  often  many 
years  after  a  verdict  has  been  rendered,  in  the  ''legal'' 
cases. 

In  this  connection  the  extreme  hopelessness  which 
characterizes  one  race  of  people,  which  have  lately  become 
very  numerous  among  us,  namely,  the  Russian  Jews,  is 
worthy  of  notice.  Many  of  these  patients  cannot  be 
reached  by  ordinary  therapeutic  means  because  they  arc 
I  impervious  to  encouragement.    Their  minds  seem  closed 

to  appeals  to  hopefulness,  and  a  preliminary  training  has 
I  to  be  used  before  much  advance  can  be  made. 

I  have  expressed  my  belief  that  the  legal  complications, 
in  these  cases,  intensify  the  illness  and  retard  the  recovery, 
but  the  question  arises,  Can  we  estimate  the  amount  of  this 
influence,  and  how  soon  does  it  become  operative?  When  a 
person  begins  instantly,  or  within  a  few  moments  of  an  ac- 
cident, to  show  the  symptoms,  not  of  simple  nervousness 
and  demoralization  alone,  but  of  typical  hysteria,  is  it 
probable,  or  is  it  impossible,  that  the  ferment  of  a  desire 
for  legal  damages  has  begun  to  work? 

I  have  seen  a  number  of  cases  where  the  patients  began 
to  feel  the  familiar  one-sided  paraesthesia  or  tremor,  or  had 
nausea  or  vomiting,  or  hysterical  rigidity,  or  other  typical 
hysterical  symptoms,  from  the  moment  of  the  shock. 

Our  own  experience  and  the  literature  of  genuine,  non- 
legal  cases  of  the  fright  neuroses  vShow  that  this  is  just 
what  we  might  expect  to  occur,  and  there  seems  at  first 
sight  to  be  no  reason  why  we  should  adduce  the  new  mo- 
tive of  a  desire  for  gain  unless  from  a  gratuitous  determina- 
tion to  see  fraud  everywhere  where  it  might  by  any  pos- 
sibility exist.  I  think,  however,  it  must  be  admitted  that 
there  is  possibly  a  scientific  justification  for  assuming  sub- 
conscious ideas  of  certain  sorts,  of  which  the  thought  of 


792  JAMES  /.   PUTNAM, 

legal  complications  may  form  one,  even  from  the  first  mo- 
ment of  the  accident.  We  all  carry  with  us,  packed  away 
in  the  depths  of  our  minds,  great  numbers  of  prejudices 
and  emotions  of  more  or  less  fixed  form,  ready  to  spring 
out,  as  tigers  spring  on  their  prey  when  the  keeper  leaves 
the  cage  door  loose.  Many  of  these  emotions  are  of  *'so- 
cial"  origin,  and,  indeed,  in  the  course  of  our  '^social" 
training  we  all  come,  but  .some  individuals  and  classes  of 
individuals  much  more  than  others,  to  have  a  host  of 
strong  though  vague  feelings,  all  the  stronger  indeed  for 
being  vague,  that  arise  in  obedience  to  the  word  "acci- 
dent," which  we  whisper  to  ourselves  at  the  moment  of  a 
railroad  collision. 

It  is  not  even  necessary  that  we  should  whisper  the 
word  **accident"  or  *1awsuit,''  not  even  that  we  should 
definitely  frame  it  in  our  thoughts.  The  word  is  indeed 
the  focal  point  at  which  the  ideas  which  give  it  its  richness 
of  meaning  converge,  but  just  as  a  blurred,  and  yet  recog- 
nizable image  is  formed  before  the  rays  of  light  reach  the 
focal  point,  so  a  vague  conception  may  be  formed  before 
the  word  which  symbolizes  the  complete  conception  has 
defined  itself  even  in  thought.  There  are  few  persons 
who  would  not  find  the  emotions  connected  with  a  dis- 
aster strengthened  if  to  the  word  or  conception  "accident" 
were  added  the  word  or  conception  "lawsuit,''  and  1  can 
readily  believe  that  among  those  to  w^honi  I  have  alluded 
as  being  forced  to  go  to  law,  if  they  can,  whenever  they 
get  injured,  the  idea  of  a  "lawsuit"  and  the  vague  sense 
of  the  need  of  "making  out  a  good  case"  should  exist  sub- 
consciously as  a  **social"  conception  of  great  power. 

I  cannot  understand  how  in  any  more  definite  sense 
than  this  the  intention  of  bringing  a  lawsuit  can  frame 
itself  in  the  mind  at  so  early  a  period  or  within  the  first 
few  moments  after  an  accident  as  to  materially  intensify 
or  color  the  symptoms. 

For  completeness'  sake  I  should  next  consider  the 
toxic  predisposing  causes,  such  as  alcohol  and  syphilis. 


POST-TRA  UMA  TIC  PSYCHOSES,  793 

which  Sanger  has  studied  so  -fruitfully .  I  must,  however, 
omit  this  branch  of  the  subject  for  the  present,  only  paus- 
ing to  express  my  impression  that  neither  alcohol  nor 
syphillis  played  a  large  role  as  a  cause  of  illness  in  the  cases 
of  the  vast  majority  of  the  patients  whom  I  have  seen 
privately. 

The  next  group  of  influences  to  be  considered — 
bearing  in  mind  that  we  are  still  dealing  only  with  the 
agencies  which  tend  to  break  down  the  established  equi- 
librium of  the  nervous  functions,  and  to  leave  the  patient 
a  prey  to  the  forces  of  disease — are  those  which  attend 
and  follow  the  accident.  Of  the  first  division  of  these  in- 
fluences I  only  care  to  remark  that  they  cannot  all  be 
profitably  grouped  together  under  the  head  of  "emotional 
excitement/'  such  as  "fright/'  although  the  tendency  of 
late  has  been  to  do  this,  partly  in  the  interests  of  a  simpli- 
fied legal  presentation  of  the  case.  In  many  cases  fright  is 
obviously  present;  in  others,  it  seems  as  obviously  to  be 
absent.  It  might  be  permissible  to  assume,  for  some  of 
the  cases  of  the  latter  class,  that  the  physiological  element 
in  fright  was  operative,  while  the  conscious  element  was 
absent,  but  this  explanation  is  not  of  universal  application. 
Fright  is  certainly  not  the  only  mental  condition  which 
exerts  an  injurious  effect  at  such  times.  Reasonable 
anxiety,  the  exhaustion  from  physical  and  mental  effort, 
the  prostrating  effects  of  pain,  grief  for  fellow  sufferers, 
are  but  some  of  the  mental  influences  at  work  during  and 
immediately  after  the  accident,  while  others  become  of 
importance  a  little  later. 

The  consideration  of  the  second  division  of  the  influ- 
ences at  stake  brings  up  the  question,  To  what  extent  does 
the  case  receive  its  stamp  from  the  events  that  cluster 
round  the  accident  itself,  and  to  what  extent,  on  the  other 
hand,  may  the  symptoms  be  due  to  causes  acting  subse- 
quently? 

Probably  we  should  all  admit  that  the  later  influences 
are  sometimes  of  great  importance,  and  it  is  certain  that. 


794  JAMES  /.    PUTNAM. 

even  where  no  distinctly  new  ones  come  in,  a  disastrous 
amount  of  fright  may  arise  from  the  recurrence  in  thought 
of  events  and  dangers  of  the  accident,  which  is  lived  over 
in  imagination,  just  as  it  is  so  often  vaguely  lived  over 
in  dreams. 

Many  instances  are  on  record  where  a  veritable  panic 
has  occurred  in  this  way,  after  all  danger  has  passed.  I 
bring  up  the  point  now  only  for  the  sake  of  calling  atten- 
tion to  the  difficulty  of  differentiating  between  these  cases 
and  those  where  the  symptoms  were  initiated  at  the  time 
of  the  accident,  but  appeared  later  after  a  lapse  of  hours 
or  days.  This  latent  interval  received — I  believe  from 
Charcot — the  striking  name  of  '^interval  of  meditation," 
the  meditation  being,  of  course,  subconscious,  and  used 
as  indicating  that  a  struggle  was  in  progress  between  the 
old  order  and  the  new.  There  is  always  the  danger  at- 
tending the  use  of  a  picturesque  expression  like  this  that 
it  will  chain  the  imagination  too  closely,  and,  in  fact,  I  do 
not  feel  wholly  satisfied  with  Charcot's  term,  and  should 
prefer  an  explanation  which  let  it  be  seen  that  in  the  inter- 
val before  the  complete  establishment  of  the  new  set  of 
symptoms  the  old  order  of  things  held  on  by  a  sort  of  mo- 
mentum, which  is  only  gradually  overcome.  A  certain 
time  elapses  before  the  forces  which  normally  control  the 
working  of  the  nervous  system  find  out,  so  to  speak,  that 
they  have  lost  their  sway,  but  finally  they  yield  with  a 
rush. 

The  next  question  to  be  considered  is  with  regard  to 
the  agencies  (class  D)  which  determine  what  form  will 
be  taken  by  the  ''readjustment"  which  follows  the  derange- 
ment due  to  the  accident. 

A  number  of  interesting  principles  here  come  into 
play,  the  majority  of  which  may  be  classified  as  follows: 

I.  It  might  be  said  that  all  persons — but  some  far  more 
than  others — carry  with  them  latent  tendencies  to  one 
or  another  of  the  typical  psychoses  or  neuroses,  which 
represent,  as  it  were,  natural  planes  of  cleavage,  taking  the 


POST^TRAUMATIC  PSYCHOSES.  795 

form  of  disease.  These  specific  affections  stand  ready  to 
assert  themselves  in  times  of  impairment  of  the  normal 
innervation,  just  as  the  specific  bacterial  invasions  are 
made  possible  by  similar  causes. 

Thus  it  is  that  Graves'  disease,  or  chorea,  or  even  epi- 
lepsy, springs  suddenly  into  existence  after  the  shock  of 
accident  or  fright. 

This  explanation  would  apply  not  only  to  the  typical 
affections  bearing,  in  their  symptomatology,  no  close  re- 
lationship to  the  injury — Graves'  disease,  for  example —  but 
it  applies  more  than  one  might  think  to  the  typical  post- 
traumatic neurasthenias  and  hysterias.  Very  often,  to  be 
sure,  we  have  to  deal,  in  these  cases,  with  groups  of  symp- 
toms forming  no  consistent  complex,  but  representing 
the  heterogeneous  effects  of  panic  and  ^'suggestion"  and 
acute  exhaustion,  and  similar  agencies,  which  impose  as 
typical  hysterias  or  neurasthenias,  but  are  not  really  such, 
and  do  not  run  the  same  course  with  them. 

The  hysterias  and  neurasthenias  following  accidents 
are,  in  reality,  susceptible  of  classification  from  two  points 
of  view;  firstly,  as  representing  simple  deviations  from 
health,  the  impression  made  by  the  patient  upon  the  ob- 
server being  distinctly  that  of  an  essentially  unaltered  in- 
dividual, with  his  functions  temporarily  out  of  working 
order  yet,  in  such  a  way  that  the  character  of  the  devia- 
tion from  health  exhibits  specific  features  of  one  or  an- 
other sort;  secondly,  as  representing  clusters  of  symptoms 
so  compact  in  themselves  and  so  different  from  the  con- 
ditions that  make  up  the  stream  of  health,  that  they  sug- 
gest separate  organisms.  This  point  is  of  importance, 
both  as  a  help  to  classification  and  as  an  expression  of 
belief  as  to  the  mode  of  origin  of  the  so-called  functional 
nervous  disorders  in  general.  We  ought  to  accustom  our- 
selves to  speak  and  think  of  **hysteroid"  affections  and 
"hysteria"  as  related  and  yet  distinct.  The  hysteroid  af- 
fections may  occur  as  aberrations  of  health,  just  as  a 
healthy  man  may  have  a  fright  or  a  fit  of  passion;  yet  be- 


796  JAMES  /   PUTNAM. 

tvveen  hysteroid  and  hysteria  there  is  only  the  diflFerence 
that  in  the  latter  case  the  healthy  influences  have  lost  their 
pre-eminence  so  far  that  there  is  but  little  attempt  at  re- 
assertion.  The  impression  made  is  no  longer  that  of  a 
diseased  individual,  but  of  an  individual  and  his  disease. 

II.  In  the  really  typical  cases  it  is  probable  that  a  cer- 
tain degree  of  predisposition  is  always  present,  but  it  has 
frequently  been  suggested  that  some  of  the  symptoms  met 
with  in  these  cases  are  due  to  an  influence  analogous  to 
wha^  is  called  "suggestion  in  the  waking  state." 

In  Dr.  Sidis'  recent  book  on  the  psychology  of  sug- 
gestion some  interesting  experi-ments  and  observations 
are  recorded  with  regard  to  suggestion  in  the  waking 
state,  which  are  very  apposite  to  this  case  in  hand,  al- 
though the  distinction  between  the  two  sets  of  phenomena 
is  probably  less  radical  than  his  account  suggests. 

He  shows  that,  in  contradistinction  to  post-hypnotic 
suggestion,  the  waking  suggestion  succeeds  best  when, 
first,  the  patient  is  prepared  by  being  plied  with  indirect 
influences,  all  pointing  to  the  final  end  in  view,  and  then  at 
last  the  effective  suggestion  is  given  of  a  sudden,  and  in  a 
wav  to  be  acted  on  at  once.  These  conditions  are  in  a 
measure  paralleled  in  the  conditions  presented  by  the 
traumatic  psychoses.  The  preparatory  influences  are  rep- 
resented by  the  disquieting  dread  of  accident,  acquired 
through  social  intercourse  and  the  newspapers  and  con- 
stituting the  "social  predisposition"  as  indicated  above; 
while  the  final  suggestion  is  represented  by  the  events  of 
the  accident  itself,  by  which  the  patient  is  suddenly  de- 
moralized, and  through  which  he  receives,  as  it  were,  the 
command,  "now  go  and  be  an  invalid,"  or  "be  unable  to 
use  your  arm,"  etc. 

In  accordance  with  this  theory,  many  of  the  symptoms 
of  the  post-traumatic  neuroses  and  psychoses,  taking  the 
form  of  pains,  of  disorders  of  sensibility  or  of  motion,  of 
mental  depression  with  a  tendency  to  recurrent  dreams,  of 
hypochondriasis  against  which  the  patient  often  struggles 


POST-TRAUMATIC  PSYCHOSES,  7^7 

in  vain,  are  due  to  the  working  out  of  impulses  resident 
in  a  mental  life  which  is  apart  from  the  ordinary  con- 
sciousness but  plays  the  part  of  its  "demon/*  In  a  similar 
way  the  nutritive  processes  may  be  affected,  and  that  to  a 
degree  to  which  the  patient's  conscious  volition  is  in- 
capable of  affecting  them. 

We  are  not  justified  in  applying  strictly  to  these  sub- 
conscious mental  processes  the  laws  with  regard  to  emo- 
tion that  are  derived  from  conscious  introspection.  It  is 
well  known  from  daily  observation  that  a  person  outward- 
ly calm  may  inwardly  be  deeply  stirred.  A  depressing  ex- 
perience which  one  strives,  and  with  apparent  success,  to 
thrust  out  of  the  mind,  may  really  remain  and  prevent 
sleep  at  night  or  excite  unpleasant  dreams,  and  no  satis- 
factory measure  may  be  present  to  consciousness  as  to 
what  the  outcome  of  the  half-felt  or  unfelt  emotion  will  be. 
Just  as  an  event,  apparently  forgotten,  may  flash  into  the 
mind  without  obvious  cause,  so  these  states  of  the 
subliminal  or  ultra  marginal  consciousness  may  come  up 
when  least  expected. 

It  is  probable  that  the  half-dazed  state  into  which  a 
person  is  liable  to  be  thrown  by  fear  or  by  the  complex 
influences  attending  an  accident  is  peculiarly  favorable  to 
the  lodgement  of  these  subconscious  fixed  ideas. 

Perhaps  we  are  hardly  justified  in  asserting  that  in 
those  cases  where  consciousness  is  instantly  lost,  as  from 
an  electric  shock,  the  capacity  for  the  reception  of  even 
subconscious  impressions  is  retained,  but  it  is  probable 
that  even  here  the  loss  of  consciousness  is  not  necessarily 
to  be  taken  as  a  warrant  that  all  the  mental  powers  have 
been  abolished.  Just  as  a  person  may  wake  up  crying  as 
from  an  unpleasant  dream,  and  yet  be  wholly  unconscious 
that  he  has  dreamt,  so  he  may  suffer  every  degree  of  im- 
pairment of  consciousness,  in  consequence  of  an  accident, 
from  simple  confusion  to  entire  unconsciousness,  and  yet 
retain  the  power  of  suffering  all  the  results  of  an  emotion* 
whether  regarded  as  a  physiological  process  or  as  a  basis 


798  JAMES  /.   PUTNAM. 

for  "suggested"  ideas.  Not  only  is  the  state  of  mind  of 
many  patients  during  the  early  moments  of  an  accident 
equivalent  to  the  half-hypnotized  condition,  but  there  are 
not  a  few  persons  who  remain  for  days  and  weeks  in  an 
unnatural — usually  excitable — condition  of  an  analogous 
sort,  in  consequence  of  which  they  are  not  reliable  judges 
of  their  own  mental  state  and  are  the  prey  of  unfavorable 
influences.  Such  persons  often  say  that  they  feel  calm; 
that  they  are  not  being  influenced  by  the  thought  of  an 
approaching  trial,  etc.,  while  in  fact  the  reverse  is  the  case. 

III.  Several  other  principles  which  are  important  in 
this  connection  have  recently  been  discussed  by  Dr.  Mor- 
ton Prince  (Boston  Medical  and  Surgical  Journal,  June 
2d,  9th,  i6th,  1898.  'The  Pathology,  Genesis  and  De- 
velopment of  the  More  Important  Symptoms  in  Trau- 
matic Hysteria  and  Neurasthenia")  with  much  clearness 
and  method.  Dr.  Prince  shows  that  fatigue  may  be  a  pure- 
ly psychical  phenomenon,  a  shadow  of  real,  toxic  ex- 
haustion; and  that,  similarly,  pain  may  arise  in  conscious- 
ness with  extraordinary  readiness  with  certain  persons,  or 
with  many  persons  in  abnormal  mental  conditions,  just  as 
other  persons  have  a  remarkable  aptitude  for  the  repro- 
duction of  visual  or  auditory  images.  Eventually,  these 
and  all  such  sensations  may,  by  pure  repetition,  become 
habitual  recurrences,  like  sensations  of  hunger.  Again, 
many  painful  or  distressing  feelings,  such  as  pain  in  the 
forehead  on  use  of  the  eyes,  and  pain  or  paraesthesia  in 
the  head  or  back  from  exertions  of  any  sort,  may  arise 
through  an  irradiation  or  diffusion  of  energy,  which  goes 
on  with  especial  force  because  of  the  irritable  condition 
of  the  nerve  centres.  Such  pains  might  be  called  "inten- 
tion" pains  after  analogy  with  "intention"  tremor. 

Morbid  association,  whereby  cerebral  events  which  have 
once  occurred  in  juxtaposition  tend  forever  after  to  recall 
each  other,  explains  the  persistent  recurrence  of  vast  nun^- 
bers  of  special  fears  and  complex  mental  states,  conscious 
or  subconscious.    At  first  this  chain  of  associated   brain 


POST-TRAUMATIC  PSYCHOSES.  799 

processes  is  made  up  of  a  relatively  small  number  of  links, 
but  there  is  a  strong  tendency  toward  a  progressive  widen- 
ing of  the  vicious  circle  and  a  continual  encroachment 
upon  the  healthy  mental  processes. 

The  first  morbid  event  (as  the  circumstance  of  the  ac- 
cident) forms  the  centre  of  a  sort  of  vortex,  which  gradu- 
ally absorbs  a  larger  and  larger  number  of  the  cerebral  re- 
flexes within  its  influence,  until  the  patient's  whole  mental 
life  seems  to  centre  on  this  single  experience. 

This  tendency  has  been  clearly  pointed  out  by  Dr. 
Mary  Putnam  Jacoby,  in  an  instructive  paper  (New  York 
Medical  Journal,  June,  1898.  *'A  Suggestion  as  to  Sug- 
gestive Therapeutics.). 

IV.  "Litigation  Symptoms^  There  are  no  special  forms 
of  symptoms,  to  my  knowledge,  which  deserve  this  name, 
but  it  is  true  that  the  desire — half  conscious,  half  recog- 
nized— to  make  out  "a  good  case"  tends  strongly  to  in- 
tensify the  hypochondriacal  condition  of  the  patients  who 
seek  relief  at  law  and  the  special  symptoms  which  char- 
acterize each  case.  It  is  doubtless  true  that  the  law,  which 
was  intended  as  a  benefaction,  often  defeats  its  object  and 
becomes  a  source  of  misfortune  and  continued  illness.  On 
the  other  hand,  the  overestimate  of  this  influence,  and 
the  failure  to  bear  in  mind  the  considerations  such  as  I 
pointed  out  in  the  early  part  of  this  paper,  often  leads  ex- 
perts for  the  defense  to  do  gross  injustice  in  special  cases. 


^44.  Uebkr  acute  Psychosen  bei  Koprostase  (Acute  Psychoses  due 
to  Constipation).  F.  von  Solder  (Jahrbticher  fiir  Psychiatrie  und 
Neurologie,  17,  1898,  p.  174). 

Careful  and  critical  histories  of  six  cases  are  here  presented  in 
which  acute  delirium  developed  following  long  attacks  of  complete 
constipation.  The  intestinal  auto-intoxication  produced  the  clinical 
picture  of  an  acute  maniacal  excitement  which  persisted  for  from 
eight  to  fourteen  days,  and  which  with  proper  treatment  in  some 
cases  resulted  in  recovery;  in  others  weakness  of  the  heart  developed 
and  the  patients  died  in  the  acute  delirious  condition.  Anatomically 
hyperemia  and  oedema  of  the  brain,  congestion  of  the  lungs,  paren- 
chymatous degeneration  of  the  kidneys,  heart  and  liver  were  tound. 
The  author  presents  the  various  views  to  account  for  the  conditions 
and  concludes  that  the  auto-toxic  theory  seems  to  accord  best  with  the 
facts.  Jelliffe. 


ON    RESECTION    OF    THE    GASSERIAN    GAN- 

GLION, 

By  W.  W.  keen,  M.D..  LL.D.. 

WITH  A  PATHOLOGICAL  REPORT  ON  SEVEN 
GANGLIA  REMOVED  BY  PROF.  KEEN,^ 

By  WM.  G.  SPILLER,  M.D. 
abstract. 

This  paper  (with  nine  colored  plates)  was  written  as 
a  contribution  to  the  three  volumes  published  in  1898,  in 
commemoration  of  the  twenty-fifth  year  of  Prof.  Durante's 
teaching  in  Rome. 

Dr.  W.  W.  Keen  said  that  he  had  done  eleven  opera- 
tions for  the  removal  of  the  Gasserian  ganglion,  and  had 
reported  six  of  these  cases.  (Transactions  of  the  Philadel- 
phia County  Medical  Society,  1894;  The  Medical  and  Sur- 
gical Reporter  for  March,  1894;  and  The  American  Jour- 
nal of  the  Medical  Sciences  for  January,  1896.)  The  re- 
sults in  these  six  cases  are  as  follows: 

Case  I.  The  mental  condition  of  the  patient  is  not 
good,  and  he  still  has  pain,  but  not  the  old  tic. 

Case  II.  The  pain  returned  in  six  months,  and  still 
continues,  although  it  is  not  so  severe  as  it  was  before  the 
operation. 

Case  III.  The  patient  died  in  a  week  from  avoidable 
septic  infection. 

Case  IV.  The  patient  was  well  at  the  end  of  three 
vears.  » 

Case  V.  The  patient  has  been  well  for  tw-o  years  and 
a  half. 

Case  VI.  The  patient  has  been  entirely  well  for  four 
years  and  a  half. 

Of  the  five  other  cases  not  heretofore  reported,  the 
following  very  brief  resume  was  given: 

*Read  at  the  twenty-fourth  annual  meeting  of  the  American  Neu- 
rological Association,  May,  1898. 


r 


RESECTION  OF  THE  GASSERIAN  GANGLION.      8oi 

Case  VII.  Removal  of  the  Gasserian  ganglion,  after 
two  prior  operations,  with  portions  of  its  roots j  recovery; 
cure  for  two  years  and  five  months.  No  return  of  the 
severe  pain,  but  paraesthesia. 

Case  VIII.  Removal  of  the  Gasserian  ganglion  as  a 
primary  operation;  possible  tear  of  the  cavernous  sinus, 
hemorrhage  controlled  by  packing;  recovery;  cure  for  one 
year  and  eight  months. 

Case  IX.  Removal  of  the  Gasserian  ganglion  after 
one  prior  operation;  wound  of  the  cerebral  vessels  while 
making  the  flap;  rupture  of  the  cavernous  sinus,  bleeding 
controlled  by  gauze  packing;  coma  and  hemorrhage,  fol- 
lowed by  death  in  three  days;  post-mortem  examination 
was  refused. 

Case  X.  Death  from  shock  in  ten  hours. 

Case  XL  Removal  of  the  Gasserian  ganglion  after  six 
prior  operations;  recovery;  cure  for  sixteen  months;  eye- 
sight lost  from  secondary  corneal  ulcer,  caused  by  patient's 
neglect. 

The  ganglia  removed  from  the  last  seven  cases,  V.  to 
XI.,  inclusive,  were  handed  to  Dr.  William  G.  Spiller  for 
examination. 

In  Case  VIII.  no  prior  operation  had  been  done.  As 
all  three  branches  were  involved  in  the  disease,  the  gan- 
glion was  removed  as  the  primary  operation.  In  six  cases, 
VI.  to  XL,  an  attempt  was  made  to  remove  the  entire 
ganglion,  and  the  illustrations  showed  perfect  success  in 
Cases  VI.  and  XL,  and  reasonable  success  in  the  others. 

Four  points  were  then  considered.  First:  Should  the 
Gasserian  ganglion  be  removed?  This  question,  the  speak- 
er said,  must  be  answered  in  accordance  with  (a)  the 
mortality,  (b)  the  result  of  the  operation  as  to  cure,  (c)  the 
possibility  of  avoiding  the  dangers  of  the  operation.  The 
mortality  was  shown  to  be  about  22  per  cent.,  much  larger 
than  should  attend  modern  surgical  operations.  As  to 
permanency  of  cure,  there  are  only  four  cases  in  over  a 
hundred  operations  in  which  pain  has  returned — one  of 


8o2  ^.    ^'  KEEN  AND  WM,  G.  SPILLER. 

Rose,  one  of  Dana,  and  two  of  Keen — but  in  Case  I.  of 
Keen  the  old  tic  did  not  return;  no  microscopical  ex- 
amination of  the  fragments  removed  was  made.  In  Case 
11.  the  microscopical  examination  revealed  no  ganglionic 
cells  or  nerve  fibres;  both  of  these,  therefore,  were  im- 
perfect operations.  Allusion  was  made  to  one  case  of 
Krause  in  which  the  sensory  root  was  found  diseased, 
and  the  pain  returned  on  the  other  side  of  the  face.  The 
speaker  said  that  the  danger  to  the  eye  can  now  be  elim- 
inated by  methods  to  be  mentioned  later.  In  view  of 
the  mortality,  which  is  sure  to  be  diminished  when  further 
experience  has  been  obtained,  and  of  the  great  probability 
of  permanent  cure,  Dr.  Keen  believed  the  ganglion  should 
be  removed. 

Secondly:  To  what  extent  should  it  be  removed?  He 
dissented  from  Tiffany's  opinion  that  the  motor  root  can 
be  saved,  and  from  Tiffany's  proposal  to  remove  the  outer 
two-thirds  of  the  ganglion,  wrongly  supposed  to  be  in 
especial  relation  with  the  second  and  third  roots,  leaving 
the  inner  third. 

Thirdly:  Should  the  gangHon  be  removed  as  the  pri- 
mary operation,  or  should  it  be  deferred  as  the  final  op- 
eration? He  emphatically  approved  at  the  present  time,  of 
the  removal  of  the  ganglion  as  the  final  operation,  partly 
in  view  of  the  danger,  partly  in  view  of  the  fact  that  there 
is  a  possibility  of  the  return  of  the  disease,  even  after  ex- 
cision of  the  ganglion.  He  urged,  therefore,  that  if,  after 
three  or  four  months,  drugs  had  not  cured  the  affection, 
that  the  surgeon  should  do  the  operation  before  the  gan- 
glion was  involved,  without  w^aiting  longer  in  the  hope  of 
arresting  the  disease. 

Fourthly:  A  few  points  in  technique  were  considered, 
of  which  the  only  one  necessary  for  mention  here,  per- 
haps, is  the  advice  for  the  preservation  of  the  eye.  At  the 
time  of  the  operation  the  eye  should  be  disinfected,  and 
the  lids  sewed  together  at  the  middle  by  two  or  three 
stitches.     Each  day  the  eye  should  be  carefully  syringed 


RESECTION  OF  THE  GASSERIAN  GANGLION,      805 

by  a  warm  boric  acid  solution,  and  at  the  end  of  four  or 
five  days  the  stitches  should  be  cut,  and  the  eye  protected 
by  a  Buller  shield,  i.  e.,  a  watch  glass  held  in  place  by  a 
rubber  plaster. 

Dr.  Spiller  reported  the  findings  in  the  seven  Gasserian 
ganglia  examined  by  him.  In  six  cases  the  lesions  were 
very  evident,  but  in  the  seventh.  Case  VIII  in  which  no 
peripheral  operation  had  been  done,  the  portion  of  gang- 
lion obtained  for  examination  was  nearly  normal.  The 
findings  in  the  more  advanced  cases  consisted  of  greatly 
swollen  medullary  sheaths  and  swollen  axis  cylinders, 
atrophied  nerve  fibres,  empty  nerve  sheaths,  atrophied 
ganglion  cells,  proliferated  connective  tissue,  and  sclerosed 
blood  vessels.  In  one  case  the  overgrowth  of  connective 
tissue  within  the  ganglion  and  the  destruction  of  nerve 
cells  were  very  marked. 

Dr.  Spiller  discussed  the  peripheral  origin  of  trifacial 
neuralgia,  and  expressed  the  opinion  that  the  relief  of  pain 
for  one,  two  or  more  years,  after  peripheral  resection  of 
•the  nerve,  was  indicative  of  the  peripheral  origin  of  the 
disease.  The  Gasserian  ganglion  is  not  divided  anatomi- 
cally into  thirds,  and  if  it  is  true  that  the  lesions  originate 
within  the  ganglion,  peripheral  resection  would  not  re- 
move the  irritation  transmitted  by  the  other  branches  of 
the  fifth  nerve,  and  we  should  not  expect  a  diminution  in 
the  pain  by  removal  of  one  of  the  branches  of  this  nerve. 

Dr.  Spiller  spoke  of  the  normal  condition  of  the  sen- 
sory root  of  the  ganglion  removed  intact  by  Dr.  Keen. 
Krause  had  found  the  sensory  root  diseased  in  one  case, 
and  in  this  patient  the  pain  had  returned  on  the  opposite 
side  of  the  face  after  excision  of  the  ganglion.  The  speaker 
referred  to  the  contrast  afforded  by  the  normal  sensory 
root  in  this  case  examined  bv  him,  and  the  abnormal  con- 
dition  of  the  fibres  of  the  peripheral  branches  in  this  same 
case,  within  the  ganglion.  As  peripheral  and  central  nerve 
fibres  of  the  ganglion  arise  from  the  same  ganglion  cells, 
Dr.  Spiller  thought  it  would  be  difficult  to  explain  this 


504  ^.    ^-  KEEN  AND  WM,  G.  S FILLER, 

contrast  afforded  by  normal  and  degenerated  fibres,  if  the 
morbid  process  were  primarily  within  the  cells  of  the 
ganglion.  As  far  as  he  was  able  to  learn  by  an  examination 
of  the  literature,  the  condition  of  the  sensory  root  had 
only  been  reported  in  the  two  cases  mentioned. 

The  abnormal  condition  of  the  sensory  root  observ^ed 
by  Krause  warns  us  that  in  some  instances  the  pain  may 
return,  even  after  removal  of  the  ganglion,  and  there  is 
abundant  evidence  now  that  pain  may  result  from  central 
lesions. 

The  speaker  said  that  there  could  be  no  doubt  that 
intense  alteration  of  a  chronic  inflammatory  character  may 
be  found  within  the  Gasserian  ganglion  in  certain  cases 
of  tic  douloureux,  and  also  that  the  sensory  root  may  be 
intact  in  such  cases.  This,  it  seemed  to  him,  was  a  satis- 
factory explanation  for  the  relief  of  pain  experienced  by 
many  patients  in  whom  the  ganglion  had  been  removed. 

Dr.  Spiller  called  attention  to  the  fact  that  if  it  could 
be  shown  that  reunion  of  the  sensory  root  does  not  occur 
after  resection  of  this  root,  division  of  the  sensory  root 
might  have  the  same  remedial  effect  as  excision  of  the  gan- 
glion, and  be  attended  by  a  much  lower  mortality.  He 
spoke  of  the  desirability  of  making  investigations  on  ani- 
mals with  this  end  in  view. 

DISCUSSION. 

Dr.  John  Punton,  of  Kansas  City,  asked  Dr.  Keen  whether 
he  thought  the  operation  of  removal  of  the  Gasserian  ganglion 
was  contraindicated  in  a  woman  of  sixty-five  with  organic 
heart  disease.  In  the  case  he  had  in  mind,  two  minor  opera- 
tions for  the  relief  of  facial  neuralgia  had  already  been  per- 
formed, with  only  temporary  benefit. 

Dr.  Charles  K.  Mills  considered  the  paper  by  Dr.  Keen  and 
Dr.  Spiller  the  most  valuable  that  had  ever  l>een  made  con- 
jointly to  the  surgery  and  pathology  of  this  important  subject. 
Dr.  Keen's  surgical  experience  in  connection  with  the  subject, 
and  his  deductions  therefrom,  would  certainly  prove  of  great 
value  to  the  neurologist  and  the  general  practitioner. 

As  regards  the  pathology  of  the  disease,  the  speaker  said 


RESECTION  OF  THE  GASSERIAN  GANGLION,      805 

he  felt  inclined  to  differ  somewhat  from  the  views  presented  by 
Dr.  Keen  and  Dr.  Spiller,  although  he  hesitated  to  do  so,  as 
those  views  were  founded  upon  an  actual  examination  of  speci- 
mens. Personally,  he  was  inclined  to  the  opinion  that  tic 
douloureux,  in  the  typical  form  in  which  we  commonly  see  it, 
was  a  degenerative  process  of  the  pyeripheral  sensory  neurons. 
He  did  not  regard  it  as  a  neuritis,  in  the  ordinary  sense  of  that 
word.  In  all  the  cases  reported  in  the  paper,  with  the  ex- 
ception of  one,  previous  operations  had  been  performed,  and 
in  every  instance,  except  in  this  one,  extensive  disease  of  the 
peripheral  processes  near  the  ganglia  was  found.  In  six  of 
them  extensive  disease  of  the  Gasserian  ganglion  also  was 
found.  We  may,  in  some  of  these  cases,  have  to  deal  with  a 
primary  degeneration  of  the  cell  body;  with  an  ascending  neu- 
ritis of  traumatic  origin,  from  the  previous  operation;  and  with 
involution.  A  strong  argument  in  favor  of  the  theor}'  that 
we  have  to  deal  with  a  true  peripheral  neuritis  is  that  when  a 
piece  of  the  nerve  is  removed,  the  patient  is  free  from  pain 
for  one  or  two  years,  or  even  for  several  years;  but,  opposed 
to  this  argument,  we  have  the  fact  that  in  the  vast  majority  of 
cases  the  pain  returns. 

Dr.  C.  L.  Dana  said  that  with  regard  to  the  pathology  of 
this  disease  he  was  inclined  to  agree  with  Dr.  Spiller.  Dr. 
Mills,  it  appeared,  was  anxious  that  we  should  not  look  upon 
the  condition  as  an  inflammatory  one.  The  term  degenerative 
neuritis  is  often  used  loosely,  and  without  any  special  refer- 
ence to  the  inflammatory  condiition.  Dr.  Dana  said  he  was 
inclined  to  believe  that  Dr.  Spill er's  specimens  and  investiga- 
tions confirmed  those  of  Dr.  Putnam  and  himself,  and  that 
in  most  of  these  cases  we  have  to  deal  with  a  degeneration  of 
the  nerve.  Dr.  Spiller's  view,  that  its  primary  origin  was  in 
the  periphery,  was  very  well  worked  out.  The  speaker  thought, 
however,  that  we  should  not  look  at  the  matter  entirely  front 
a  microscopic  standpoint.  Tic  douloureux  is  a  disease  not 
only  of  the  nerve,  but  is  an  expression  of  general  exhaustion, 
or  the  onset  of  degenerative  changes.  Some  persons  recover 
from  it  by  proper  rest  and  change  and  the  use  of  certain 
restoratives.    In  a  number  of  cases  it  is  a  self-limited  disease. 

The  sp>eaker  said  he  felt  under  obligation  to  Dr.  Keen  for 
having  p^resented  the  surgical  and  therapeutic  sides  of  this 
subject  so  fully.  His  personal  experience,  however,  in  con- 
nection with  surgical  interference  in  these  cases  had  been 
very  unsajtisfactory,  and  had  strongly  inclined  him  against 
such  measures.  He  had  the  impression  that  surgeons  now 
do  not -claim  to  be  able  to  do  anything  more  than  to  relieve  the 
pain  for  a  period  varying  from  six  to  eighteen  months.  Dr. 
Dana  said  that,  perhaps,  his  prejudice  in  this  respect  arose 


8o6  W^.    ^'  KEEN  AND   IVM.  G.  SPILLER. 

horn  the  fact  that  most  of  the  patients  he  had  seen  were  "bad 
cases,"  who  had  all  been  cut  in  one  way  or  another,  and  gen- 
•erally  were  worse  off  for  it  in  the  end.  A  surgical  operation 
done  in  the  early  stage  of  the  disease  may  actually  precipitate 
the  malady,  and  aggravate  it.  The  speaker  said  he  could  un- 
derstand how  a  clean-cut  operation  in  these  cases  might  re- 
lieve the  symptoms  for  a  long  time,  but  many  operators  did 
not  do  that  kind  of  work;  they  left  a  lacerated  nerve  stump 
behind,  and  it  was  not  to  be  wondered  at  that  Dr.  Spillei 
found  degenerated  axis  cylinders. 

As  regards  the  removal  of  the  Gasserian  ganglion,  Dr. 
Dana  said  that  the  value  of  the  operation  was  established  up 
to  a  certain  point,  but  he  had  found  patients  very  reluctant  to 
submit  to  it. 

In  conclusion,  the  speaker  said  he  had  great  faith  in  the 
value  of  toxic  doses  of  strvchnia  in  the  treatment  of  tic  dou- 
loureux. 

Dr.  Ira  Van  Giesen  stated  that  he  had  made  a  number  of 
examinations  of  resected  nerves,  including  portions  of  the 
fifth,  and  had  found  an  obliterating  endarteritis  of  the  vessels 
accompanying  the  nerves,  similar  to  that  reported  by  Dr. 
Dana.  The  speaker  said  he  looked  upon  the  disease  of  the 
vessels  as  the  primary  cause  of  the  changes  in  the  nerve  fibres. 
After  nerve  section  we  may  be  sure  that  connective  tissue  will 
appear  at  the  severed  ends,  with  cicatrization  and  a  gradual 
return  of  the  symptoms. 

Dr.  Keen,  in  closing,  said  the  question  was  purely  a  clini- 
cal one.  Any  operation  which  could  give  relief  in  tic  dou- 
loureux, he  thought,  was  justifiable,  even  in  patients  with  an 
organic  heart  lesion;  in  such  cases  extra  precautions  were 
necessary  in  giving  the  anaesthetic.  He  did  not  agree  with 
Dr.  Dana  regarding  the  unsatisfactory  results  of  operative  in- 
terference in  these  cases;  his  own  experience  had  convinced 
him  to  the  contrary.  In  the  cases  where  he  had  operated  the 
patients  were  free  from  pain  for  periods  varying  from  one  to 
three  years,  and  he  was  inclined  to  beliteve  that  if  an.  early 
peripheral  operation  had  been  done,  the  results  would  have 
been  still  better.  He  agreed  with  Dr.  Dana  that  in  some 
cases  the  use  of  massive  doses  of  strvchnia  was  very  efficacious. 

Dr.  W.  G.  Spiller,  in  closing,  said  that  on  account  of  the 
reasons  given  he  was  much  inclined  to  believe  tliat  this  disease 
was  usually  originally  in  the  peripheral  fibres.  He  had  ex- 
amined the  supraorbital  and  infraorbital  nerves  removed  by 
Dr.  Keen  as  a  primary  operation,  in  a  case  of  trifacial  neu- 
ralgia, and  had  found  them  much  diseased.  Pain  had  not  re- 
turned when  the  patient  was  seen  a  number  of  months  after 
the  operation. 


^liuicvd  iS'nsts. 


A  CASE  OF  CEREBRAL  ATAXIA  AFFECTING 
CHIEFLY  THE  RIGHT  UPPER  EXTREMITY 
WITH  MARKED  INVOLVEMENT  OF  THE 
STEREOGNOSTIC  SENSE. 

By  INGERSOLL  OLMSTED.  M.B..  TOR., 

Physicfan  to  the  City  Hospital,  Hamilton,  Ont. 

The  patient^  H.  P.  D.,  aet.  27  years,  a  clerk,  was  referred 
to  me  by  my  friend,  Dr.  A.  B.  Osborne,  of  this  city,  on  the  20th 
of  July,  1898.  Dr.  Osborne  states  that  the  patient  first  con- 
sulted him  on  the  nth  of  last  May,  and  complained  of  double 
vision.  When  the  patient  was  coming  from  the  station  he  had 
difficulty  in  selecting  the  proper  sidewalk,  and  avoiding  people. 
I  have  taken  the  following  extracts  from  Dr.  Osborne's  notes. 

*'May  nth.  The  pupils  are  equal  an^  act  consensually  to 
light  and  with  convergence.  Right  vision  =  ^i  L.  V.  =  y^^g 
with  correction  =^.  Under  mydriasis;  R.  V.  =  ^^  with  cor- 
rection =  5.  L.  V.  =:^  with  correction  =  §.  Fundi,  normal. 
Outward  movement  of  right  eye  restricted.  Cover  test  shows 
outward  movement  of  readjustment. 

**May  30th.  Cover  test  shows  no  movement  of  readjust- 
ment, with  colored  glasses  can  only  induce  diplopia  by  looking 
to  extreme  right  and  upward. 

"Jwne  3rd.      No  diplopia. 

"July  14th.  Patient  thinks  the  vision  of  his  right  eye  is 
failing.  R.  V.  =  j%  with  correction  =  ^V-  L.  V.  =  -jV  with 
correction  =  ^.  No  change  in  the  right  fundus  to  account 
for  the  failure  of  vision. 

"July  2oth.  Fundi,  normal.  Outward  movement  of 
right  eye  limited.  Homonymous  diplopia  when  looking  to 
the  right.  Vision  R.  =yV  ^vith  correction  =  4.  Vision  L.  =3^ 
with  correction  =  J. 

"No  history  of  lues  could  be  elicited,  yet  he  was  given 
specific  treatment.  By  the  3rd  of  June  the  diplopia  had 
entirely  disappeared,  but  returned  on  the  T4th  of  July.  The 
following  day  the  patient  felt  a  numbness  in  the  thumb,  index 
and  middle  fingers  of  the  right  hand,  also  a  prickling  sensation, 
intermittent  in  character,  beginning  in  the  right  lip  and  ex- 
tending from  there  to  the  eye  and  ear  of  the  same  side.    Owing 


8o8  IXGERSOLL  OLMSTED. 

apparently  to  the  numbness  of  his  fingers  he  found  difficulty  in 
writing." 

His  history,  taken  July  20th,  is  as  follows : 

Father  died  at  65  years  of  Bright's  disease.  Mother  died 
when  66,  cause  unknown.  Both  parents  had  been  troubled 
somewhat  during  life  with  rheumatism.  One  ancestor  two 
or  three  generations  back,  he  states^  had  been  insane.  One 
sister  aet.  33,  is  very  nervous;  four  others  are  Hving  and 
healthy;  three  are  dead,  two  died  in  infancy  and  one  at  31  years 
of  some  intestinal  disease,  the  nature  of  which  the  patient  does 
not  know.  Two  brothers  are  living  and  healthy;  two  are  dead, 
one  died  in  infancy  and  one  at  13  years  of  paralysis  following 
measles.  No  history  of  cancer  or  of  tumor  of  any  kind  in 
family. 

Previous  history  good.  Does  not  remember  having  had  any 
disease.  He  denies  lues,  but  admits  having  had  intercourse 
on  three  or  four  occasions.  Three  years  ago  when  riding  a 
bicycle,  he  had  a  collision  with  another  rider  going  in  the  oppo- 
site direction,  was  thrown  from  his  wheel,  partially  stunned, 
and  received  a  contusion  of  one  eye,  but  does  not  remember 
which  one.  He  was  sore  for  a  few  days,  but  felt  no  other  ill 
effects  from  his  accident.  He  says  he  has  always  lived  care- 
fully, uses  alcohol  very  moderately,  but  tobacco  in  excess  at 
times.  Since  July  15th  he  has  felt  the  numbness  in  the  right 
thumb  and  fingers  previously  described.  The  sensation  in  the 
right  side  of  the  face,  he  speaks  of  as  a  flush,  and  says  it  is  a 
prickling  warmish  feeling  beginning  at  the  upper  lip  and  ex- 
tending to  eye  and  ear.  It  passes  off  in  a  few  seconds  to  return 
in  four  or  five  minutes.  When  his  attention  is  drawn  to  it,  he 
thinks,  this  sensation  comes  more  frequently.  He  has  never 
felt  anything  similar  in  his  right  leg.  He  is  a  well  developed 
man  of  medium  size,  intelligent,  answers  questions  promptly 
in  a  clear  distinct  voice,  but  appears  slightly  nervous  when 
being  examined.  The  skin  is  normal  in  appearance,  and  free 
from  scars;  no  cicatrix  on  prepuce  or  corona  glandis,  no  en- 
largement of  the  inguinal,  epitrochlear  or  cervical  lymphatic 
glands,  no  roughness  on  clavicles  (except,  perhaps,  a  little  on 
left),  ribs  or  tibiae.  The  ausculation  of  the  cranium  on  percus- 
sion yields  negative  results.  No  tenderness  over  the  nerves 
of  the  face  or  of  the  extremities ;  no  affection  of  hearing.  The 
tongue  is  protruded  in  the  median  line  and  its  muscles  are 
properly  innervated.  No  affection  of  taste.  The  examina- 
tion of  the  heart,  lungrs*  and  abdominal  organs,  is  negative. 
The  urine  contains  neither  albumin  nor  sugar. 

The  eye  movements  in  all  directions  are  good,  except 
slight  lateral  nystagmus  on  either  side.  The  pupils  are 
equal  and  respond  normally  to  light  and  on  accommodation. 


A    CASE  OF  CEREBRAL  ATAXIA,  809^ 

The  facial  and  mascatory  muscles  act  normally;  jaw-jerk  pres- 
ent. Touch,  pain^  heat  and  cold  sensation  are  normal  on 
both  sides  of  the  face. 

The  UK>er  Extremities:  The  arms  are  muscular,  move- 
ments free  in  all  directions;  no  ataxia  on  this  examination,  or 
tremor.  The  power  is  good,  and  equal  on  both  sides;  the 
elbow-jerk  and  biceps-jerk  are  present.  The  sensations  of 
touch,  pain,  heat  and  cold  are  unimpaired,  except,  perhaps,  to 
a  very  slight  degree  in  the  thumb,  index  and  middle  fingers  of 
the  right  hand.  (The  stefeognostic  sense  was  not  tested  at 
this  time.) 

The  scapular,  epigastric,  abdominal  and  cremasteric 
reflexes  are  markedly  exaggerated  on  the  right  side.  There  also 
appears  to  be  some  hyperaesthesia  of  the  right  face,  arm,  and 
trunk. 

Lower  Extremities:  The  legs  are  muscular  and  of  equal 
power.  The  knee-jerk  on  the  left  side  is  present,  but  on  the 
right  side  is  very  much  diminished  and  can  only  be  produced 
very  slightly  with  motor  reinforcement.  No  Romberg  symp- 
tom, gait  normal. 

Sensation  of  both  legs  is  normal  as  regards  touch,  pain, 
heat  and  cold. 

July  25th.  The  patient  is  in  much  the  same  condition,  but 
complains  that  his  hand  and  arm  feel  much  stiffer,  and  the 
numbness  affects  the  whole  hand;  when  he  buttons  and  unbut- 
tons his  clothes,  the  buttons  feel  as  though  they  had  been 
broken  in  two  and  only  one-half  remained.  The  right  side  of 
his  face  also  seems  sore  and  shaving  has  been  painful.  He 
says  that  the  stiffness  of  the  hand  makes  it  very  difficult  for  him 
to  write,  and  when  in  my  office  he  frequently  opens  and  closes 
his  hand,  apparently  attempting  to  remove  the  stiffness.  He 
savs  that  his  right  leg  tires  much  more  quickly  than  the 
left. 

The  electrical  examination  shows  ready  response  of  all  the 
muscles  to  the  faradic  current. 

Aug.  loth.  During  the  past  two  weeks  the  patient  has 
been  getting  worse.  The  condition  of  his  eyes  varies ;  at  times 
there  is  diplopia,  but  at  others  none.  The  flush  or  paraes- 
thesia  of  the  right  side  of  the  face,  is  more  marked,  and  extends, 
he  states,  down  the  side  of  his  neck  to  the  right  shoulder  and 
arm.  There  is  well  marked  ataxia  of  the  right  arm  and  hand. 
When  he  brings  his  index  fingers  together  there  is  difficultv 
in  getting  them  to  touch.  When  asked  to  touch  his  nose  with 
his  right  forefinger,  he  makes  the  attempt  with  a  certain  stiff- 
ness and  uncertainty,  and  usually  touches  the  face  at  a  point 
some  distance  to  the  right  of  the  nose;  with  the  fingers  of  his 
left  hand,  however,  he  executes  this  movement  with  precision. 


L- 


8lO  INGERSOLL  OLMSTED. 

When  asked  to  write,  he  takes  up  the  pen  very  awkwardly,  and 
has  to  use  the  left  hand  to  fix  it  properly  between  the  fingers 
of  his  right  hand  so  as  to  get  the  point  of  the  pen  to  come  in 
contact  with  the  paper  correctly.  The  writing  is  done  with 
slow,  irregular,  uncertain  movements,  and  appears  when  fin- 
ished quite  unlike  his  former  hand.  The  letters  are  trem- 
ulously and  irregularly  formed,  have  not  the  same  slant,  and 
the  curves  are  made  with  difficulty.  The  more  he  writes  the 
worse  the  writing  becomes. 

In  Fig.  I  the  handwriting  of  the  patient  before  the  onset 
of  this  affection  is  illustrated.  In  Fig.  2  is  reproduced  a 
sample  of  his  writing  at  the  date  of  this  note. 


FiG:  I. 


^<r0^r^hy-XAJo^ 


/H^ 


lyQs^ 


1 


Fig.  II. 


The  movements  of  the  right  shoulder,  arm  and  hand  are 
all  carried  out  with  much  less  dexterity  than  those  of  the  left. 
The  muscular  power  of  both  sides,  as  measured  with  the  dyna- 
mometer, is  about  equal.  The  patient  says  that  not  only  the 
hand,  but  the  whole  arm  and  shoulder,  has  the  stiff  feeling. 

Sensation  to  touch,  heat  and  cold  is  perfect  on  both  sides 
of  the  body,  while  that  of  pain  is  dulled  in  the  right  arm  and 
on  the  right  side  of  the  trunk.  The  face,  neck  and  leg  on  the 
right  side  are  as  sensitive  to  pain  as  on  the  opposite  side.  The 
most  interesting  feature  of  the  case  is  the  fact  that  the  stereog- 
nostic  sense  is  very  much  disturbed  in  the  right  hand.  He 
cannot  recognize  a  key,  piece  of  money,  or  pen  when  placed  in 


A  CASE  OF  CEREBRAL  ATAXIA,  8ll 

his  right  hand,  although  they  were  recognized  at  once  when 
placed  in  the  left.  He  cannot  button  or  unbutton  his  clothes 
with  the  right  hand.  He  is  able  to  tell  a  knife  when  placed  in 
his  affected  liand.  The  farado-cutaneous  sensibility  is  clearly 
diminished  in  the  right  arm,  hand  and  on  the  right  side  of  Ihe 
trunk. 

Aug.  17th.  The  patient  remains  in  much  the  same  condi- 
tion except  that  the  stereognostic  sense  is  even  more  involved 
than  on  the  previous  examination.  He  does  not  know  a  coin, 
brush,  scissors,  pipe,  ball  or  cube  when  placed  in  the  right 
hand,  but  names  them  correctly  when  they  are  put  in  the  left. 
He  can  give  no  information  regarding  the  shape  of  the  articles, 
but  can,  to  a  certain  extent,  tell  their  consistence  when  they  are 
placed  in  the  right  hand.  On  testing  the  other  parts  of  his 
body,  as  well  as  possible,  using  a  book,  a  brush,  rough  and 
smooth  surfaced  articles,  it  is  found  that  on  his  right  arm  and 
over  the  right  half  of  the  trunk,  he  cannot  recognize  a  brush 
or  an  oblong  block  2x3  inches,  but  does  so  on  the  correspond- 
ing parts  of  the  left  side.  He  recognizes  a  book  the  measure- 
ments of  which  are  3x6  inches,  when  it  is  placed  on  either  side 
of  the  body.  He  can  also  tell  a  rough  surface  when  it  is 
placed  on  the  right  half  of  the  trunk. 

It  appears  that  the  stereognostic  sense  is  thus  almost  com- 
pletely lost  in  the  right  hand,  and  that  it  is  to  a  certain  extent 
impaired  in  the  right  forearm,  right  arm  and  right  half  of  the 
trunk.  This  statement  is  also  true  for  the  muscular  sense 
which  was  tested  by  means  of  different  quantities  of  mercury  in 
bottles.  A  bottle  weighing  three  ounces  feels  to  him  as  heavy 
as  one  weighing  nine  ounces.  The  position  of  the  right  arm, 
hand  and  fingers,  when  changed  by  the  examiner,  is,  however, 
immediately  recognized  by  the  patient.  All  finer  movements 
of  the  right  hand  and  forearm  are  most  clumsily  performed, 
and  the  patient  tends  to  drop  articles  placed  in  his  hand. 

It  is  also  noticed  that  when  he  rises  suddenly  from  his 
chair  to  a  standing  posture  he  has  a  tendency  to  go  forward 
and  a  little  to  the  right  (propulsion).  He  states  that  he  has 
noticed  this  tendency  to  go  forward  and  to  the  right  on  two  or 
three  occasions  during  the  last  few  days. 

Dr.  Osborne's  note  of  August  17th  says: — "Fundi,  nor- 
mal, no  diplopia  with  colored  glasses.  R.  V.  =  3^  not  im- 
proved by  glasses.  L.  V.  =  ^  with  glasses  =  %.  Cover 
test  shows  outward  movement  of  readjustment.  Pupils  act 
normally. 

"The  fields  of  vision  which  are  here  given  show  marked 
contraction  for  white  and  red.  Each  temporal  half  is  the  one 
most  involved." 


8l2 


r.XGERSOLL  OLMSTED. 


We  have  before  us,  then,  a  well  marked  case  of  involve- 
ment of  the  stereognostic  sense  implicating  principally  the 
right  hand  and  upper  extremity.  It  is  not  associated  with 
actual  paralysis,  but  rather  with  a  pronounced  ataxia  man- 
ifested by  an  inability  to  carry  out  accurately  finer  move- 
ments, such  as  those  concerned  in  writing,  buttoning,  un- 
buttoning, and  the  like. 

While  disturbance  of  the  stereognostic  sense  is  by  no 
means  uncommon  in  cases  of  hemiplegia,  the  appearance 
of  this  symptom  in  the  manner  here  reported,  is,  if  the 
bibliography  is  to  be  relied  upon,  an  extremely  rare  occur- 
rence. As  a  matter  of  fact,  there  has  been,  thus  far,  no 
case  to  my  knowledge  reported  in  which  a  symptom-com- 
plex identical  with  that  of  the  patient  described  above. 


The  innermost  circles  represent  the  boundaries  of  the 
red  fields;  the  middle  circles  those  of  the  white. 

md  with  a  similar  mode  of  onset  (absence  of  recent 
rauma)  has  been  observed. 

The  cases  approaching  the  one  here  described  are  (i) 
he  classical  case  described  by  Wernicke^  (2)  the  case  re- 
:ently  described  by  von  Monakow*,  and  (3)  the  case  re- 
)Orted  by  Burr,^  of  Philadelphia. 

In  Wernicke's  case  there  had  been  traumatic  injury 
o  the  skull,  with  involvement  of  the  region  of  the  arm 

>  Wernicke.  C.  Arb.  &.  A.  psych.  Kllnik  in  Breslau  Leipzig,  1S9;, 
-  p.  a35- 

'Von   Monakow,  C.  Gehirn pathologic.      Wien,  1897,  p.  410  etseq. 

•  Burr,  C.  W.  A  Case  of  Psychic  Ansesthesia.  J.  of  Nerv.  and 
lent,  Dis,,  xxv.  p.  37. 


A    CASE  OF  CEREBRAL  ATAXIA,  813 

area  of  the  cortex  on  the  left  side.  The  case  of  von  Mon- 
akow  was  also  one  of  trauma  followed  by  trepanation.  In 
Burr's  case  there  had  been  a  blow  upon  the  skull  in  the 
tenth  year  of  life,  followed  by  transient  paralysis  of  motion 
and  loss  of  sensation,  and  by  permanent  disturbance  of  the 
stereognostic  sense.  At  the  time  of  his  report  the  patient 
was  24  years  of  age,  and  on  grasping  things  in  his  pocket 
with  the  affected  hand  the  objects  could  not  be  recog- 
nized. Burr  is  inclined,  however,  to  regard  his  case  as 
hysterical  in  nature.  It  is  interesting  to  note  that  all  the 
cases  thus  far  reported,  including  the  present  one,  have 
been  individuals  under  30  years  of  age. 

One  might  give  an  opinion,  and  probably  a  tolerably 
accurate  one,  as  to  the  exact  localization  of  the  lesion  in 
the  case  here  reported.  The  exact  nature  of  the  disease 
can  at  present  be  only  a  matter  of  speculation.  The 
writer  prefers,  however,  to  reserve  his  judgment  with  re- 
gard to  both  points.  The  case  will  be  carefully  watched 
and  its  future  progress  and  termination  subsequently  re- 
ported. 

*  I  take  this  opportunity  of  thanking  my  friend,  Dr. 
Osborne,  not  only  for  having  referred  the  patient  to  me, 
but  also  for  his  notes  on  the  case. 


Note. — There  was  absolutely  no  disturbance  of  *' word-seeing  "  or 
**  word-hearing." 


jloicijetg  'g.tpavts. 


NEW  YORK  NEUROLOGICAL  SOCIETY, 
Stated  Meeting,  Oct.  4,  1898. 

Frederick  Peterson,  M.D.,  President. 

DOUBLE  ATHETOSIS  FROM  INFANTILE  C^R^BRAL 

PALSY. 

Dr.   L.   Stieglitz  presented  a  boy,  sixteen  years  of 
age,  the  youngest  of  several  children.    All  the  others  had 
been  well  at  birth,  but  he  had  been  born  asphyxi^ited,,,  <^\- 
though  the  labor  was  normal.    He  did  not  walk  yntil  five 
years  old.    At  the  age  of  seven  years  he  h^cl  scarl^ttina, 
and  after  that  time  the  peculiar  movements  which  he  now 
exhibits  became  worse.     Soon  after  birth  it  was  noticed 
that  he  moved  his  arms,  legs  and  head  in  a  peculiar  way. 
After  a  few  years  the  movements  remained  at  a  standstill 
until  the  attack  of  scarlatina.    On  voluntary  motion,  the 
movements  are  aggravated.     His  face  shows  a  constant 
succession  of  grimaces.     The  peculiar  movements  affect 
the  trunk,  as  well  as  the  upper  and  lower  extremities. 
The  tongue  and  the  eyeballs  are  free  from  these  move- 
ments.    The  deep  reflexes  of  the  arms  are  lively,  as  are 
also  the  knee-jerks,  but  not  more  than  in  many  healthy 
children.     His  mental  development  is  very  good,  but  his 
physical  development  is  rather  deficient.     Close  study  of 
the  movements  led  Dr  .Stieglitz  to  believe  that  the  case 
was  one  of  double  athetosis,  due  to  infantile  cerebral  palsy, 
the  result  of  a  lesion  occurring  at  the  time  the  child  was 
born  asphyxiated.    These  cases  rarely  show  any  defective 
mental  development.     In  cases  of  athetosis  the  lesion  is 
probably  usually  in  the  lenticular  nucleus,  or  in  the  corpus; 


t 


X£ir  YORK  NEUROLOGICAL  SOCIETY,  815 

Striatum,  and  it  is  not  surprising  that  there  is  no  epilepsy 
or  disturbance  of  the  mental  development. 

DISCUSSION. 

Dr.  B.  Sachs  said  that  as  he  recalled  similar  cases  that  he 
had  seen,  he  was  forced  to  the  conclusion  that  the  one  just  pre- 
sented was  a  most  excellent  illustration  of  the  combination 
of  the  choreiform  and  the  athetoid  movements.  The  prob- 
ability of  a  non-cortical  origin  was,  of  course,  very  great. 
That  there  was  a  direct  relation  between  the  typical  spastic 
cases  of  infantile  cerebral  palsy  and  the  choreic  and  chorei- 
form athetoid  cases  he  verily  believed.  In  a  number  of  cases 
he  had  found  that  peripheral  restraint  on  these  unruly  mem- 
bers, kept  up  for  months,  had  had  a  remarkaly  good  effect. 

Dr.  Edward  D.  Fisher  said  that  he  now  had  under  obser- 
vation a  boy  of  the  same  ap^e,  who  presented  almost  exactly 
the  same  symptoms,  except  that  they  were  not  quite  so 
severe.  It  seemed  to  him  that  the  lesion  was  very  apt  to  be 
subcortical.  The  absence  of  epileptic  conditions  did  not 
mean  necessarily  that  the  lesion  was  not  a  cortical  one.  The 
lesion  was  certainly  not  an  extensive  one  in  the  motor  tract. 

Dr.  Joseph  Collins  said  that  he  agreed  entirely  in  the  diag- 
nosis made  by  Dr.  Stieglitz,  and  he  was  glad  to  see  such  a 
typical  illustration  of  this  group  of  cases.  He  did  not  favor 
the  name  "athetosis,"  nor  would  he  apply  it  to  this  case. 
Taking  the  case  in  its  entirety  he  would  look  upon  it  as  an  ex- 
ample of  the  choreic  form  of  infantile  cerebral  palsy.  He  was 
inclined  to  think  that  the  involvement  was  primarily  of  the 
corpus  striatum  and  quite  as  much  so  of  the  optic  thalamus, 
and  he  based  this  opinion  on  the  study  of  the  patient's  mo- 
tions, coupled  with  his  spastic  gait.  Tlie  question  of  the  ex- 
istence of  epilepsy  in  such  a  case  did  not  seem  to  him  of  much 
importance,  for  the  opinion  was  growing  yearly  that  idiopathic 
epilepsy  is  a  cortical  disease.  He  had  tried  peripheral  re- 
straint for  months  at  a  time  without  observing  the  slightest 
benefit,  even  temporarily. 

Dr.  Peterson  thought  the  case  was  undoubtedly  one  of 
post-paralytic  morbid  motion,  and  he  agreed  with  Dr.  Collins 
that  athetosis  was  not  a  proper  name.  The  position  was  athe- 
toid, but  the  movement  was  rather  a  polymyoclonus.  The 
term  "athetosis"  should  be  applied  to  a  slow,  vermicular  move- 
ment. 

Dr.  C.  A.  Herter  remarked  that  he  thought  the  term  was 
applied  to  much  more  rapid  movements,  and  it  did  not  seem  to 
him  that  there  was  a  proper  pathological  basis  for  such  a  dis- 
tinction as  that  made  by  the  last  speaker. 

Dr.  Collins  thought'  the  term  "athetosis"  should  be  limit- 


8 1 6  NE  W  YORK  NEUROLOGICA L  SO C/ETV. 

ed  to  rhythmical  movements,  and  "choreic"  to  non-purposive, 
dancing  movements. 

Dr.  Stieglitz,  in  closing  the  discussion,  said  that  in  cases 
of  infantile  cerebral  palsy  all  the  different  varieties  of  move- 
ments mentioned  were  often  combined,  so  that  perhaps  it 
would  be  better  to  select  a  name  which  would  cover  all  of 
them.  When  the  boy  is  less  excited  the  movements  are  usu- 
ally less  rapid,  and  more  vermicular  in  character.  Under  or- 
dinary conditions,  he  does  not  present  a  spastic  facies.  The 
restraint  treatment  had  been  advocated  by  Dr.  Hammond 
when  he  had  first  described  these  cases. 

DISSEMINATED  INSULAR  SCLEROSIS. 

Dr.  Joseph  Collins:  The  patient  who  is  before  you  has 
the  symptoms  of  two  rather  obscure  diseases  of  the  ner- 
vous system,  and  I  bring  him  here  that  you  may  assist  me 
in  determining  the  one  from  which  he  suffers.  He  is  41 
years  old,  married,  and  by  occupation  a  silk  weaver.  His 
personal  history  is  that  he  has  been  a  user  of  stimulants 
and  tobacco,  the  latter  rather  intemperately.  Physically, 
he  has  led  a  very  active  life,  and  in  many  directions,  par- 
ticularly fencing  and  boxing.  He  has  been  an  amateur 
athlete.  The  only  point  of  interest  in  his  family  history  is, 
according  to  his  own  statement,  that  a  brother  younger 
than  him  by  two  years,  complains  of  the  same  trouble  in 
walking  that  he  does.  When  our  patient  was  33  years  old, 
he  had  a  sore  on  the  penis  for  which  he  was  treated  by 
Dr.  Geo.  H.  Fox.  The  latter  assured  him  that  this  sore 
was  of  the  nature  of  a  chancroid,  and  gave  him  only  local 
treatment.  Aside  from  bubo,  which  complicated  it,  this 
terminated  uneventfully  in  a  few  weeks,  during  which  time 
he  was  treated  in  private  practice  by  Dr.  Fox.  Aside 
from  the  attack  of  the  grippe,  which  he  had  in  1892,  he 
has  been  quite  well.  His  present  illness  dates  back  nearly 
three  years,  the  initial  symptom  having  been,  he  thinks, 
dizziness,  which  was  sufficiently  great  to  interfere  with 
his  locomotion.  Apparently  this  vertigo  was  not  contin- 
uous, because  he  says  that  when  it  would  come  he  would 
have  to  hold  to  something  to  prevent  him  from  falling. 
About  this  time    he  must  have  had  some. trouble  with 


f 


XEIV  YORK  NEUROLOGICAL  SOCIETY.  gl/ 

his  sight,  for  it  appears  that  he  went  to  the  New  York 
Eye  and  Ear  Infirmary,  where  he  was  told  that  he  had 
locomotor  ataxia.  The  symptoms  that  next  appeared 
after  the  dizziness  seem  to  have  been  what  he  describes 
as  piercing  pains  in  the  calves  and  the  sensation  of  heavy 
weights  in  the  thighs.  So  far  as  I  am  able  to  infer,  this 
constitutes  the  major  part  of  the  patient's  complaint  until 
the  beginning  of  the  present  summer,  although  it  should 
be  said  that  he  has  been  sexually  impotent  since  two  years. 
The  fact  that  he  has  been  unable  to  work  has,  according 
to  his  own  statement,  preyed  very  much  upon  his  mind 
and  made  his  symptoms  worse.  About  six  mnoths  ago 
his  bowels  and  bladder  became  functionally  derelict,  and 
sometimes  the  one  or  the  other  would  discharge  their 
contents  without  his  being  aware  of  it.  At  this  time, 
likewise  his  speech  and  handwriting  became  affected,  both 
in  very  much  the  same  way  as  they  are  now.  That  is,  the 
enunciation  is  measured  and  scanning,  the  intonation 
rather  high  and  uniform,  while  the  handwriting  is  very 
irregular  and  ataxic.  About  the  same  time,  the  patient 
avers  tlfet  he  became  uncommonly  emotional.  He  would 
burst  into  tears  at  one  time,  and  at  another  would  grin  or 
smile  senselessly.  Accompanying  these  physical  symp- 
toms, the  patient  underwent  a  psychical  alteration.  He 
says  that  he  became  very  forgetful,  that  he  was  unable 
to  read  understandingly,  even  the  newspapers.  This 
state  persists  in  a  very  much  slighter  degree  to-day.  For 
instance,  it  is  quite  impossible  to  elicit  the  symptoms  of 
his  disease  except  by  asking  him  leading  questions,  and 
he  forgets  easily.  At  present,  he  is  able  to  concentrate 
the  attention  sufficiently  to  read  a  newspaper  or  magazine 
understandingly. 

His  complaint  at  the  present  time  is  of  difficulty  in 
locomotion  and  impaired  dextrality.  The  abnormalities 
of  articulation  and  the  slight  psychical  aberrations  do  not 
concern  him  sufficiently  to  complain  of  them.  The  func- 
tions of  the  bladder  and  bowels  are  now  more  nearly  nor- 


Si 8  NEW  YORK  NEUROLOGICAL  SOCIETY. 

mal,  although  occasionally  there  is  some  incontinence, 
especially  of  urine.  He  does  not  complain  of  pain,  nor 
of  tight  band  sensation  about  the  waist,  and  the  feeling 
as  if  there  were  heavy  weights  in  the  thighs  has  disap- 
peared. Examination  shows  a  man  of  medium  height 
and  good  muscular  development,  whose  body  is  the  seat 
of  a  marked  deformity  due  to  a  cervico-dorsal  scoliosis 
which  he  believes  to  have  been  caused  by  carrying  heavy 
loads  in  the  right  hand  or  on  the  right  shoulder  during 
boyhood.  As  to  the  plausibility  of  such  an  explanation 
each  one  must  determine  individually.  Both  feet  show 
the  deformity  which  is  known  as  pes  cavus,  pied  bot  of  the 
French  writers.  The  plantar  surface  of  each  foot  is  very 
much  hollowed  beneath  the  arch,  while  all  the  toes  are 
forcibly  extended  save  the  first  phalanx,  which  tends  to 
claw  the  floor.  When  the  patient  stands,  titubation  of 
the  whole  body  is  the  most  striking  phenomenon,  and 
this  persists,  though  to  a  lesser  degree,  when  he  sits.  The 
gait  is  ataxic  and  reeling;  unlike  the  ordinary  taboid  pa- 
tient, he  does  not  watch  his  feet  while  walking.  He  is 
rather  more  inclined  to  fix  some  point  at  or  ne^  his  ob- 
jective, and  keep  his  vision  on  it  until  he  reaches  it. 
Station  is  extremely  uncertain  when  the  feet  are  approxi- 
mated, and  when  he  closes  the  eyes  under  such  circum- 
stances he  is  pretty  sure  to  fall.  The  superficial,  or  cuta- 
neous reflexes  are  present.  The  tendon  jerks  of  the  lower 
extremity  are  all  absent,  while  of  the  upper  extremity 
they  are  all  present.  The  right  palpebral  fissure  is  some- 
what larger  than  the  left,  and  to  explain  this  the  patient 
says  that  it  followed  an  attack  of  sore  eyes.  The  pupils 
are  of  medium  size,  slightly  asymmetrical,  and  do  not  re- 
spond to  light.  When  the  backgrounds  of  the  eyes  are 
viewed  with  the  ophthalmoscope  the  left  optic  discs  ap- 
pear rather  pale,  a  state  of  pink  atrophy.  The  right  optic 
nerve  is  normal.  Tactile  and  thermal  sensibilities  seem  to 
be  normal.  There  is  well  marked  analgesia  over  both 
legs.     The  patient  has  been  examined  four  times  onlv 


jVEH^  YORK  NEUROLOGICAL  SOCIETY.  819 

with  great  care,  but  the  analgesia  seemed  to.be  present 
on  each  occasion,  although  varying  somewhat  in  intensity. 
There  is  no  perversion  of  sensibility  in  any  other  part  of 
the  Jbody.  Color  sense  is  normal,  and  the  visual  fields  are 
unchanged.  Senses  of  smell,  taste  and  hearing  are  in- 
tact. The  trouWc  with  speech  and  writmg  have  been 
already  sufficiently  referred  to  above. 

Now,  the  question  arises,  has  this  patient  Friedreich's 
disease,  or  has  he  multiple  sclerosis?  Perhaps,  indeed 
this  question  is  not  sufficiently  comprehensive.  Some 
may  be  inclined  to  ask,  and  legitimately,  I  think,  can 
diseases  of  the  cerebellum  be  eliminated  on  the  one  hand, 
and  genuine  tabes  on  the  other?  Personally,  I  am  in- 
clined to  the  opinion  that  the  case  is  one  of  disseminated 
insular  sclerosis,  although  perhaps  the  evidence  pointing 
to  such  a  diagnosis  is  not  so  direct  or  convincing  as  some 
might  wish.  If  a  brief  analysis  of  the  symptoms  be  made, 
it  will  at  once  be  seen  that  there  exists  a  certain  number 
of  conditions  which  are  usually  considered  inimical  to  the 
diagnosis  of  Friedreich's  disease.  These  are,  first,  the 
patient's  age;  second,  the  sensory  disturbances;  third, 
the  perversion  of  function  of  the  uro-genital  sphere,  and 
fourth,  loss  of  the  pupillary  light  reflex  and  paleness  of 
the  temporal  side  of  the  optic  nerves.  On  the  other  hand, 
all  of  these,  and  the  other  symptoms  and  physical  accom- 
paniments which  the  patient  presents,  including  the  de- 
formities of  the  trunk  and  foot,  can  be  explained  by  the 
existence  of  islets  of  sclerosis  in  the  posterior  columns, 
in  the  oblongata,  and  possibly  in  the  cerebellum.  If  my 
diagnosis  be  the  correct  one  you  will  agree  with  me,  I 
think,  that  it  is  one  of  the  most  atypical  thus  far  reported. 

DISCUSSION. 

Dr.  Sachs  said  he  was  of  the  opinion  that  the  case  was 
probably  a  somewhat  atypical  example  of  multiple  sclerosis. 
There  was  after  all  not  so  much  difference  between  this  case 
of  multiple  sclerosis  and  the  cases  of  combined  sclerosis  that 
one  sees,  for  he  had  observed  cases  of  combined  sclerosis 


820  NEW  YORK  NEUROLOCtCAL  SOCIETY. 

which  at  one  stage  had  presented  all  the  symptoms  of  a  spas- 
tic paralysis,  and  subsequently  the  appearance  of  typical  cases 
of  tabes. 

Dr.  Fisher  said  he  would  agree  with  the  diagnosis  of  dis- 
seminated sclerosis,  basing  it  largely  on  the  mental  condition 
and  the  character  of  the  speech,  particularly  the  former. 

REMARKS    ON    THE    KIDNEYS   IN    CASES    OF    CEREBRAU 
HEMORRHAGE  AND  CEREBRAL  SOFTENING. 

Dr.  Christian  A.  Herter  read  a  paper  with  this  title,  in 
which  he  gave  some  of  the  results  of  his  observations  in 
464  autopsies  on  adults  at  the  Presbyterian  Hospital. 
There  were  twenty-three  cases  of  cerebral  hemorrhage,, 
eleven  of  cerebral  softening  and  one  of  softening  and 
hemorrhage.  The  three  cases  of  hemorrhage  in  patients 
with  large  kidneys  showed  the  lesions  of  chronic  diffuse 
nephritis.  Six  of  the  patients  with  small  kidneys  were 
males,  while  all  the  patients  with  large  kidneys  were 
females.  Of  the  patients  with  large  kidneys,  four  had 
cerebral  softening,  two  thrombosis  and  two  embolism. 
The  great  majority  of  the  medium  kidneys  were  granular. 
In  the  cases  of  cerebral  softening  the  kidneys  presented 
a  granular  surface  and  freely  stripping  capsules.  Accord- 
ing to  this  series  of  observations,  cerebral  hemorrhage 
was  most  frequent  among  persons  with  small  granular 
kidneys,  and  least  frequent  in  those  having  large  kidneys. 
None  of  the  cases  of  hemorrhage  had  smooth  kidneys, 
on  the  other  hand,  the  majority  of  the  cases  of  cerebral 
softening  were  associated  with  smooth  kidneys  and  freely 

stripping  capsules.  Where  there  is  a  high  arterial  tension 
and  the  urine  is  of  low  specific  gravity  and  contains  very 

little  albumin,  and  few,  if  any,  casts,  it  may  be  inferred 
that  the  kidneys  are  small  and  granular,  and  this  con- 
dition, in  cerebral  cases,  points  strongly  to  hemorrhage. 

DISCUSSION. 

Dr.  Mary  Putnam  Jacobi  said  that  she  had  recently  seen  a 
case  which  bore  on  the  relation  of  uraemia  and  hemorrhage. 
The  patient  was  a  woman  of  about  forty-five,  who  had  been 
previously  in  excellent  health.     She  awoke  one  morning  to 


NEW  YORK  NEUROLOGICAL  SOCIETY.  821 

find  that  her  vision  was  extremely  dim.  The  next  day  she 
complained  of  double  vision,  and  a  paresis  of  the  abducens  ap- 
peared and  increased  until  the  muscle  became  completely  par- 
alyzed. The  urine  on  several  examinations  was  found  entirely 
free  from  albumin,  and  granular  casts  were  found  without  the 
use  of  the  centrifuge.  The  urine  contained  a  large  quantity 
of  urea.  The  dimness  of  vision  was  probably  uraemic  and 
the  paresis  of  the  abducens  due  to  a  very  minute  hemorrhage 
in  the  sixth  nerve. 

Dr.  Herter  said  that  it  seemed  to  him  probable  that  in  Dr. 
Jacobi's  case  the  symptoms  were  due  to  hemorrhage  rather 
than  oedema,  although  the  latter  should  always  be  borne  in 
mind.  It  was  a  common  thing  to  find  considerable  urea  dur- 
ing the  uraemic  state.  This  was  probably  to  be  explained  by 
a  gradual  accumulation  of  the  urea  in  the  blood,  owing  to  the 
defective  action  of  the  kidneys,  and  this  accounted  for  the 
fact  that  these  patients  often  pass  a  normal  quantity  of  urea 
in  the  urine  at  the  time  that  the  symptoms  of  acute  uraemia 
are  present. 

TRAUMATIC  H^MATOMYELIA,  WITH  REPORTS  OF  CASES 

WITH  AND  WITHOUT  AUTOPSY. 

Drs.  Pearce  Bailey  and  P.  R.  Bolton  presented 
a  paper  on  this  subject  from  which  extracts  were 
read  by  Dr.  Bailey.  Speaking  of  that  class  of  cases 
in  which  the  haematomyelia  is  consequent  upon  injury  to 
the  spinal  column,  the  authors  said  that  in  a  large  pro- 
portion the  general  destruction  of  nerve  tissue  is  so  severe 
that  hemorrhage  can  have  had  but  little  influence.  The 
blood  is  poured  out  first  and  most  profusely  into  the 
gray  matter,  and  this  central  limitation  is  often  very 
sharply  defined.  The  columnar  extension  of  the  blood 
is  usually  in  the  gray  matter  of  the  anterior  or  posterior 
horns,  and  the  column  extends  further  upward  than  down- 
ward. Occasionally  it  may  extend  into  the  white  matter 
just  behind  the  middle  commissure.  These  hemorrhages 
are  most  commonly  found  at  autopsy  between  the  fifth 
cervical  and  the  third  dorsal  segments.  The  lower  dorsal 
or  lumbar  cases  either  do  not  come  to  autopsy  or  else 
only  after  so  long  a  time  that  it  is  difficult  to  draw  def- 
inite   conclusions    regarding    the    pathological    findings. 


822  NEW  YORK  NEUROLOGICAL  SOCIETY. 

The  evolution  of  the  lesion  in  spinal  hemorrhage  is  some- 
what obscure.  The  natural  tendency  is  to  absorption  of 
the  blood  so  that  cavity  formation  is  an  early  consequence 
of  ha;matomyelia.  A  symptom  of  some  importance  is  a 
band  of  therm o-anaesthesia  extending  a  little  distance 
above  the  general  autesthesia.  In  primary  h«ematomyelia 
bleeding  into  the  substance  of  the  cord  constitutes  the 
primary  lesion.  There  are  two  forms,  viz. :  ( i )  the 
localized;  and  (2)  the  disseminated.  A  force  sufficient 
to  rupture  the  blood  vessels  of  the  spinal  cord  must  affect 
the  nerve  elements,  hence  when  bleeding  is  prominent 
it  is  reasonable  to  expect  lesions  of  the  nerve  cells.  In  the 
majority  of  cases,  however,  the  hemorrhage  is  the  most 
important  factor.  The  focal  form  of  primary  hjema- 
tomyelia  is  always  found  in  the  lower  cervical  or  upper 
dorsal  region.  Most  of  the  cases  result  from  falls.  One 
form  of  injury  which  is  especially  fertile  in  producing  this 
injury  is  a  sudden  bending  of  the  neck,  such  as  occurs 
in  falling  of  heavy  weights  on  the  neck,  diving  in  shallow 
water,  etc.  The  symptoms  differ  from  those  of  crushes  of 
the  cord,  in  which  the  white  and  gray  matter  are  both 
implicated  The  paralysis  is  at  first  flaccid  everywhere, 
and  the  reflexes  generally  are  either  diminished  or  lost. 
An  injury  to  any  part  of  the  spinal  cord  above  the  upper 
lumbar  region,  severe  enough  to  cause  paraplegia,  will 
usually  inhibit  or  abolish  the  knee-jerk  for  a  time.  This 
is  eventually  followed  by  an  exaggeration.  In  the  muscles 
of  the  lower  extremities  the  paralysis  usually  changes 
within  three  weeks  from  the  flaccid  to  the  spastic  type. 
Immediately  after  the  accident  the  paralysis  of  motion 
is  usually  wide-spread  and  severe.  Sensibility  to  touch 
is  little,  or  not  at  all,  modified  in  primary  focal  hsema- 
tomyelia;  there  is,  however,  analgesia  or  thermo- 
amesthesia,  or  both.  In  the  cases  reported  the  power  to 
distinguish  between  heat  and  cold  was  lost  while  sen- 
sibility to  pain  was  unaffected.  Compared  to  the 
prognosis  of  secondary  cases  of  injury,  the  outlook  in 


NEIV  YORK  NEUROLOGICAL  SOCIETY,  82^ 

primary  focal  haematomyelia  is  favorable.  Primary  dis- 
seminated haeraatomyelia  occurs  after  severe  general 
traumatism.  In  these  cases  capillary  hemorrhages  were 
found  throughout  the  cerebro-spinal  axis.  Microscopic 
examination  shows  small  masses  of  red  blood  cells  lying, 
for  the  most  part,  in  the  gray  matter,  but  also  in  the  white 
matter.  They  are  not  accompanied  by  other  evidence  of 
destruction,  and  are  not  artefacts. 

DISCUSSION. 

Dr.  Sachs  said  that  there  seemed  to  be  every  reason  to  sup- 
pose that  in  many  cases  which  were  classified  as  of  secondary 
origin  there  must  have  been  effusion,  not  only  into  the  cord, 
but  around  the  cord.  On  this  account,  the  question  arose  as 
to  whether  many  of  the  symptoms  might  not  be  due  to  com- 
pression of  the  root  fibres.  He  had  seen  dissociation  of  sen- 
sation as  one  of  the  earliest  symptoms  of  Pott's  disease  and 
Pott's  paralysis.  It  need  not,  therefore,  be  a  symptom  of  de- 
struction of  the  gray  matter.  He  recalled  a  series  of  cases 
that  were  not  traumatic  in  origin,  were  rather  slow  of  onset,  and 
occurred  in  adults,  and  yet  presented  all  the  typical  symptoms 
described  under  the  head  of  haematomyelia.  The  question 
arose  as  to  whether  in  the  non-traumatic  cases  the  peculiar  ar- 
rangement of  the  blood  vessels  in  the  spinal  cord  might  not 
account  for  some  of  the  cases  in  his  series.  A  case  now  un- 
der observation  was  instructive  for  the  reason  that  the  lower 
extremities  alone  were  affected,  and  there  was  an  association 
of  the  spastic  symptoms  with  a  dissociation  of  sensation. 

Dr.  OnufT  said  that  he  had  seen  the  case  just  referred  to  by 
the  last  speaker.  The  patient  stated  that  soon  after  a  tiresome 
bicycle  ride  he  noticed  that  he  could  not  urinate  easily.  The 
next  morning  there  was  a  tingling  sensation  in  the  legs,  but  it 
was  not  for  five  days  that  a  partial  paraplegia  appeared.  At 
this  time,  incontinence  of  faeces  was  also  noticed.  There  was 
atrophy  of  the  leg  affecting  chiefly  the  adductors  of  the  right 
thigh.  The  sensation  of  pain  was  exaggerated,  so  that  there 
was  a  marked  drawing  up  of  the  limb  when  it  was  pricked. 
The  difficulty  of  urination  was  followed  by  incontinence.  The 
atrophy  in  the  thigh  would  seem  to  indicate  a  higher  lesion, 
while,  on  the  other  hand,  the  initial  bladder  and  rectal  symp- 
toms would  point  to  a  lower  lesion. 

Dr.  Fraenkel  said  that  he  thought  the  abolition  of  the  re- 
flexes in  such  cases  as  those  described  in. the  paper  was  of 
much   diagnostic   importance.     Enough   cases   had  been   re- 


824 


NEW  YORK  NEUROLOGICAL  SOCIETY. 


ported  to  show  that  even  in  the  face  of  the  absence  of  the 
reflexes  it  was  possible  for  a  communication  to  exist  between 
the  upper  and  lower  portions  of  the  cord.  He  regretted  that 
the  condition  of  the  deep  sensibility  had  not  been  recorded  in 
the  cases  quoted. 

Dr.  Bailey  remarked  that  in  one  case  in  which  the  reflexes 
were  absent,  the  muscular  sensation  had  returned. 


145.       Un   CAS   DE   SURDITY   VERBALE   PURE   TEKMIN^E  PAR  AFHASIE  SENSOR- 

lELLE,  suivi  d'autopsie  (Word-Dcafncss  Terminating  in  Sensor}' 
Aphasia;  Autopsy).  Dejerine  and  Serieux  (Joum.  de  M^.,  Feb. 
6,  1898). 

In  reporting  this  case  the  authors  say  that  only  four  cases  have 
been  recorded  of  what  Lichtheim  called  sub-cortical  word-deafness, 
and  what  Dejerine  has  proposed  to  call  pure  word-deafness.  In  this 
condition  the  patient  has  lost  simply  the  comprehension  of  spoken 
language  and  the  power  of  repeating  and  writing  to  dictation. 

The  present  case  is  one  of  the  four  and  was  reported  by  Serieux 
in  1893.  After  that  date  the  patient  gradually  grew  worse  and  the 
speech  difficulty  became  extended  into  a  general  sensory  aphasia. 
The  autopsy,  with  careful  microscopic  examination,  revealed  no 
sign  of  a  focal  lesion,  but  a  general  atrophy  of  the  temporal  con- 
volutions, bilateral,  and  diminishing  in  degree  from  above  down- 
ward. This  atrophy  was  caused  by  changes  strictly  cortical,  and 
involving  primarily  the  cells,  the  more  superficial  ones  most.  The 
authors  sum  up,  briefly,  as  follows: 

T.  This  autopsy  definitely  settles  the  question  of  the  localization 
of  pure  word-deafness,  showing  it  to  be  due  to  a  lesion  exclusively 
cortical,  consisting  in  this  case  of  a  chronic  poliencephalitis,  while 
in  the  case  of  Pick  the  lesion  was  both  cortical  and  sub-cortical. 
This  is  the  first  case  of  the  kind  that  has  been  shown  to  be  due  to  a 
purely  cellular  lesion. 

2.  The  case  shows,  as  does  that  of  Pick,  that  pure  word-deafness 
is  due  to  a  bilateral,  temporal  lesion,  located  in  the  ordinary  auditory 
centre. 

3.  Considering  this  localization,  it  appears  probable  that  in  pure 
word-deafness  we  have  to  do,  not  with  a  separation  of  the  auditory 
centre  from  the  centre  of  recognition  of  words,  but  with  an  impair- 
ment of  the  functions  of  the  former.  This  opinion  is  corroborated 
by  the  fact  that  this  patient,  although  she  preserved  the  sense  of 
hearing  for  a  long  time,  gradually  lost  it. 

4.  The  gradual  and  progressive  transformation  of  pure  word- 
deafness  into  a  sensory  aphasia  is  to  be  emphasized.  For  a  con- 
siderable time  the  patient  possessed  intact  the  faculty  of  internal 
language,  and  it  was  only  by  degrees  that  the  auditory  centre  for 
words  became  involved  and  that  then  appeared  alexia,  "jargona- 
phasia,"  and  paragraphia.  Patrick. 


^tvlscopt. 


Wiih  the  Assistana  of  the  FoUoxving  Collaborators: 

ChasXewis  ALLEN,M.D.,Wash.,D.C.R.  K  Macalester,  M.D.,  N.Y. 
J.  S.  Christison,  M.D.,  Chicago,  111.  J.  K.  Mitchell.  M.D.,  Phila.,  Pa 
A.  FsBSifAN,  M.D.,  New  York.  H.  Patrick,  M.D.,  Chicago,  111. 

S.  £.  Jeluffb,  M.D.,  New  York.  Joseph  Sailer,  M.D.,  Phila..  Pa. 
Wm.C.Krauss,M.D.,  Bu£Falo,  N.Y.  Henry  L.  Shively,  M.D.,  N.  Y. 
W.  M.  Leszynsky,  M.D.,  New  York.  A.  Sterne,  M.D.,  Indianapolis. 


CLINICAL  NEUROLOGY. 

146.  Dritte  Mitthkilung  ueber  die  paroxysmale,  familiaere  Laeh- 
MUNG  (A  Third  Communication  Concerning  the  Paroxysmal,  Family 
Paralysis).  S.  Goldflam  (Deutsche  Zeitschrift  fiir  Nervenheilkunde, 
xi,  1897,  3  and  4). 

Goldflam  has  been  able  to  observe  this  peculiar  disease  in  an- 
other family,  and  in  several  additional  members  of  the  family  he 
previously  reported.  One  case  may  be  given  in  detail.  The  attacks 
began  in  the  eighth  year  of  life,  and  occurred  once  or  twice  a  year 
until  the  seventeenth  year,  but  from  this  time  until  the  present 
(twenty-second  year)  they  have  occurred  monthly,  or  at  shorter  in- 
tervals. They  usually  begin  in  the  evening  with  general  weakness 
and  drowsiness,  and  while  they  pass  off  during  sleep,  as  a  rule,  they 
may  result  in  complete  paralysis,  which  lasts  twenty-four  to  forty- 
eight  hours,  or  longer.  Improvement  usually  begins  in  the  evening, 
and  motion  is  restored  within  a  few  hours.  Consciousness,  speech, 
deglutition  and  the  action  of  the  sphincters,  are  not  affected.  The 
pain  experienced  during  the  attack  is  probably  the  result  of  the 
complete  immobility.  Occasionally  the  weakness  begins  acutely. 
When  the  weakness  is  felt  in  the  morning  hours  the  patient  can 
sometimes  ward  off  the  paralysis  by  active  movement  and  massage. 
Peculiar  changes  in  the  electrical  reactions  are  noted.  A  copious 
meal  seems  to  produce  an  attack.  Goldflam  observed  complete  and 
flaccid  paralysis  of  the  muscles  of  all  the  extremities  and  neck  in 
this  man,  but  the  movements  of  the  face,  tongue,  eyeballs  and 
throat;  the  functions  of  the  bladder  and  rectum;  the  general  sen- 
sation, and  the  special  senses,  were  not  affected.  Examination  of  the 
gastric  contents  revealed  nothing  abnormal.  The  most  important 
etiological  factor  is  the  family  predisposition.  The  changes  in  the 
electrical  reactions  of  the  nerves  of  the  face,  between  the  attacks, 
shows  that  the  cranial  nerves  are  not  intact.  There  seems  to  be 
some  relation  between  the  paroxysmal  family  paralysis  and 
dystrophia  muscularis  progressiva,  for  Bernhardt  has  observed 
these  diseases  in  a  father  and  son.  Changes  in  the  muscular  fibres 
(rarefaction    and    vacuolization)    were    observed    by    Goldflam    in   a 


826  PERISCOPE. 

number  of  cases,  and  were  not  limited  to  one  family.  They  resemble 
those  described  by  Dejerine  and  Sottas  in  m'yotonia  congenita.  In 
the  second  family,  which  Goldflam  reports,  the  three  eldest  children 
were  affected.  Spiller. 

147.  Entehalgie  ( Enteralgia).     Potain  (La  Clinique,  Jan.,  1897). 

In  a  clinical  lecture  on  the  above-named  affection,  the  author 
first  remarks  that  abdominal  pain  is  in  no  wise  of  diagnostic  im- 
portance as  it  is  common  to  a  host  of  divers  affections,  and  con- 
sequently the  first  step  in  the  examination  must  be  -the  exclusion  of 
all  organic  disease,  including  tabes,  the  painful  crises  of  which  may 
closely  simulate  enteralgia. 

The  positive  symptoms  of  the  latter  disease  are  recurrent  attacks 
of  severe,  paroxysmal,  cramp-like  pain,  generally  beginning  in  the 
right  hypochondrium,  and  following  the  course  of  the  transverse  and 
descending  colon,  coming  on  without  apparent  exciting  cause,  with- 
out reference  to  the  ingestion  of  food  and  accompanied  by  char- 
acteristic and  peculiar  stools.  For  a  day  or  two  preceding  the  ap- 
pearance of  pain  the  stools  become  hard  and  their  evacuation  difficult; 
as  the  colic  appears  and  continues  the  stools  are  progressively  smaller 
and  may  become  ribbon-like  or  about  the  size  of  a  lead  pencil.  With 
the  cessation  of  the  paroxysm  their  calibre  gradually  increases,  and 
a  copious  evacuation  or  even  diarrhoea  terminates  the  cycle.  An 
attack  lasts  from  a  few  hours  to  several  days,  and  during  its  con- 
tinuance the  sigmoid  flexure  may  be  distinctly  felt  as  a  hard  cord  that 
is  sore  but  not  exquisitely  tender  to  pressure.  There  is  complete 
anorexia,  emesis  is  frequent  and  may  be  biliary,  moderate  tympanites 
is  generally  present,  as  is  also  rectal  tenesmus  with  frequent  desire  to 
defecate. 

The  two  important  causes  of  the  affection,  which  is  to  be  con- 
sidered as  a  neurosis,  are  a  neuropathic  disposition  and  the  uric  acid 
diathesis — Xarihritisme — the  gouty,  rheumatic  tendency.  As  the 
essential  condition  is  intestinal  spasm,  in  the  treatment  purgatives 
are  to  be  carefully  avoided,  belladonna  and  opium  being  the  proper 
remedies;  but  ether  or  valerianate  of  ammonium  is  also  recommended, 
and  hot  baths  may  be  tried.  Between  the  attacks  general  measures 
alone  are  to  be  relied  upon.  Gastric  purgatives,  salines,  aloes  and 
senna  are  to  be  avoided.  For  constipation,  castor  oil,  sulphur  and 
rhubarb  are  preferred  according  to  the  author.  Mild  hydrothera- 
peutics  constitute  an  admirable  therapeutic  measure,  but  batJi  or 
douche  should  never  be  employed  when  the  patient  is  fatigued,  for 
instance,  after  active  exercise.  If  there  be  laxity  of  the  abdominal 
parietes  it  is  to  be  treated  by  vigorous  and  oft  repeated  faradism. 
The  most  important  as  well  as  the  most  difficult  element  of  treatment, 
however,  must  be  a  perfect  physical  and  mental  hygiene. 

Patrick. 

148.  Casuistische  Mittheilungen  aus  DEM  Gebiete  der  Neurop.a- 
THOLOGiE  (Clinical  Communications  in  Neuropathology).  M.  Dink- 
ier (Deutsche  Zeitschrift  fUr  Nervenheilkunde,  xi,  1897,  3  and  4). 

I.  Encephalitis  acuta  hemorrhagica  (?)  recidiva. 

A  child  of  neuropathic  ancestry,  born  in  normal  labor,  had  no 
signs  of  disease  until  he  was  two  years  of  age.  At  this  period  he 
fell  from  a  stool  upon  the  occiput,  vomited,  had  tonic  and  clonic 
convulsions  in  the  right  arm  and  leg  which  gradually  ceased  within 
two  days,  leaving  a  right-sided  hemiparesis  of  a  few  days*  duration. 
About  a  year  later  he  had  another  slight  fall,  after  which  fever,  un- 


periscope:  827 

consciousness,  vomiting,  convulsions  on  the  left  side  of  the  body 
appeared,  and  within  a  few  days  left-sided  hemiplegia,  lasting  2^ 
week  and  a  half  was  noticed.  After  the  attack  the  child's  mind  was 
somewhat  enfeebled  and  he  had  nocturnal  enuresis.  At  the  age  of 
four  years,  aftei;  a  fall  from  a  step,  he  had  a  temporary  renewal  of 
his  former  symptoms.  A  few  months  later  he  had  another  attack 
with  transitory  hemiplegia  and  transitory  amaurosis  of  both  eyes 
without  pupillary  symptoms.  The  patient  was  received  into  the  hos- 
pital during  this  last  attack. 

The  diagnosis  of  tuberculous  meningitis  seemed  improbable,  ovif 
account  of  the  transitory  nature  of  the  hemiplegia  and  the  bilateral 
amaurosis,  for  the  latter,  Dinkier  says,  is  not  a  sign  of  meningitis. 
The  symptoms  indicated  at  least  two,  and  probably  three,  foci  of 
disease.  The  motor  tract  could  not  have  been  destroyed.  The 
lenticular  nucleus  is  very  vascular,  and  is  a  favorite  location  for 
encephalitis.  It  is  probable  that  numerous  small  hemorrhages  oc- 
curred in  this  body,  or  which  is  less  likely  on  account  of  the  speedy 
restitution,  in  the  entire  motor  cortex  of  the  right  side.  The 
amaurosis  was  believed  to  be  due  to  lesions  in  the  white  matter  of 
both  occipital  lobes,  as  its  transitory  character  was  not  in  favor  of 
cortical  destruction,  or  the  absence  of  pupillary  symptoms  of 
thalamic  lesions. 

2.  Syphilitic  disease  of  the  right  frontal  lobe  with  neuritis  optica 
duplex  prgecipue  dextra. 

A  man,  thirty-one  years  old,  complained  of  severe  headache  inr 
the  frontal  and  temporal  regions,  which  was  more  severe  on  the 
right  side  at  night  Typical  mucous  plaques,  bilateral  optic  neuritis, 
involving  especially  the  right  side,  right-sided  mydriasis  and  dis- 
turbance of  equilibrium  with  forced  movements  toward  the  left  were 
noticed.  The  process  was  undoubtedly  syphilitic.  The  lesion  was 
believed  to  be  a  gumma,  involving  the  optic  nerves  and  the  right 
frontal  lobe. 

3.  Syphilitic  vascular  disease  of  the  left  Sylvian  artery. 

The  symptoms  in  this  case,  transitory  left-sided  paralysis  of  the 
tongue  and  arm,  formication  in  arm  and  leg,  etc.,  could  be  referred 
to  lesions  of  the  right  parietal  and  temporal  regions  and  basal 
ganglia.  The  most  interesting  features  were  found  in  the  peculiar 
sequence  of  the  symptoms,  and  in  the  right-sided  homonymous 
hemianopsia,  with  right-sided  optic  atrophy  and  hemianoptic  pupil- 
lary reaction.  Spiller. 

149.     Arret  de  d^veloppement  du  membre  superieur  coNsfecuxiF  a  la 

TRAUMATISM     DAT  ANT     DE     L'eNFANCK,     ATROPHIE    MUSCULAIRE    NUME- 

RiQUE  (Numerical  Muscular  Atrophy  in  a  Case  of  Arrested  Devel- 
opment of  the  Upper  Extremity).  Klippel  (La  Presse  M^dicale, 
62,  1897,  p.  49). 

Klippel  gives  the  clinical  history,  and  the  pathological  report  in  the 
case  of  a  man  who  in  consequence  of  an  injury  to  his  left  elbow  at  the 
age  of  three  years,  had  an  arrest  of  development  of  the  left  upper  ex- 
tremity, and  who  died  at  the  age  of  54  from  pulmonary  tuberculosis.  A 
number  of  measurements  taken  during  life  showed  a  considerable  differ- 
ence in  length  and  circumference  between  the  right  arm  and  the  left. 
The  left  elbow  joint  was  completely  ankylosed.  The  very  careful 
and  thorough  pathological  examination  showed  that  there  was 
neither  diminution  in  volume  nor  change  in  structure  in  the  histo- 
logical elements  in  the  affected  extremity,  but  that  there  was  a  dis- 
tinct diminution  in  their  number.  The  palmaris  longus  muscle,  when 
measured  at  the  same  points  on  the  two  sides,  gave  right,  circum- 


828  PERISCOPE. 

ference  4%  cm.,  left  3%  cm.  The  difference  in  volume  was  also 
•evident  in  other  muscles  of  the  forearm.  The  individual  muscle 
£bres  were  of  the  same  size  on  the  two  sides,  but  on  the  left  they 
were  fewer  in  number.  The  pronator  teres  and  pronator  quadratus 
had  disappeared  on  the  left  side,  their  usual  position  being  occupied 
by  an  aponeurotic  layer.  The  right  median  nerve  contained  nineteen 
bundles  of  fibres,  the  left  sixteen,  but  the  individual  nerve  fibres 
showed  no  degeneration.  The  bones  on  the  left  side  were  altogether 
smaller  than  on  the  right,  but  their  structure  was  the  same.  The  an- 
terior horn  of  the  spinal  cord  in  the  cervical  region  was  smaller  on 
the  left  side  than  on  the  right,  and  in  one  section  of  actual  count  there 
were  found  thirty-five  cells  in  the  right,  only  eighteen  in  the  left  an- 
terior horn.  In  the  brain,  the  right  ascending  parietal  convolution 
was  slightly  narrower  than  the  left.  Allen. 

150.  Alimentaere  Glycosurie  bei  Krankheiten  des  Centralnerven- 
SYSTEMS  (Alimentary  Glycosuria  in  Diseases  of  the  Central  Nervous 
System).  Von  Oordt  (Miinchener  Medicin.-Wochenschrift,  i,  1898, 
p.  2). 

The  author  examined  the  urine  of  178  patients  suffering  from 
different  diseases  of  the  nervous  system,  both  functional  and  organic, 
after  having  caused  to  be  ingested  in  each  case  grape  sugar — 100  grm. 
dextrose — under  suitable  precautions  against  error.  The  Trommer, 
Nylander,  Phenylhydrazin  and  Tenreatatich  tests  were  used  and 
the  sugar,  when  present,  was  determined  quantitatively  by  the 
polariscope.  He  draws  the  following  conclusions.  Alimentary 
glycosuria  occurs  in  a  certain  percentage  of  cases. 

a.  In  diseases  of  the  structures  within  the  cranial  cavity,  and  is 
here  caused,  partly  by  encroachment  upon  the  "diabetes  centre," 
partly  by  central  disturbances"  of  nutrition  resulting  from  encroach- 
ment upon  the  cranial  space,  pain,  psychical  disturbances  and  differ- 
ent reflex  processes. 

b.  In  a  group  of  functional  neuroses,  neurasthenia,  hysteria  and 
traumatic  neuroses. 

It  does  not  occur  in  a  number  of  other  neuroses,  in  true  epilepsy; 
generally  not,  in  diseases  of  the  spinal  cord,  where  there  is  no  in- 
volvement of  the  medulla.  Alimentary  glycosuria  can  pass  into 
spontaneous  glycosuria.  Allen. 

151.  1st  die  progressive  Paralyse  aus  den  microscopischen  Befun- 
DEN  AN  der  Grosshirnrinde  pathologisch-anatomisch  diagnosti- 
ciRBAR  (Can  General  Paresis  be  Diagnosed  with  the  Microscope). 
O.  Schmidt  (AUgemeine  Zeitschrift  fiir  Psychiatrie,  54,   1S97-98, 

p.  178). 

The  author  presents  an  excellent  resum^  of  the  various 
pathological  findings  which  have  been  described  by  various  authors 
and  which  have  been  regarded  as  characteristic  of  the  disease.  He 
shows  that  hardly  any  of  the  various  lesions  are  constant.  Thus 
though  the  vessels  are  usually  affected,  they  are  not  always  diseased, 
and  moreover  similar  lesions  have  been  described  in  other  affections. 
The  sclerotic  areas  are  not  constant  and  are  subject  to  much  variation. 
The  newer  researches  on  the  changes  in  the  ganglion  cells  would 
seem  to  offer  the  best  opportunities  for  definite  conclusions,  yet 
these  have  not  been  always  corroborated,  nor  are  they  universal 
The  changes  in  the  nerve  fibres  are  inconclusive  and  the  general 
conclusion  would  seem  to  be  that  a  need  exists  to  differentiate 
anatomical  types  and  correlate  if  possible  the  clinical  phenomena. 

Jelliffe. 


"SooU  "^tvltws. 


Gehirnpathologie.  I.  Allgemeine  Einleitung.  II.  Localisation. 
III.  Ge»irnblutungen.  IV.  Verstopfung  der  Hirnarterien. 
Von  Dr.  C.  v.  Monakow,  A.  O.  Professor  der  Neurologic  an  dor 
Universitat  in  Zurich.  Mit  211  Abbildungen.  Nothnagel's  Spe- 
cielle  Pathologi©  und  Therapie.  Bd.  IX.  Theil  I.  Wien.  1897 
(A.  Holder).     Pp.  I — IX  and  1 — 924. 

This  volume,  from  the  pen  of  a  man  already  famous  for  his  re- 
searches in  human  neurology  and  the  experimental  pathology  of  the 
nervous  system,  Prof.  C.  von  Monakow,  of  Zurich,  merits  more  than 
passing  attention.  No  matter  upon  what  topic  this  investigator  and 
teacher  might  choose  to  dwell,  his  subscription  of  an  article  would 
attract  to  it  the  attention  of  most  neurologists,  but  dealing,  as  the 
book  before  us  does,  in  large  part  directly  with  the  field  in  which  its 
author's  own  investigations  and  experiments  have  been  most  fruitful, 
its  advent  will,  we  feel  sure,  be  everywhere  greeted  with  enthusiasm. 

The  volume  forms  a  part  of  the  elaborate  system  which  has  for 
some  time  been  appearing  under  the  editorial  supervision  of  Prof. 
Nothnagel,  of  Vienna.  The  system  as  a  whole  is  an  exceedingly 
strong  collection  of  monographs,  and  really  does  much,  along  with 
a  few  others  which  could  be  mentioned,  to  redeem  this  method  of 
medical  publication  from  the  disrepute  into  which  it  was  fast  being 
driven;  for  the  superficial  compilations,  hurriedly  thrown  together, 
which,  under  the  names  of  systems  and  handbooks,  have  been  dis- 
seminating loose  and  indifferent  medicine  and  worse  rhetoric  in  this 
and  other  countries  for  some  time  past,  bade  fair  to  condemn  it 
utterly.' 

Von  Monakow's  book,  as  its  title  indicates,  is  divided  into  four 
principal  parts.  Under  the  first  heading,  the  General  Introduction  to 
Cerebral  Pathology,  he  considers:  At  the  Anatomy  of  the  Brain; 
B,  the  Physiology  of  the  Brain;  C,  the  General  Pathology  of  the 
Central  Nervous  System,  and  D,  the  Clinical  Manifestation  of  Or- 
ganic Diseases  of  the  Brain. 

The  sub-section  dealing  with  the  anatomy  of  the  brain  makes 
interesting  reading.  Although,  from  the  nature  of  the  book,  of  necessity 
brief,  reference  will  be  found  to  the  principal  well-established  facts. 
After  a  short  introduction,  in  which  the  phylogeny  and  ontogeny  of 
the  nervous  system  are  considered,  the  author  immediately  passes  on 
to  a  description  of  the  morphological  constituents,  the  principal 
centres  and  important  bundles  of  fibres  of  the  adult  brain.  The  sulci 
and  gyri  of  the  pallium,  the  basal  ganglia,  the  projection-fibres,  com- 
missures and  association  bundles  all  receive  due  attention.  The  ac- 
count given  of  the  diencephalon,  mesencephalon  and  rhombencephalon 
is  brief,  but  being  entirely  free  from  padding  will  be  found  suffi- 
ciently full  for  most  of  the  needs  of  the  clinician.  The  text  is  accom- 
panied by  simple  but  helpful  anatomical  illustrations. 

The  neurological  histologist  will  perhaps  complain  of  the  small 
amount  of  space  allotted  to  the  "elements  of  the  nervous  system,"  and 
it  must  be  admitted  that,  even  bearing  in  mind  only  the  needs  of  the 
practical  man,  this  section  might  have  been  lengthened  with  advan- 
tage.    One  gains  the  impression,  which  is  probably  true,  that  von 


830  BOOK  RE!/J£^S. 

Monakow  has  been  more  interested  in  experimental  physiology  and 
pathology,  and  the  study  oi  cases  of  secondary  degeneration,  than 
in  the  application  o(  modern  cytotogical  methods  to  the  investiga- 
tion of  the  structure  of  the  nerve  cells. 

The  general  architectonics  of  the  nervous  system  are,  on  the 
other  hand,  very  satisfactorily  examined,  and  the  author  is  to  be 
ctingratulaled  upon  his  concise  and  clear  presentation  of  the  con- 
ception of  the  neurone-compiexes — the  grouping  together  of  neurones 
to  form  special  functional  elementary  mechanisms.  This  is  pre- 
ceded by  a  somewhat  detailed  account  of  the  principal  methods  em- 
ployed in  the  investigation  o(  the  finer  cerebral  architecture.  The 
methods  of  serial  sectioning,  of  comparative  anatomy,  of  ontogeny, 
including  the  following  of  myelinization  in  serial  sequence,  llie 
method  of  Golgi  and  its  modifications,  are  in  turn  referred  to.  As 
might  be  expected,  much  stress  is,  and  with  right,  laid  upon  the  im- 
portance of  the  study  of  secondary  degenerations  in  the  tissues  de- 
rived from  human  beings,  who,  during  life,  have  suffered  from  lesions 
of  the  nervous  system,  which  have  been  carefully  studied  at  the  bed- 
side. It  is  by  means  of  such  studies  and  of  similar  ones  upon 
tissues  derived  from  experimental  animals  that  von  Monakow  him- 
sell,  following  upon  von  Gudden.  has  been  able  to  contribute  so  lib- 
erally to  the  general  stock  of  neurological  knowledge.  The 'method 
of  investigation  based  upon  an  examination  of  suitable  instances  of 
congenital  malformations  also  receives  its  fair  share  of  praise.  It 
will  be  recalled  that  it  was  by  this  method  that  von  Leonowa,  work- 
ing with  von  Monakow.  proved  that  the  spinal  ganglia,  with  (heir 
ganghon-cells,  and  peripheral  and  central  nerve  fibres  along  with  a 
complete  muscular  system,  can  become  developed  in  the  entire  ab- 
sence of  the  spinal  cord. 

The  classification  given  by  von  Monakow  of  the  gray  matter,  and 
of  the  white  matter  is  new;  the  novelty  consists,  not  in  the  dis- 
tinction of  the  nuclei  of  origin  of  the  motor  and  sensory  nerves,  and 
in  the  recognition  of  the  nuclei  terminales  of  the  central  axones  of 
the  spinal  and  cerebral  peripheral  sensory  neurones,  for  these,  since 
the  embryological  studies  of  His,  have  met  with  general  acquiescence, 
but  rather  in  the  grouping  of  certain  gray  masses  in  the  diencephalon, 
mesencephalon  and  rhombencephalon  as  cerebral  appanages  or  de- 
pendencies (Grosshirnantheile).  Under  the  designation  Grosshirn- 
antheile  von  Monakow  includes  all  those  structures  which,  though 
anatomically  not  always  consisting  of  homogeneous  masses  of  gray 
substance,  still  in  their  functions  as  well  as  in  their  whole  economy 
(nutrition)  are  wholly  or  partially  dependent  upon  the  cerebral  cortex. 
These  gray  masses  are  evidently  phylogenetically  young,  for  they  are 
absent  in  lower  forms  and  increase  progressively  in  size  and  number 
in  direct  prooortion  to  the  development  of  the  cerebrum.  Here,  in 
the  first  place,  are  classed  by  von  Monakow  the  majority  of  the  nuclei 
of  the  thalamus,  and  especially  the  corpora  geniculata  (lateral  and 
medial)  of  the  two  sides.  The  substantia  nigra,  certain  elements  in 
the  superior  colliculi,  pons  and  medulla  also  come  in  this  category. 
This  view,  which,  it  may  be  recollected,  has  been  more  than  once  ad- 
vanced on  previous  occasions  by  the  same  author  in  special  articles, 
also  assumes  that  the  majority  o(  while  fibres  extending  between  the 
cerebral  dependencies  and  the  cerebral  cortex  are  corticopetal.  not 
corticofugal  in  direction.  Other  neurologists  have  held  this  view 
with  regard  to  the  corpora  geniculata,  bttt  the  theory  is  not  in  har- 
mony with  prevalent  conceptions  regarding  many  of  the  thalamic 
nuclei.  Should  it  prove  to  be  true,  as  von  Monakow  apparently  be- 
lieves,   that  all   of  the  thalamo-cortical  axones  are  corticopetal   in 


BOOK  REVIEWS.  83 1 

direction,  and  further,  that  the  bundle  of  axones  from  each  nucleus 
of  the  thalamus  is  distributed  to  a  perfectly  definitCt  circumscribed 
and  ascertainable  cortical  area,  then  the  hypotheses  held  by  many 
neurologists  with  regard  to  the  nature  and  functions  of  the  thalamus 
and  with  regard  in  general  to  the  relations  existing  between  the 
diencephalon  and  telencephalon  will  have  to  be  materially  altered. 
At  present,  however,  it  seems  scarcely  safe  to  deny  the  existence  of 
€very  and  any  corticofugal  connection  between  the  pallium  and  the 
thalamus. 

While  von  Monakow's  treatise  is  on  the  whole  remarkable  for 
its  accuracy  and  carefulness  of  statement,  still  one  or  two  points  to 
which  exception  might  be  taken  are  observable.  In  the  first  place, 
the  bundle  of  medullated  axones  formed  by  the  descending  limbs 
of  bifurcation  of  the  central  axones  of  the  peripheral  sensory  neurones 
which  correspond  to  the  sensory  portion  of  the  N.  trigeminus 
is  spoken  of  as  a  rule  as  the  "aufsteigende  Wurzel."  although  the 
author  is  careful  to  say  that  the  fibres  arise  from  the  Gasserian  gan- 
glion and  that  they  terminate  in  the  medulla.  Why  the  majority  of 
German  writers,  and  it  must  be  confessed  also  a  goodly  number  of 
English  neurologists,  persist  in  designating  as  ascending  root  a  bundle 
which  they  certainly  know  consists  of  descending  fibres  is  difficult  to 
understand.  Any  one  who  lias  taught  the  anatomy  of  the  nervous 
system  to  medical  students  knows  that  the  difficulties  of  neurological 
instruction,  especially  with  regard  to  the  direction  followed  by  the 
axones  of  the  various  fasciculi,  are  sufficiently  great  even  when  the 
nomenclature  applied  is  entirely  rational.  It  is  but  little  wonder  that 
students  resent  being  told  that  the  axones  of  an  ascending  root 
descend!  Might  it  not  be  well  to  do  away  then  with  the  false  term, 
especially  since  it  can  be  replaced  by  the  entirely  satisfactory  "tractus 
spinalis  nervi  trigemini."  ? 

The  description  given  by  von  Monakow  of  the  vestibular  nuclei 
in  the  rhombencephalon  is,  in  the  opinion  of  the  reviewer,  open  to 
serious  criticism.  The  nuclei  terminales  seem  to  be  confused  in  the 
text  (p.  82)  with  the  nuclei  originis  of  the  nerve,  a  matter  of  little  im- 
portance perhaps  to  a  reader  of  much  experience  (for  is  not  similar 
confusion  omnipresent  in  neurological  bibliography?),  but  most  un- 
fortunate for  the  less  advanced  student.  Part  of  the  vestibular  nerve 
arises,  von  MonakoM  states,  in  the  medulla;  the  nerve,  he  emphasizes, 
has  nothing  to  do  with  Deiters'  nucleus,  but  arises  in  the  main  from 
Bechterew's  nucleus!  He  admits  that  a  part  of  the  vestibular  nerve 
has  its  origin  in  Scaroa's  ganglion.  The  report  in  this  connection 
will,  we  feel  sure,  be  materially  altered  in  a  second  edition. 

Objection  might  with  justice  be  made  to  the  description  on  p. 
114,  in  which  the  so-called  N.  opticus  is  assumed  to  be  homologous 
with  the  peripheral  sensory  nerves;  and  to  that  on  p.  128,  in  which 
the  path  underlying  the  impulses  concerned  in  visual  perceptions  is 
designated  as  "zweigliederig."  but  these  are  minor  criticisms  and 
too  much  stress  is  not  to  be  laid  upon  them. 

In  sub-section  B,  the  physiology  of  the  brain  is  dealt  with.  After 
emphasizing  the  extraordinary  importance  of  animal  experiment  for 
the  investigation  of  the  cerebral  functions,  a  portion  of  the  work 
which,  by  the  way,  might  be  read  ^yith  advantage  by  those  who  are 
still  in  doubt  as  to  the  utility  and  justifiableness  of  vivisection,  the 
author  treats  of  the  diflFerences  of  function  in  the  various  gross  sub- 
divisions of  the  brain  in  different  groups  of  animals.  For  though 
telencephalon,  diencephalon,  mesencephalon,  metencephalon  and 
myelencephalon  are  in  a  large  series  of  animals  to  be  regarded  as 
derivatives  of  similar  portions  of  the  primitive   medullary  tube,   yet 


832 


BOOK  REVIEWS. 


they  are  by  no  means  always  exactly  homologous.  On  the  contrary 
they  differ  markedly  in  the  individual  representatives  of  the  vertebrate 
series,  not  only  quantitatively  but  also  qualitatively  in  degree  of  de- 
velopment, and  in  the  significance  of  each  of  the  parts  for  the  neural 
economy.  In  this  connection  von  Monakow  calls  attention  especially 
to  the  experimental  results  of  Steiner  and  Schrader  on  lower  forms, 
and  of  von  Gudden,  Goltz,  Horsley  and  Schaefer,  Munk  and  others 
on  higher  forms.  He  concludes  that  the  difference  in  behavior  of 
animals  after  cerebral  defect  corresponds  completely  to  the  morpho- 
logical differences  in  the  foundations  and  memberment  of  the  indi- 
vidual cerebral  centres.  The  lower  an  animal  stands  phylogenetically, 
the  less  does  the  intelligence,  sensation  and  locomotion  of  the  animal 
suffer  from  removal  of  the  cerebrum.  If  cerebral  removal  does  give 
rise  to  symptoms  of  this  sort,  they  concern  in  the  lower  forms  first 
the  intelligence  and  the  spontaneous  taking  of  food,  and  only  later 
in  higher  forms  (with  gradually  increasing  intensity)  are  the  indi- 
vidual senses  injured,  especially  that  of  sight;  serious  disturbance  of 
gross  locomotion  does  not  result  from  cerebral  defect  until  the  highest 
phylogenetic  stages  have  been  reached.  Von  Monakow,  therefore, 
views  with  favor  the  theory  advanced  by  Steiner  when  he  defines  a 
brain  to  be  a  general  movement  centre,  in  connection  with  the  activi- 
ties of  a  nerve  of  special  sense.  Wherever  these  conditions  meet, 
there  a  brain  exists.  The  higher  the  animal,  the  farther  forward  the 
centres  of  control  (Wanderung  der  Function  nach  dem  Vorderende). 
Von  Monakow  extends  the  conception  of  Steiner  by  utilization  of 
anatomical  and  physiological  studies,  classifying  the  centres  as  "phy- 
logenetically  old"  and  "phylogenetically  young."  By  the  former  he 
means  the  fundamental  neural  structure,  already  indicated  in  Amo- 
ccetes,  which  contains  all  the  mechanisms  necessary  for  primitive  or 
"mechanical"  life;  this  structure  is  characterized  by  the  tolerably 
great  functional  independence  of  its  parts  (mid-brain,  hind-brain, 
after-brain).  By  the  latter  he  means  the  "supplementary"  structure, 
represented  by  the  cerebral  cortex  and  the  regions  of  the  cerebrum 
dependent  upon  this  and  developed  in  direct  proportion  to  it,  namely, 
his  Grosshirnantheile.  This  supplementary  structure,  which  attains 
to  its  highest  development  in  man,  is  further  characterized  by  the 
principle  of  the  strict  subordination  of  the  so-called  Grosshirnantheile 
to  the  cerebrum,  and  the  principle  of  the  co-operation  of  several  por- 
tions  of  the  brain  anatomically  widely  separated  from  one  another. 

For  each  of  the  organs  of  special  sense  there  would  appear  to  be 
two  anatomically  separated  nuclei  of  reception  in  the  cerebrum,  one 
phylogenetically  old,  the  other  phylogenetically  young.  It  is  espe- 
cially through  the  latter  that  the  connection  for  the  cerebral  cortex  is 
made.  In  man,  for  the  reception  of  sensory  pictures  and  for  the 
majority  of  complex  reflex  acts  which  are  acquired  through  the 
intervention  of  consciousness,  it  is  the  phylogenetically  young  struc- 
ture which  is  active.  In  lower  forms  the  young  and  old  centres  are 
very  incompletely  differentiable  anatomically,  while  in  the  lowest  ver- 
tebrates the  phylogenetically  young  centres  appear  to  be  entirely 
absent.  Thus  in  connection  with  the  optic  neurones,  the  mesencepha- 
lic terminations  of  the  N.  opticus  would  correspond  to  the  phyloge- 
netically old  center,  while  the  diencephalic  terminations  (in  the  corpus 
geniculatum  laterale  and  the  pulvinar  of  the  thalamus)  would  corre- 
spond to  the  phylogenetically  young  centre.  In  fish  the  whole  N.  oo- 
ticus  terminates  in  the  roof  of  the  mesencephalon;  the  diencephalic 
termination  is  met  with  first  in  birds  (Edinger);  in  man  the  mesen- 
cephalic termination  by  means  of  the  brachium  quadrigeminum  su- 
perius  is  relatively  insignificant,  while  the  terminations  in  the  corpus 


BOOK  REVIEWS. 


833 


geniculatum  laterale  and  pulvinar  and  the  connections  by  way  of  these 
through  the  radiatio  occipitothalamica  Gratioleti  with  the  cortex  of 
the  lobus  occipitalis  are  developed  ad  maximum. 

By  all  means  the  best  portion  of  the  sub-section  under  considera- 
tion, however,  is  the  extensive  review  of  the  results  of  physiological 
experiment  upon  the  cerebral  cortex.  As  might  have  been  expected, 
the  discussion  here  is  masterously  handled,  and  the  reader  is  led  in 
an  orderly  manner  through  the  various  researches  dealing  with  elec- 
trical excitation,  and  extirpation  of  points  and  areas  of  the  cortex. 
The  cortical  areas  of  the  so-called  motor  zone,  those  for  cutaneous 
and  muscular  sense,  those  for  vision  and  those  for  hearing  are  suc- 
cessively considered,  and  the  sub-section  closes  with  some  remarks 
upon  the  restitution  of  cortical  functions  after  cerebral  defect,  to- 
gether with  brief  reference  to  the  doctrines  of  "association  centres*' 
in  the  brain  as  formulated  by  Flechsig. 

The  general  pathology  of  the  central  nervous  system  is  next  taken 
up.  The  author's  classification  of  cerebral  diseases  rs  given  on  p. 
227.  He  divides  them  into  four  groups:  i.  General  or  partial  dynamic 
disturbances  (including  the  "functional  diseases").  2.  Diffuse  and  lo- 
calized diseases  of  the  brain  and  its  membranes  of  circulatory  and  in- 
flammatory nature.  3.  System-diseases,  and,  4.  Focal  diseases  of  the 
brain  and  its  membranes.  Only  those  of  the  fourth  category  are  con- 
sidered in  the  volume  before  us  (and  of  those  practically  only  the 
diseases  dependent  upon  arterial  alterations),  the  other  diseases  of 
the  cerebrum  being  dealt  with  by  various  writers  in  other  portions  of 
Nothnagel's  System. 

The  paragraphs  upon  pathological  alterations  in  the  ganglion- 
cells,  like  those  dealing  with  the  normal  histological  appearances  of 
these  structures,  will  scarcely  prove  satisfactory  to  those  whose  inter- 
est and  research  are  directed  chiefly  toward  such  problems.  Still,  the 
principal  points  are  mentioned,  and  it  is  worthy  of  note  that  the 
author  includes  certain  important  conditions  not  infrequently  met 
with  which  are  too  often  overlooked  by  investigators  who  are  entirely 
under  the  spell  of  methylene  blue  and  soap. 

One  turns  naturally  with  much  expectation  of  thoroughness  to 
the  chapter  on  secondary  degeneration,  and  in  so  doing  does  not 
meet  with  disappointment.  This  portion  of  the  book  is  admirable. 
The  origin,  course  and  significance  of  the  degenerative  process  are 
fully  described.  Not  onFy  is  the  secondary  degeneration  in  the  sense 
of  Waller  properly  valued,  but  the  cellulipetal  degeneration  following 
injury  to  an  axone,  and  the  alterations  in  the  cell-body  of  the  neurone 
due  to  such  causes  are  clearly  described.  The  secondary  alterations 
resulting  from  the  application  of  the  method  of  von  Gudden  receive 
especial  attention.  The  finer  histological  changes  are  illustrated  by 
drawings. 

The  atrophy  of  the  II.  Order,  or  so-called  tertiary  atrophy,  for 
example  such  as  affects  the  diencephalo-telencephalic  neurones  ex- 
tending from  the  corpus  geniculatum  laterale  to  the  lobus  occipitalis 
after  enucleation  of  an  eye,  or  that  which,  after  defect  of  the  lobus 
parietalis,  concerns  the  neurones,  the  cell-bodies  of  which  are  situated 
in  the  nuclei  funiculi  gracilis  et  cuneati,  is  clearly  distinguished  from 
ordinary  secondary  degeneration;  the  process  is  here  so  sharply  char- 
acterized that  there  can  no  longer  be  any  excuse  for  the  confusion 
which  has  unfortunately  marred  many  contributions  to  the  literature 
of  this  subject  in  the  past.  Von  Monakow,  at  the  conclusion  of  the 
pages  dealing  with  the  degenerations,  cites  some  of  the  more  im- 
portant examples  of  secondary  degeneration  in  the  brain  of  man  and 
the  higher  animals  after   extensive   cerebral   lesion,   especially   those 


«34 


BOOK  REVIEWS. 


which  are  of  value  from  a  clinical  standpoint  or  of  particular  interest 
for  general  pathology. 

ro  the  clinician  the  portion  of  the  book,  amounting  to  something 
more  than  loo  pages,  dealing  with  the  clinical  characters  of  organic 
diseases  of  the  brain  will  prove  unusually  attractive.  The  author  di- 
vides these  into:  (a)  Phenomena  of  a  general  nature  (including  head- 
ache, vertigo,  respiratory  disturbances,  alterations  in  the  temperature 
and  circulation,  vomiting,  and  finally  disturbances  of  a  psychic  na- 
ture); and  (b)  Focal  phenomena  (motor,  ataxic,  sensory  And 
trophic).  His  profound  anatomical  and  physiological  knowledge  here 
stands  him  in  good  stead,  and  the  clinical  symptoms  of  cerebral  dis- 
ease are,  as  far  as  present  knowledge  will  permit,  supplied  with 
rational  explanations. 

The  second  principal  part  of  the  book  treats  of  Cerebral  Locali* 
zation,  a  topic  which,  considering  its  complexity,  the  immense  bib- 
liography pertaining  to  it,  and  the  uncertainty  which  still  exists  with 
regard  to  many  fundamental  points,  is  most  satisfactorily  handled. 
Everywhere  one  sees  the  hall-mark  of  a  rich  personal  experience,  and 
one  cannot  help  wishing,  after  reading  such  an  article,  that  medical 
publications  in  general  could  in  some  way  be  limited  to  those  ema- 
nating from  men  who  have  some  actual  first-hand  knowledge  of  the 
things  of  which  they  write. 

The  motor  region,  the  parietal  lobe,  the  visual  area,  the  frontal 
gyri,  are  in  turn  dealt  with,  and  the  effects  of  gross  and  minute  lesions 
described  in  detail.     Of  enormous  value  are  the  individual  cases  cited 
in   which,   following   upon    a    thoroughly   conducted    clinical    study 
during  life,  there  has  been  a  modern  autopsy  with  not  simply  macro- 
scopic examination  of  the  central  nervous  organs,  but  also  a  thorough 
study  of  serial  sections  with  the  micr'oscope.     The  time  has  gone  past 
when  the  old-time  slicing  up  of  a  brain  at  a  post  mortem  examination 
can  advance  our  knowledge  of  cerebral  pathology.     It  is  necessary 
now,  in  order  to  make  progress,  to  determine  exactly  not  only  the 
actual  nature     and  limits  of  cortical  or  ganglionic  involvement  in  a 
given  case,  but  also  to  establish  definitely  the  extent  of  the  disease  in 
the  white  matter,  and  to  decide  how  much  of  this  is  due  to  the  di- 
rect encroachment  of  the  primary  pathological  process  and  how  much 
of   it   represents   disease     of  a   secondary   nature.     Von    Monakow*s 
laboratory,  in  Ziirich.  has  been  especially  active  in  the  sectioning  of 
pathological  human  brains  and  has  set  an  example  to  the  world  of 
what  far-reaching  results  may  be  obtained  from  accurate  studies  of 
this  kind.     One  brain  fully  described  in  this  way  is  worth  a  hundred 
incomplete  reports.     Since  the  author,  in  this  subdivision  of  his  work, 
has  not  only  carefully  weighed  his  own  results,  but  has  instituted  a 
comparison  with  those  of  others,  the  frequent  consultation  of  these 
pages   by    both    clinicians   and    pathologists    may   be   predicted   with 
confidence.     It  would -require  more  space  than  that  at  our  disposal  to 
attempt  an  analysis  of  the  various  lesions  dealt  with  here.     Perhaps 
the  most  interesting  section,  though  it  seems  invidious  to  select,  is 
that  dealing  with  disturbances  in  the  central  visual  apparatus,  under 
which   heading  hemianopsia,    hemichromatopsia.   cortical   and   mind- 
blindness,  alexia  and  optic  aphasia  are  discussed.     The  hypothesis  of 
the  Ziirich  neurologist  with  regard  to  the  explanation  of  the  behavior 
of  the  macula  in  hemianopsia  is  pleasing,  but  the  anatomical  proof  has 
still  to  be  brought. 

The  chapters  dealing  with  the  localization  of  disturbances  of 
speech  of  cortical  origin  are  worthy  of  being  reprinted  in  the  form 
of  a  separate  monograph.  It  is  in  these  that  the  scientific  openness 
of  mind  of  the  author  is  perhaps  most  in  evidence.       The  deliberate 


BOOK  REVIEWS.  835 

presentation  of  objective,  clinical  and  pathological  facts  to  the  exclu- 
sion as  far  as  possible  of  the  schemata  and  hypotheses  which  abound 
m  works  on  aphasia  is  matter  for  gratitude.  True,  to  the  beginning 
medical  student,  one  or  another  of  the  various  schemes  of  aphasia  is 
doubtless  helpful,  but  to  the  man  who  attempts  to  gain  a  deeper 
knowledge  of  the  subject,  the  method  of  inquiry  which  moulds  its 
conceptions  on  realities  is  of  far  greater  value.  And  after  all,  may 
not  "students  of  the  better  sort"  have  some  books  written  for  them? 
There  is  reason  to  be  thankful  that  there  are  certain  books,  like  this 
of  von  Monakow's,  that  are  something  more  than  milk  for  babes! 
The  clinical  types  of  aphasia  ordinarily  met  with  are  first  described 
at  some  length,  and  afterwards  the  pathological  anatomy  of. the  dis- 
turbances of  speech,  and  the  finer  localization  within  the  speech  re- 
gion of  the  cortex  are  undertaken.  This  method  of  handling  the 
material  necessarily  leads  to  considerable  repetition,  but  with  a  sub- 
ject which  is  even  yet  obscure,  notwithstanding  the  strenuous  efforts 
which  have  been  made  to  illuminate  it,  rehearsals  of  known  facts, 
especially  when  viewed  from  different  visual  angles,  are  not  only 
permissible  but  desirable.  If  the  reader  were  to  carry  away  with  hinf 
no  more  than  a  vivid  impression  of  the  possible  variability  of  the 
clinical  picture  in  aphasia  and  a  consciousness  of  the  inadequacy  of 
all  attempts  thus  far  made  to  afford  a  satisfactory  anatomical  explana- 
tion for  the  various  clinical  types,  the  perusal  of  these  pages  would  be 
well  worth  the  while. 

The  section  on  localization  includes  also  a  discussion  of  lesions 
in  the  capsula  interna,  the  basal  ganglia,  the  cerebral  peduncle,  the 
corpora  qi|adrigemina,  the  pons  and  the  cerebrum,  and  closes  with 
an  exhaustive  analysis  of  internal  and  external  ophthalmoplegia. 

The  last  two  sections  of  the  work  deal  with  cerebral  hemorrhages 
and  with  embolism  and  thrombosis  of  the  cerebral  arteries.  The 
anatomy  of  the  cerebral  circulation  is  fully  described,  the  descriptions 
being  accompanied  by  excellent  illustrations,  many  of  which  are  in 
colors.  The  pathology  and  symptomatology  of  these  affections  are 
thoroughly  gone  into,  not  only  in  general,  but  with  especial  reference 
to  lesions  involving  single  arteries  and  their  branches.  Nor,  as  some- 
times happens  with  writers  well  versed  in  pathology  and  diagnosis, 
have  the  sections  on  prognosis  and  therapy  been  neglected.  The  prac- 
tical man,  who  wishes  to  know  exactly  what  to  do,  not  only  in  cere- 
bral emergencies,  but  also  in,  the  often  more  puzzling  after-care  of  a 
case,  will  find  here  explicit  instructions  for  his  guidance.  A  judi- 
ciously selected  list  of  titles  of  original  articles  adds  to  the  value  of 
the  various  sub-divisions  of  the  work. 

The  publishers  have  done  their  part  well.  The  introduction  of 
colors  into  the  figures  in  the  text  makes  decidedly  for  clearness.  An 
occasional  misprint  meets  the  eye.  for  example  "heriditaren"  on  p. 
220,  and  "Nouronencomplexen"  on  p.  225,  but  considering  the  size 
of  the  work  and  the  rapidity  with  which  it  must  have  been  written 
and  put  through  the  press,  misprints  are  remarkably  few  in  number. 

On  the  whole,  von  Monakow's  boak  represents  a  most  valuable 
contribution  to  cerebral  pathology,  and  can  be  warmly  recommended 
to  all  who  are  interested  in  the  healthy  or  diseased  human  brain. 

Lewellys  F.  Barker. 

Leitfaden    dek    PHVsu)LO(;isrnKN    Psv(  Hoi.o(;iE.     In  15  Vorlesungen, 

von  Prof.  Dr.  Th.  Ziehen  in  Jena,  mit  23  Abbildungen  im  Text. 

Vierte  theilweise  umgearbeitete  Auflage.     Gustav  Fischer,  Jena. 

1898. 

For  the  alienist  this  present  volume  is  one  of  the  most  useful 
introductions  to  the  study  of  psychological  phenomena  that  we  have 


836 


BOOK  REVIEWS. 


had  the  pleasure  of  seeing.  The  author  allies  himself  most  dis- 
tinctly with  the  English  psychologists  as  opposed  to  the  teachings 
of  Wundt  in  his  "apperceptionslehre."  That  such  a  method  of  in- 
terpretation has  great  advantages  from  the  practical  point  of  view, 
the  results  of  the  teachings  of  Ziehen's  earlier  editions  is  abundant 
evidence.  The  psychology  of  Ziehen  is  distinctly  not  the  old 
speculative  introspective  psychology  of  many  writers,  even  modern:  it 
is  pure  physiological  psychology  or,  as  he  would  seem  to  prefer  the 
name,  psycho-physics:  a  study  of  those  psychical  processes  with 
especial  reference  to  their  physiological  accompaniments:  processes 
capable  of  being  measured.  And  in  his  fifteen  chapters  he  gives 
methods  of  determining  quantitative  and  qualitative  differences  in 
psychical  'processes.  He  first  discusses  general  considerations;  the 
five  following  take  up  the  primary  types  of  sensation.  Chapter 
6,  on  sight,  has  been  much  enlarged  and  rewritten,  constituting  a 
distinctly  new  treatment  of  the  subject.  Chapter  8,  on  memory 
images  and  the  formation  of  concepts,  is  mostly  recast.  Chapters  lo, 
II  and  12  treat  of  association  of  ideas  and  of  attention,  the  subject 
of  the  ego  and  of  memory.  Chapter  13  deals  with  sundry  psycho- 
physical phenomena,  somnambulism,  hypnotism,  etc.,  while  chapters 
14  and  15  discuss  motor  expression  and  activities,  speech  and  the 
will.    This  present  edition  is  certainly  to  be  much  commended. 

Jelliffe. 


BOOKS  RECEIVED. 


"An  American  Text-Book  of  Gynaecology,*'  edited  by  J.  M.|Baldy, 
M.  D.    W.  B.  Saunders,  Philadelphia. 

"A  Clinical  Text- Book  of  Medical  Diagnosis,"  by  Oswald  Vier- 
ordt,  M.  D.,  and  Francis  H.  Stuart,  A.  M.,  M.  D.  W.  B.  Saunders, 
Philadelphia. 

"An  American  Text-Book  of  the  Diseases  of  Children,"  by  Louis 
Starr,  M.  D.    W.  B.  Saunders.  Philadelphia. 

"A  Text-Book  of  Materia  Medica,  Therapeutics  and  Pharma- 
cology," by  Geo.  F.  Butler,  Ph.  G.,  M.  D.  W.  B.  Saunders,  Phila- 
delphia, Pa. 

"Clinical  Lectures  on  Mental  Disea.ses,"  by  T.  S.  Clouston,  M.  D. 
Lea  Bros.  &  Co.,  Philadelphia  and  New  York. 

"The  Royal  Road  to  Health,"  by  Chas.  A.  Tyi^rell,  M.D. 

"State  of  New  York;  State  Commission  in  Lunacy;  Ninth  Annual 
Report". 

"The  Sexual  Instinct  and  Its  Morbid  Manifestations,",  by  Dr.  B. 
Tarnowsky.    Chas.  Carrington,  Paris. 

"Vermischte  Aufsatze,"  von  P.  J,  Mobius.    J.  A.  Barth,  Leipzig. 

"Arbeiten  aus  dem  Gesammtgebiet  der  Psychiatrie  und  Neuro- 
pathologie,"  von  R.  Krafft-Ebing.    J.  A.  Barth,  Leipzig. 

"Die  Leitung  der  Electricitat  im  lebenden  Gewebe,"  von  Dr.  Fritz 
Frankenhauser.    A.  Hirschwald,  Berlin. 

"Degenerados  Criminosos,"  estodo  por  Manoel  Bernardo  Calmon 
du  Pin  e  Almeida.    V.  Oliveira  &  Co.,  Bahia. 

"Untrodden  Fields  of  Anthropology."     Chas.  Carrington.  Paris. 

"Les  Actualites  M6dicales."  Les  Etats  Neurastheniques,  formes 
cliniques,  diagnostic,  traitement,  par  Gilles  de  la  Tourette.  Bailliere 
ct  Fils,  Paris,  1898. 

"Psychologic  de  I'instinct  sexuel,"  par  Dr.  J.  Roux.  Bailliere  et 
Fils,  Paris,  1898. 


p(i|ii|P7ii|ii|ii|Pi(nfnfii|M«n|ri|n|ii|ll|li|li||i^|i|||i|||i|||i|||i|f>7"r*n«r<r*r] 

Cocaine  Discoids  "Sdmffdm's" : 

The  Safest,  Most  Efficient,  and  Convenient  Means  ; 
for  'Producing  Local  Anaesthesia. 

Coc&ine  Discoids  consist  of  pure  cocaine  hydrochlorate,  withoat  odmixtnre  of  foreign 

material  to  impair  its  activity,  and  in  quantities  accnrately  determined  by  weight.   Owingto  - 

their  mode  of  manof  actnre.  not  beiog  compressed,  they  dissolre  readilv  in  one  drop  of  water.  ^ 

Instead  of  keeping  on  band  ready-made  solutions,  which  are  liable  to  detenorate,  the 

doctor  has  how  at  his  disposal  a  means  of  obtaining  * 

Preohly  Prepared  Cocaine  Solutions  of  Any  Desired  Strength  * 

at  a  moment's  notice,  and  the  quantity  of  the  drag  employed  during  ansesthesia  ia  always  * 

known,  and  not  a  matter  of  conjecture.  ^ 

Cocaine  Discoids  are  indicated  in  all  conditions  demanding  the  use  of  this  drug,  as  a 

local  aniesthetic,  as  in  the  treatment  of  diseases  of  the  eyes,  nose  and  throat,  in  general  • 

surgery,  and  in  dentistry,  especially  for  cataphoresis.  ^ 

Discoids  containing  4  gr.  .14  .SO 

"                "         Igr.  .16  .56 

"                "          i  gr-  -16  .60 

"                "         igr-  .18  .70 

Cocaine  Discoids  are  manufactured  solely  by  . 

Schieffelin  8  Co.,  New  Yak.   ■_ 

L.1.., »,..»,.  1.,  t. ,  t, ,  i.„  »„ »..,  t„  t. ,  t„ »..,  1...  ■■ , ». ,  t, .  t, .  t, .  i.  ■>,  ,1. ,  t„  t,.a 


ii|iii;ii|iii|iii;iiijfi;w|W|Wtw|Wfi;wri;TiiW|iif<;wrtp<pi<>i)W^ 

Sddeffelin's 

c/llkaline  c/lntiseptic  and  'Prophylactic, 

Bensotyptus  is  an  agreeabte  Alkaline  solution  of  various  highly 
approved  antiseptics,  so  combined  that  one  supplements  the  action  of 
the  other.    Its  ingredients  are  alt  of  recognixed  value  in  the  treatment 

Catarrhal  c/iffecHons 

becaxtse  of  their  cleansing,  soothing,  and  healing  properties.  Benso- 
typtus is  highly  recommended  in  all  diseases  of  the  nose  and  throat, 
both  acute  and  chronic,  and  as  a  mouth-'wash  and  dentifrice.  It  i$ 
also  indicated  for  internal  use  in  affections  of  the  stomach  and  intes- 
tines tithere  an  agreeable,  unirritating,  and  efficient  antiseptic  and 
Mnt^ermentative  is  required. 
FMmi^>lds  on  apoBcaUm  t 


Schieffelin  &  Co.,  Ne<w  York. 


OV7 


7«f.  26  ISHtembtt  1898 


,  gggtlbe  Journal 

,,       ' /  Of 

i   Metvoud  anb  Cental  S^ieeadc 

TOe  Bmerican  l^eurolodtcal  Hseociation 
TTbe  Devp  l^orft  Deuroloaical  Society?  anD 

Zt)c  pb^a^eIpbia  Deurolooical  ^cieti? 

EDITORS 

Or.  CHARLES  L.  DANA  Dr.  HUQH  T.  PATRICK 

Or.  P.  X.  DERCUM  Dr.  JA5.  J.  PUTNAM 

Or.  CHA5.  K.  MILLS  Dr.  B.  SACH5 

Dr.  M.  ALLEN  STARR 

ASSOCIATE  EDITOR 

Dr.  WILLIAM  Q.  5P1LLER 

MANAQINQ  EDITOR 

Dr.  CHARLES  HENRY  BROWN 

90  W.  45tli  5tr«et.  N«w  York 
TABLE  OP  CONTENTS  ON  PAGES  U.  AND  ly. 

FOREIGN  AND  DOMESTIC  AGENTS 

Berahard  Hermann,  Thalstraase  a,  I^eipzig,  Germany.   S.  Karger,  Charitestr.  3,  Berlin,  Gerauiuy 
Trfibner  &  Co.,  I<udgmte  Hill,  I^ndon.    H*  Stei^rer  &  Co.,  25  Park  Place, 
New  York.     B.  Westermann,  812  Broadway,  New  York. 
Gttstave  E.  Stechert,  9  B.  16th  Street  New  York. 


PRINTED  BY  W.  N.  JENNINGS.  i6a  LEONARD  ST.,  NEW  YORK 


ISSUBD  MONTHLY  $300  PER  YEAR 

Entered  at  the  Post-Office  in  New  York  as  Second-Class  Matter. 

Copyright,  1898. 


1/rv  a,  .f^oJluXMji'U',  -^-W^**  fr^^' 


VOL.   XXV. 


December,  1898. 


THE 


Journal 


OF 


No.  12. 


DEC  12  1898 


Nervous  and  Mental  Disease 


(Drlfiitml  ^vtitUs. 


A  CASE  OF  SYRINGOMYELIA  AND  TWO  CASES 
OF  TABES  WITH  TRUNK  ANAESTHESIA.* 

By  HUGH  T.  PATRICK,  M.D., 

Proiessor  of  Neurology  in  the  Chicago  Po'icliiiic ;   Associate  Professor  of  Nervous 
Diseases,  Northwestern  University  Medical  School,  etc. 

Case  i.-  Syringomyelia.  L.  M.,  a  Swede,  aged  38  years, 
an  iron  moulder,  was  first  seen  December  12th,  1897,  through 
the  kindiness  of  Dr.  G.  W.  Johnson.  He  had  smallpox  when 
six  years  old,  and  a  year  or  two  later  sustained  a  severe  fall, 
which  rendered  him  unconscious  for  four  or  five  hours  and 
bedfast  for  two  or  three  weeks,  but  there  seems  to  have  been 
no  fracture  or  serious  local  injury.  Although  unusually 
strong  previous  to  the  present  affection,  he  had  indtilged  to 
excess  in  alcohol  and  venery,  and  at  the  age  of  27  or  28  con- 
tracted venereal  sores  of  indeterminate  character.  This  was 
repeated  three  years  later,  there  being,,  so  far  as  can  be  learned, 
on  neither  occasion  any  secondaries;  nor  is  there  any  history 
of  subsequent  symptoms  indicative  of  syphilis.  On  several 
occasions  he  had  been  severely  chilled  by  exposure  to  cold 
drafts  when  greatly  heated  by  his  work,  having  fallen  asleep 
where  he  lay  down  to  rest. 

In  his  opinion  the  present  trouble  began  during  the  sum- 
mer of  1889  or  1890.  In  the  spring  of  one  of  these  years  (he  is 
not  certain  which)  he  was  made  foreman,  and  in  consequence 
had  no  occasion  to  do' manual  labor.  In  the  autumn  he  re- 
sumed his  former  work,  and  then  noticed  that  his  back  and 

*Read  at  the  twenty-fourth  annual  meeting  of  the  American  Neu- 
rological Association,  May,  1898. 


838  HUGH  T.   PATRICK. 

arms  were  not  so  strong  as  formerly.  He  had  some  diffi- 
culty in  lifting  and  handling  heavy  objects.  In  all  probability 
the  disease  of  the  cord  had  begun  before  this,  for  during  the 
year  preceding  the  first  noticeable  weakness  he  was  never  free 
from  felons.  These  affected  principally,  but  not  exclusively, 
the  right  ^nd.  Without  apparent  cause,  and  without  pain,  a 
finger  would  swell  to  about  twice  the  natural  size,  feel  clumsy 
for  some  days,  finally  discharge  pus,  and  gradually  heal.  No 
sequestra  came  away,  but  on  one  occasion  a  good-sized 
slough,  that  looked  like  a  tendon,  separated,  and  w-hen  this  was 
"pulled  out  by  the  roots"  it  hurt,  but  not  excessively.  In  talk- 
ing with  the  patient  about  it,  I  received  the  impression  that 
this  operation  was  very  much  loss  painful  than  it  would  have 
been  in  a  normal  person.  What  is  still  more  conclusive  is  the 
fact  that  two  or  three  years  before  the  first  motor  symptoms 
appeared,  he  had  a  whitlow  on  the  middle  finger  of  the  right 
hand,  followed  by  diffuse  cellulitis,  for  which  three  incisions 
were  made,  notably  one  on  the  dorsum  of  the  hand  about  an 
inch  and  a  half  in  length ;  and  that  these  incisions  were  not 
very  painful.  About  a  year  after  he  first  noticed  the  dimin- 
ished strength,  he  developed  what  was  called  erysipelas  of 
the  same  hand  and  forearm.  For  this  two  free  incisions  were 
made  and  a  large  drainage  tube  drawn  through.  Neither  the 
inflammation  nor  the  operation  occasioned  suffering,  al- 
though he  cannot  say  that  they  were  entirely  devoid  of  pain. 

Gradually  the  weakness  of  the  back  and  arms  increased, 
the  left  arm,  he  thinks,  being  rather  worse  than  the  right, 
and  during  the  first  year  power  in  the  legs  also  began  to  fail, 
as  he  can  remember  that  sometimes  after  the  day's  work  he 
was  scarcely  able  to  walk  home,  and  found  ascending  steps  par- 
ticularly difficult.  The  ankles  seemed  weaker  than  the  knees 
and  hips.  For  two  years  after  the  beginning  of  the  disability 
he  was  able  to  continue  at  his  trade,  with  the  exception  of  six 
weeks  at  about  the  end  of  the  first  year.  At  this  time  he  awoke 
one  morning  to  find  the  right  arm  and  hand  almost  complete- 
ly paralyzed.  This  seems  to  have  been  an  ordinary  pressure 
(sleep)  paralysis,  which  allowed  him  to  resume  work  in  six 
weeks,  although  he  thinks  that  the  arm  never  fully  regained 
its  former  usefulness.  After  this  the  right  arm  and  hand  were 
less  efficient  than  the  left.  It  should  be  remarked  that  three 
years  previous  to  this  sudden  disability  of  the  right  arm,  he 
had  had  a  similar  but  less  severe  paralysis  of  the  same  arm. 
which  I  attribute  to  the  same  cause,  and  which  kept  him  from 
work  only  two  or  three  weeks.  He  was  at  the  time  of  these 
attacks  a  steady  and  excessive  drinker. 

During  the  two  years  after  the  onset  of  the  disease,  when 
he  was  still  occupied  as  a  moulder,  he  constantly  had  blisters 


A    CASE  01-  SYRINGOMYELIA,  839 

» 

on  his  hands,  and  was  greatly  puzzled  because,  as  he  expresses 
it,  **his  hands  blistered  so  much  easier  than  those  of  the  other 
workmen."  This  was  doubtless  due  in  great  part  to  the  al- 
ready existing  analgesia.  He  was  never  conscious  of  burning 
himself;  had  not  the  warning  of  normal  sensation,  and  con- 
sequently the  blisters  seemed  to  appear  without  adequate 
cause.  1  am  inclined  to  think,  however,  that  the  skin  of  these 
patients  may  in  reality  blister  with  abnormal  facility,  as  is  the 
case  in  many  other  forms  of  paralysis.  '  The  tendency  is  seen 
in  examination  of  the  patient,  for  ordinary  pin-pricks  cause 
great  weals  to  arise  within  a  few  minutes,  and  with  a  test  tube 
of  hot  water  I  raised  several  blisters. 

The  power  of  the  upper  extremities  has  slowly  decreased 
to  the  present  time,  the  disability  being  much  more  pronounced 
about  the  shoulders  than  in  the  hands,  but  the  patient  affirms 
that  the  strength  of  the  legs  has  improved  somewhat  during 
the  last  year.  About  a  year  and  a  half  ago  the  hands,  more 
especially  the  right,  began  to  show  vasomotor  disturbance. 
They  would  frequently  get  red  or  dusky,  and  become  soane- 
what  swollen.  The  feet  also  became  slightly  enlarged,  so  that 
the  patient  was  obliged  to  increase  the  number  of  his  shoes 
from  nine  to  ten.  There  has  been  no  pain  at  any  time,  and 
no  spasm  or  twitching,  although  he  has  noticed  that  after 
grasping  an  object  for  some  time,  the  hand  tends  to  cramp 
in  the  same  position.  Sexual  power  has  been  lost  for  four 
years,  having  begun  to  fail  quite  a  year  before  its  extinction. 
This  seems  relatively  early  for  syringomyelia. 

Examination  reveals  a  sufficiently  typical  picture  of  this 
disease.  Both  shoulders  droop,  the  right  rather  more  than  the 
left,  the  arms  are  pendulous,  suggesting  by  their  position  and 
motion  as  the  patient  walks  progressive  muscular  atrophy  ot 
dystrophy;  the  gait  is  typically  spastic,  but  he  "toes  out"  a 
little  beyond  the  normal,  and  the  feet  are  everted  and  flat,  the 
Tight  more  so  than  the  left.  From  the  lower  part  of  the  neck 
down,  all  muscles  seem  to  be  more  or  less  paretic,  but  very 
unequally  so.  The  legs  are  more  spastic  than  weak,  the 
patient  still  being  able  to  walk  two  or  three  miles  at  a  slow 
rate,  while  the  musculature  of  the  upper  arms  and  shoulder 
girdle  is  almost  completely. useless.  Although  he  shrugs  the 
shoulders  with  considerable  power,  the  rigfht  trapezius  above 
the  shoulder,  and  the  left  one  higrher  up,  are  decidedly  atrophic 
and  correspondingly  weak.  Indeed,  at  these  parts  they  cannot 
be  seen  to  contract  at  all.  Both  supraspinati  and  the  right 
infraspinatus  are  wasted;  the  scapulae  seem  too  far  from  the 
spine,  the  borders  are  not  parallel,  and  the  patient  is  practically 
unable  to  approximate  them,  that  is,  to  draw  the  shoulders 
well  back.    The  deltoids  are  markedly  atrophic,  but  although 


840  HUGH  T.  PATRICK. 

the  left  is  apparently  more  wasted  than  the  right,  he  can 
raise  the  left  arm  almost  to  the  horizontal  for  a  moment,  while 
abduction  of  the  right  is  reduced  to  almost  nil.  Rotation  is 
exceedingly  poor,  and  worse  on  the  righ^  side.  Biceps  and 
triceps  are  wasted,  flabby  and  very  weak,  the  posterior  muscles 
being  rather  weaker  than  the  anterior,  but  even  flexion  is  so 
feeble  that  feeding  himself  is  a  considerable  task.  Although 
the  two  sides  in  this  location  are  much  alike  (circumference, 
R.  \\\,  L.  II  inches),  some  movements  at  the  shoulder  and  el- 


PlGS.    I    AND    II,      SVRINGOMVBLIA. 


bow  are  better  on  one  side  and  some  on  the  other.  The  pec- 
torals are  not  very  strong,  but  could  not  be  called  atrophic. 
The  forearm  muscles  are  in  a  decidedly  better  conditioo  than 
those  erf  the  upper  arm.  Atrophy  is  not  apparent  here  and  the 
grasp  is  fair,  but  the  extensors  on  the  left  side  are  distinctly 
weaker  than  on  the  right,  as  in  grasping  strongly  the  hand 
flexes  at  the  wrist,  as  it  does  in  wrist-drop,  although  not  to 


A    CASE  OF  SYRINGOMYELIA.  84I 

an  equal  degree.  Pronation  and  supination  are  quite  defec- 
tive, supination  more  so  than  pronation,  and  both  worse  on 
the  right  side.  Spreading  and  approximating  the  fingers  are 
feebly  executed,  more  (eebly  on  the  left. 

The  cranial  nerves  are  intact,  including  pupillary  reactions 
and  visual  fields  for  white,  blue,  red  and  green.  As  m  all  cases 
of  this  disease,  the  sensory  conditions  are  interesting.  They 
are  indicated  in  brief  by  the  diagrams  (Figures  I  to  1\),  which, 
however,  must  be  supplemented  by  a  few  words. 


Fics.  Ill  ANn  IV.  SvRiNcOMVELiA,  (Same  case  shown  by  Figs.  I  and  II). 
Horizontal  shading  indicates  total  loss  of  pain  sense.    Perpen- 
dicular shading  indicates  aneeathesia  to  firm  touches. 

First,  the  band  of  tactile  anaesthesia  about  the  trunk,  al- 
though unmistakable,  is  not  absolute.  That  is,  to  demonstrate 
and  outline  it,  very  light  touches  are  necessary.  The  lighter' 
the  touch,  the  broader  the  anEesthetic  band,  and  if  quite  firm 
touches  are  made  with  a  camels-hair  brush,  no  anaesthetic 
zone  is  evident.  At  no  point  on  the  body  is  there  complete 
tactile  anfesthesia.    I  may  add  that,  as  is  the  case  with  trunk 


84- 


HUGH  T,   PATRICK, 


anaesthesia  in  tabes,  the  anaesthetic  area  is  wider  when  ex- 
amined from  its  middle  toward  the  borders  than  when  the 
latter  are  determined  by  approaching  the  zone  of  anaesthesia 
from  above  qr  below,  where  sensation  is  normal.  Aside  from 
this  variation,  the  lower  border  of  the  anaesthesia  is  so  uncer- 
tain that  no  exact  limit  can  be  determined.  Second,  although 
diminution  of  the  pain  sense  is  distinct  quite  to  the  limits 
indicated  by  Figures  I  and  II,  analgesia  is  not  complete  in  all 
of  this  area.  In  Figures  III  and  IV  is  shown  the  extent  of  com- 
plete analgesia.  Third,  sensation  for  both  touch  and  pain  is  de- 
cidedly better  on  the  right  than  on  the  left  side.  Fourth,  the 
tongue  of  analgesia  extending  from  the  dorsal  area  to  the 
vertex  is  not  unique,  although  examples  of  it  seem  to  be 
very  rare.  Gilles  de  la  Tourette  and  Zaguelmann*  report  a 
case  in  which  analgesia  of  the  nape  of  the  neck  and  back  of 
the  head  existed  as  an  isolated  area,  and  Solder^  has  recorded 
two  cases  in  which  the  analgesia  extended  upward  in  a  way 
quite  similar  to  that  shown  in  Figure  II.  In  one  of  these  the 
area  gradually  spread  until  it  included  the  entire  head  ex- 
cept the  face,  a  distribution  that  is  not  very  exceptional.  It 
should  be  added  that,  aside  from  variations  already  cited, 
there  are  spots  of  relatively  small  size,  apparently  located  at 
random  in  the  anaesthetic  and,  especially,  in  the  analgesic 
areas,  where  sensation  is  more  acute  than  in  the  surrounding 
parts.  The  patient  seems  to  be  rather  more  sensitive  to  the 
faradic  brush  than  to  other  painful  impressions.  Loss  of  the 
thermic  sense  practically  coincides  in  distribution  with  the 
analgfesia,  except  that  it  seems  to  be  less  uniform  in  degree. 

Plantar,  cremasteric  and  abdominal  reflexes  are  absent. 
The  knee-jerks  are  exaggerated,  as  are  also  the  Achilles  jerks: 
there  is  incomplete  ankle  clonus  on  both  sides.  The  wrist- 
tap  (radius  flexor  reflex)  is  absent.  From  the  regions  indi- 
cated by  dots  in  the  diagrams,  a  lively  reflex  is  excited  by  pin- 
pricks, although  these  are  not  at  all  painful,  and  occasionally 
this  was  noted  in  pricking  the  trunk  about  or  below  the  level  of 
the  umbilicus. 

The  hands  are  "pudgy,"  thick,  clumsy  looking,  a  little  on 
the  "spade"  order,  inclined  to  be  cold  and  cyanosed,  but  they 
are  not  deformed.  The  puffiness  is  resistant,  and  does  not  pit 
on  pressure,  and  there  is  no  enlargement  of  the  bones.  The 
feet  present  a  similar  appearance,  and  there  is,  besides,  pes 
planus  with,  on  the  rigfht  side,  so  much  eversion  of  the  foot 
and  protrusion  of  the  inner  bones  of  the  tarsus  as  to  suggest 
an  arthropathy.  There  is  no  other  joint  trouble  and  no  more 
lateral  curvature  of  the  spine  than  occurs  in  many  normal 

^  Nouv.  Iconog.  de  la  Salp.,  vol  ii.,  p.  311. 

'  Neiirolog.   Centralb.,  June  15th,   1898,   p.   571. 


A    CASE  Of  SVRIXGOMYELIA,  843 

persons.  In  the  examination  nothing  has  been  discovered  ex- 
cept the  anaesthesia  that  would  suggest  leprosy.  The  patient 
says  that  often  rotation  of  the  head  is  accompanied  with  a 
grating  in  the  neck,  and  this  can  be  felt  by  the  observer  plac- 
ing a  hand  up>on  the  patient's  head  or  neck.  The  feeling  is 
something  between  that  of  crepitus  and  a  click. 

Changes  in  the  electric  reactions  are  not  striking.  All 
the  atrophic  muscles  show  diminished  response  to  the  faradic 
current,  and  in  the  atrophic  portions  of  the  trapezius  the  con- 
traction is  distinctly  slow.  These  same  portioils  (of  the  tra- 
pezius) show  degeneration  reaction  to  galvanism ;  that  is,  the 
response  is  very  slow  and  the  contraction  long  persisting. 
Other  muscles  respond  by  quick  contractions. 

Case  11.  Tabes.  A.  K.,  married,  52  years  old,  was  first 
seen  March  13th,  1898,  through  the  kindness  of  Dr.  E.  R. 
Bennett.  About  25  years  ago  he  contracted  a  venereal  sore, 
followed  by  a  suppurating  bulx)  and  a  number  of  enlarged 
glands  in  either  groin.  The  inguinal  and  postcervical  glands 
are  now  slightly  enlarged,  also  the  epitrochlear  on  the  right 
side.  There  is  no  further  evidence  of  syphilitic  disease  to  be 
discovered  either  in  the  history  or  examination. 

The  first  intimation  of  the  present  disease  seems  to  date 
hack  about  seven  years,  when,  after  dancing  at  a  picnic,  the 
legs  felt  tired  out  of  all  proportion  to  the  exertion,  and  there 
was  a  sensation  of  tension  or  drawing  about  the  calves  and 
popliteal  spaces.  (This  seems  to  be  a  frequent  symptom  of 
incipient  tabes.)  After  this  the  same  feeling  was  noticed 
when  he  was  at  work;  as  the  patient  expresses  it,  he  felt  as 
if  he  had  walked  a  thousand  miles.  In  the  course  of  a  year 
or  so  bladder  symptoms  appeared.  With  a  sudden  call  to 
micturate  there  w^ould  be  incapacity  to  start  the  stream 
promptly,  and  involuntary  escape  of  a  few  dro|>s  of  urine  was 
not  infrequent.  A  little  later  he  began  to  have  at  longer  or 
shorter  intervals  a  sensation  as  if  some  one  had  suddenly 
gripped  the  left  calf,  and  later  still  an  occasional  stinging  pain 
in  the  leg  or  foot.  Typical  shooting  pains  have  never  been 
present.  Five  years  ago,  from  no  apparent  cause,  the  left 
great  toe  became  greatly  swollen  and  congested;  after  a  few 
days  it  "broke,"  giving  exit  to  a  little  dark,  bloody  serum,  and 
then  rapidly  became  gangrenous.  It  was  amputated  by  Dr. 
Bennett,  and  the  wound  healed  promptly.  There  was  some 
pain  at  the  time  of  the  acute  swelling,  but  no  particular  atten- 
tion w^as  paid  to  the  sensory  conditions  at  that  time.  Shortly 
after  the  operation  the  left  leg  became  enormously  swollen,  al- 
most to  the  knee,  but  this  swelling  disappeared  in  a  few  days, 
and  after  several  weeks  he  went  back  to  work.  It  was  then 
noticed  that  the  left  foot  was  everted,  and  that  there  was  a 


844  HUGH  T,   PATRICK. 

marked  bony  protrusion  at  the  inner  side  of  the  instep.  A 
few  months  after  the  operation  a  dusky  swelling  appeared  on 
the  stump,  which  discharged  a  dark  serum  for  a  short  time, 
and  then  healed.  At  about  this  period  the  patient  found  that 
in  putting  on  his  trousers  he  had  to  steady  himself  by  bracing 
his  head  against  the  wall.  Nine  months  after  the  loss  of  the 
great  toe  the  second  toe  on  the  other  foot  became  swollen  and 
dark,  then  turned  black,  and  it  was  amputated  three  weeks 
after  the  first  change.  Union  was  prompt  and  perfect.  By 
the  time  he  had  recovered  from  this  incident  control  of  the 
legs  was  too  poof  to  allow  resumption  of  his  occupation.  For 
alK)ut  a  year  longer  he  got  about  with  the  aid  of  sticks  and 
(later)  crutches,  but  for  the  last  three  years  has  been  confined 
to  a  wheeled  chair,  which  he  propels  with  the  arms.  He  can 
now  neither  walk  nor  crawl,  has  had  no  sexual  power  for  a 
year,  and  for  the  last  two  months  there  has  been  rectal  incon- 
tinence when  the  bowels  were  loose. 

Achilles-jerk,  knee-jerk,  wrist-tap  and  plantar  reflex  are 
absent,  the  abdominal  reflexes  are  exagfgerated.  The  left 
pupil  is  larger  than  the  right,  and  there  is  reflex  iridoplegia. 
Incoordination  is  very  pronounced  in  the  lower  extremities, 
less  marked  but  distinct  in  the  upper  extremities,  and  seems 
unusually  prominent  in  the  pelvo-femoral  muscles.  Sense  of 
position  is  very  much  impaired  and  muscle  tonus  greatly  di- 
minished. The  left  trapezius  muscle  is  atrophied  in  its  upper 
(cervical)  part,  and  the  left  arm  is  also  somewhat  wasted,  being 
ij  cm.  less  in  circumference  than  its  fellow.  There  is  entire 
absence  of  the  pectoralis  major  on  the  right  side.  Of  the  latter 
muscle,  there  is  a  strong  strand  arising  from  about  2\  inches 
of  the  clavicle;  not  a  vestige  below  this.  I  consider  this 
anomaly  to  be  a  congenital  defect,  as  in  the  aplastic  parts  there 
is  not  the  least  trace  of  muscle,  and  yet  the  patient  has  never 
been  conscious  of  any  disability.  As  a  carpenter  he  used  plane 
and  saw  without  inconvenience,  and  as  a  young  man  struck 
out  from  the  shoulder  like  his  companions.  He  says,  too, 
tliat  his  mother  in  making  clothes  for  him  when  a  child  re- 
marked that  he  had  a  crooked  chest. 

For  me,  the  interest  in  the  case  is  almost  confined 
to  the  sensory  conditions  and  the  spontaneous  loss  of 
the  toes.  Cases  I  and  II  taken  together  and  considered 
in  connection  with  some  cases  of  syringomyelia,  afford 
food    for    reflection    and     future    comparison.       A    year 

ago  I  reported  to  this  association*  a  case  of  syringomyelia 
■Journal  of  Nervous  and  Mental  Disease,  October,  1897. 


L 


A    CASE  OF  SYRINGOMYELIA.  845 

with  trunk  anaesthesia,  and  the  preceding  case  (Case  I.) 
constitutes  an  additional  example  of  the  same  thing.  The 
first  one  showed  anaesthesia  and  analgesia  more  closely 
corresponding  to  the  tegumentary  sensory  representation 
of  the  segments  of  the  spinal  cord  than  any  reported  up 
to  that  time,  and,  so  far  as  I  know,  such  a  striking  case  has 
not  been  reported  since.  It  showed  the  identical  distribu- 
tion often  found  in  tabes,  with  the  striking  difference  that 
the  area  of  analgesia  was  large  and  that  of  tactile  anaes- 
thesia a  narrower  zone  in  the  middle  of  the  analgesic  sur- 
face. The  exact  reverse  ordinarily  obtains  in  the  trunk 
anaesthesia  of  tabes,  as  shown  by  Laehr,*  Bonnar*^  and 
myself.® 

The  present  case  and  the  following  one  constitute 
striking  exceptions  to  this  rule.  At  least  in  the  present 
state  of  our  knowledge  of  this  symptom  in  tabes,  the  topo- 
graphical relation  of  analgesia  and  tactile  anaesthesia 
shown  by  these  two  cases  must  be  regarded  as  very  un- 
usual, and  much  more  closely  resembling  that  found  in 
syringomyelia. 

In  A.  K.  (Case  II.)  the  analgesia  extends  in  front  from 
the  lower  border  of  the  second  rib  almost  to  the  umbilicus, 
and  includes  the  inner  surface  of  the  arms,  stopping  at  the 
wrist  on  the  left  side,  but  covering  the  little  finger  of  the  right. 
(Figures  V  and  VI).  The  analgesia  on  the  arms,  however, 
is  not  so  marked  as  on  the  trunk,  and  the  line  bounding 
it  is  most  indistinct;  it  is  impossible  to  say  exactly  where 
it  begins.  The  zone  of  tactile  anaesthesia  extends  from 
just  above  the  nipple  to  the  xiphoid  cartilage.  Behind, 
the  sensory  condition  is  more  like  that  prevailing  in 
tabes.  The  tactile  blunting  extends  higher,  while  its 
lower  border  practically  coincides  with  that  of  the  anal- 
gesia. Queerly  enough,  the  latter  extends  on  to  the 
arms,  and  the  former  does  not.    Considering  this  anom- 

*Arch.    f.    Psych.,    1895,   Bd.  xxvii.,  Heft  3. 
•  New  York  Medical  Record,  May  22d,  1897. 
•New  York  Medical  Journal,  February  6th,  1897. 


846  HUGH   T.   PATRICK. 

alous  distribution,  it  is  proper  to  say  that  a  number  of 
examinations  revealed  the  same  condition.  On  the  legs 
there  is  the  usual  dulling  df  both  tactile  and  painful  im- 
pressions, the  former  being  the  more  in  evidence.  Sen- 
sory conduction  is  delayed,  and  impressions  not  at  first 
painful  often  produce  a  burning  sensation  that  is  de- 
cidedly disagreeable. 


Figs.  V  ani>  VI.     Tabes. 
HorizoDtel   shadioc  indicates   analgesia.      Perpendicular  sh&ding  in- 
dicates tactile  anesthesia.    The  ordinar};  anssthesia  of  the  lower 
extremities  is  not  indicated  in  the  diagrams. 

Atrophy  of  muscles  about  the  neck  and  shoulders  is 
not  frequent  in  tabes,  and  the  wasting  of  the  upper  part 
of  the  trapezius  is  of  some  interest,  as  being  almost  the 
exact  counterpart  of  that  found  in  the  case  of  syringo- 
myelia (L.  M.).  Probably  still  more  exceptional  is  gan- 
grene of  the  toes  in  this  disease.     Pitres^  has  reported  an 

'  Revue  Neurot.,  1893.  P-  202. 


A    CASE  OF  SYRINGOMYELIA,  847 

nstance,  and  so  has  Kornfeld.®  The  case  of  the  latter, 
however,  was  one  of  acute  neuritis  added  to  tabes. 
Joffroy  and  Achard*  have  recorded  a  case  of  spontaneous 
gangrene  in  tabes,  but  the  disease  was  already  in  the  ter- 
minal stage  ;  the  patient  had  ''pied-bot  tabetique"  with  ex- 
treme tension  of  the  skin  due  to  the  deformity,  and  died 
three  days  after  the  gangrene  supervened.  Besides,  the  gan- 
grene in  this  case  was  not  "in  mass,"  but  simply  a  gan- 
grenous ulcer.  Indeed,  it  seems  strange  that  the  occur- 
rence is  not  more  frequent,  considering  some  of  the  other 
severe  trophic  accidents  of  tabes,  such  as  the  perforating 
buccal  ulcer  with  bone  exfoliation  reported  by  Letulle 
and  Lermoyez,*^  Hudelo**  and  Leo  Newmark,*^  and  con- 
sidering that  there  would  seem  to  be  principally  differ- 
ences of  degree  between  perforating  ulcer  of  the  foot, 
whitlow  with  sequestrum  and  gangrene  of  the  toes.  The 
case  that  I  report  was  once  shown  in  a  medical  society  as 
a  probable  example  of  Morvan's  disease,  and  although  I 
am  not  aware  that  the  diagnosis  between  this  disease  and 
locomotor  ataxia  has  given  rise  to  difficulty,  that  between* 
tabes  and  syringomyelia  has  been  embarrassing  to  more 
than  one  observer.^^  Even  in  the  present  instance,  the 
sensory  symptoms,  the  localized  atrophy  of  the  trapezius 
and  the  trophic  lesion  of  the  toes  might,  at  a  certain  stage 
of  the  affection,  have  caused  the  diagnostician  to  hesitate. 

Case  hi.  Tabes.  This  case  is  sufficiently  typical  in  every 
respect,  excepting  the  sensory  conditions  on  the  trunk  and 
arms.  The  patient  is  a  man,  45  years  old,  who  contracted  a 
small  venereal  sore  about  25  years  ago,  can  recall  no  further 
S3'inptoms  indicative  of  syphilis,  and  first  noticed  slight  in- 
coordmation  of  the  legs  seven  years  ago.  Included  in  the  his- 
tory are  pains  in  the  lower  extremities,  transient  ptosis  and 

•  Semaine  Med.,  November  9th,  1892,  p.  442,  and  Wien  med. 
Prcsse,  December  nth,  1892,  p.  1,986. 

•Arch,  de  Med.  exper  et  d'anatoraie  path.,  1889,  No.  2,  p.  24. 

«*  Med  Week,  1894,  p.  355- 

"  Sec.  franc,    de    derm,    et    de    syph.,  May  13th,  1893. 

"  Med.  News,  January  26th,   1895. 

"Parmentier:  Nouvelle  Iconographie  de  la  Salpetriere,  vol.  iii., 
1890,  p.  213.    Bruns:  Neurolog.  Centralb.,  1897,  p.  511. 


848  HUGH  T.   PATRICK. 

diplopia,  impaired  sexual  power,  and  a  modMate  degree  of 
cystic  incompetence.  At  present  there  are  small  Argyll-Rob- 
ertson pupils,  loss  of  the  knee-jerks,  well  marked  ataxia  of 
the  lower  extremities,  slight  incoordinaticm  of  the  tipper  ex- 
tremities and  complete  analgesia  of  the  ulnar  trunk.  On  the 
legs  the  seni^ory  blunting  is  that  usually  found  in  cases  of 
tabes  not  far  advanced;  that  is,  tactile  anaesthesia  is  very  slight, 
analgesia  very  distinct,  and  both  gradually  decrease  in  degree 


Fics.  VII  AND  VIII.    Tabm. 
Horizontal  shadiog  indicatea  analgesia.     PerpesdicuUr  sbading  in- 
dicates tactile  aasathesia.     Tbe  ensEStheEia  on  the  lower  ex- 
tremities is  not  indicated  in  the  diagrams. 

from  the  feet  upward.  On  the  trunk  and  arms  the  distribution 
oi  impaired  sensation  is  much  like  that  already  described  as 
occurring  in  syringomyelia  (Figures  VII  and  VIII).  Not  only 
is  the  area  of  analgesia  much  more  extensive  than-that  of  tactile 
anaesthesia  extending  from  the  trunk  on  to  the  arms  (the  tac- 
tile ansesthesia  being  limited  to  the  former),  but  on  the  latter 
it  presents  the  segmental  distribution,  with  border  at  right 
angles  to  the  limb,  often  seen  in  syringomyelia,  but  rare  in 
tal)es.  In  this  case  also  the  persistence  erf  the  peculiar  sensory 
conditions  lias  been  confirmed  by  repeated  examinations. 


I 


A    CASE  OF  SYRINGOMYELIA.  849 

I  regret  to  say  that  I  have  no  explanation  of  the  dis- 
tribution and  character  of  the  sensory  symptoms  in  these 
cases  that  is  at  all  satisfactory  to  myself,  nor  have  I  even 
an  opinion  that  is  new.  At  the  last  m-eeting  of  the  as- 
sociation Dr.  Knapp^*  presented  an  able  paper  covering 
similar  cases,  and  1  have  now  nothing  to  add  to  the  sev- 
eral hypotheses  and  opinions  then  presented,  but  simply 
present  these  instances  as  a  clinical  contribution  to  a  sub- 
ject not  very  well  imderstood. 

DISCUSSION 

Dr.  P.  C.  Knapp  said  that  a  year  ago  he  had  read  a  paper 
before  the  association  on  the  subject  of  sensory  disturbances 
in  cord  lesions;  he  had  been  unable  to  throw  much  light  on 
the  subject  then,  and  now  he  knew  even  less  about  it.  Cer- 
tainly, the  study  of  sensory  disturbances,  especially  in  tabes, 
shows  that  they  do  not  follow  any  definite  course.  Sometimes 
we  get  the  well  defined  sensory  disturbance  of  the  so-called 
spinal  distribution,  at  other  times  disturbances  of  the  stock- 
ing, or  glove,  or  sleeve  type;  sometimes  such  symtoms  are 
absent  entirely,  or  we  may  get  one  set  of  symptoms  one  week 
and  another  the  next.  In  some  cases  we  get  analgesia;  in 
others,  analgesia  with  more  or  less  anaesthesia  or  hyperaes- 
thesia.  As  a  rule,  in  tabes  the  analgesia  is  more  extensive 
than  the  anaesthesia. 

We  certainly  see  cases  of  syringomyelia  with  analgesia, 
and  considerably  later  in  the  course  of  the  disease  there  is 
anaesthesia  in  a  more  limited  area  than  the  analgesia.  In 
hysteria  it  is  common  to  find  analgesia  on  one  side  of  the  body 
without  any  anaesthesia. 

In  conclusion,  Dr.  Knapp  said  it  was  a  question  in  his 
mind  whether  analgesia  is  the  result  of  a  slight  disturbance 
of  the  sensory  tract  and  anaesthesia  is  the  result  of  a  much 
greater  disturbance,  or  whether  we  are  dealing  with  two  sep- 
arate tracts,  one  for  pain  and  one  for  tactile  sensibility. 

Dr.  B.  Sachs  thought  the  view  that  the  well  known  sensory 
symptoms  of  syringomyelia  were  almost  pathognomonic  of 
that  disease  could  no  longer  be  entertained.  The  speaker  said 
he  had  observed  two  cases  of  Pott's  paralysis,  with  dissociated 
sensory  symptoms  confined  to  the  extremities;  in  two  other 
cases  dissociated  sensation  occurred  first  in  the  distribution 
of  the  trigeminal  nerve.    In  one  of  these  cases,  seen  about  a 

''Journal  of  Nervotis  and  Mental  Disease,  September,  1897. 


850  HUGH   T,   PATRICK, 

year  ago,  there  was  absolute  loss  of  pain  and  temperature 
sense  in  the  distribution  of  the  trigeminal  nerve,  while  in 
other  parts  of  the  body  sensation  remained  entirely  normal. 
The  speaker  said  he  had  no  satisfactory  explanation  to  offer 
for  these  unusual  cases.  In  another  class  of  cases  he  had 
observed  symptoms  which  resemble  those  of  syringomyelia, 
inasmuch  as  they  have  their  origin  in  the  cervical  region  of 
the  cord,  but  they  become  absolutely  stationary,  and  remain 
so  for  long  periods — in  some  cases  at  least  five  years.  An 
unusual  feature  of  these  cases  is  that  the  sensory  symptoms  are 
not  as  typical  as  they  are  in  many  cases  of  syringomyelia.  Al- 
most every  form  of  sensation  is  somewhat  involved,  and  there 
:s  not  that  sharp  distinction  between  the  analgesia  and  the 
anaesthesia  that  there  is  usually  in  syringomyelia. 

Dr.  Sachs  said  he  wished  to  inquire  whether  cases  of  dis- 
sociated sensation  within  the  distribution  of  the  trigeminal 
nerve  had  been  observed  by  any  one  else,  and  whether  such 
cases  developed  the  symptoms  of  syringomyelia  later  on. 

Dr.  Frank  R.  Fry  said  he  had  seen  two  cases  of  dissociated 
sensory  disturbance  of  the  fifth  nerve.  In  neither  of  the  two 
cases  was  any  trophic  disturbance  noticed;  there  was  merely 
a  disturbance  of  sensation  in  the  region  of  the  fifth  nerve.  In 
one  case  this  was  more  marked  in  the  upper  than  in  the  lower 
division  of  the  nerve.  In  the  latter  region  it  seemed  impossible 
to  produce  pain. 

Dr.  Patrick,  in  closing,  said  he  did  not  agree  with  the 
statement  made  by  Dr.  Knapp,  if  he  referred  to  the  impaired 
sensation  on  the  trunk,  that  in  tabes,  as  a  rule,  the  analgesia  is 
more  extensive  than  the  anaesthesia.  On  the  trunk*  tactile 
anaesthesia  is  more  extensive  than  the  analgesia,  and  appears 
sooner,  while  in  the  lower  extremities  the  reverse  holds  good. 
By  some  the  view  is  held  that  the  analgesia  is  due  to  a  less 
pronounced  involvement  of  the  sensory  tracts  than  that  which 
causes  anaesthesia,  but  this  explanation  is  hardly  adequate. 

Dr.  Patrick  said  that  the  dissociation  of  sensation  on  the 
extremities  in  several  diseases  was  not  very  uncommon:  for 
example,  in  Pott's  paraplegia,  multiple  neuritis  and  tabes. 


•-,^ 


A  CASE  OF  HUNTINGTON'S  CHOREA  WITH  RE- 
MARKS UPON  THE  PROPRIETY  OF  NAMING 
THE  DISEASE  "DEMENTIA  CHOREICA."' 

By  FRANK  K.  HALLOCK,  M.D., 
Cromwell,  Conn. 

The  histories  of  the  majority  of  reported  cases  of 
Huntington's  chorea  begin  rather  abruptly  with  an  ac- 
count of  the  appearance  of  the  choreiform  movements 
and  do  not  furnish  data  for  the  study  of  the  earlier  stages 
of  the  disease.  The  following  case  is,  therefore,  of'  in- 
terest chiefly  because  it  shows  clearly  the  course  and  order 
of  development  of  the  degenerative  process,  the  dementia 
and  chorea  paralleling  each  other  as  the  degeneration 
progresses.  The  case  illustrates  a  well-recognized  type 
of  chronic  progressive  hereditary  chorea,  atid  viewing  it 
from  the  psychological  standpoint,  one  is  strongly  inclined 
to  consider  the  chorea  as  of  secondary  importance  to  the 
underlying  dementia,  thereby  warranting  the  descriptive 
and  pajthologically  more  correct  name  of  "dementia 
choreica." 

The  patient  is  the  wife  cf  a  college  professor,  native  of 
Massachusetts^  40  years  old,  and  has  been  under  direct  personal 
observation  the  past  year.  The  accompanying  table  shows  the 
hereditary  history  of  the  patient.  It  is  not  known  whether  the 
great-grandfather  of  the  patient  or  his  antecedents  had  chorea. 
The  neuropathic  tendencies,  however,  were  transmitted  through 
him.  His  wife  was  a  very  vigorous  woman,  and  of  their  eleven 
children  only  one,  it  is  believed,  had  the  disease.  This  one, 
the  fourth  child,  was  the  grandfather  of  the  patient.  He  and 
his  two  sons  used  alcohol  to  excess  during  their  lives.  The 
mother  of  the  patient  came  of  better  stock,  but  was  probably 
never  a  very  strong  woman,  and  after  the  birth  of  the  patient 
became  a  nervous  invalid.  Beyond  what  is  stated  in  the  dia- 
gram of  descent,  nothing  is  known  of  the  rest  of  the  family, 
except  that  a  male  cousin  of  the  father  was  insane  and  confined 


*Read  at  the  twenty-fourth  annual  meeting  of  the  American  Neu- 
rological Association,  May,  1898, 


852  FRAXK  K.  HALLOCK, 

in  the  asylum  at  Taunton,  Mass.  A  glance  at  the  family  his- 
tory shows  the  strong  tendency  to  degeneration  almost  to  the 
point  of  extermination.  The  reduced  number  of  offspring, 
early  deaths,  and  the  earlier  onset  and  somewhat  shorter  course 
of  the  chorea  are  significant  facts. 

The  patient  was  never  very  strongs  but  up  to  the  beginning 
of  the  disease  she  enjoyed  fairly  good  health.  No  rheumatism, 
tuberculosis,  or  other  special  disease  is  reported  in  the  family. 
She  was  married  at  twenty-one,  and  has  had  no  children  or 
miscarriages.  In  1890,  the  thirty-second  year  of  her  age,  the 
first  s)rmptom  of  the  disease  showed  itself.  This  consisted  of  a 
mental  change  rather  than  any,  choreiform  movement.  There 
was,  however,  a  single,  isolated  motion  observed  at  this  time, 
namely,  a  rythmical  movement  of  the  thumbs  during  chiu-ch 
service.  The  mental  change  was  the  prominent  feature  and 
was  manifested  by  a  mild  depression  and  lack  of  confidence  in 


Cr«ot-   Grandfather 

n«urotic        (cKoreo?)      died      of    6ft  yr«. 
'moI*.    remol*.  IW^oI«.    0<9t</f»fM»r     Mbltt. .   fem«l» .  Mile  Te-i^-le    MaU.  I^«mal«.    Mak.^ 


tAla^m^Jt,  tAs^mtXM.  ^*m^m^*f ,  vrJMtm  ^mdti 

^♦»r.        M,m  r»f«oU       Aiw/»  MaU  FcmaU     Mole    f«mal«     Jlf0*t       fW<*i»    A<**r  ickMr 


n««vouS.ncrr«.«        di^Hmk^     4»rr»  <*.d«»  J,yr,       4«rr«    4*^^     «4«/««     ck^«»    e^rw  «W.n 


/'        ^         \ 


r«mol«  Mak 


Not*   •Til*  fi«m««     af    "t^e**      a/r«&tad     arc     in     th^ic^ 


herself.  She  did  not  complain,  but  seemed  to  be  nervous  and 
fearful  of  being  left  alone.  If  she  went  shopping  without  com- 
pany she  would  become  bewildered  and  lose  her  way  home. 
In  1 89 1  and  '92  the  same  lack  of  confidence  continued,  and  in 
addition  the  mental  confusion  and  bewilderment  increased. 
There  was  more  difficulty  in  comprehension,  and  she  would  not 
talk  with  people.  The  motor  symptoms  accompanying  this 
deepening  of  the  mental  condition  consisted  of  no  true  chorei- 
form movements,  but  of  so-called  "choking  spells."  While 
seated  at  the  table  she  would  suddenly  throw  her  head  back, 
gasp  for  breath,  and  then  hurriedly  reach  for  water  to  drink. 
Later  on  these  throat  spasms  occurred  in  the  night  and  seemed 
to  be  semi-hysterical  in  character. 

In  1893  the  mental  condition  of  the  patient  changed.  In- 
stead of  being  afraid  to  leave  home  and  reluctant  to  meet 
people,  she  now  became  full  of  confidence,  wanted  to  travel 
and  visit  friends.     Before,  she  was  very  subdued  and  anxious 


A    CASE  OF  HUNTIXGTON'S  CHOREA,  853 

to  keep  in  the  background;  now  she  began  to  feel  mildly  ex- 
alted and  pushed  herself  forward,  emulating  the  acts  of 
others.  The  "choking  spells"  at  table  and  the  thumb  move- 
ments in  church  continued  to  be  noticed  with  varying  fre- 
quency. In  1894  the  evidence  of  mental  weakness  became 
more  noticeable.  In  ordinary  sewing  she  could  not  learn  to  do 
the  simplest  things.    Her  memory  began  to  fail. 

In  1895  the  first  decided  choreiform  movements  appeared- 
The  "choking  spells"  grew  less  and  were  replaced  by  stagger- 
ing movements  which  were* first  noticed  in  entering  and 
leaving  street  cars  or  carriages.  Difficulty  in  holding, 
objects  was  experienced,  knife,  fork  and  other  articles  being 
repeatedly  dropped.  The  menstruation  at  this  time  became 
irregular  and  remained  so  a  year  and  a  half.  Greater  mental 
confusion  and  failure  of  memory  were  observed.  In  1896  the 
movements  continued  to  increase  in  the  extent  of  muscular 
involvement.  When  at  rest,  e.  g.,  in  church,  she  was  quiet,  with 
the  exception  of  occasional  arm  or  leg  movements  and  a  ryth- 
mical motion  of  the  head  which  consisted  of  looking  up  at  the 
clergyman  and  then  down  to  the  pew.  In  walking  the  irregu- 
larity of  movement  became  so  great  that  she  appeared  to  be 
intoxicated.  Disturbance  of  speech  and  irregularity  in  hand- 
writing were  noticed.  In  1897,  her  thirty-ninth  year,  she  first 
came  under  observation. 

Examination. — The  patient  is  a  medium  sized  woman, 
and,  with  the  exception  of  the  chorea  and  a  rather  blank  facial 
expression,  presents  quite  a  normal  appearance.  There  are 
no  physical  stigmata  of  degeneration.  The  heart,  lungs  and 
kidneys  are  normal  and  her  general  condition  is  excellent. 
There  is  no  evidence  of  atheroma.  The  muscular  development 
is  uniformly  well  marked.  The  menstrual  flow  is  regular,  but 
for  the  last  six  months  has  been  scanty.  Vision,  pupils  and 
fundus  normal.  Hearing,  smell,  taste  and  general  sensibility 
correct.  Muscular  and  temperature  senses  perfect.  No  tremor 
or  true  ataxia.  Romberg  symptom  absent.  Skin  reflexes 
present.  Tendon  reflexes  active,  especially  knee-jerk,  which 
is  slightly  exaggerated.  No  ankle  clonus.  Electrical  reac- 
tions normal. 

Choreiform  Movements. — ^All  muscles  of  the  body  are  in- 
volved, including  eyeball,  tongue,  pharynx,  larynx  and  dia- 
phragm. Patient  cannot  hold  the  eyes  steady  in  the  presence  of 
another.  They  shift  and  wander  almost  constantly,  due  in  part 
to  irregularity  of  movements  of  ocular  muscles  and  in  part  tc^ 
motipns  of  head.  The  tongue  is  protruded  straight  and  has 
a  large  muscular  development.  It  is  moved  about  in  the 
mouth  and  between  the  lips  very  unevenly,  causing  the  char- 


^54  FRANK  K,   HALLOCK. 

acteristic  disturbance  in  articulation,  which  is  labored,  hesitat- 
ing, broken  in  word  sounds  and  sentences,  ending  often  in  a 
mild  explosive  utterance.  The  irregularity .  of  action  of  the 
laryngeal  muscles  and  imperfect  control  of  the  air  column  aug- 
ment the  difficulty  in  articulation.  Coughing,  choking,  and  a 
variety  of  minor  vocal  sounds  are  of  frequent  occurrence. 
Swallowing  is  similarly  uneven  in  its  execution.  The  move- 
ments of  the  facial  muscles  cause  every  form  of  grimace.  The 
trunk  and  extremities  are  subject  to  all  possible  movements, 
producing  an  undulating  distortion  of  the  body  and  limbs  from 
their  normal  position.  The  gait  is  wobbling  and  uneven,  each 
step  varying  in  its  excursion  as  to  height  and  latitude. 

The  two  sides  of  the  body  are  equally  aflFected  and  all  move- 
ments are  greatly  intensified  in  the  presence  of  another  person. 
When  lying  down  or  moving  about  alone  the  chorea  is  very 
much  less.  All  motion  ceases  during  sleep.  Volition  has  a 
brief  effect  in  quieting'  the  movements.  Occasionally  the 
patient  is  subject  (possibly  as  the  result  of  dreams,  certainly 
from  some  centrally  initiated  impulse)  to  convulsive-like  move- 
ments at  night,  in  which  the  body  is  tossed  from  one  side  of  the 
bed  to  the  other,  or  repeatedly  wheeled  around  in  a  circle. 
Spasms  of  choking  and  difficulty  in  breathing  also  occur  at 
limes  during  the  night.  The  character  of  the  movements  dif- 
fers from  that  of  the  convulsive  tics  and  Sydenham's  chorea 
in  being  slower  and  more  comprehensive.  The  motions  are 
easier  and  wave-like  and  resemble  more  closely  athetosis,  with- 
out, however,,  any  tendency  toward  contraction  or  fixation  of 
the  muscle  group  at  the  completion  of  the  movement. 

.  Mental  Symptoms. — The  ordinary  appearance,  behavior 
and  conversation  are  fairly  normal.  The  disposition  and  tem- 
perament, with  the  exception  of  the  depressed  condition  at  the 
onset  of  the  disease,  has  always  been  happy  and  contented. 
Closer  examination  reveals  distinct  and  decided  dementia 
which  is  manifested  by  loss  and  inaccuracy  of  memory,  both  for 
near  and  remote  events;  a  child-like  simplicity,  interest  and 
pleasure  in  little  matters ;  a  lack  of  appreciation  of  her  condition 
both  as  regards  the  choreic  movements  and  mental  deficiencies; 
a  failure  of  the  power  to  reason  or  be  taught  the  simplest 
things,  mental  and  physical.  Volition  is  diminished,  but  there 
is  an  impatient  and  impulsive  desire  to  follow  out  any  idea, 
reasonable  or  otherwise,  which  comes  in  her  mind.  She  has 
no  hallucinations  or  delusions.  Her  mental  condition,  in  brief, 
is  like  that  of  a  child.  She  is  very  happy  to  the  point  of  a 
mildly  exalted  state.  Busies  herself  reading  and  fussing  over 
little  details  in  her  daily  routine.  Enjoys  social  life,  but  is 
equally  content  to  be  alone. 


L 


A    CASE  OF  HUNTINGTON'S  CHOREA.  855 

Treatment. — ^Arsenic,  bromide,  hyoscine,  hyosciamus  and 
silver  nitrate  in  ordinary  doses  had  no  effect  on  the  chorea.  In 
larger,  paralyzing  doses  some  reduction  of  the  movements  was 
noticed,  but  the  reaction  after  ceasing  their  use  was  worse  than 
before.  Rest,  isolation  and  the  hygienic  regulation  of  the 
-daily  life  gave  the  best  result,  producing  a  temporary  improve- 
ment noticeable  both  in  the  physical  and  mental  conditions. 
After  the  experimentation  with  drugs  was  over  and  she  went 
on  the  rest  treatment  the  patient  gained  twenty-three  pounds. 

The  following  psycho-physiological  considerations 
based  upon  the  symptoms  presented  by  this  patient  will 
be  of  service  in  correctly  interpreting  the  true  nature  of 
Huntington's  chorea. 

Conceiving  the  arc  of  sentient  life,  or  physical  mani- 
festations, to  consist  of  three  parts,  we  have  on  one  side 
the  flow  of  afferent  stimulations  from  the  periphery  to 
the  coordinating  centres  of  the  central  nervous  system, 
and  on  the  other  side,  the  sending  forth  from  these  centres 
efferent  impulses  resulting  in  motor  activity.  The  nerve 
centres,  spinal  and  encephalic,  occupy  the  middle  point  of 
the  arc.  Examination  of  the  nerves  of  the  special  senses 
and  the  general  sensibility  shows  that  the  peripheral  stim- 
uli are,  in  the  main,  normally  received  and  transmitted. 
Likewise  testing  the  motor  apparatus  reveals  the  fact  that 
the  motor  nerves  transmit  the  efferent  impulses,  such  as 
they  are,  properly  and  thait  the  muscles  are  in  good  order 
and  respond  correctly  to  these  impulses. 

The  cause  for  the  irregular  and  abnormal  behavior  of 
the  muscles,  therefore,  does  not  lie  in  the  muscles  them- 
selves nor  in  their  innervation,  but  in  the  peculiar  charac- 
ter of  the  impulses  they  receive.  These  impulses  arise  in 
the  nerve  centres,  hence  we  may  conclude  that  here  is  the 
true  seat  of  the  disorder.  The  nerve  centres  chiefly  in- 
volved are  those  of  the  tortical  and  subcortical  motor 
areas  and,  disregarding  the  variable  and  coarser  anatom- 
ical findings,  the  essential  lesion,  as  described  by  Oppen- 


856  FRANK  K.  HALLOCK. 

heim*,  Dana^,  Michell  Clarke*,  Facklam*  and  Collins^,  is 
of  the  nature  of  a  chronic,  parenchymatous  encephalitis. 

The  symptoms  of  this  case  support  this  view  of  the 
pathology  of  the  disease  in  two  respects,  one  is  the  fact 
that  direct  psychical  influences  are  the  most  potent  causes 
of  the  choreic  manifestations;  any  emotional  excitement 
or  stimulation  of  the  mental  faculties  greatly  exaggerating 
the  movements.  The  other  is  the  complete  change  of 
consciousness,  or  ego  of  the  individual,  and  the  signs  of 
distinct  mental  deterioration  manifested  in  the  form  of  a 
progressive  dementia. 

With  comparatively  few  exceptions  the  histories  of 
reported  cases  state  that  the  chorea  was  noticed  first  and 
the  mental  symptoms  appeared  later.  It  is  natural  that 
this  should  be  so,  because  the  chorea  as  a  rule  is  the  con- 
spicuous and  absorbing  symptom  which  brings  the  patient 
to  the  notice  of  the  physician.  Added  to  this  is  the  fact 
that  the  disorder  is  quite  commonly  thought  of  and 
treated  as  a  neurosis  rather  than  psychosis,  and  the  mental 
aspect  of  the  case  is  consequently  not  apt-  to  be  so 
thoroughly  investigated.     (Charcot®,  Lannois^,  Jolly®.) 

The  writer  is  of  the  opinion  that  if  more  care  were 
taken  in  studying  the  life  history  of  the  patient  it  would 
be  found  in  a  large  number  of  cases  that  at  the  time  of 
onset,  if  not  before,  distinct  changes  in  the  mental  con- 
dition were  already  present.  Huber®  was  one  of  the  first 
to  report  a  case  showing  clearly  the  signs  of  mental  de- 
terioration previous  to  the  appearance  of  the  chorea. 
Several  other  cases  have  been  similarly  reported  and  re- 

>  Arch.  f.  Psych.-,  xxv.,  3. 

•  Journal  Ncrv.  and  Ment.  Dis.,  Sept.,  1895. 
»  Brain,  xx.,  77,  1897. 

<  Arch.  f.  Psych.,  xxx.,  i,  1897. 

•  Boston  Med.  and  Surg.  JournaL  Dec.  23, 1897. 

•  Lecons  du  Mardi.  Policlinique,  I.  and  II.,  1887  and  1888. 
7  Rev.  de  m^d.,  Aug..,  1888.    Le  bulletin  m^.,  Nov.,  1894. 

•  Neurol.  Centralblatt,  x.,  June,  1891. 

•  Virchow's  Archiv.,  cviii.,  i  and  2, 


A    CASE  OF  HUNTINGTON'S  CHOREA.  857 

cently  Facklam^^,  in  an  extended  review  of  the  disease, 
states  that  five  of  his  eight  cases  showed  previous  mental 
change. 

A  comparative  study  of  the  different  kinds  of  motor 
disturbance  in  connection  with  the  various  lesions  of  the 
central  nervous  system  would  be  of  distinct  value  in  broad- 
ening our  conception  of  such  a  disease  as  Huntington's 
chorea.  Such  a  study  should  induce,  on  the  one  hand, 
the  neurologist  to  consider  cases  of  tic,  Friedreich's  ataxia, 
paralysis  agitans,  athetosis,  etc.,  more  from  the  psycho- 
logical standpoint  than  is  at  present  done,  and  on  the 
other  hand,  the  alienist  would  be  induced  to  attach  more 
significance  to  the  play  of  the  motor  symptoms  in  the 
insane. 

To  illustrate  the  importance  of  taking  a  comprehen- 
sive view  of  the  disorders  of  motility  I  will  cite  a  case  of 
generalized  tic,  characterized  by  pronounced  motor  symp- 
toms  with,  as  commonly  considered,  almost  no  mental 
peculiarities.  In  support  of  the  view  that  the  convulsive 
tics  are,  in  the  main,  a  degenerative  disorder,  we  will  find 
that  the  majority  of  cases,  even  of  mild  type,  show  certain 
psychical  defects  or  departures  in  mental  action  from  the 
normal  standard.  Noting,  for  instance,  that  the  body 
and  limb  movements  are  rapid  and  changeable  we  will  dis- 
cover that  the  mental  functions  are  similarly  affected. 
The  patient  is  apt  to  be  restless  and  impulsive  in  conduct, 
finding  it  difficult  to  keep  the  attention  concentrated  on 
one  line  of  intellectual  work.  The  memory  is  often  ca- 
pricious and  there  frequently  exists  a  superficial  concep- 
tion of  the  affairs  of  life.  The  mind  is  hurried  and  irregu- 
lar in  action  just  as  the  muscular  movements.  In  fact 
the  movements  are  almost  exactly  paralelled  by  the 
mental  habits.  Pursuing  the  examination  further  will  re- 
veal other  associate  imperfections  of  the  psychical  state. 

My  purpose  in  alluding  in  this  connection  to  such  a 

w  Loc.  cit. 


858  FRANK  K.   HALLOCK. 

disease  as  convulsive  tic  is  to  bring  out  the  fact,  first,  that 
motor  activity  is  the  outward  expression  of  the  state  of 
the  motor  centres,  and  secondly,  that  these  centres  are 
intimately  connected  by  association  fibres  with  those  of 
higher  consciousness^^  and,  therefore,  there  is  good  reason 
to  believe  that  whenever  we  find  distinct  and  permanent 
motor  disturbance  of  cerebral  origin  we  may  also  expect 
to  meet  a  certain  kind  or  grade  of  mental  deficiency  or 
impairment.  This  impairment  will  vary  according  to  the 
degree  and  type  of  the  affection.  It  is  true  that  it  need 
not  necessarily  be  present  at  all,  as  it  is  possible  to  con- 
ceive that  the  motor  centres  alone  functionate  imperfectly 
without  involvement  of  the  higher  centre  association 
fibres.  The  rule  is,  however,  as  Amdt^^  has  clearly  stated, 
that  we  will  generally  find  some  mental  deficiency  if  we 
study  carefully  the  habits,  characteristics  and  inner  life 
of  the  individual.  Ordinary  cHnic  or  private  visits,  unless 
very  frequent,  often  fail  to  reveal  the  facts  of  this  kind. 
One  must  almost  live  with  his  patient  to  fully  appreciate 
the  psychical  side  of  many  of  the  so-called  neuroses. 
Hence,  in  spite  of  the  criticism,  and  citation  of  a  case  to 
the  contrary,  of  so  thorough  a  student  of  chorea  as  Sink- 
ler^*,  we  are  forced  by  psychological  reasons  to  believe 
that  Diller**  is  right  in  asserting  that  chorea  long  con- 
tinued is  almost  invariably  connected  with  mental  ab- 
normalities. 

In  the  case  of  tic  we  may  suppose  the  motor  centres  to 
be  chiefly  affected  with  shght  involvement  of  the  adjoin- 
ing or  association  centres.  In  ordinary  chronic  dementia 
these  adjoining  centres  of  ideation,  etc.,  are  deeply  af- 
fected, while  the  motor  centres  themselves  are  compara- 
tively perfect  in  function,  except  as  they  are  brought  in 


"  Flechsig(L.  F.  Barker):     **  Sense  Areas  and  Association  Cen- 
tres."    Journal  Nerv;  and  Ment.  Dis.,  xxiv..  6. 

"  Arch.  f.  Psych.,  I.,  3,  p.  509. 

"  N.  Y.  Med.  Record,  March,  1892. 

'<  Am.  Journal  Med.  Sc,  April,  1890. 


L 


A    CASE  OF  HUNTLXGTOX'S  CHOREA,  859 

play  secondarily,  as  is  frequently  seen  in  the  rhythmic 
movements  or  habitual  body  posturing  of  such  patients. 
Tic,  paralysis  agitans  and  athetosis  manifestly  cannot  be 
considered  psychoses,  if  we  ^ibide  by  the  definition  of  the 
term,  but  Huntington's  chorea,  if  we  place  it  in  the  cate- 
gory with  dementia  paralytica  and  dementia  senilis,  and  view 
it  as  an  afTection  of  the  combined  motor  and  association 
centres,  may  unquestionably  be  classed  as  a  psychosis. 

In  determining  whether  the  term  "dementia"  is  ap- 
plicable to  Huntington's  chorea  it  will  be  noticed  that 
the  point  of  view  makes  a  difference  in  our  conception^ 
The  neurologist  chiefly  interested  in  the  motor  symptoms- 
is  apt  to  underrate  the  picture  of  psychical  decay  before 
him,  while  with  the  student  of  insanity,  if  he  has  givea 
the  subject  thought,  there  is  far  less  difficulty  in  appre- 
ciating the  unmistakable  features  of  a  true  dementia  with 
the  disorder  of  motility  occupying  a  position  of  secondary 
importance.  Phelps**^  makes  an  excellent  plea  in  this  lat- 
ter direction,  and  a  further  witness  on  the  side  of  the 
alienist's  conception  is  the  reviewer  of  Osier's  "Treatise 
on  Chorea"  in  the  Journal  of  Mental  Science,  April,  1895^ 
in  which  he  raises  the  question:  Why  not  a  general 
chorea,  as  well  as  a  general  paralysis  of  the  insane  ?  It  is 
interesting  to  note  in  this  connection  that  Golgi*®  pointed 
out,  in  1874,  the  similarity  in  pathological  lesions  between 
chronic  hereditary  chorea  and  progressive  paralysis. 
Since  then  this  comparison  has  been  made  by  several 
others.  (Hoffmann^'',  Phelps^ *^,  Bondurant^®.) 

Setting  aside  for  the  moment  the  question  of  the 
propriety  of  the  designation,  dementia,  we  need  be  in  no 
doubt  as  to  the  prognosis,  course,  futility  of  treatment 
and  termination  of  Huntington's  chorea.       Given  the 

*»  Journal  Nerv.  and  Ment.  Dis.,  Oct.,  1892. 

>*  Rivlsta  Clinica,  1874  (abs.  Jo.  Ment.  Sc,  xxii.,  p.  322). 

"  Virchow's  Archiv.,  cxi.,  3,  p.  513. 

19  Hosp.  Bull.,  Second  Minnesota,  1892. 

'•Journal  Nerv.  and  Ment.  Dis.,  Oct.,  1896. 


1 


S6o  FRANK  K.  HALLOCK, 

heredity  and  the  characteristic  chorea  appearing  in  middle 
life,  the  prognosis  can  be  stated  with  a  surety  fully  equal 
to  that  of  dementia  paralytica  and  dementia  senilis.  The 
slowness  of  onset  of  the  mental  deterioration  and  the  cases 
exhibiting  melancholic  or  maniacal  symptoms  do  not  in  the 
least  preclude  the  prognosis,  and  so  in  reality  a  diagnosis 
of  progressive  dementia. 

One  of  the  chief  difficulties  in  considering  hereditary 
chorea  a  form  of  dementia  lies  in  the  variation  in  type 
which  is  noticed  to  exist  among  reported  cases.  Thus, 
the  cases  cited  by  Hoffmann^®  and  by  Chaufford^*,  of 
chronic  hereditary  chorea  without  psychic  disturbance 
make  one  question  the  completeness  of  their  observations; 
the  patient  of  Sinkler**,  34  years  old,  choreic  from  birth, 
and  normal  mentally;  the  two  cases  of  Bower^^,one36  years 
old,  choreic  at  30,  with  previous  history  of  alcoholism  and 
paraplegic  attack,  the  other,  32  years  old,  with  chorea  of 
three  years  standing,  not  hereditary,  and  no  mental  symp- 
toms; these  and  such  other  manifestations  of  chronic  pro- 
gressive chorea  as  have  been  observed  must  be  considered 
as  exceptions  to  the  general  type  under  consideration. 
The  special  character  of  the  degenerative  process  and  its 
manner  of  attacking  the  neuron,  the  rate  of  its  progress 
and  the  locality  of  the  tracts  and  areas  affected  must  ex- 
plain in  this,  as  in  all  similar  diseases,  such  variations  as 
the  above.  Until  more  recently  the  cases  Ijave  not  been 
seen,  or  for  some  other  reason,  European  authors  seem 
to  have  had  more  difficulty  in  recognizing  such  a  distinct 
form  of  hereditary  chorea  as  exists  in  this  country.  Cer- 
tainly American  writers  have  portrayed  a  type,  such  as 
this  case  represents,  with  singular  uniformity,  and  it  is 


«>  Loc.  cit. — Questioned  by  Herringham,  Brain,  xi.,  p.  416;  also 
by  Sinkler,  Journal  Nerv.  and  Ment.  Dis.,  xiv.,  p.  80. 
«»  Le  bulletin  med.,  April,  1896. 
«  Med.  Record,  March,  1892. 
^  Journal  Nerv.  and  Ment.  Dis.,  March,  1890. 


A   CASE  OF  HUNTINGTON'S  CHOREA.  86r 

only  to  cases  resembling  this  class  that  the  term  dementia 
is  strictly  applicable. 

It  may  be  argued  that  the  term  dementia  can  be  ap- 
plied with  equal  right  to  epileptic  as  well  as  hereditary 
choreic  conditions.  Practically  this  is  just  yvhat  is  done 
when  the  dementia  is  well-defined,  but  the  term  is  not 
serviceable  earlier  in  the  disease,  as  it  is  in  the  case  of 
Huntington's  chorea,  because  the  appearance,  course  and 
duration  of  the  mental  deterioration  cannot  be  foretold 
with  satisfactory  definiteness.  The  variable  frequency  of 
the  epileptic  attacks  prevents  the  accuracy  of  prognosis, 
such  as  is  attainable  when  we  are  dealing  with  a  non-in- 
termittent, steadily  progressive  process  of  degeneration 
such  as  exists  in  general  paralysis,  dementia  senilis  and 
Huntington's  chorea. 

This  cursory  review  of  the  extent  to  which  the  body 
movements  may  express  the  state  of  the  motor  and  as- 
sociated higher  consciousness  centres  must  arouse  inter- 
est in  the  effect  of  inherited  tendency  to  degeneration  as 
an  etiological  factor  in  the  disorders  of  motility.  Thus, 
it  will  be  noted  that  in  such  diseases  as  tic,  paralysis  agi- 
tans,  athetosis,  Friedreich's  ataxia,  Huntington's  chorea 
and  dementia  senilis  the  decadence  of  the  neuron  is  more 
slowly  progressive  and  is  marked  by  a  disturbance  rather 
than  loss  of  the  power  of  movement.  The  paralysis,  if 
present,  is  relatively  less  prominent  and  does  not  become 
pronounced  until  later.  In  dementia  paralytica  and  other 
diseases  of  the  brain  and  cord  which  are  secondary  in- 
fections, or  to  some  other  positive  intercurrent  process, 
the  progress  of  the  affection  is  more  rapid  and  there  is  a 
combination  of  both  disorder  and  paralysis  of  motion,  the 
latter  appearing  earlier  and  as  a  more  distinct  symptom 
than  is  the  case  when  the  neuron  loses  its  normal  functions 
as  the  result  of  a  natural  mal-development  or  premature 
degeneration. 

In  conclusion  it  may  be  stated  that  a  comprehensive 


( 


862  FRANK  K,   HALLOCK, 

view  of  Huntington's  chorea  of  the  type  here  reported 
based  upon  the  clinical,  pathological  and  psychological 
data  at  our  command  warrants  the  following  assertions  :— 
first,  that  it  is  a  progressive,  degenerative  disease  of  the 
brain,  fundamentally  different  from  ordinary  or  Syden- 
ham's chorea;  secondly,  that  the  chief  physical  manifesta- 
tions of  the  disease  are  the  choreiform  movements  which 
are  of  secondary  importance,  merely  indicating  the  nature 
of  the  cerebral  lesion;  thirdly,  that  the  character  of  the 
mental  symptoms  can  best  be  described  by  the  term  de- 
mentia ;  and  fourthly,  if  the  above  assertions  can  be  veri- 
fied, then  the  disorder  should  be  classed  with  such  diseases 
as  dementia  paralytica  and  dementia  senilis. 

It  may  seem  a  stretch  of  the  imagination  to  compare 
the  tremor  and  other  motor  disorders  of  senility  to  the 
choreiform  movements,  but  if  we  conceive  of  a  degenera- 
tive process  thrust  violently  upon  the  individual  in  middle 
life,  the  resemblance  between  the  two  diseases  is  not  so 
unlike.  Pathologically  this  is  certainly  what  occurs,  and 
the  view  here  maintained  is  well  set  forth  by  Dana^*  in 
speaking  of  the  disease  as  a  teratological  defect. 

The  propriety,  as  well  as  the  advisability,  of  applying 
the  name  "dementia  choreica*'  to  Huntington's  chorea  is  of 
course  open  to  question,  but  if  the  term  proposed  excites 
a  broader  conception  of  the  disease  than  is  at  present  taken 
and  directs  attention  to  the  psychological  significance  of 
the  disorders  of  motility  it  will  have  served  its  purpose. 

DISCUSSION. 

Dr.  J.  J.  Putnam  thought  that  the  view  presented  was  a 
broadening  one  to  the  mind.  Whether  or  not  we  had  to  do  in 
such  processes  with  joint  conditions  was  always  open  to  doubt. 
One  saw  the  occurrence  of  various  physical  stigmata  side  by 
side  with  physiological  and  psychological  evidence  of  degen- 
eration, and  sometimes  without  them.  The  same  was  true 
with  regard  to  these  morbid  processes,  but  when  the  collocation 


«^  Journal  Nerv.  and  Ment.  Dis.,  Sept.,  1895. 


A    CASE  OF  HUNTINGTON'S  CHOREA,  863 

became  a  fairly  definite  one,  it  was  highly  important  to  recog- 
nize it.  What  appealed  to  him  most,  perhaps,  was  the  state- 
ment regarding  a  logical  connection  between  disorders  of 
movement  and  the  psychical  defects.  Possibly  that  gap  was 
not  so  wide  as  one  might  suppose. 

Dr.  Sinkler  said,  with  regard  to  the  renaming  of  the  dis- 
ease, that  he  had  always  thought  the  name  "Huntington's 
chorea"  was  undesirable,  both  on  account  of  the  fact  that,  in 
general;  the  naming  of  diseases  after  individuals  is  undesirable, 
and  because  Huntington  was  not  the  first  writer  to  describe 
this  peculiar  form  of  hereditary  chronic  chorea.  It  had  been 
described  as  long  ago  as  1841  in  Dunglison's  "Practice  of 
Medicine"  by  Waters,  and  in  1863  by  Lyon,  The  name  which 
Dr.  Hallock  proposed  was,  perhaps,  also  undesirable,  because 
it  led  to  a  risk  of  confusion  with  chorea  insaniens.  He  thought 
also  that  the  writer  made  too  sweeping  an  assertion  when  he 
said  that  all  chorea  of  long  standing  leads  to  mental  disorder. 
He  quite  agreed  with  him,  however,  that  in  the  hereditary  type, 
mental  symptoms  sooner  or  later  develop  without  fail,  but  it 
is  the  rtde  that  the  mental  symptoms  develop  long  after  the 
choreic  symptoms  begin. 

Dr.  Joseph  Collins  said  it  seemed  to  him  that  there  was  a 
more  important  reason  than  that  given  by  the  last  speaker 
why  Huntington's  chorea  should  not  be  rechristened,  accord- 
ing to  the  suggestion  in  the  paper,  namely,  that  in  ordinary 
Sydenham's  chorea  there  is  often  slight  dementia.  In  fact, 
in  every  case  of  chorea  of  any  considerable  intensity  and  dura- 
tion there  is  always  a  slight  grade  of  dementia,  described  in 
the  books  as  hebetude,  mental  sluggishness  and  the  like,  but 
which  is  after  all  a  slight  dissociation  of  the  components  of  the 
mind.  Hence,  he  could  not  see  the  propriety  in  singling  out 
Huntington's  chorea  and  calling  it  dementia  choreica.  There 
might  be  some  who  did  not  call  up  the  clinical  picture  of  mental 
and  motor  disturbance  when  the  eponymic  nomenclature  was 
employed,  but  they  were  certainly  very  few.  If  we  are  bound 
to  change  the  name  of  this  disease  he  preferred  to  wait  until 
we  can  designate  by  a  term  that  shall  encompass  the  patho- 
logical progress,  and,  perhaps,  also  the  distinctive  clinical 
features. 

With  regard  to  the  basic  lesion  of  Huntington's  chorea,  he 
had  so  recently  written  upon  the  subject  that  he  would  only 
say  that  it  seemed  to  him  fairly  well  proven,  considering  the 
findings  in  his  own  case,  and  in  those  of  Dana  and  Oppenheim, 
which  were  all  parallel,  that  the  disease  is  a  form  of  chronic 
parenchymatous  encephalitis. 

Dr.  C.  K.  Mills  thought  the  paper  of  Dr.  Hallock  was  a 


864  I'RANK  K,  HALLOCK, 

• 

suggestive  one,  and,  on  the  whole,  the  name  proposed  was  a 
good  one.  The  objections  which  had  been  offered  to  it  by  the 
previous  speakers  would  hardly  hold  on  a  careful  study  of  the 
matter.  Chorea  insaniens  is  a  term  applied  to  a  definite  form 
of  acute  or  subacute  mental  disorder^  which  is  distinctly  differ- 
ent from  that  found  in  Huntington's  chorea,  and  while  some 
mental  disorder  is  frequently  present  in  many  cases  of  chorea, 
using  the  word  dementia  in  the  technical  sense,  he  scarcely 
thought  it  could  be  said  that  even  prolonged  cases  of  Syden- 
ham's chorea  lead  to  true  dementia.  Other  forms  of  disease 
besides  Huntington's  chorea  may  do  this.  The  paper  is  another 
evidence  of  the  increasing  interest  being  taken  in  the  integrat- 
ing of  the  numerous  facts  which  we  now  have  regarding  the 
nervous  system.  With  regard  to  the  diseases  that  Dr.  Hallock 
would  associate  with  Huntington's  chorea,  it  seemed  to  him 
unwise  to  class  the  latter  with  dementia  paralytica.  In  de- 
mentia paralytica  there  were  certain  pathological  conditions 
which  in  most  cases  were  due  to  acquired  disease  of  a  peculiar 
type,  the  indirect  cause  frequently  being  syphilis. 

Dr.  Hallock,  in  closing  the  discussion,  said  that  he  thought 
Dr.  Mills  had  answered  the  chief  objections  raised  by  Drs. 
Sinkler  and  Collins  against  the  use  of  the  name.  In  his  own 
mind,  viewing  the  question  of  psychical  degeneration  from  the 
teratological  standpoint,  he  was  inclined  to  divide  the  process 
into  three  general  grades:  First,  into  the  degeneration  occur- 
ring in  early  life,  represented  by  the  adolescent  insanities  and 
mental  abnormalities;  second,  into  the  degeneration  in  middle 
life,  such  as  Huntington's  chorea;  third,  into  that  which  occurs 
at  the  climacteric  period  or  later  in  life,  represented  by  dementia 
senilis.  Certainly  the  type  of  dementia  senilis,  which  is  more 
purely  psychic  and  not  markedly  arteriosclerotic,  can  be  con- 
sidered, in  one  sense  at  least,  a  teratological  defect,  only  further 
removed  in  lifetime  than  is  the  case  with  Huntington's  chorea. 


252.  ZuR  Frage  von  den  Laehmungserscheinungen  bei  Pasteur* 
SCHEN  iNfPFUNGEN  (Paralytic  Symptoms  following  Pasteur  Injec 
tions).  L.  O.  Darkschewitsch  (Neurologisches  Centralblatt,  17, 
1898. 

The  author  presents  the  histories  with  clinical  notes  of  two  cases 
of  paralysis  following  Pasteur's  treatment  of  hydrophobia.  The  main 
symptoms  were  those  of  paresis  of  the  extremities  with  parsesthesia 
pain  and  ataxia.  The  electrical  reactions  were  less  pronounced  and 
there  was  some  atrophy  of  the  small  muscles  of  the  hands  in  one  of 
the  cases.  In  the  second  case  there  was  developed  a  double  facial 
paralysis. 

Both  cases  recovered,  though  the  first  case  retained  some  parses- 
thetic  symptoms  with  slight  ataxia  of  the  fingers  of  the  left  hand  for 
over  a  year.  Jelliffe. 


■ 

i 


THE  BRUCE  MICROTOME.* 

By  C.  EUGENE  RIGGS,  A.M.,  M.D. 

The  Bruce  microtome,  designed  by  my  friend,  Prof. 
Alexander  Bruce,  of  Edinburgh,  and  made  by  A.  Frazer, 
of  that  city,  is  intended  especially  for  cutting  celloidin 
preparations  under  the  surface  of  alcohol.  Its  construc- 
tion is  very  simple.  It  consists  of  a  heavy  metal  tank,  2 
cm.  deep,  20  cm.  wide  and  90  cm.  long,  inside  measure- 
ments. A  square  middle  section  is  6  cm.  deeper  than  the 
other  portions  of  the  tank.  In  the  centre  of  the  deep 
portion  is  the  object-holder.  Orientation  is  secured 
through  a  ball  and  socket  joint,  which  may  be  clamped  to 
any  position.  The  object-holder  is  moved  vertically  by 
a  large  but  delicate  micrometer  screw,  moving  in  a  heavy 
sleeve  attached  under  the  centre  of  the  tank. 

Automatic  feeding  is  obtained  by  a  system  of  levers 
put  in  motion  by  the  knife-block,  and  acting  on  a  ratchet- 
wheel  on  the  lower  extremity  of  the  micrometer  screw. 
The  knife-block  is  4  cm.  in  thickness  and  25  cm.  long.  It 
moves  in  a  V-shaped  groove  running  the  full  length  of 
the  tank.  The  cutting  stroke  is  given  to  the  block  by  a 
weight  and  pulley  attached  to  one  end,  and  the  return 
stroke  by  a  treadle  and  pulley.  Two  bronze  arms,  which 
may  be  adjusted  at  any  desired  angle,  are  attached  to  the 
block  and  suspend  the  knife  within  the  tank. 

The  knife  is  5  cm.  wide  and  has  an  effective  cutting 
edge  of  30  cm. 

The  whole  apparatus  is  supported  on  four  heavy  metal 
legs. 

In  operation  the  knife  is  first  adjusted;  then  the  tank 


♦Read  at  the  twenty-fourth  annual  meeting  of  the  American  Neu- 
rological Association,  May,  1898. 


866  C.   EUGENE  RIGGS. 

is  filled  with  50  to  80  per  cent,  alcohol,  sufficient  to  sub- 
merge the  edge  of  the  knife.  From  1.5  to  2  litres  of  fluid 
are  sufficient.  When  the  block  is  in  place  and  ready  for 
cutting,  the  operator  draws  back  the  knite,  which  at  the 
same  time  feeds  the  block  upward,  by  a  stroke  of  the 


treadle.  He  removes  his  pressure  from  the  treadle  and 
the  weight  and  pulley  produce  the  cutting  stroke.  Both 
hands  of  the  operator  are  free  for  handling  the  sections. 

The  good  points  about  the  instrument  may  be  summed 
upas  follows: 


THE  BRUCE  MICROTOME,  867 

1.  Its  simplicity.  Any  intelligent  person  can  under- 
stand it  and  operate  it.  One  which  has  been  in  use  two 
and  a  half  years  in  my  pathological  laboratory  has  not 
once  been  in  the  least  out  of  order. 

2.  .Its  accuracy.  Exceedingly  thin  sections  may  be 
cut  on  it  without  "skipping."  This  is  accomplished  by  the 
large  size  and  rigidity  of  the  parts  preventing  vibration, 
and  by  the  fact  that  the  entire  block  and  the  edge  of  the 
knife  are  constantly  under  alcohol. 

3.  Its  capacity.  While  the  object-holder  is  not  suf- 
ficiently delicate  in  its  adjustment  for  the  finest  embryo- 
logical  work,  the  largeness  of  the  section  is  limited  only 
by  difficulties  in  embedding  technique  and  by  the  width 
of  the  tank. 

4.  Its  rapidity.  The  instrument  is  operated  entirely 
by  foot  power,  and  both  hands  are  free  for  removing  the 
sections,  which  are  very  easily  removed. 

Several  minor  improvements  might  be  made  in  the  in- 
strument at  small  additional  expense,  but  even  as  it  now 
stands  it  fulfills  very  perfectly  all  the  requirements  made 
on  a  celloidin  microtome. 


253.       SUL   TIPO     PROGKNEO     NEI     SANI     DI     MENTE,    NKGLI    ALIENATI    E   NEI 

CRiMiNALi  (On  a  Type  of  Prognathism  in  Normal,  Insane  and 
Criminal  Individuals).  G.  Peli  (Archio  di  Psichiatria,  19,  1898, 
p.  611). 

The  author  discusses  the  type  of  prognathism  in  which  the 
under  jaw  protrudes  beyond  the  upper  and  gives  a  statistical  study 
of  much  value.  He  shows  that  this  condition  is  found  in  from  2  to  3 
per  cent,  of  normal  individuals.  In  the  insane  the  figures  of  various 
authors  are  given  showing  a  large  amount  of  variation.  Richter 
gives  I  per  cent,  and  GiuflFrido-Ruggeri,  44  per  cent.,  and  others 
give  intermediate  percentages  between  these  extremes.  The  author's 
own  investigations  covered  some  six  hundred  observations  on  the 
insane,  one  hundred  criminal  insane  and  two  hundred  criminals.  His 
figures  are  about  as  follows.  In  the  insane  this  condition  was 
present  in  28  per  cent,  of  the  men  and  15  per  cent,  of  the  women; 
among  the  criminal  ifisane,  33  per  cent,  among  the  men,  and  among 
criminals,  38  per  cent,  in  men  and  21  per  cent,  in  women.  Among 
the  criminals  this  condition  was  more  prevalent  in  those  who  had 
committed  grave  offenses,  such  as  murder  and  robbery. 

Jbllifpb. 


A  CLINICAL   CONSIDERATION    OF    HERPES 

ZOSTER.* 

By  LEONARD  WEBER,  M.D., 

Dr.  Weber  said  that  herpes  zoster  occurs  usually  on 
one  side  only,  and  that  bilateral  symmetrical  involvement 
is  very  rare,  although  Eulenburg,  Kaposi  and  others  have 
observed  such  cases.  Inasmuch  as  diseased  conditions 
of  the  Gasserian  ganglion  and  of  the  lumbar  intervertebral 
ganglia  in  cases  of  herpes  have  been  seen  and  described 
by  Baerensprung,  Kaposi  and  others,  there  can  be  no 
doubt  that  ganglionic  *  affections,  parenchymatous, 
hemorrhagic,  etc.,  may  be,  and  often  are,  the  cause  of 
shingles.  Clinical  observation  has  shown,  however,  that 
these  are  not  the  causes  in  every  case,  and  that  herpes 
may  be  produced  by  inflammation  of  peripheral  nerves. 
Frequently,  for  instance,  it  does  not  follow  the  entire 
course  of  a  nerve,  but  appears  only  along  its  most 
peripheral  part.  Again,  it  has  been  seen  in  the  territory 
of  nerves  that  were  in  a  state  of  irritation  or  congestion 
through  wounds,  abscesses  or  tumors  in  their  neighbor- 
hood. There  are  numerous  reports  by  various  authors 
of  cases  of  herpes  in  which  nodular  perineuritis  or  inter- 
stitial and  parenchymatous  neuritis  have  been  demon- 
strated in  the  affected  nerve  branches. 

In  Dr.  Weber's  own  collection  of  twenty-three  cases 
of  herpes  the  largest  number  were  intercostal;  after  these 
cervical  and  cervico-brachial  were  most  numerous,  then' 
followed  facial  and  abdominal,  and  finally,  in  a  few  cases 
the  scalp  or  thigh  was  affected.  The  majority  of  the 
patients    were    not    in    good    health    when    attacked; 


'Read  at  the  twenty-fourth  annual  meeting  of  the  American  Neu 
rological  Association,  May,  1898. 


L 


CONSIDER  A  TION  Oh  HERPES  ZOSTER,  869 

rheumatism,  renal  disease,  uricacidaemia,  spinal  neurasthe- 
nia, spinal  syphilis,  being  noted  in  them.  The  single 
case  of  herpes  gangrenosus  in  the  postauricular  region  of 
the  occipitaHs  magnus  branch  of  the  third  cervical  nerve 
was  in  a  tall,  stout  and  vigorous  man  of  forty-four  years 
who  was  very  nervous  and  excitable,  but  appeared  to  be  in 
general  good  health. 

Dr.  Weber  insisted  upon  scrupulous  cleanliness  in  the 
local  treatment  of  zona  and  dusted  the  part  with  bismuth 
powder  or  covered  it  with  a  25  per  cent,  to  50  per  cent, 
bismuth  salve.  He  used  ten  to  fifteen  grain  doses  of 
quinine  two  or  three  times  daily  during  a  week  or  more 
for  the  severe  neuralgia  following  herpes.  Fowler's 
solution  in  rapidly  increasing  doses  has  not  been  of  much 
service  to  him  in  the  treatment  of  herpetic  neuralgia. 
Ten  to  fifteen  grains  of  iodide  of  potassium  given  three 
times-daily  with  or  without  one-thirtieth  grain  strychnine, 
according  to  the  presence  or  absence  of  cardiac  weakness, 
have  been  valuable  where  the  neuralgia  was  associated  with 
oedematous  swelling  and  induration  of  the  parts.  As 
long  as  the  neuralgia  stage  lasts  patients  are  very  sensi- 
tive to  even  slight  changes  of  temperature  or  motion  of 
the  affected  parts.  They  must  be  kept  very  quiet  in  even 
temperature  and  carefully  nursed.  Prolonged  exposure 
to  cold  and  damp,  severe  muscular  strain,  acute  and 
chronic  infectious  diseases  and  gastro-intestinal  auto-in- 
fection play  an  important  part  in  the  causation  of  herpes. 
Dr.  Weber  observed  a  case  of  zona  of  the  shoulders  fol- 
lowing scarlatina. 

DISCUSSION. 

Dr.  J.  J.  Putnam  did  not  think  the  argument  advanced^ 
that  the  whole  nerve  was  not  involved  in  cases  of  herpes  zoster, 
was  thoroughly  sound.  The  vesicles  indicated  local  invasion 
of  bacteria  from  without  at  certain  points,  but  they  did  not  in- 
dicate to  what  extent  innervation  was  impaired.  In  a  case 
which  he  had  seen,  where  the  entire  area  of  distribution  of  the 
supraorbital  nerve  was  involved,  the  skin  had  become  de- 


8/0  LEONARD    WEBER. 

pressed,  thin  and  white,  not  only  in  the  localities  where  the 
vesicles  had  occurred,  but  over  the  entire  area,  indicating  a 
•more  widespread  impairment  of  innervation  than  the  distribu- 
tion of  the  vesicles  would  have  suggested* 

Dr.  Putnam  was  inclined  to  b^eve  that  the  lesion  in  these 
cases  was  far  back,  to  say  the  least,  since  in  one  case  under  his 
observation  where  the  patient  had  suffered  from  repeated  at- 
tacks of  herpes  zoster  section  of  the  supraorbital  nerve  was 
done  as  far  back  as  possible,  yet  it  did  not  relieve  the  pain. 

Dr.  W.  G.  Spiller  thought  that  there  could  be  little  doubt 
that  herpes  is  connected  with  disease  of  the  nerves  and  ganglia, 
especially  of  the  sensory  fibres.  He  did  not  know  of  any  case 
in  which  the  vesicles  were  present  with  symptoms  indicating 
involvement  of  the  motor  fibres  alone.  He  had  been  able  to 
observe  a  pathological  condition  of  one  of  the  spinal  ganglia, 
which  was  probably  the  cause  of  herpes  in  a  case  studied  in 
the  service  of  Dr.  Kovacs,  of  Vienna.  The  patient  had  Pott's 
disease  and  suffered  from  an  attack  of  zoster  confined  to  a 
thoracic  nerve  of  one  side.  At  the  necropsy  the  ganglion  be- 
longing to  this  nerve  was  found  covered  with  miliary  tubercles, 
while  the  ganglion  just  above,  which  had  been  removed  by 
mistake,  was  apparently  normal.  Dr.  Spiller  thought  that  the 
evidence  in  favor  of  the  existence  of  herpes  from  lesions  con- 
fined to  the  spinal  cord  was  not  at  all  satisfactory. 

Dr.  W.  M.  Leszynsky  said  that  in  recent  years  he  had 
come  to  regard  herpes  zoster  as  one  of  the  symptoms  of  a 
peripherial  neuritis,  and  had  treated  the  patients  accordingly 
with  excellent  results.  For  the  purpose  of  relieving  the  acute 
pains,  especially  in  the  intercostal  variety,  he  had  found  the 
Paquelin  cautery  remarkably  efficacious.  One  application 
to  the  spine  in  the  region  of  the  posterior  roots,  corresponding 
to  the  affected  nerves,  was  often  sufficient  to  relieve  the  pain, 
and  render  special  internal  treatment  unnecessary. 

Dr.  Wharton  Sinkler  agreed  with  Dr.  Weber's  view,  that 
in  herpes  zoster  the  lesion  was  not  always  a  peripheral  one. 
It  may  be  situated  in  the  cord  or  spinal  ganglia.  The  speaker 
mentioned  the  case  of  a  woman  of  seventy,  with  rheumatic 
arthritis,  who  had  an  attack  of  herpes  zoster  along  the  ante- 
rior crural  nerve ;  it  was  followed  by  a  gangrenous  condition  of 
the  part,  and  in  spite  of  opiates,  potassium  iodide,  arsenic, 
quinine  and  numerous  other  internal  and  local  remedies,  the 
woman  died  of  exhaustion  in  three  months. 

Dr.  C.  L.  Dana  agreed  with  the  view  taken  by  Dr.  Spiller 
that  in  most  cases  the  trouble  is  in  the  nerve — probably  in  the 
sensory  branch — and  deeply  seated.  Practically,  herpes  zos- 
ter is  mostly  seen  by  the  neurologist  on  account  of  the  after- 
effects of  the  disease.     Tt  was  not  uncommon,  he  said,  to  see 


CONSIDERATION  OP  HERPES  ZOSTER.  871 

zoster  followed  by  severe  forms  of  neuralgia  affecting  the  in- 
tercostal, crural  or  facial  nerves.  He  had  seen  a  number  of 
cases  of  tic  douloureux  following  an  attack  of  herpes  zoster, 
and  could  also  recall  one  case  of  very  severe  and  obstinate 
paraesthesia  affecting  one  of  the  intercostal  nerves  as  the  sequel 
of  herpes  zoster.  TTie  patient  was  given  all  sorts  of  drugs,  un- 
derwent the  "rest  cure/'  and  had  a  gynaecologist  operate 
upon  her,  but  all  without  avail.  Finally  she  got  well  under  toxic 
doses  of  strychnia. 

Dr.  Weber,  in  closing,  said  that  as  none  of  his  cases  had 
come  to  autopsy,  he  could  not  tell  whether  they  were  of  local 
or  central  origin.  He  believed,  however,  that  certainly  one- 
half  of  the  cases  were  of  peripheral  origin. 


254.  A  Study  of  the  Lesions  in  a  Cajse  of  Trauma  of  the  Cervical 
Region  of  the  Spinal  Cord  Simulating  Syringomyelia.  James 
Hendrie  Lloyd  (Brain,  21,  1898,  p.  21). 

Lloyd  here  reports  in  extenso  his  post  mortem  findings  in  a  case 
of  traumatic  affection  of  the  cervical  region  of  the  cord,  a  full  clinical 
history  of  which  he  had  published  in  the  Journal,  June,  1894.  The 
case  presented  many  features  common  to  hemiplegia,  yet  that  it  was 
not  a  cerebral  lesion  would  seem  to  have  been  indicated  by  the 
spinal  deformity,  the  absence  of  paralysis  of  the  face  or  tongue,  sen- 
sory changes  and  the  atrophy  and  fibrillation  of  the  paralyzed  muscles. 
It  also  showed  the  arrangement  of  the  Brown-Sequard  paralysis, 
paralysis  of  motion  on  one  side  and  sensory  changes  on  the  other. 
In  addition  the  peculiar  dissociation  symptoms  and  muscular  atrophy 
of  the  shoulder  and  arm  showed  its  relations  to  a  syringomelic  process. 
The  patient  died  five  years  after  the  injury  of  an  intercurrent  disease. 

The  autopsy  showed  quite  extensive  flattening  of  the  cord  from 
about  the  fourth  to  seventh  cervical  segment,  the  seventh  cervical 
segment  being  involved  to  the  greatest  extent,  the  whole  cord  here 
being  flattened  or  ribbon  like.  The  left  half  of  the  cord  being  greatly 
injured.  The  area  of  greatest  involvement  included  the  left  antero- 
lateral column  (pyramidal  tract,  cerebellar  tract,  and  Gowers*  tract), 
the  anterior  and  posterior  horns,  the  anterior  portions  of  the  posterior 
columns,  and  the  gray  and  the  white  commissures.  The  detailed 
description  cannot  be  here  abstracted  nor  the  excellent  and  full 
discussion  of  the  physiology  of  the  different  fibre  tracts.  The  author 
briefly  recapitulates  thus.  "It  may  be  said  that  tactile  impressions 
pass  directly  up  the  posterior  columns  by  way  of  the  exogenous 
fibres  of  the  same  side,  while  painful  and  thermal  impressions  pass 
into  the  gray  matter  and  through  the  cell  bodies  of  the  second 
order  of  neurons  whose  axis  cylinders,  in  a  large  majority  at  least, 
pass  across  to  the  opposite  side  of  the  cord  and  up  the  lateral  columns, 
especially  in  Gowers'  tract."  Jelliffe. 


THE  RESULTS  OBTAINED   BY  THE  OPERATION: 

OF  PARTIAL  THYROIDECTOMY  IN  EIGHT 

CASES  OF  GRAVES'  DISEASE.* 

By  J.  ARTHUR  BOOTH,  M.D. 

The  histories  of  eight  cases  of  Graves'  disease  with  the 
results  obtained  by  the  removal  of  one  lobe  of  the  thyroid 
gland  were  reported.  Five  persons  were  cured  by  the- 
operation,  one  was  benefited,  in  one  little  improvement 
was  noticed,  and  one  died.  The  mortality  from  the  opera- 
tion is  seven  per  cent. 

DISCUSSION. 

Dr.  Theodore  Diller,  of  Pittsburg,  inquired  whether  any 
bad  symptoms  developed  immediately  or  shortly  after  the 
operation  in  the  successful  cases  reported  by  Dr.  Booth. 

Dr.  J.  J.  Putnam,  of  Boston,  said  he  had  already  reported 
two  cases  of  thyroidectomy  for  Graves'  disease,  with  death 
following  in  one  instance  and  gradual  improvement  in  the 
other.  Since  then  he  had  had  another  case  which  resulted 
fatally  after  the  removal  of  the  cervical  sympathetic.  Although 
the  general  health  of  this  patient  was  very  poor,  still  the  opera- 
tion, apparently,  precipitated  his  death,  and  the  speaker 
thought  that  this  case  rather  lessened  the  probability  of  the 
view  that  death  occuring  shortly  after  thyroidectomy  is  due 
to  the  absorption  of  thyroid  products,  as  has  been  suggested. 

Dr.  Putnam  said  that  a  very  favorable  point  in  connection 
with  the  cases  reported  by  Dr.  Booth  was  that  the  operations 
were  all  done  by  the  same  surgeon.  In  all  the  more  serious 
operations — those  on  the  stomach,  for  example — ^the  results 
are  better  in  a  series  done  by  a  specially  trained  surgeon  than 
in  a  series  of  scattered  cases  done  by  different  men. 

Dr.  W.  M.  Leszynsky,  of  New  York,  said  he  had  had  two 
cases  of  Graves*  disease  operated  on  during  the  past  year. 
One  of  the  patients  had  improved  very  much;  the  oth^r  died 
thirty-six  hours  after  the  operation.  There  was  no  kidney 
complication,  and  death  was  ascribed  to  acute  thyroidism. 


♦Read  at  the  twentv-fourth  annual  meeting  of  the  American  Neu- 
rological Association,  May,  1898. 


* 


OPERATION  OF  PARTIAL  THYROIDECTOMY,    873 

The  case  was  a  very  pronounced  one,  and  the  patient  was 
allowed  to  rest  for  nearly  two  weeks  previous  to  the  operation. 
Dr.  Booth,  in  reply  to  Dr.  Diller,  said  that  with  the  excep- 
tion of  a  slight  rise  in  temperature  there  were  no  alarming 
symptoms  subsequent  to  the  operation  in  any  of  his  cases,  ex- 
cept in  the  fatal  case.  He  was  not  inclined  to  accept  the 
theory  that  sudden  death  after  these  operations  is  due  to  the 
rapid  absorption  of  the  thyroid  secretion;  this,  he  thought,  was 
hardly  probable,  as  all  the  bleeding  points  are  not  only  tied,  but 
also  cauterized,  and  the  greatest  care  in  the  technique  of  the 
operation  is  exercised. 


255.   The  Pathologic   Impulse    to    Drink.      W.  L.  Howard,  M.D. 

(Medicine,  March,  1898). 

Dipsomania  is  a  symptom  of  defective  inhibition.  It  is  most 
common  among  those  living  at  a  high  nervous  pressure — physicians, 
litterateurs  and  business  men.  Exhibition  of  nervous  energy  always 
lessens  inhibition.  The  cells  of  the  cortex  become  exhausted  by  long- 
continued  expenditure  of  energy;  the  individual  resorts  to  alcohol  to 
relieve  his  restlessness,  the  result  of  this  cell  exhaustion,  and  which 
prevents  him  from  attending  to  his  ever  pressing  duties.  It  is  then  that 
the  defective  inhibition  is  shown,  and  the  uncontrollable  impulse 
hreaks  the  bounds  of  reason.  The  pathologic  condition  of  the  cells 
is  probably  analogous  to  the  hypothetic  pathology  of  hysteria.  The 
protoplasm  of  the  cortical  cells  becomes  used  up  by  continued  work 
without  the  rest  necessary  for  recuperation,  and  while  in  this  state 
a  small  amount  of  alcohol  rapidly  cuts  the  higher  centres  off  from 
the  lower,  causing  a  loss  of  inhibitory  power.  A  continuance  of  these 
conditions  results  in  such  changes  that  each  attack  leaves  the  con- 
nection between  the  higher  and  lower  centres  less  active,  with  a 
lessened  amount  of  functional  force  in  the  cortical  cells.  Some  cases 
-of  dipsomania  can  be  directly  traced  to  the  absence  of  early  educa- 
tion in  not  correcting  uncontrollable  impulses  in  childhood,  but  here 
we  will  find  the  child  has  inherited  a  richly  neurotic  soil.  There  is 
another  class  of  dipsomaniacs,  whose  history  shows  early  disturbance 
•of  cortical  cells  during  their  development  periods.  These  are  the 
•cases  which  in  infancy  have  been  g^ven  alcohol  in  some  form.  Among 
other  causes  may  be  mentioned  autointoxication.  In  considering 
prophylaxis  and  cure,  it  is  important  to  bear  in  mind  the  somatic 
cycles  by  which  many  of  our  unconscious  actions  are  governed.  ITie 
long  rhythms  are  habits  of  organic  activity.  The  long  rhythms  in 
nutrition  and  heat  regulations  of  the  body  are  factors  in  augmenting 
the  periodicity  of  dipsomania.  Under  pathologic  conditions  such  as 
hypothetically  exist  in  this  psychic  explosion,  its  intervals  appear  to 
be  governed  by  the  organic  cycles,  including  the  monthly  rhythm  of 
the  female,  and  which  in  this  sex,  at  this  time,  is  often  marked  by 
slight  attacks  of  dipsomania.  Suggestion,  with  or  without  hypnosis, 
is  of  considerable  value.  Everything  possible  must  be  done  to  pre- 
vent the  exhaustion  of  nerve  force,  and  efforts  made  to  store  up  re- 
serve material.  The  physiologic  rhythms  must  be  watched,  and  when 
we  see  the  approach  of  the  ebb  of  these  rhythms  the  patient  must  be 
carefully  guarded.  Freeman. 


CHLOROSIS  AND  RETINOPAPILLITIS  * 

I 

By  H.  M,  bannister,  M.D., 

Member  of  the  Ameri'^an  Netiroloffical  Association;  ot  the  American  Medico- 
Psychological  Afcsuciation  and  of  the  Chicago  Academy  Of  Medicine. 

• 

The  following  case  is  reported  as  possibly  of  interest  in 
some  respects,  and  because  it  is  of  a  class  that  has  been 
considered  rare,  though  it  i§  probable  that  such  conditions 
are  more  frequent  than  has  been  generally  supposed.  Since 
commencing  to  write  the  account,  I  have  heard  of  at  least 
three  other  cases  occurring  within  a  short  period  in  the 
practice  of  other  physicians  of  my  acquaintance,  present- 
ing more  or  less  similar  peculiarities,  and  giving  rise  to 
the  same  questions  of  diagnosis: 

Miss  J.  M.,  ag^  21,  reported  as  previously  always  in  goov. 
health,  and  with  good  family  history,  without  tuberculous, 
cancerous  or  neurotic  taint,  so  far  as  could  be  ascertained, 
was  taken  rather  suddenly  with  a  severe  headache,  on  Oc- 
tober 13th,  1896.  This  passed  off  in  the  course  of  the  day, 
leaving  her  in  her  usual  comfortable  condition.  The  only 
precursors  of  the  attack  were  a  feeling  for  a  week  or  two  of 
becoming  rather  more  readily  fatigued  on  exertion  than  was 
usual,  and  a  scantiness  of  the  menstrual  flow  at  the  last 
regular  period.  She  had  always  been  normal  in  this  respect, 
and  had  noticed  the  change,  but  she  did  not  regard  it  as  re- 
markable or  consider  herself  as  out  of  health,  nor  had  any- 
thing been  remarked  on  the  part  of  her  family  as  to  her  ap- 
pearance or  behavior.  On  the  morning  of  the  14th  the  head- 
ache recurred  with  such  severity,  and  was  attended  with  such 
nausea  and  vomiting,  that  she  took  to  her  bed  and  called  in 
Dr.  G.  P.  Head,  to  whom  I  am  indebted  for  the  above  facts, 
to  prescribe  for  her.  The  headache  was  described  by  her  as 
being  more  intense  and  more  often  on  the  right  side,  but  only 
for  a  short  period,  and  there  was  a  point  over  the  right  parietd 
eminence  that  was  decidedly  tender  to  the  touch.  Any  at- 
tempt to  rise  from  the  recumbent  position  was  attended  with 
severe  nausea  and  vomiting  of  the  cerebral  type,  though  it  did 

♦Read  at  the  twenty-fourth  annual  meeting  of  the  American  Neu- 
rological Association,  May,  1898. 


CHLOROSIS  AND  RETINOPAPILLITIS.  875 

not  specially  aggravate  the  headache.  There  were  pronounced 
photophobia  and  an  almost  absolute  anorexia  and  rejection  of 
food  by  the  stomach.  The  temperature  was  normal,  or  nekrly 
so;  at  no  time  during  this  day  or  the  following  days  did  it  rise 
more  than  a  degree  or  two,  and  then  only  for  short  intervals, 
never  much  exceeding  109  and  rarely  rising  above  99.  The 
pulse  was  not  specially  accelerated,  was  not  ovef  70,  and  other- 
wise not  noticeably  abnormal.  The  bowels  were  constipated 
and  the  urine  scanty  and  high  colored.  Reflexes  were  nor- 
mal. 

The  headache  continued  unintermittingly ,  as  described,  after 
the  I5th,ins^it^  of  treatment  with  various  anodynes,  phenace- 
tin,  antipyrin,  caiiTiabis  indica,  bromides,  ergot,  etc.,  and  be- 
came even  more  aggravated.  Only  morphine  hypodermically 
was  found  effective,  and  this  was  administered  in  increasing 
doses,  till  one-third  of  a  grain  twice  on  the  17th  and  i8th  and 
three  times  oin  the  19th  was  found  necessary  in  order  to  obtain 
sleep  and  respite  from  the  pain.  The  sleep  was  broken,  and 
it  was  necessary  by  the  19th  for  the  physician  to  administer 
one  dose  after  midnight  to  carry  the  patient  through  till  morn- 
ing in  tolerable  comfort. 

On  the  morning  of  October  20th  I  saw  the  patient  with 
Dr.  Head  for  the  first  time.  She  was,  notwithstanding  the 
little  nourishment  she  had  taken,  not  yet  excessively  reduced  in 
flesh;  her  normal  weight  must,  I  judged,  have  been  near  one 
hundred  and  forty  or  forty-five  pounds,  though  she  was  rather 
short  in  stature.  She  was  pale  and  anaemic  in  appearance, 
lips  and  conjunctiva  showing  this  decidedly;  her  tongue  was 
covered  with  a  thick,  dirty  appearing  fur;  her  pupils  were  con- 
tracted, pulse  was  not  over  50,  and  temperature  was  slightly  ' 
subnormal.-  The  bowels  were  said  to  be  decidedly  constipated ; 
the  urine  was  scanty,  and  was  estimated  at  not  over  ten  ounces 
in  the  twenty-four  hours;  its  specific  gravity  was  1,030,  its  re- 
action acid,  and  it  contained  no  albumin  or  sugar.  The  odor 
of  the  urine  was  rather  peculiar,  but  this  was,  perhaps,  at- 
tributable to  some  of  the  many  drugs  she  had  taken.  She 
was  very  sensitive  to  any  irritation,  and  the  room  had  to  b6 
kept  darkened,  both  on  account  of  the  photophobia  and  the 
nervousness  produced  by  the  light.  Even  the  examination 
appeared  to  aggravate  her  headache,  which,  except  when  un- 
der the  full  influence  of  the  morphine,  was  always  more  or  less 
distressing;  in  fact,  she  claimed  to  be  at  no  time  entirely  free 
from  it.  It  was,  as  stated,  worse  as  a  rule  on  the  right  side; 
but  the  pain  radiated  down  the  back  of  the  neck,  and  that 
region  appeared  stiff  and  ten<ier.  She  complained  much  of 
roaring  in  her  ears,  especially  the  right,  but  there  was  no  pro- 
nounced anaemic  murmur.    Her  mind  seemed  perfectly  clear; 


876  ^-  ^^-   BANNISTER. 

her  vision  was  at  this  time,  she  thought,  perfectly  unimpaired 
There  were  some  epigastric  distress  and  tenderness,  but  none 
over  the  abdomen  generally,  and  no  motor  symptoms  other 
than  those  explainable  by  the  pain  and  stiffness  in  the  neck, 
and  every  movement  of  her  limbs  or  change  of  position  was 
distressing  and  dreadjed  on  account  of  its  liability  to  aggravate 
the  headache.  At  no  tSme  had  there  been  any  delirious  symp- 
toms, convulsions,  or  signs  of  marked  mental  impairment; 
even  the  effects  of  a  full  hypodermic  dose  of  one-third  of  a 
grain  of  morphine,  with  one-hundredth  of  a  grain  of  atropine, 
were  not  noticeable,  so  far  as  causing  any  mental  hebetude 
was  concerned. 

There  was,  and  had  been,  no  cough,  and  the  lungs  were 
healthy.  The  heart  sounds  w^ere  pure,  and  there  was  no  pro- 
nounced anaemic  murmur.    There  was  a  slight  leucorrhoea. 

It  was  thought  advisable  to  have  a  more  thorough  ex- 
amination of  the  urine  made,  and  this  was  done  on  the  23d, 
when  I  saw  the  patient  the  second  time  with  Dr.  Head,  her 
condition  appearing  practically  unaltered  in  the  interim.  The 
urine  was  found,  as  on  the  former  occasion,  nearly  normal, 
acid  in  reaction,  had  a  specific  gravity  of  1,032,  contained  urea 
3  per  cent.,  considerable  pus  and  epithelial  cells,  but  no  al- 
bumin or  sugar.  The  blood  examination  showed  haemoglobin 
45  per  cent.,  red  blood  corpuscles  3,224,000.  On  this  visit  the 
patient,  while  in  other  respects  unchanged,  complained  of  a 
slight  dimness  of  vision  that  had  just  become  perceptible  to 
her.  The  pupils  were  contracted  as  before  and  reacted  nor- 
mally: there  were  no  anomalies  of  function  in  the  ocular 
muscles.  The  vision  was  not  tested  other  than  to  make  sure 
that  it  was  only  very  slightly  impaired;  she  was  able  to  dis- 
tinguish objects  fairly  well  in  the  darkened  room,  but  said 
they  were  not  as  distinct  as  they  had  been.  On  account  of 
the  contracted  pupils  and  the  very  nervous  condition  of  the 
patient,  the  attempt  to  obtain  a  satisfactory  view  of  the  fundus 
on  this  occasion  was  unsuccessful. 

On  the  strength  of  the  blood  findingis,  with  the  other  symp- 
toms, a  provisional  diag:nosis  of  chlorosis  was  made,  and  the 
patient  put  upon  arsenic  and  iron  treatment  in  the  form  of 
Steam's  haemoferrum,  3  grains  every  three  hours,  with  T-50 
grain  of  arsenite  of  soda.  Nourishment  was  given  by  the  only 
method  that  that  had  thus  far  been  found  successful,  viz.,  a 
tablespoonful  of  Fairchild's  panopepton  with  a  little  ice  every 
two  hours.  Under  this  treatment,  by  the  26th  of  October, 
there  appeared  to  be  some  improvement,  the  headache  was 
less  intense,  and  the  morphine  injectioms  were  reduced  to  three 
daily,  the  nig^ht  dose  hein^  disoensed  with.  On  the  27th,  Dr. 
Head  was  able,  by  dilating  the  pupil,  to  get  a  view  of  the 


^ 


CHLOROSIS  AND  RETINOPAPILLITIS.  877 

fundus  oculi,  and  found  decided  left  optic  neuritis,  with  a  less 
advanced  sta^e  of  the  same  in  the  right  eye.  The  patient  about 
this  time  z^lso  complained  on  one  or  two  occasions  of  a  tem- 
porary numbness  of  the  right  arm,  with  some  impairment  of 
motion  in  the  same,  but  this  did  not  come  directly  under  Dr. 
Head's  observation.  ExanMination  of  the  blood  with  the  mi- 
croscope during  this  time  showed  marked  irregularity  of  out- 
line of  some  of  the  blood  disks. 

I  saw  the  patient  for  the  third  time,  with  Dr.  Head,  on  Oc- 
tober 30th,  1896.  Her  condition  had  so  far  improved  that  she 
was  able  to  sleep  nights  without  a  second  anodyne  injection, 
and  her  headache  was  rather  less  severe  during  the  day.  She 
was  still,  however,  taking  three  times  daily  one-third  of  a 
grain  of  morphine  hypodermically,  and  her  only  nourishment 
was  the  panopeptoin.  In  other  respects,  her  condition  was  the 
same  as  on  the  second  visit,  but  the  vision  was,  if  anything, 
a  little  poorer,  according  to  her  statements.  She  seemed  to 
see  and  recognize  persons  and  things  fairly  well  when  close 
at'  hand,  but  complained  of  a  certain  vagueness  and  indistinxrt- 
ness  in  their  outlines.  As  the  pupils  had  been  artificially  di- 
lated, I  obtained  a  good  view  of  the  fundi.  In  the  left  eye 
the  margin  of  the  disk  was  altogether  obliterated,  and  the  only 
way  to  recognize  its  location  was  by  a  possibly  darker  shade 
and  the  convergence  of  the  swollen  ajid  tortuous  vessels.  Im 
the  right  eye  the  condition  was  much  less  advanced,  but  there: 
was  pronounced  optic  neuritis. 

The  mental  condition  of  the  patient  was  the  same  on  all 
occasions.    She  appeared  bright  and  hopeful  of  recovery. 

From  this  time  on  the  improvement  steadily  continued,  the 
headache  became  less  intolerable,  the  stomach  more  tolerant 
of  food,  and  on  the  15th  of  November  the  optic  neuritis  had 
largely  subsided;  the  vision  was  improving,  according  to  the 
patient's  own  statement;  she  was  able  to  be  out  and  visit  the 
doctor  at  his  office.  The  morphine  injections  were  discon- 
tinued, and  Blaud's  pill  substituted  for  the  haemoferrum,  but 
through  the  month  of  November  there  remained  a  slight  de- 
gree of  headache  and  some  nausea  in  the  morning.  Menstru*-- 
ation,  which  was  scanty  in  October,  beginning  on  the  5th, 
and  was  missed  altogether  in  November,  reappeared  at  the- 
normal  i>eriod  on  December  3d.  On  the  21st  of  this  month 
she  considered  herself  well;  there  was  very  little  headache,  if 
any;  appetite  and  digestion  were  normal.  The  vision  was  con- 
sidered normal,  and  examination  showed  an  almost  normal' 
appearing  disk  in  each  eve.  I  did  not  myself  see  the  patient 
professionally  after  October  ^oth,  1896.  but  canr  testify  that 
her  general  appearance  was  that  of  nerfect  heaWl.  The  iixwn 
an^.  ar^^^iQ  treatment  was  kept  up  till  about  t^^ctcideftrrfftfte 


.  I 


878  H.   -if.   BANNISTER. 

year,  viz.,  Bbud's  pill,    5  grains,  arsen.  strychn,  1-32  grain, 
arsen.  soda  i-ioo  grain,   t.  d. 

This  observation  is  defective  in  several  ways,  in  the 
lack  of  repeated  determinations  of  hemoglobin,  of  e;xact 
measurements  of  the  visual  defect,  and  in  several  other 
special  points,  where  fullness  and  accuracy  would  have 
made  it  more  valuable.  As  it  is,  however,  it  has,  I  think, 
a  Certain  interest,  as  showing  the  severity  of  the  symp- 
toms that  sometimes  may  accompany  chlorosis,  and  the 
possible  errors  of  diagnosis  to  which  they  may  give  rise. 
But  for  the  suddenness  of  the  onset  of  the  headache  and 
other  symptoms,  which  suggessed  a  doubt  as  to  the  exist- 
ence of  brain  tumor,  and  led  to  the  examination  of  the 
blood,  that  diagnosis  would  have  seemed  probably  the 
correct  one,  and  in  fact  I  did  not  feel  absolutely  sure  of 
its  error  till  the  success  of  the  iron  and  the  arsenic  treat- 
ment had  assured  it.  The  case  is  almost  unique,  so  far  as 
I  have  been  able  to  find,  in  the  severity  of  the  symptoms 
of  headache  and  vomiting  and  the  reported  temporary 
motor  disturbance  of  the  right  arm.  As  this  last  was  not 
observed  and  tested  by  a  physician,  its  importance  cannot 
be  altogether  satisfactorily  estimated,  but  the  patient's 
statements  are  at  least  worthy  of  noting.  Any  hysterical 
element,  I  may  say,  was  not  at  all  prominent  in  the  case, 
if  it  existed;  the  patient,  in  fact,  appeared  very  little,  if  at 
all,  hysterical  in  the  usoal  sense  of  the  word. 

In  this  case  the  reduction  of  the  haemoglobin  was  not 
excessive  at  the  time  of  examination,  but  the  want  of  suc- 
cessive examinations  affects  the  value  of  this  fact.  The 
subsequent  poikilocytosis,  which  was  very  marked,  would 
perhaps  indicate  a  corresponding  less  percentage  than 
was  noted.  The  asymmetrical  character  of  the  optic  neu- 
ritis is  worth  noting,  though  such  cases  are  not  uncom- 
mon, the  right-sided  occurrence  of  the  headache  for  the 
most  part,  while  the  eye  symptoms  were  most  intense  on 
the  left,  may  also  be  worthy  of  mention.  The  rapid 
improvement  under  the  iron  and  arsenic  treatment  is  ac- 


CHLOROSIS   AND   RETISOPAPILLITIS,  §79 

cording  to  precedents  in  such  cases,  and  here  it  appears 
to  have  been  instituted  sufficiently  early  to  insure  perfect 
restoration  of  vision,  a  point  that  is  insisted  upon  by 
Gowers.^  In  our  case  the  visual  disturbance  was  evidently 
only  slight,  as  judged  by  the  subjective  symptoms  narrated 
by  the  patient. 

Optic  disturbances  in  chlorosis  have  been  noted  for 
many  years;  the  earliest  reference  I  have  found  is  that  by 
Prael,^  but  they  have  been  often  ignored  in  the  text- 
books. Osier,  for  example,  makes  no  mention  of  these 
symptoms,  and  there  are  other  works  equally  deficient. 
Dieballa,*  in  reviewing  the  literature,  quotes  Hayem 
(Du  Sang,  1889),  and  Luzet  (La  Chlorose,  1892)  as  also 
not  including  optic  neuritis  in  the  symptoms  of  chlorosis, 
and  speaks  of  the  complication  as  one  of  the  greatest 
rarities.  That  it  is  such  I  much  doubt,  but  think  rather 
that  it  is  very  commonly  overlooked,  sometimes  possibly 
to  the  patient's  serious  detriment.  De  Schweinitz*  rather 
apologizes  for  introducing  a  case  of  this  nature  into  a  pa- 
per on  ''Monocular  Optic  Neuritis,''  and  says  it  was  intro- 
duced simply  to  call  attention  to  the  therapeutic  measures 
desirable  in  such  cases,  thus  apparently  speaking  of  them 
as  comparatively  common  occurrences.  Ordinarily,  it  is 
probable  that 'the  symptoms  are  not  severe,  and  the  optic 
disorder  may  even  progress  till  an  incurable  impairment 
of  vision  is  produced.  The  following  case,  for  the  notes 
of  which  I  am  indebted  to  Dr.  C.  D.  Westcott,  is  possibly 
the  type  of  many  others,  some  of  which  do  not  come  under 
the  care  of  any  specialist  or  have  the  intraocular  conditions 
recognized: 

M.  K.,  aged  2,^^  bookkeeper  and  stenographer,  came  first 
under  observation  December  23d,  1895.     She  had  for  some 

^  British  Medical  Journal,  1880,  ii.,  p.  780;  also  Med.  Ophthal- 
moscopy. 

•  Bleichsucht  mit  Amaurose,  Monatsschr.  f.  med.  Augenh.  u.  Chi- 
rurg.,  Leipsig,  1840,  iii.,  pp.  187-190. 

•Deutsche  med.  Wochenschr.,  1896,  No.  2C. 

*  Philadelphia  Polyclinic,  1896,  v.,  No.  50. 


88o  H,  M.  BANNISTER. 

time  complained  of  daily  headiaches  and  eye  fatigue.  She  had 
always  been  nervous,  and  had  bad  repeated  attacks  of  nervous 
exhaustion.  She  thought  her  present  health  was  good,  with 
the  exception  of  the  above  mentioned  symptoms  and  fatigue 
from  overwork.  She  was,  however  anaemic,  and  had  ameoor- 
.fhoea.  Examination  of  the  eyes  showed  externally  only  hypcr- 
•semia  of  the  conjunctiva.  Refraction  test  showed  compound 
hyperopic  astigmatism  of  moderate  degree  in  both  eyes. 
Vision  with  correction  was  normal,  20/20  in  both  eyes.  Ex- 
iamination  of  the  fundus  showed  marked  hyperaemia  of  (fisk  and 
retina  of  right  eye.  She  was  referred  to  the  family  physician 
for  treatment  of  her  general  condition. 

January  15th,  1896.  H3rperaemia  of  disk  still  present,  but 
Stationary. 

October  i6th,  1897.  She  returned  with  reduced  vision  of 
right  eye,  20/30;  decided  papillitis  and  general  hyperaemia  of 
retina  and  exudate  in  the  macula.  Fields  for  white  were 
normal. 

February  26th,  1898.  Vision  of  left  eye  was  normal;  of 
right.  20/30;  outline  of  disk  was  indistinct;  no  papillitis  or  ret- 
inal hypersemia  and  no  decided  atrophy  were  noted;  general 
condition  was  improved. 

The  details  of  treatment  are  not  given  in  this  account. 
We  have  here  a  case  of  anaemic,  probably  chlorotic,  retino- 
papiilitis,  in  which  the  patient  was  so  far  negligent  of  her 
condition  as  to  let  it  progress  till  her  vision  was  perma- 
Yiently  somewhat  impaired.  Dr.  Westcott  had  also  notes 
of  another  similar  instance,  and  they  are  suggestive,  at 
lekst,  of.  the  possible  greatei*  frequency  of  chlorotic  optic 
neuritis  than  is  generally  supposed  to  be  the  case. 

Motor  symptoms  have  not  been  generally  reported, 
but  the  cerebral  irritation  that  can  cause  optic  neuritis 
can  very  possibly  be  enough  to  also  give  rise  to  local  irri- 
tation or  paralytic  phenomena.  Those  in  the  case  here 
reported  are  worthy,  at  least,  of  some  consideration,  and 
in  Dieballa's  patient  there  was  strabismus.  Severe  sen- 
sory disturbances,  headache,  etc.,  rarely  fail  to  occur,  but 
it  is  only  exceptionally  that  they  are  present  to  such  an  ex- 
tent as  in  the  case  here  reported. 

The  cause  of  the  optic  neuritis  is,  we  may  safely  say,  a 
cerebral  irritation,  the  exact  nature  of  which  is,  at  best. 


^ 


CHLOROSIS  AND  RETjAV^^iI^^LLLTM>,  -         8^i  , 

only  a  matter  for  conjecture.  Lately  cert9in  French  ,au-_ 
thorSj  Charrin,*^  Etienne  and  Demange,  have  strongly  ad-_ 
vocated  an  autointoxication  theory  of  the  disorder,  and 
this,  while  in  accord  with  the  trend  Of  ideas  at  the  present 
time,  also  affords  a  ready  possible  explanation  of  the  spe-  _ 
cial  symptoms  in  these  cases.  It  may  be  a  too  ready  one, 
and  the  real  facts  may  remain  to  oe  developed  in  an  en- 
tirely different  line;  but  just  now  it, gives  as  plausible  a 
theory  as  any  at  our  command.  If  th^  menstrual  function 
is  really  in  any  way  an  excretory  one,  as  some  have  held, 
or  if  the  internal  secretion  of  the  ovary  may  become  per- 
verted or  insufficient  in  such  a  way  as  to  poison  the  sys- 
tem and  produce  chlorosis,  it  is  not  going  much  further 
to  presume  that  it  may  in  special  cases  cause  symptoms 
strongly  resembling  those  of  organic  cerebral  disease,  and 
lead  to  embarrassing  mistakes  in  diagnosis.  The  resem- 
blances of  this  chlorotic  optic  neuritis,  with  its  attending 
symptoms,  to  cases  of  brain  tumor,  have  been  already 
noted  by  Gowers  and  others,  and  have  been  illustrated  by 
published  cases.  The  one  here  offered  is  given  as  an  es- 
pecially striking  example  of  this  particular  type. 

•Internat.  Med.  Congress,  1897. 

•Congres  Fran^ais    de  Med.  Internat,-,  Semaine  Med.,  April  23d, 
1898. 


256.  Thyroid    Extract   for    Backward  Chii«drsn.    Dukes  (Brit 
Med.  Jour.,  i.,  1898,  p.  618). 

The  author  reports  very  pleasing  results  from  the  administration 
of  thyroid  to  a  child  described  simply  as  "backward," — from  the 
rather  meagre  description,  it  would  seem  backward  physically  rather 
than  mentally.  She  was  well-formed  and  intelligent,  but  small;  also 
very  pale,  in  spite  of  administration  of  iron  and  arsenic.  At  the  age 
of  fifteen  she  measured  52^  inches  instead  of  58^  inches,  weighed 
sixty-two  pounds  instead  of  eighty-eight  pounds,  and  had  the  general 
appearance  of  a  child  of  eight  or  nine.  On  «,  five-grain  tablet  of 
"thyroid  extract"  once  a  day,  later  increased  to  twice  a  day,  she  had 
lost  her  pallor,  had  begun  to  grow  and  was  much  more  brisk  and  lively. 

Patrick. 


BRAIN  t;umor  simulated  by  anemia .• 

By   HUGH  T.   PATRICK.   M.D.. 
Chicago. 

As  a  supplement  to  Dr.  Bannister's  t  more  complete 
paper  the  following  case  may  not  be  without  interest: 

B,  M.,  a  domestic,  21  years  of  age,  was  referred  to  me 
in  February,  1895,  by  Dr.  William  H.  Wilder,  as  she  had 
"some  symptoms  of  brain  tumor."  For  about  six  weeks 
she  had  been  suffering  from  constant  and  severe  headache, 
more  or  less  diffuse,  but  of  greatest  intensity  in  the  left 
temporal  and  supraorbital  regions,  the  pain  often  keeping 
her  awake  at  night.  Shortly  after  the  beginning  of  the 
cephalalgia  double  vision  made  its  appearance.  This  was 
not  a  simple  blurring  or  confusion  of  objects,  but  distinct 
homonymous  diplopia,  due  to  paresis  of  the  external 
rectus  of  the  right  eye.  She  gave  a  history  of  numerous 
momentary  attacks  of  blindness,  and  complained  of  dizzi- 
ness. There  was  intense  double  choked  disk,  with  some 
small  retinal  hemorrhages,  vision  was  reduced  to  20/60 
in  either  eye,  and  the  visual  fields  were  notably,  though 
not  markedly,  contracted,  as  shown  in  Figures  I.  and  II.' 

There  was  nothing  of  importance  in  the  family  his- 
tory, except  that  the  mother  had  died  of  cancer  of  the 
breast  at  the  age  of  fifty.  The  patient  had  diphtheria 
when  six  years  old,  but  after  that  had  remained  well  and 
vigorous  until  two  or  three  years  before  consulting  Dr, 
Wilder,  when  she  had  begun  to  have  about  one  yearly 
attack  of  moderate  anaemia.     When  I  saw  her  she  pre- 

*Presented  at  the  twenty-fourth  annual  meeting  of  the  American 
Neurological  Association,  May,  1898. 

i  Journal  of  Nervous  and  Mental  Disease,  this  issue. 
■  'For  Figures  I.  to  IV.  and  for  the  eye  findings  I  am  indebted 
to  Dr.  Wilder. 


BRAIN  TUMOR  SIMULATED  BY  ANAEMIA,       883 

sented  all  the  signs  and  symptoms  of  anaemia  except 
pallor  of  the  face  and  lips.  There  was  dyspnoea  and  pal- 
pitation on  exertion,  a  feeling  of  languor,  anorexia  (es- 
pecially for  meat),  and  constipation.  The  vertigo,  I  found, 
was  neither  constant  nor  paroxysmdl,  but  was  caused  by 
stooping,  and  more  especially  by  rising  from  the  stoop- 
ing posture,  and  the  attacks  of  transient  amaurosis,  which 
Dr.  Wilder  informs  me  have  been  emphasized  by  Hirsh- 
berg  as  a  sign  of  brain  tumor,  were  also  confined  to  the 
moments  of  postural  change.  For  several  months  there 
had  been  amenorrhoea.  Examination  revealed  a  soft 
blowing  murmur  over  tjie  base  of  the  heart,  a  venous  hum 

Figs.  I.  and  II. 


=  White. 


4.     -f  -  -I-  =  Red. 
='.Green. 


in  the  neck  and  50  per  cent,  of  the  normal  proportion  of 
haemoglobin.  There  was  no  evidence  of  tuberculosis  or 
of  any  general  or  visceral  disease.  As  no  focal  signs  could 
be  discovered,  as  the  anaemia  would  account  for  all  the 
symptoms  except  the  paresis  of  the  external  rectus,  and 
as  this  could  generally  be  overcome  wholly  or  in  part  by 
a  strong  effort,  I  made  a  diagnosis  of  anaemia  only,  ex- 
cluding tumor  for  the  time  being*.  The  patient  was  put 
on  full  doses  of  iron  and  arsenic,  liberal  diet  and  plenty 
of  fresh  air,  and  in  a  few  days  some  sHg-ht  improvement 
was  perceptible  in  the  amount  of  haemoglobin,  the  ap- 


SB4 


^Ua}i  T,  PATRICK., 


pearance  of  Afe  qptic  disks,  the  size  of  tBe  visual  fields! 
and  in  the  geateral  symptoms.  Progress  fiw:  the  better  was 
constant,  but  rather  slow.  By  the-  ead  of  May  (three- 
months)  th«  patient's  condition  was  very  satisfactory  ini 
every  i?vay,  although  she  could  not  be  saidl  to  be  cured. 
The  doubte  vision  had  quite  disappeared,  but  there  was- 
still  some  slight  headache,  and  neiither-  blbod  nor  optic 
disks  were  quite  normal.  Examination  at  this  time  by 
Dr.  Wilder  showed  vision  to  be  5/10  in  either  eye  and. 
the  fields  of  vision  decidedly  improved,  as^  shown  in. 
Figures  III.  and  IV.;  quite  a  material  gain,  it  will  be 
granted,  but  scarcely  enoughi  to.  prove  my  diagnosis  be- 
yond a  peradventure. 

Figs.  UX  A^d  IV. 


White. 


+  -  +  -  + 
Green. 


-  =^Red. 


During  the  next  month  she  made  some  further  im- 
provement, and  then  passed"  from  observation,  until  a  re- 
cent letter  brought  her  in  to>  report — a  little  more  than 
three  years  after  the  first  examination.  She  says  that 
she  remained  away  because  she  considered  herself  cured, 
and  has  remained  tolerably  well  ever  since,  except  that 
every  spring  there  was  a  slight  return  of  the  former 
trouble.  On  such  occasions  she  took  the  same  medicine 
(iron  and  arsenic)  that  had  been  prescribed  for  her,  and 
always  reqqwr^ed.  within  a:  reasonablisL*  time    The  diplopia^ 


BRAIN  TUMOR  SIMULATED  BY  ANAEMIA.       885 

has  not  recvUT<^y  the  hcadacKes  have  never  been  so  bad, 
and  vision  has  never  been  so  much  reduced  as  at  the  time 
I  treated  her.  At  present  she  has  no  headache  or  dizzi- 
ness, there  is  neither  systolic  murmur  nor  venous  hum, 
and  she  has  her  full  quota  of  haemoglobin.  In  the  ab* 
sence  of  Dr.  Wilder  from  the  city,  Dr.  Robert  Tilley  was 
good  enough  to  control  my  examination  of  the  eyes,  and 
reported  that  the  left  disk  seemed  rather  hy peraemic,  that 
the  right  "suggested  a  suspicion  of  beginning  atrophy," 
and  that  the  arteries  in  both  seemed  small.  He  also  dis- 
covered one-half  dioptre  of  astigmatism,  and  with  a  cyl- 
inder of  this  strength  the  patient's  vision  was  normal. 

FlCrS.    V.    AND   VI. 


»  White. 
-f  -  =  Red. 


-  -  =  Blue. 
=  Green, 


About  a  week,  later  Dr.  Wilder  confirmed  the  results  of 
this  examination,  adding  that  the  left  disk  looked  as  if 
the  swelling  had  not  entirely  subsided,  and  that  along 
the  vessels  of  the  right  fundus  were  distinct  traces  of  con- 
nective tissue,  evidently  remnants  of  the  previous  choked 
disk.  Evidence  of  this  was  also  to  be  seen  in  a  slight  tor- 
tuosity of  the  vessels.  I  expected  the  doctor  to  find  a 
weakness  of  the  right  external  rectus,  slight  enough  to 
be  overcome  in  a  state  of  health,  but  sufficiently  pro- 
nounced to  cause  diplopia  in  the  presence  of  exhaustion 
or  extreme  anaemia,  but  the  Maddox  rod  and  prisms  re- 


886  HUGH  r.   PATRICK. 

vealed  only  one  degree  of  esophoria  and  normal  ratio  ol 
abduction  to  adduction,  although  the  dynamic  condition 
of  all  the  external  ocular  musculature  was  below  par. 
The  visual  fields  remain  slightly  contracted,  as  shown  by 
Figures  V.  and  VI. 

In  this  connection  it  might  be  of  interest  to  mention 
a  case  now  under  observation.  A  married  woman,  aged 
32,  had  been  for  a  period  of  three  or  four  years  to  a  great 
extent  disabled  by  pelvic  inflammation.  This  not  only 
caused  great  suffering,  but  interfered  with  her  appetite, 
general  nutrition  and  disposition,  so  that  she  became  thin 
and  nervous,  and  spent  a  good  deal  of  time  in  bed  or  on 
a  couch.  At  length  an  operation  relieved  the  pelvic 
lesions,  and  since  that  time  she  has  had  no  symptoms 
referable  to  the  uterus  or  adnexa.  About  the  time  of 
the  operation,  she  began  to  suffer  greatly  from  almost 
constant  headache,  to  which  was  soon  added  occasional 
vomiting  and  left  internal  strabismus.  After  the  opera- 
tion, although  the  local  conditions  were  all  that  could  be 
desired,  convalescence  seemed  delayed  and  the  headache 
continued.  A  neurologist  was  consulted,  who,  I  am  in- 
formed, pronounced  the  trouble  to  be  anaemia  and  ner- 
vousness. I  saw  the  patient  about  four  weeks  later.  She 
was  very  pale,  thin  and  weak,  but  examination  of  the 
blood  showed  it  to  be  practically  normal,  and  there  was 
nothing  to  indicate  disease  of  thoracic  or  abdominal  or- 
gans. The  intense  cephalalgia,  pronounced  paresis  (al- 
most paralysis)  of  the  left  abducens,  typical  choked  disks, 
dizziness,  a  history  of  two  abortive  or  atypical  fits,  slight 
difference  in  the  knee-jerks  and  the  patient's  complaint 
of  a  weakness  in  one  leg  (although  no  difference  could  be 
detected  on  examination)  pointed  to  the  existence  of  a 
brain  tumor;  a  diagnosis  that  seems  to  be  confirmed  by 
the  subsequent  course  of  the  case,  although  only  four 
weeks  have  elapsed  since  my  first  examination. 

The  case  of  anaemia  was  apparently  one  of  tumor ;  the 
case  of  tumor  apparently  one  of  anaemia. 


"gtvlacovt. 


With  the  Assistance  of  the  Follotuing  Collaborators: 

Chas.Lewis  ALLEN,M.D.,Wash.,D.C.R.  K.  Macalester^  M.D.,  N.Y. 
J.  S.  Christison,  M.D.,  Chicaga,  111.  J.  K.  Mitchell.  M.D.,  Phila.,  Pa 
A.  Freeman,  M.D.,  New  York.  H.  Patrick,  M.D.,  Chicago,  111. . 

S.  E.  Jelliffe,  M.D.,  New  York.  Joseph  Sailer,  M.D.,  Phila.,  Pa. 
Wm.C.Krauss,M.D.,  Buffalo,  N.Y.  Henry  L.  Shively,  M.D.,  N.  Y. 
W.  M.  Leszynsky,  M.D.,  New  York.  A.  Sterne,  M.D.,  Indianapolis. 


CLINICAL  NEUROLOGY. 

257.      Dk  l'ORGANOTHERAPIE  OVARIENNE  en  PARTICULIER  dans  LE  TRAITfe- 

ment  de  la  chlorose    (Ovarian   Organotherapy  in   Chlorosis). 
Werth  (La  M6d.  Moderne,  May  18,  1898,  p.  318). 

Werth,  of  Keil,  is  said  to  have  been  the  first  to  employ  (in  1896) 
ovarian  extract  in  menstrual  disorders,  followed  soon  after  by  Main- 
zer,  Mond,  Landon,  and  later  by  numerous  others. 

The  recent  theories  of  the  usefulness  of  this  form  of  organotherapy 
are  founded  upon  various  views  of  the  probable,  or  possible,  part 
played  by  the  internal  secretions  of  the  ovaries. 

Spillman  and  Etienne,  and  Etienne  and  Demange,  Von  Noorden 
and  others  declare  the  usefulness  of  properly  made  preparations  of 
ovarian  substance,  and  say  that  no  intolerance  has  been  observed, 
even  with  prolonged  use,  and  recommend  an  almost  indefinitely  con- 
tinued dose  after  castration  during  troubles  due  to  the  menopause 
and  in  chlorosis,  insisting  upon  the  origin  of  the  latter  from  dis- 
turbances or  suppressions  of  the  ovarian  secretion. 

MtTCHELL. 

258.  Relations  entre  les  maladies  du  syst^.me  nerveux  et  la  glvco- 
surie  (Relations  between  Diseases  of  the  Nervous  System  and 
Glycosuria).     L.  Jumon  (La  Med.  Moderne,  June  25,  1898,  p.  405). 

Numerous  observations  of  late  years  have  called  attention  to  the 
relations  between  glycosuria,  permanent  or  transitory,  and  disorders 
of  the  central  nervous  system,  as  well  as  in  consequence  of  very 
various  traumatisms,  especially  those  of  the  cranial  region. 

It  has  been  noted,  too,  that  an  alimentary  glycosuria  in  persons  in 
apparent  good  health  may  be  followed  by  true  diabetes.  Von  Jaksch, 
Striimpell  and  others  have  accordingly  sought  to  establish  a  close 
connection  between'  neurotic  troubles  and  glycosuria,  and  have  seen 
in  the  latter  symptom  a  "neuropathic predisposition  to  diabetes."  Van 
Jaksch  goes  so  far  as  to  believe  the  presence  of  glycosuria  a  fact  of 
diagnostic  importance  in  cases  where  traumatic  neurosis  is  difficult  of 
recognition. 


888  PERISCOPE, 

Van  Ordt,  feeding  a  number  of  patients  suffering  from  various 
nervous  diseases,  with  an  excess  of  glycose  and  dextrose,  found  a  large 
percentage  (14  per  cent.)  presented  glycosuria  phenomena  as  a  result. 
The  experiment  is  hardly  a  fair  one  in  view  of  the  almost  constant 
presence  in  neuropathic  patients  of  gastric  or  intestinal  disorder  in 
some  form.  The  experiment  included  178  patients  with  widely  different 
maladies,  and  the  general  conclusions  to  be  drawn  are  not  important. 
As  might  have  been  anticipated,  glycosuria  was  not  found  constantly 
associated  with  any  special  diseases,  but  was  a  little  more  frequent  with 
diseases  of  the  encephalon.  No  doubt  in  many  cases  it  was  present  as 
an  expression  of  the  general  lowering  of  nutrition;  but  nevertheless  it 
is  true  that  its  appearance  and  its  fluctuations  with  the  intensity  of  the 
nervous  disease  testify  to  a  relation  with  pathological  processes  in  the 
central  nervous  system. 

In  glycosuria  consequent  upon  trauma  the  symptoms  appear  to  be 
related  rather  to  the  nervous  phenomena,  to  the  traumatic  neurosis, 
that  is  to  say,  than  to  the  injury  itself,  and  again  individual  predis- 
position must  be  taken  into  account,  else  we  cannot  explain  why  the 
same  grave  psychic  syndromes  should  determine  glycosuria  in  one 
case  and  not  in  another. 

Glycosuria  was  noted  in  neurasthenia,  hysteria  and  post-trau- 
matic neurosis;  it  was  not  found  in  other  neuroses,  in  true  epilepsy, 
nor  in  general  in  spinal  diseases  not  affecting  the  bulb. 

W.  Ebstein  has  examined  the  relations  between  epilepsy  and 
diabetes  from  three  points  of  view:  i,  epilepsy  as  a  result  of  dia- 
betes; 2,  diabetes  as  a  result  of  epilepsy,  and  3,  the  two  maladies  as  a 
result  of  one  cause. 

The  first  is  not  a  frequent  case.  In  sixteen  cases  of  diabetic  coma 
Dreschfeld  saw  convulsions  only  once,  and  in  eighty  reported  cases  of 
coma  but  six  cases  of  convulsions  are  noted,  where  albuminuria  was 
not  present  to  account  for  the  seizures. 

Jacoby  considers  diabetic  epilepsy  as  an  intermittent  acetonaemic 
manifestation. 

The  second  may  be  subdivided  into  two  classes,  according  to 
whether  there  is  simply  a  passing  glycosuria  after  the  attacks  or  a 
chronic  diabetes.  A  passing  glycosuria  has  been  noticed  by  some 
former  authors,  but  neither  Ebstein  nor  Huppert  has  seen  it,  a  result 
which  agrees  with  Van  Ordt. 

True  diabetes  consequent  upon  epilepsy  has  never  been  noted 
except  in  Griesingers's  case,  which  he  attributed  to  an  abuse  of 
sugary  food. 

As  to  the  third  class,  the  causes  may  be  general  or  local;  hered- 
itary predisposition  and  family  habit  may  play  a  large  part  in  both 
disorders,  but  the  co-existence  of  the  two  diseases  is  certainly  not 
common.  Ebstein  quotes  one  case.  In  two  other  cases  with  symp- 
toms pointing  to  hemi-lateral  cerebral  lesions  the  patients  suffered 
also  with  intermittent  diabetes.  Ebstein  concluded  that  if  glycosuria 
is  not  more  frequently  observed  in  epileptic  patients,  especially  those 
suffering  from  the  Jacksonian  type  of  the  disease,  it  is  only  because 
the  urine  is  not  frequently  enough  examined  for  sugar. 

Mitchell. 

259.  ZuR  MULTiPLEN  Hkrdsklerosk  (Concemlng  Multiple  Sclerosis). 
M.  Probst  (Deutsche  Zeitschrift  fiir  Nervenheilkunde,  12,  1897- 
1898.  p.  446). 

The  writer  reports  a  case  which  presented  clinically  the  appear- 
ance of  amyotrophic  lateral  sclerosis,  but  proved  on  microscopical 


P£kiSCOPE.  889 

examination  to  be  one  of  disseminated  sclerosis.  A  matt  of  fifty-four 
years  had  bulbar  symptoms,  with  muscular  atrophy  and  spastic  pare- 
sis. Disturbance  of  deglutition  and  speech,  atrophy  of  the  tongue  and 
lips,  bilateral  facial  paralvsis,  atrophy  of  the  small  muscles  of  the 
hands,  spastic  paresis  of  tne  lower  extremities,  indicated  involvement 
of  the  motor  tracts.  The  classical  symptoms  of  multiple  sclerosis, 
intention  tremor,  scanning  speech,  ocular  disturbance,  etc.,  were  not 
present,  but  the  patient  had  vertigo  and  a  somewhat  slow  reaction  of 
the  pupils.  The  lesions  were  confined  to  the  medulla  oblongata,  pons 
and  a  portion  of  the  corpora  quadrigemina.  Muscular  atrophy  is 
rarely  seen  in  multiple  sclerosis,  but  has  been  reported,  and  usually 
no  change  has  been  found  in  the  ganglion  cells  of  the  anterior  horns. 
Probst  found  in  his  case  diminution  in  number  and  shrinkage  of 
these  cells  in  the  upper  part  of  the  cervical  cord.  Secondary  degen- 
eration of  the  direct  and  crossed  pyramidal  tract  was  especially  note- 
worthy, and  extended  from  the  proximal  end  of  the  pons  into  the 
lumbar  cord.  It  was  apparently  due  to  a  sclerotic  area  in  the  pons. 
Secondary  degeneration  has  only  been  observed  in  a  few  cases  of  dis- 
seminated sclerosis.  The  columns  of  GoU  were  sclerotic  from  the 
upper  thoracic  region  to  the  nuclei  of  these  columns,  and  the  in- 
tensity of  the  process  was  greatest  m  the  upper  part  of  the  cord. 
The  bulbar  symptoms  were  explicable  on  account  of  the  affection 
of  the  bulbar  nuclei  and  nerves.  Probst  does  not  believe  that  this 
case  was  a  combination  of  disseminated  sclerosis  and  amyotrophic 
lateral  sclerosis,  because  the  vertigo  was  the  first  sign  of  the  disease, 
because  the  muscular  atrophy  did  not  progress  as  rapidly  as  it  usu- 
ally does  in  amyotrophic  lateral  sclerosis,  because  the  degeneration  of 
the  cells  of  the  anterior  horns  was  not  as  great  as  is  usually  seen  in 
this  affection,  and  because  the  secondary  degeneration  of  the  pyra- 
midal tracts  began  in  a  sclerotic  focus. 

From  a  study  of  fifty-eight  clinical  cases  of  disseminated  sclerosis, 
Probst  finds  that  the  sexes  are  about  equally  affected,  that  the  dis- 
ease is  most  common  between  twenty  and  thirty  years  of  age,  that 
exposure  to  cold  and  wet  is  the  most  common  cause,  and  that  in- 
fectious processes  come  next  in  etiological  importance. 

Spiller. 

260.  EiN  Fall  von  isolierter  Facialis-und  Hypoglossus-Laehmung 

NEBST    PSYCH ISCHER   ALTERATION  INFOLGE  VON   TyPHUS  ABDOMINALIS 

(A  Case  of  Isolated  Paralysis  of  the  Facial  and  Hypoglossal 
Nerves  with  Psychical  Alteration  in  Consequence  of  Typhoid  Fe- 
ver). A.  Friedlander  (Monatsschrift  fiir  Psychiatric  und  Neurol- 
ogie,  4,  1898,  p.  no). 

A  boy,  not  hereditarily  afflicted  but  not  of  normal  psychical  devel- 
opment, presented  no  unusual  symptoms  until  he  became  fourteen  or 
fifteen  years  old.  He  had  been  obedient  until  this  time,  but  now  be- 
came disobedient  and  excited,  spoke  much,  ran  from  the  house  with- 
out any  known  motive,  etc.;  later  he  became  more  quiet  and  was  able 
to  work.  He  had  a  severe  attack  of  typhoid  fever,  and  during  the 
convalescence  he  manifested  symptoms  of  acute  dementia  and  had 
paralysis  of  the  right  facial  nerve.  His  behavior  was  that  of  a  little 
child.  He  exhibited  mind  blindness,  forced  laughter  and  periodic 
attacks  of  intense  anger,  and  made  bad  poetry;  in  short,  he  presented 
the  symptom-complex  of  dementia  prsecox.  The  paralysis  of  the 
right  facial  nerve  and,  to  some  extent  of  the  right  hypoglossal,  was 
not  believed  to  be  peripheral,  as  the  electrical  reactions  were  normal; 
or  cortical,  as  sensation  was  not  affected.  It  was  thought  to  be  the 
result  of  a  small  area  of  softening  or  of  a  hemorrhage  in  the  white 


890 


PERISCOPE. 


matter  close  to  the  surface  of  the  lower  portion  of  the  anterior  central 
gyrus.  Spiller. 

261.  Casuistische  Mittfilungen  aus  DEM  Gebiete  der  Muskelpatho- 
LOGiE  (Clinical  Communications  Concerningthe  Pathology  of  the 

•     Muscles).   R.  Cassirer  (Monatsschrift  f iir  Psychiatrie  und  Neurolo- 
gie,  3,  1897,  p.  491,  and  4,  1898,  p.  21). 

Cassirer  reports  the  clinical  histories  of  several  cases  illustrating 
the  difficulties  of  diagnosis  in  diseases  causing  muscular  atrophy. 
The  first  case  was  in  a  young  girl.  The  disease  began 
with  severe  pain  in  the  lower  limbs  and  the  patient  be- 
came quite  weak  in  these  parts.  Improvement  was  soon  noted. 
About  a  year  later  the  child  had  diphtheria  and  scarlatina  with 
oedema.  The  weakness  of  the  lower  extremities  increased  and  the 
motility  of  the  arms  diminished.  No  pain  was  experienced..  After 
two  years,  during  which  time  the  improvement  was  gradual,  the 
small  foot  muscles  of  the  plantar  surface,  the  quadriceps  femoris,  the 
ilio-pso^s,  and  the  adductors  of  the  thigh,  the  deltoid,  supraspinatus. 
infraspinatus,  and  triceps  muscles  were  especially  involved,  while  the 
remaining  muscles  of  the  thigh,  pelvis,  abdomen  and  back  were  Uttle 
affected.  The  paralysis  was  not  a  degenerative  one  and  pseudo-hy- 
pertrophy was  not  seen.  The  tendon  reflexes  corresponded  in  in- 
tensity to  the  degree  of  muscular  atrophy.  No  objective  or  sub- 
jective disturbance  of  sensation  was  present. 

The  cause  of  this  affection  could  not  be  neuritis  or  spinal  lesion, 
chiefly  on  account  of  the  absence  of  sensory  changes  during  a  long 
period,  and  the  absence  of  a  degenerative  paralysis.  The  very  slight 
fibrillary  twitchings,  the  youthful  age  of  the  patient  and  the  irregular 
and  extensive  atrophy,  were  not  regarded  as  favoring  the  diagnosis 
of  spinal  muscular  atrophy. 

The  variations  in  the  symptoms  and  the  atrophy  of  the  shoulder 
muscles,  with  integrity  of  the  muscles  of  the  hand  and  forearm, 
were  against  the  diagnosis  of  progressive  neurotic  muscular  atrophy, 
while  the  acute  onset  of  the  process  with  pain,  the  many  variations 
in  the  symptoms  and  the  distribution  of  the  muscular  atrophy  were 
not  characteristics  of  progressive  muscular  dystrophy.  The  case  was 
regarded  as  one  of  primary  myopathy,  resulting  from  polymyositis, 
and  as  not  conforming  to  any  of  the  known  types  of  muscular 
atrophy. 

Two  cases  of  progressive  neurotic  muscular  atrophy  are  described 
which  closely  resembled  clinically  the  case  just  mentioned,  but  in  ' 
these,  qualitative  electrical  changes  were  noted.  Although  cases  of 
muscular  dystrophy  with  reaction  of  degeneration  have  been  reported, 
they  are  very  exceptional,  and  if  such  reaction  occurs  the  diagnosis  of 
muscular  dystrophy  can  only  be  made  when  the  muscular  atrophy  in 
its  distribution  is  characteristic  of  this  disease.  Degenerative  reac- 
tion Cassirer  regarded  as  sufficient  to  exclude  the  possibility  of  pro- 
gressive muscular  dystrophy. 

A  case  of  acute  anterior  poliomyelitis  is  reported,  in  which  later 
the  signs  of  progressive  muscular  dystrophy  were  noted.  No  similar 
combination  of  the  two  diseases  seems  to  have  been  recorded  in 
literature.  Cassirer  says  a  connection  may  have  existed  between  the 
two   diseases,   but   that  proof  was   not  offered.  Spiller. 

262.  The  Neurasthenic  Symptoms  of   Gastro-Intestinal  Disease.' 
G.  W.  McCasky,  M.  D.  (Med.  Record,  54,  1898,  p.  371). 

There  is  one  type  of  gastric  disease  in  which  for  some  reason  the 
local  sensory  symptoms  of  the  stomach  disorder  are  almost  entirely 


PERISCOPE.  891 

wanting,  and  the  local  disease  is  more  or  less  completely  masked  by 
the  secondary  toxaemic  and  neurasthenic  phenomena,  which  cannot 
!'«  successfully  treated  without  removing  the  primary  cause.  More 
commonly,  however,  the  gastric  symptoms  are  not  so  latent.  In- 
testinal symptoms  are  much  more  likely  to  be  overlooked.  The 
neurasthenic  symptoms  in  intestinal  disease  vary  greatly.  General 
fatigue  sensations  are  quite  common.  These  may  be  mild  and  limited 
to  a  feeling  of  lassitude,  with  inordinate  fatigue  on  slight  exertion. 
In  severer  cases  the  various  grades  of  neurasthenic  pains  are  mani- 
fested sometimes  in  very  aggravated  forms.  These  pains  may 
overshadow  everything  else  and  rack  the  patient's  nervous  system 
day  and  night,  with  disastrous  results  upon  both  the  nerves  and 
general  nutrition.  Incapacity  for  sustained  mental  effort  may  be 
shown  in  various  degrees.  This  may  be  the  result  of  vasomotor 
disturbances  of  the  cerebal  cortex,  histochemical  changes  of  the  cor- 
tical cells,  or  the  direct  action  of  toxins.  General  sensory  disturbances 
are  very  frequent.  Paraesthesia  and  pruritis  are  the  most  commonly 
met  forms.  These  parxsthesiae  generally  occur  in  distinct  episodes, 
lasting  from  a  few  days  to  a  few  weeks.  Exhausting  insomnia  is 
among  their  effects,  as  ttte  exacerbations  are  mostly  nocturnal.  Ver- 
tigo is  very  troublesome  in  some  cases.  It  occurs  in  paroxysms 
during  the  height  of  digestion,  or  when  the  stomach  is  empty.  In 
others  it  occurs  whenever  the  patient  shifts  from  the  recumbent  to 
the  efect  posture  or  vice  versa.  Muscular  weakness  is  very  frequent 
as  a  neurasthenic  symptom,  independently  of  the  weakness  expressive 
of  the  general  debility  from  inanition  present  in  aggravated  cases  of 
gastro-intestinal  disease.  The  mental  state  tends  toward  depression. 
The  digestive  apparatus  suffers  like  all  other  parts  of  the  organism 
from  lowered  nerve  function  and  thus  it  happens  that  in  a  large 
number  of  dyspeptics  the  gastro-enteric  disease  is  primarily  neu- 
rasthenic, but  rapidly  becomes  more  than  this.  The  reason  is  that 
secretion  and  motility,  the  principal  factors  in  primary  digestion,  • 
are  dependent  upon  nerve  force.  The  vigilant  germ  is  ever  ready 
to  seize  upon  the  remnants  of  retarded  digestion,  producing  gases  and 
toxins,  which  by  chemical  and  mechanical  irritation  still  further  im- 
pair secretion  and  motility,  thus  ever  working  in  a  vicious  circle. 

Freeman. 

263.      UeBER  DAS    'MNTERMITTIRENDE    HiNKEN"    UND    ANDERE    NERVOESB 

Stoerungen  in  Folge  von  Gepaesserkrankungbn  (Concerning 
the  Intermittent  Lameness  and  Other  Nervous  Disturbances 
Resulting  from  Vascular  Diseases).  W.  Erb  ( Deutsche  Zeitschrif t 
fiir  Nervenheilkunde,  13,  1898,  p.  i). 

Erb  reports  a  number  of  cases  of  this  affection  which  was  made 
well  known  under  the  title  of  intermittent  claudication  by  the  writings 
of  Charcot.  The  literature  is  thoroughly  reviewed.  The  condition  in 
animals  was  recognized  some  years  before  Charcot  reported  a  case 
in  man. 

Erb,  with  his  assistants,  has  examined  more  than  seven  hundred 
cases,  in  order  to  determine  the  frequency  of  the  absence  of  the 
pulse  in  the  foot.  He  has  found  that  at  every  age  and  in  both  sexes, 
when  arteriosclerosis  in  a  marked  degree,  cardiac  trouble,  or  anoma- 
lies of  the  skin,  do  not  exist,  the  pulsation  of  the  foot  arteries  is 
present  almost  without  exception,  and  its  absence  must  be  regarded 
as  pathological. 

Arteriosclerosis  of  the  arteries  of  the  foot  with  absence  of  every 
detectable  pulsation  may  occur,  without  any  indication  of  the  inter- 
mittent lameness,  nervous  or  vascular  disturbances,  or  gangrene.    In 


892  PERISCOPE. 

such  cases,  however,  .the  circulation  must  be  sufficient  for  the  needs 
of  the  part 

Intermittent  lameness  may  exist  without  absence  of  the  {Mxlse  in 
any  of  the  arteries  of  the  foot  and  without  distinct  evidence  of  arterio- 
sclerosis. Arteriosclerosis  of  the  deeper  vessels  Qr  temporary  vas- 
omotor disturbance  may  be  the  cause  of  this  lameness  in  such  cases. 

Purely  mechanical,  anatomical  changes  are  not  sufficient  to 
explain  the  condition  of  intermittent  lameness,  but  functional  changes 
in  the  vessels  are  necessary. 

The  affection  is  usually  of  gradual  development,  and  not  infre- 
quently at  first  is  unilateral,  but  may  be  bilateral.  Sensory  disturb- 
ances, usually  after  walking  or  even  during  rest,  are  the  first  symp- 
toms. These  consist  of  a  creeping  or  tickling  sensation  with  a  feeling 
of  tension,  coldness,  sometimes  of  heat,  more  rarely  pain  in  the  feet 
and  calves  of  the  legs.  Circulatory  disturbances  are  generally  early 
signs,  and  the  feet  are  often  blue  and  cold,  especially  when  pendent 
or  after  walking.  Motor  weakness  after  use  of  the  low^r  limbs,  with 
spasm  of  the  foot  and  calf  muscles,  manifests  itself  within  a  short 
time.  The  clinical  picture  is  not  always  the  same;  sometimes  the 
sensory  disturbances,  sometimes  the  vasomotor,  sometimes  the  spasms 
are  more  pronounced,  but  the  essential  features  of  the  disease  are 
always  present.  The  patient  is  entirely,  or  almost  entirely,  well  during 
repose  and  when  he  begins  to  walk,  but  after  walking  a  little  distance 
the  symptoms  appear  and  he  is  obliged  to  rest  a  short  time  until  his 
normal  condition  is  restored.  The  arteries  of  the  foot  are  found  to 
be  more  or  less  diseased,  and  not  infrequently  pulsation  is  absent; 
in  some  cases  the  large  arteries  of  the  lower  limbs  are  also  sclerotic. 
The  intermittent  lameness  should  be  regarded  as  a  danger  signal  of 
gangrene. 

In  the  few  anatomical  investigations  which  have  been  made 
obliterating  arteritis  and  chronic  phlebitis  have  been  found,  and  in 
*  some  instances  secondary  changes  in  the  nerves,  muscles,  skin,  joints 
and  bones. 

The  causes  of  intermittent  lameness  are  those  of  arterio* 
sclerosis,  especially  tobacco  when  used  to  excess,  syphilis  and  extreme 
cold.  Erb  says  there  can  be  no  doubt  that  excessive  use  of  tobacco 
leads  to  arteriosclerosis,  contracted  kidneys,  degeneration  of  the 
cardiac  muscle,  angina  pectoris,  etc. 

The  diagnosis  usually  is  easy. 

In  the  treatment  all  causes  of  arteriosclerosis  should  be  removed^ 
and  energetic  use  of  cold  and  hot  water,  mustard*  vigorous  massage, 
excessive  movements  of  the  lower  limbs,  tight  bands,  etc.,  are  to  be 
avoided.  Articles  of  diet,  such  as  strong  coffee  and  tea,  which  affect 
the  vasomotor  system;  drugs  such  as  ergot  and  digitalis,  which  act 
on  the  vessels,  must  be  forbidden.  The  feet  and  legs  must  be  kept 
warm.  Iodide  of  potassium  should  be  given  for  the  arteriosclerosis, 
and  warm  applications,  and  especially  the  galvanic  (not  the  faradic) 
current,  in  the  form  of  the  galvanic  footbath,  should  be  employed  to 
enlarge  the  vessels.  Cardiac  tonics  which  increase  the  blood  pressure 
are  desirable,  and  strophanthus  is  preferable  to  digitalis.  Antipyrin 
or  phenacetin  may  be  used  for  the  pain.  Rest  is  of  great  importancet 
and  every  wound  of  the  feet  must  be  carefully  attended  to. 

Erb  suggests  the  name  of  dysbasia  intermittens  angiosclerotica 
for  this  affection.  Spiller. 

264,  Acute  Endartkritic  Myelopathy. 

Under  the  above  title,  Biemacki  (Deutsche  Zeits.  f.  Nerv.,  April  j 

30,  1897)  describes'  three  cases  of  spinal  cord  disease  that  in  course  J 


PERISCOPE.  893 

and  terminktiofi  were  exceedingly  like  acute  myelitis,  but  in  which  a 
careful  microscopic  examination  showed  entire  absence  of  in* 
flammatory  changes,  the  sole  lesion  being  an  endarteritis  of  the  piai 
vessels.  The  duration  of  the  disease  from  the  appearance  of  distinct 
spinal  symptoms  to  the  fatal  termination  was  from  eight  to  twenty 
days,  and,  as  stated,  the  clinical  picture  was  that  of  acute  myelitis; 
that  is,  quickly  progressing  paraplegia  with  sensory  disturbance, 
paralysis  of  bladder  and  bowel  and  the  rapid  formation  of  massive 
decubitus. 

The  author  is  at  great  pains  to  demonstrate  what  has  long  been 
known  to  most  neurologists;  viz.,  that  there  is  such  a  thing  as  soften- 
ing of  the  cord  from  vascular  occlusion,  and  that  it  is  quite  distinct 
from  myelitis. 

The  obliterating  endarteritis  in  the  reported  case  was  quite 
sufficient  to  produce  all  the  symptoms  noted,  and  the  principal 
points  of  interest  are:  first,  the  very  slight  changes  discovered  in 
the  nerve  fibres  and  ceHs  of  the  cord;  second,  the  occurrence  in  one 
case  of  the  sensory  dissociation  generally  found  in  syringomyelia 
and  almost  peculiar  to  it  (i.  e.,  loss  of  pain  and  temperature  sense 
with  preservation  of  tactile  sense);  third,  the  peculiar  relation  of  the 
knee-jerks  to  the  other  symptoms  and  the  seat  of  the  most  advanced 
lesions;  and  fourth,  lack  of  explanation  of  the  rapid  course  of  the 
disease,  the  arterial  changes  being  essentially  chronic  in  character. 
The  last  difficulty  has  apparently  not  occurred  to  the  author,  but 
would  seem  to  demand  elucidation.  The  almost  normal  appearance 
of  the  cord  was  probably  due  to  the  short  course  of  the  disease, 
sufficient  time  not  having  elapsed  for  the  occurrence  of  chemical 
changes  in  the  tissues  that  we  know  as  disintegration  and  de- 
generation. Regarding  the  condition  of  sensation  and  the  apparent 
inconstant  behavior  of  the  deep  reflexes,  it  can  only  be  said  that 
there  is  much  still  to  be  learned  concerning  this,  and  cases  of  diffuse 
lesion  such  as  those  reported  by  Biernacki,  are  illy  adapted  for 
illumination  on  these  subjects 

On  the  whole,  we  see  no  adequate  reason  why  these  three  cases 
should  constitute  an  excuse  for  adding  a  new  term  to  neuro- 
pathology. Arterio-sclerosis  of  the  spinal  arteries,  due  to  syphilis, 
senility  and  other  causes,  is  well  known,  sufficiently  comprehensive 
and  sufficiently  exact  to  embrace  all  such  cases,  but  we  do  think  that 
it  should  be  more  constantly  in  the  mind  of  the  practitioner  than  is  at 
present  the  case.  Patrick. 

265.      KLINISCHER  BlITRAG  ZUR  LbHRE  V0.\  DXR'  DYSTROPHIA  MUSCULARIS 

PROGRESSIVA  (A  Cliuical  Contribution  to  Progressive  Muscular 
D3^trophy).  J.  Hoffmann  ( Deutsche  Zeitschrift  f lir  Nervenheil- 
kunde,  is,  1897-1898,  p.  418). 

ftoffmann  reports  two  cases  in  twin  brothers  which  show  that 
progressive  muscular  dystrophy  may  appear  in  the  clinical  picture  of 
bulbar  paralysis,  contrary  to  the  generally  accepted  opinion.  The 
imperfect  closure  of  the  eyelids  was  noticed  by  the  mother  in  both 
boys  in  early  infancy,  and  this  indicated  that  the  disease  was  con- 
genital or  early  acquired.  Later,  paralysis  and  atrophy  of 
the  facial  muscles,  atrophy  of  the  tongue,  paralysis  of  the 
soft  palate — in  one  child  paralysis  of  the  muscles  of  mas- 
tication— were  observed.  The  disease  differed  from  bulbar  paraly- 
sis in  the  involvement  of  the  muscles  of  the  forehead,  and  in  the 
absence  of  fibrillary  twitching  and  reaction  of  degeneration;  and 
differed  from  the  family  form  of  infantile  bulbar  paralysis  in  the  mask- 
like expression  of  the  face,  the  tapir  mouth,  the  lagophthalmos,  the 
condition  of  the  muscles  elsewhere  in  the  body,  etc. 


894 


PERISCOPE. 


As  differential  points  between  the  family  form  of  infantile  pro- 
gressive bulbar  paralysis  (Fazio,  Londe)  and  the  iMilbar  form  of  mns- 
cular  dystrophy,  Hoffmann  mentions  the  rapid  progress  of  the  former 
disease,  as  well  as  the  fibrillary  twitching,  the  reaction  of  degenentionf 
changes  in  other  nerves  (opticus),  and  the  absence  of  the  ordinary 
signs  of  dystrophy  in  the  trunk  and  limbs.  In.  some  cases  tiie  diag- 
nosis is  impossible. 

Between  the  congenital  absence  of  the  nuclei  and  the  dystrophy 
of  the  facial  muscles,  the  arrest  of  the  process  is  a  sign  in  favor  of 
the  former  condition,  especially  when  the  process  is  unilateral  and 
combined  with  abducens  paralysis.  In  one  of  Duchenne's  cases  of 
muscular  dystrophy,  however,  the  atrophy  of  the  muscles  was  con- 
fined to  the  face  for  thirty  years.  The  occurrence  of  the  atrophy  in 
more  than  one  member  of  the  family  and  the  tapir  mouth  are  in  favor 
of  the  diagnosis  of  dystrophy. 

Hoffmann  reports  two  cases  which  show  that  in  muscular  dys- 
trophy the  atrophy  may  begin  in  the  peripheral  parts  of  the  limbs, 
and  the  condition  may  resemble  that  of  progressive  neurotic  mus- 
cular atrophy. 

Hoffmann  shows  in  this  paper  that  muscular  dystrophy  (i)  may 
begin  as  bulbar  paralysis  and  remain  as  such  a  long  time;  (2)  that  it 
may  begin  in  the  lower  leg  and  forearm  muscles,  and  (3)  that  ex- 
ternal ophthalmoplegia  may  be  one  of  its  signs.  All  the  voluntary 
muscles  may  be  affected  in  muscular  dystrophy,  but  no  case  has  yet 
been  reported  in  which  the  disease  began  in  the  small  muscles  of 
hand  and  foot.  He  is  inclined  to  class  the  much-cited  case  of  Oppen- 
heim  and  Cassirer  under  the  dystrophies,  and  not  to  regard  it  as  a 
special  form  of  disease.  Spiller. 

266.  UeBER  CeNTRALE  Er weigh  UNO  DES  RUECKENM.\RKES  BEI  MENIN- 
GITIS Syphilitica  (On  Central  Softening  of  the  Spinal  Cord  in 
Syphilitic  Meningitis).  Wullensoeber  (Miinchener  Medicinische 
Wochenschrift,  45,  1898,  p.  1,017). 

A  woman  of  28  years,  with  a  history  of  having  had  syphilis,  pre- 
sented the  following  train  of  symptoms:  first,  severe  pains  in  the  loins 
radiating  to  the  front  of  the  abdomen,  next  headache,  then  we^ikness 
and  tonic  contractions  in  the  legs;  patellar  reflexes  were  lost,  and  she 
had  intercurrent  disturbances  of  vision,  but  no  alteration  of  sensation 
for  either  touch,  pain  or  temperature,  and  no  ataxia.  The  trouble 
progressed,  there  was  complete  paralysis  of  the  legs,  with  atrophy  of 
the  muscles,  and  sphincter  paralysis,  bed  sores  developed.  The 
patient  died  about  fifteen  months  after  coming  under  observation. 
The  autopsy  showed  syphilitic  cerebro-spinal  meningitis,  with  com- 
pression of  the  spinal  cord,  and  the  production  of  a  central  cavity 
extending  from  the  midlumbar  to  the  upper  dorsal  region  of  the 
cord.  This  cavity  was  most  developed  in  the  middle  and  lower  dorsal 
region,  where  it  occupied  almost  the  whole  of  the  usual  site  of  the 
gray  matter.  No  development  of  gliomatous  tissue  was  to  be  found 
about  the  borders  of  the  cavity.  There  was  ascending  degeneration  in 
the  cervical,  and  descending  degeneration  in  the  lower  lumbar  region. 
The  arteries  of  both  brain  and  cord  showed  characteristic  syphilitic 
arteritis.  On  account  of  the  absence  of  gliomatous  tissue,  the  author 
thinks  that  syringomyelia  can  be  excluded,  and  regards  the  case  as 
one  of  necrosis  of  the  spinal  cord,  due  to  syphilitic  disease  of  the 
vessels.  On  searching  the  literature  of  the  last  twenty  years  he  could 
find  but  four  observations  of  cases  in  which  syphilitic  meningitis  was 
accompanied  by  the  formation  of  a  cavity  in  the  spinal  cord. 

Allen. 


PERISCOPE.  895 

267.       UeBER    PuPILLENSTAR&K    IM    HYSTERISCHEN  ANFALLB   NEBST  WEIT- 

EREN  Bemerkungen  zur  Symptomatologie  und  Differentialdiag- 
NosE  hysterischer  UND  EPiLEPTiscHSR  Anfaklle  (On  Immobile 
Pupils  in  Hysteria,  with  notes  on  the  Symptomatology  and  Differ- 
ential Diagnosis  of  Epileptic  and  Hysterical  Attacks).  J.  P.  Karp- 
lus  (Jahrbiicber  ftir  Psychiatrie  und  Neurologie,  17,  1898,  p.  i). 

Karplus  here  presents  an  extended  series  of  observations  with 
critical  clinical  histories  of  some  eighteen  cases  of  hysteria.  Particular 
attention  is  paid  to  the  condition  of  the  pupils.  In  general  he  is  op- 
posed to  the  view  that  immobility  of  the  pupils  is  of  diagnostic  value 
in  the  differentiation  of  hysteria  and  epilepsy,  stating  that  in  the 
attacks  of  hysteria  major  the  pupils  may  be  found  to  present  exactly 
the  same  phenomena  that  are  to  be  found  in  epileptic  convulsions. 
In  the  consideration  of  hysteria  without  convulsions  he  shows  that 
in  these  cases,  three  in  number,  the  patients  "lay  as  if  dead"  with 
closed  lids,  and  in  all  of  them  there  was  immobility  of  the  pupils  to 
light. 

Similar  conditions  were  noted  in  the  cases  of  hysteria  with  con- 
vulsive respiratory  movements  in  which  there  was  no  loss  of  con- 
sciousness, also  in  cases  with  partial  seizures  and  in  still  milder  cases. 
The  symptom  has  been  found  by  him  to  be  quite  a  common  one  in 
various  hysterical  conditions. 

He  further  speaks  of  immobility  of  the  pupils  as  a  cortical  phe- 
nomenon, believing  that  both  dilatation  and  contraction  have  their 
representatives  in  the  cortex,  and  that  if  for  any  reason  the  impulses 
from  the  cortex  to  the  smooth  muscle  fibres  of  the  iris  are  cut  off, 
a  condition  of  cramp  exists  in  the  iris  musculature  which  is  the  basis 
of  the  phenomenon  in  question.  Thus  in  a  hysterical  condition,  a 
condition  of  cramp  exists  in  the  iris  musculature  similar  to  that  found 
in  the  limbs  whereby  an  analogous  loss  of  the  patellar  reflex  may  be 
noted.  Jelliffe. 

268.  Zur  Lehrb  vom  Rueckenmarksabscsss.  Concerning  Abscess 
of  the  Spinal  Cord.  H.  Schlesinger  (Deutsche  Zeitschrift  fiir 
Nervenheilkunde,  10). 

This  case  of  abscess  of  the  spinal  cord  reported  by  Schlesinger 
makes  the  tenth  now  on  record.  A  woman  of  twenty-eight  years  was 
suddenly  paralyzed  in  both  lower  extremities,  and  had  complete  loss 
of  sensation  and  much  pain  in  these  parts.  She  had  also  a  girdle  feel- 
ing, rigidity  of  the  muscles  and  tenderness  on  pressure  of  the  verte- 
bral column.  Vesical  paralysis  and  decubitus  were  noted.  Death 
occurred  about  nine  weeks  after  the  beginning  of  the  acute  symp- 
toms. At  the  autopsy  an  abscess,  due  to  staphylococci,  was  found 
in  the  sacral  and  lumbar  regions,  extending  into  the  lower  thoracic 
portion  of  the  cord.  Peculiar  foci  were  observed  in  the  lower  thoracic 
region,  which  were  believed  to  be  due  to  anaemic  necrosis.  A  moderate 
degeneration  was  traced  along  the  anterior  fissure,  through  the  tho- 
racic into  the  cervical  region,  and  was  believed  to  represent  the  fibres 
of  Marie's  ascending  sulcomarginal  bundle.  Spiller. 

269.  Derm ato-Neu ROSES.  (Savill.  Clinical  Journal,  March  2d  and 
9th,  1898). 

In  two  clinrcal  lectures  the  author  groups  dermato-neuroses  into 
"(a)  those  in  which  the  lesion  is  situated  in  the  course  of  a  periph- 
eral nerve  (sensory  or  mixed) ;  (b)  those  where  the  lesion  is 
probably  situated  in  the  central  nervous  system  (brain  or  cord); 
{c)  those  where  the  lesion  is  to  be  found  at  the  end  of  the  centrip- 


896 


FMklSCOPB. 


etal  or  sensory  nerve;  and,  finally  (d),  those  in  which  the  mis- 
chief is  located  in  some  part  of  the  sympathetic  nervous  system." 

In  the  first  patient  shown  section  of  the  median  nerve  had  been 
done  ten  years-  before  neuroses.  The  author  divides  the  post-oper- 
ation time  into  three  periods.  During  the  first  two  months  there 
were  what  he  calls  paralytic  symptoms.  There  was  paralysis  of  the 
muscles  and  anaesthesia  of  the  skin  supplied  by  the  median  nerve,  as 
well  as  congestion,  increased  perspiration  and  glossy  skin  in  its 
distribution.  The  first  and  second  fingers  became  thinner.  At  the 
beginning  of  the  third  month  began  what  he  calls  the  irritation 
stage.  The  patient  had  neuralgic  pains  and  tenderness  along  the 
course  of  the  nerve,  vesicles  appeared  on  the  knuckles  and  over  the 
terminal  joints  of  the  index  and  second  fingers,  and  the  skin  over 
the  radial  half  of  the  palm>  was  red^r  and  more  wrinkled  than  on 
the  ulitar  half.  This  condition  lasted  for  six  months,  when  the 
bulbous  growth  which  had  formed  at  the  point  of  section  was  cut 
out  and  nerve-sutures  done,  after  which  the  patient  made  a  perfect 
recovery. 

The  second  case  was  one  of  facial  hemiatrophy,  which  came  on 
after  a  severe  bump  on  top  of  the  head.  The  author  considered  it 
to  be  due  to  a  paralytic  lesion  of  the  fifth  nerve,  because  there  was 
wasting  and  weakness  of  the  muscles  of  mastication.  Queerly 
enough,  he  does  not  state  the  condition  of  sensation,  but  the  text 
reads  as  if  it  had  been  intact. 

He  next  presented  a  case  of  severe  facial  neuralgia,  with  herpes 
on  the  forehead  and  grave  changes  in  cornea  and  vitreous,  as  a  case 
of  **irritative  lesion"  of  the  same  nerve.  It  is  contended  that  an 
actual  gross  lesion  of  a  sensory  or  mixed  nerve  produces  skin 
changes,  and  that  these  differ  with  the  nature  of  the  lesion. 

"A  destructive  lesion  will  produce  glossy  skin;  and,  also,  if  the 
lesion  be  severe  and  last  long  enough,  extensive  atrophy  of  the  skin 
and  its  appendages.  An  irritative  lesion  in  dM  same  position  will 
produce,  though  apparently  in  a  shorter  time,  the  opposite  con- 
dition, viz.,  wrinkled  or  rough  skin  in  the  whole  area  of  distribution; 
the  vesicles  will  often  appear  in  some  parts  of  the  area  supplied  by 
the  irritated  nerve." 

As  an  illustration  of  tropho-neurosis  from  cerebral  influence,  the 
case  of  a  young  woman  is  cited  who  for  three  successive  winters 
had  suffered  with  pustular  eruption  on  the  hands.  She  was  subject 
to  hysterical  fainting  fits  and  attacks  of  migraine;  but  as  she  was 
employed  at  a  large  draper's  where  her  hands  were  much  exposed 
in  handling  the  cloths,  it  may  be  fairly  questioned  if  the  case  was 
one  of  hysterical  skin  affection. 

Sclerodermic  changes  from  syringomyelia  were  instanced  among 
the  tropho-neuroses  of  spinal  cord  diseases. 

Two  examples  of  skin  affection  supposed  to  be  due  to  lesions 
of  the  ends  of  sensory  nerves  were  shown.  The  first  was  a  case  of 
prurigo  in  an  elderly  man.  The  author  believes  that  this  disease  is 
always  caused  by  some  disorder  of  the  blood,  generally  due  to  some 
gastro-intestinal  disturbance,  and  he  finds  a  uniformlv  successful 
remedy  in  chloride  of  calcium.  &ut  the  doses  must  be  large,  be- 
ginning with  twenty  grains  and  Working  up  to  forty-five  g^rains,  three 
times  a  day.  The  patient  presented  had  obtained  complete  relief 
from  thirty  grains  thrice  daily,  after  meals. 

As  a  reflex  dermato-neurosis  due  to  irritation  ■  of  sensory  nerves 
in  a  distant  part,  the  author  exhibited  a  case  of  facial  chloasma  in  a 
young  woman  with  endometritis  and  a  small  uterine  fibroma. 

Although    only    thirty-one    years    old,     she    had    pronotmced 


PBRJ SCOPE.  897 

wrinkies  around  eyes  and  mouth  and  the  hands  were  harsh  and 
wrinkled,  all  of  which  the  doctor  attributed  to  the  condition  of  the 
womb.  In  a  footnote  he  says  that  as  the  uterine  functions  gradually 
improved  after  curettement,  the  chloasma  and  wrinkles  disappeared, 
to  reappear  four  months  later  with  a  return  of  the  menorrhagia. 

Under  tropho-neuroses,  caused  by  disorder  of  the  sympathetic 
nervous  system,  were  classed  Raynaud's  disease,  acroparaesthesia, 
giant  urticaria,  fugitive  erythema  and  hyperidrosis.  The  vaso-motor 
cases  have  in  common,  paroxysmal  appearances  of  the  symptoms, 
symmetry  of  distribution,  initial  pallor  followed  by  congestion,  tend- 
ency of  exposed  parts  to  be  affected  and  preponderance  of  women  in 
the  victims.  Patrick. 

270.  The  Lumleian  Lectures  on  Some  Problems  in  Connection  with 
Aphasia  and  Other  Speech  Defects.  Lancet  (April  3d,  loth 
and  24th  and  May  ist,  1897).  Also  On  a  Case  of  Amnesia  of  18 
Years'  Duration  with  Autopsy.  H.  Charlton  Bastian  (Vol.  80  of 
the  Medico-Chirurgical  Transactions). 

In  his  "Lumleian  Lectures,"  the  author  begins  with  a  con- 
sideration of  the  method  of  the  storing  up  of  word  memories,  and 
their  reproduction  as  speech.  There  are  three  kinds  of  verbal 
memory,  i.  "Auditory  memory;  the  memory  of  the  sound  of  words.'" 
2.  "Visual  memory;  the  memory  of  the  visual  appearances  (printed  or 
written)  of  words."  3.  "Kinaesthetic  memory;"  the  latter  being  sub- 
divided into  "glosso-kinaesthetic"  memories,  i.  e.,  "the  memories  of 
the  different  groups  of  sensory  impressions,  resulting  from  mere 
movements  of  the  vocal  organs  during  the  utterance  of  words,"  and 
"cheiro-kinaesthetic"  memories;  i.  e.,  "the  memories  of  the  different 
groups  of  sensory  impressions,  emanating  from  muscles,  joints,  and 
skin,  during  the  act  of  writing  individual  letters  and  words."  Since 
the  centres  for  these  different  kinds  of  memories  are  not  only  in 
relation,  each  to  its  own  afferent  fibres,  but  are  also  closely  con- 
nected with  each  other  by  commissural  or  associational  fibres,  the 
memory  or  recollection  of  a  word  in  one,  probably  involves  some 
simultaneous  activity  in  one  or  more  of  the  other  centres.  The 
centre  for  visual  word  memories  is  located  in  the  angular  gyrus  and 
perhaps  partly  in  the  supramarginal  lobule;  that  for  auditory  word 
memories  in  the  posterior  lialf  or  two-thirds  of  the  upp^r  temporal 
convolution.  The  author  has  previously  stated  his  opinion  that  the 
motor  centres  of  Ferrier  and  others  "are  really  sensory  centres  of 
kinaesthetic  type,  by  means  of  which  movements  are  guided."  The 
"glosso-kinaesthetic"  centre  is  located  in  Broca's  region.  The 
"cheiro-kinaesthetic"  centre  cannot  be  so  positively  determined,  but 
the  author  is  inclined  to  follow  Eauld,  and  to  place  it  in  the  posterior 
part  of  the  second  frontal  gyrus. 

He  suggests  that  the  auditory  and  visual  word  centres  are  joined 
by  a  double  set  of  commissural  fibres,  and  that  there  is  a  particularly 
close  connection  between  the  auditory  and  "glosso-kinaesthetic" 
centres  on  the  one  hand,  and  between  the  visual  and  "cheiro- 
kinaesthetic"  centres  on  the  other.  In  the  study  of  speech  defects 
then,  there  are  to  be  considered  lesions,  a,  in  the  word  centres  them- 
selves; b,  in  the  different  commissures  by  means  of  which  these 
centres  are  connected;  c,  in  the  fibres  connecting  the  two  kin- 
aesthetic  word  centres  with  their  related  motor  centres  in  the  bulb 
and  cervical  region  of  the  cord;  d.  in  these  motor  centres  themselves. 
"Words  are  the  symbols  with  which  our  thoughts  are  inextricably 
interwoven."    Their  revived  "images"  "may  enter  into  thought  pro- 


898 


PERISCOPE. 


cesses  by  more  or  less  simultaneous  renewal  of  activity  iri  different 
regions  of  the  cerebral  cortex."  The  revival  may  be  as  the  sound  of 
spoken  words,  as  the  visual  impressions  of  written  or  printed  words, 
or  as  "the  feelings  of  the  muscular  contractions  concerned  in  the 
pronuniciation  of  words."  The  two  former  are  the  more  distinct  and 
easily  reproduced,  the  latter  very  vague. 

There  are  two  distinct  and  opposed  views  as  to  the  method  of 
word  recall  in  ordinary  thought.  According  to  the  first,  words 
are  revived  "as  faint  excitations  of  the  processes  occurring  in  motor 
centres  during  the  articulation  of  words."  The  second  view  is  that 
words  are  revived  mainly  "as  auditory  ideas  or  images."  This  latter 
view  the  author  strongly  advocates,  and  gives  his  reasons  for  so 
doing  very  fully.  Word  recall  may  take  place  and  doubtless  does 
take  place  also  as  the  revival  of  a  visual  memory,  and  in  some  persons 
the  ability  to  recall  words  through  the  memory  of  their  appearance 
when  written  or  printed  is  very  marked.  In  the  great  majority  of 
people,  however,  the  memory  of  the  sound  of  spoken  words  seems 
that  most  easily  revived.  On  this  basis  individuals  may  be  classified 
as  "visuals"  and  "auditives,"  according  as  the  one  faculty  or  the 
other  predominates.  "In  ordinary  persons,  the  four  memories  of 
words  seem  to  be  called  into  play  in  definite  couples" — "the  auditory 
and  glosso-kinsesthetic  revivals  taking  place  during  articulate  speech, 
and  the  visual  and  cheiro-kinsesthetic  revivals  taking  place  during 
ordinary  writing."  The  functional  association  between  the  auditory 
and  glosso-kinaesthetic  centres  and  that  between  visual  and  chciro- 
kinaesthetic  centres  is  extremely  close.  The  word  centres  are  ia 
health  excited  to  activity  i**  by  sensory  impressions  from  with- 
out; 2^  by  association  (i.  e.,  by  an  impulse  communicated  from 
another  centre  during  some  act  of  perception  or  thought  process); 
3**  by  voluntary  recall  of  past  impressions.  The  author  reviews  the 
theories  which  have  been  proposed  to  account  for  the  predominant 
influence  of  the  left  hemisphere  upon  speech  without  pronouncing 
for  one  or  another,  but  insists  upon  the  fact  that  the  right  hemisphere 
does  not  remain  entirely  uneducated,  but  receives  to  some  extent 
visual  and  auditory  speech  impressions,  and  may  possibly  be  able 
to  some  extent  at  least  to  take  on  a  vicarious  action,  when  the 
centres  of  the  left  side  are  injured.  He  strongly  opposes  the  idea 
of  a  separate  centre  for  concepts.  Passing  to  the  consideration  of 
lesions  producing  speech  defects,  he  confines  himself  to  the  study 
of  those  of  the  four  word  centres.  The  frequent  association  of 
aphasia  with  agraphia  he  ascribes  to  the  proximity  of  the  speech 
and  writing  centres,  and  of  their  afferent  fibres  to  one  another, 
combating  the  view  that  a  lesion  restricted  to  Broca's  region  will 
produce  agraphia  as  well  as  aphasia.  The  question  as  to  whether  an 
isolated  lesion  of  Broca's  region  will  always  produce  verbal  amnesia 
and  alexia  is  answered  negatively.  While  there  is  on  record  no  case 
of  pure  agraphia,  the  author  holds  to  his  idea  of  a  cheiro-kinaesthetic 
centre,  suggesting  that, it  occupies  so  limited  an  area  that  a  lesion 
in  that  region  is  always  large  enough  to  produce  paralysis  of  other 
movements  of  the  hand  and  arm,  at  the  same  time  as  agraphia. 

The  division  of  aphasia  into  a  motor  and  sensory  form  is  not 
in  accordance  with  his  views.  He  prefers  to  limit  the  term  aphasia 
to  speech  defects  the  result  of  lesions  in  Broca's  region,  using  that 
of  aphemia  for  those  due  to  subcortical  lesions,  leaving,  those,  due  to 
lesions  of  the  visual  and  auditory  centres  to  be  grouped  as  amnesia, 
visual  or  auditory.  He  then  proceeds  to  point  out  the  most  common 
combinations  of  symptoms  of  lesions  in  the  various  word  centres, 
illustrating  them  by  numerous  case  histories.     A  close  study  of  these- 


PERISCOPE.  899 

shows  surprising  and  at  first  sight  contradictory  results.  While 
insisting  throughout  upon  the  superior  importance  for  speech,  in 
most  persons,  of  the  auditory  centre,  the  author  thinks  that  some 
cases  of  speech  preservation  where  the  auditory  centre  was  destroyed, 
may  be  explained  by  the  theory  that  the  affected  individuals  were 
"strong  visuals."  In  other  apparently  anomalous  cases,  extending 
over  years,  the  original  injury  may  have  been  less  extensive  than 
that  found  after  death.  In  those  cases  in  which  power  of  speaking 
has  been  gradually  regained,  he  thinks  that  the  right  auditory  centre 
may  have  been  by  degrees  educated  to  act  through  the  commissural 
fibres  upon  the  glosso-kinaesthetic  centre  of  the  left  side.  He  ex- 
plains the  cases  of  word  blindness  without  agraphia,  by  assuming 
that,  the  subjects  being  strong  "auditives,"  the  cheiro-kin aesthetic 
centre  was  influenced  directly  from  the  auditory  centre.  The  cases 
of  destruction  of  the  centres  in  both  hemispheres  are  so  few  and 
their  histories  so  incomplete  that  the  author  does  not  attempt  to 
explain  their  symptoms  at  any  liength.  For  a  discussion  of  the  forty- 
three  cases  mentioned,  see  the  original.  In  his  'other  paper  the 
author  gives  a  very  complete  history  extending  over  eighteen  years  of 
a  remarkable  case  of  speech  defect,  in  which,  though  the  autopsy 
showed  complete  destruction  of  the  angular  and  marginal  gyri,  of 
the  superior  and  part  of  the  middle  temporal  convolutions,  and  of 
part  of  the  ascending  frontal,  second  frontal,  and  ascending  parietal 
convolutions  on  the  left  side,  Broca's  region  being  uninvolved, 
there  was  neither  word  deafness,  word  blindness,  nor  agraphia. 
Spontaneous  speech  was  however  very  limited,  and  though  the 
patient  could  read  and  understand  what  he  read,  and  could  copy 
with  his  left  hand,  he  could  neither  write  spontaneously,  nor  from 
dictation,  nor  could  he  read  aloud.  Allen. 

271.  Paralysis   ok    the  Sixth  Nerve    Followed  kv   Diplegia:   Re- 
covery.    Wood  (Brit.  Med.  Jour.,  Apr.  3,  1897). 

• 

The  author  reports  an  interesting  case,  apparently  of  acute  toxic 
or  infectious  origin,  but  thrombosis  was  not  excluded. 

A  healthy  lad  of  18,  of  gouty  heredity,  gradually  developed  during 
two  days,  paralysis  of  the  right  sixth  nerve  and  in  the  succeeding 
five  days,  left  hemiplegia,  inchiding  the  lower  part  of  the  face.  The 
orbicularis  palpebrarum  and  the  frontalis  were  not  involved  and  sen- 
sation was  normal  except  for  a  feeling  of  numbness  on  the  paralyzed 
side.  The  hemiplegia  rapidly  improved  and  in  two  weeks  had  quite 
disappeared,  but  four  days  before  this,  distinct  bulbar  paralysis  came 
on  and  in  five  days  had  become  very  marked,  the  tongue,  lips,  pharynx 
and  probably  larynx  being  affected.  From  this  condition  the  patient 
also  rapidly  recovered  and  a  month  later  was  practically  well  except- 
ing the  abducens  paralysis,  a  trace  of  which  remained  five  months 
after  the  beginning  of  the  trouble. 

The  author  seems  unwilling  to  make  a  diagnosis,  but  likens 
the  case  to  an  acute  poliomyelitis  of  the  medulla  and  pons — a  com- 
parison that  seems  to  us  to  be  eminently  rational.         Patrick. 

272.  Thyroid  Chlor«'SIS.     Dr.   Capitan   (The  Medical  Week,  5,  1897, 
p.  609). 

» 

Dr.  Capitan,  noting  the  well  known  fact  that  in  chlorotic  sub- 
jects the  thyroid  gland  is  frequently  enlarged,  states  that  Professor 
Hayem  has  found  this  to  be  the  case  in  twenty-nine  patients  out  of 
thirty-five  under  his  observation.  Tlic  goitre  is  usually  very  small 
and  very  soft,  though  sometimes  it  is  pulsating,  in  which  latter  case 


900  PERISCOPE. 

the  general  symptoms  of  mild  Graves'  disease  are  -^ually  present* 
The  author  thinks  that  the  chlorotic  condition  is  dependent  upon  this 
small  degree  of  exophthalmic  goitre,  and  is  due  to  one  of  the  varieties 
of  thyroid  intoxication.  He  considers  this  further  demonstrated  by 
the  fact  that  such  cases  have  improved  rapidly  under  the  administration 
of  a  rather  strong  solution  of  iodine  and  iodide.  Such  patients  treated 
exclusively  by  tablets  of  iodothyrin  lose  the  chlorotic  and  exoph- 
thalmic phenomena  within  a  few  weeks.  Mitchell. 

273.  UebeR  die  Heilung  aseptischer  traumatischer  Gshirnver- 
LBTZUNGEN  (Concerning  the  Healing  of  Aseptic  Traumatic  Cerebral 
Wounds;.     T.  Tschistowitsch  (Ziegler*s  Beitrage,  vol.  23,  No.  2). 

The  writer  reviews  carefully  the  literature  on  the  regeneration 
of  nerve  tissue,  and  shows  that  the  results  obtained  by  the  different 
investigators  are  contradictory.  He  himself  performed  a  number  of 
experiments  on  rabbits,  dogs  and  pigeons.  He  experimented  in 
three  different  ways,  he  thrust  a  cold  or  hot  needle,  or  small  tubes 
made  of  celloidin  into  the  brain,  or  he  excised  pieces  of  cerebral 
tissue,  always  under  antiseptic  measures.  The  most  important 
conclusions  which  he  formed  from  his  studies  are,  that  after  cerebral 
injury  the  restoration  of  tissue  -is  almost  entirely  accomplished  by 
proliferation  of  the  connective  tissue  of  the  pia  and  vessels.  The 
neuroglia  plays  an  unimportant  part,  and  forms  merely  a  secondary 
sclerotic  zone  about  the  scar  or  foreign  body,  and  this  only  in  those 
cases  in  which  the  irritation  from  the  wound  is  unusually  great  and 
of  sufficiently  long  duration.  In  gradual  destruction  of  the  specific 
elements  of  cerebral  tissue  this  gliar  sclerosis  may  possibly  be  more 
intense.  This  hyperplasia  of  the  neuroglia  is  probably  caused  by 
special  forms  of  irritation.  He  was  not  able  to  observe  any  re- 
generation of  nerve  cells,  but  is  more  guarded  in  his  statements  con- 
cerning the  possibility  of  regeneration  of  nerve  fibres.  The 
capability  of  the  ventricular  ependyma  to  proliferate  is  very  slight. 
The  ependyma  may  cover  a  limited  portion  of  the  inner  surface  of 
the  brain  which  has  been  deprived  of  these  cells,  but  it  has  no  part 
in  the  restoration  of  nerve  cells  or  of  cerebral  tissue.     Spiller. 

274.  AcROMftoALiE  CHKZ  UN  NEGRE  Aofe  DE  14  ANS  (Acromegaly  in  a  Negro 
aged  Fourteen  Years).  Valdes  (La  Presse  M^icale,  No.  78, 
1897.  p.  174). 

Valdes  (of  Matanzas,  Cuba)  reports  a  case  of  acromegaly  in  a 
fourteen  year  old  negro  boy.  The  excellent  reproductions  of  his 
photographs,  and  the  outlines  of  the  foot  and  hand  of  the  patient 
as  compared  with  those  of  healthy  individuals,  show  that  the  disease 
was  fully  developed  and  characteristic.  The  patient  suffered  from 
headache  and  from  muscular  weakness,  and  besides  enlargement 
of  the  hands  and  ffeet.  presented  an  increase  in  size  of  the  lower 
jaw  and  a  cervico-dorsal  kyphosis.  He  had  no  visual  nor  auditory 
disturbance.  Allen. 

275.  La  (iHiANDOLA  TiROiDE  NEGLi  ALiENATi  (The  Thyroid  in  Mental 
Affections).     P.    Amaldi  (Revista  Sperimentali  di  Freniatria,  23, 

1897,  p.  3")- 

In  an  extensive  article  of  some  forty  pages,  the  author  presents 
the  results  of  a  study  of  some  107  cases,  69  men  and  38  women.  In 
the  men  some  58  per  cent,  showed  changes  in  the  thyroids  and  in 
the  women  53  per  cent,  of  the  thyroids  were  affected.  In  senile 
dementia  and  in  pellagra  the  changes  were  more  manifest.  Colloidal 
and  granular  degenerative  changes  were  the  most  common  types  of 
lesion  found.  Jelliffe. 


^ 


Sook  ^jeuieius. 


LeS    MYELITES   SYPHIUTlgUES,  FORMES    CLLNQUES,   ET    TRAITEMENT,   PAR    LE 

Dr.  Gilles  de  la  Tourette,  professeur  acir^ge  a  la  faculte  de 
MEDICINE  de  Paris  (Actualites  m^dicales),  J.  B.  Baillierc  et  Fils, 
Paris,  1898. 

Spinal  syphilis  is  a  subject  of  some  importance,  since  in  its  clinical 
forms  it  closely  resembles  certain  types  of  spinal  disease  which  have  a 
bad  prognosis  and  which  are  not  amenable  to  treatment,  whereas  in 
certsrin  cases  of  spinal  syphilis  treatment  is  singularly  efhcacious. 
The  author  here  has  given  in  small  compass  an  excellent  picture  of 
the  various  syphilitic  affections  of  the  spinal  cord;  syphilitic  Pott's 
disease,  intravertebral  gummata,  myelitis  in  a  restricted  sense,  ma- 
lignant early  syphilis  of  the  nervous  tissues  of  the  cord,  acute  and 
chronic  and  irregular  general  myelitis.  He  also  discusses  the  question 
of  hereditary  syphilis,  both  as  manifested  in  infancy  and  when  delayed. 
The  brochure  is  to  be  commended  as  a  short  and  graphic  description 
for  the  general  practitioner  conversant  with  the  French. 

Jelliffe. 

PsYCHOLOGiE  DE  l'instin'CT  skxuel.  p._  Jo'innv  Roux,  medecin  adjoint 
(design^)  des  asiles  d'alienes  do"  Lyon.  J.  B.  Bailliere  et  Fils, 
Paris,  1898,  I  fr.  50. 

In  this,  one  of  a  new  series  of  brochures,  Dr.  Roux  gives  an  ex- 
planation of  the  sexual  instinct  which  is  purely  mechanical.  Starting 
on  purely  materialistic  foundations,  he  shows  that  the  function  in  all 
of  its  manifestations  has  a  peripheral  causative  factor.  The  different 
chapters  -are  short  and  discuss  severally:  The  organic  base  of  the 
sexual  desire;  physical  love,  choice  and  a  theory  of  the  evolution  of 
love;  superior  forms  of  love;  evolution  of  love,  etc.  This  small  work 
is  quite  entertaining  and  well  worth  the  reading,  though  it  contains 
little  that  is  strikingly  new  or  profound.  Jelliffe. 

Die  Geschwuelste  des  Nervensystems,  Hirngescmiwuelste,  Ri^ecken- 

MARKSGESCHWUELSTE,      GeSCHWUELSTE     DER      PeRIPHEREN       NeRVEN. 

Eine  Kliniscbe  Studie  von  Dr.  Ludwig  Bruns,  Nervenarzt  io 
Hannover.     S.  Karger,  Berlin,  1897. 

Dr.  Bruns  has  very  modestly  called  his  splendid  monograph  a 
"clinical  study."  In  Eulenberg's  Real  Encyclopadie,  Bruns  contributed 
the  article  which  by  further  study  and  growth  has  evolved  to  the 
present  volume  of  nearly  four  hundred  pages.  It  is  a  complete  and 
exhaustive  treatise,  which  bears  the  stamp  of  an  authority  who  has 
made  thorough  researches  in  this  field,  and  is  a  storehouse  of  informa- 
tion drawn  from  a  rich  experience. 

The  subject  matter  is  divided  into  three  portions,  the  first  dealing 
with  tumors  of  the  brain,  the  second  with  tumors  of  the  spinal  cord 
and  the  third  with  tumors  of  the  peripheral  nerves.  Each  section  is  a 
monograph  by  itself,  with  full  citations  of  the  more  important  litera- 
ture. In  the  first  portion,  under  the  pathology  of  brain  tumors,  Bruns 
distinguishes  three  main  types.     The  neoplasms  proper:   (i)   Glioma, 


902  BOOK  REVIEWS, 

Sarcoma,  Osteoma,  Poammoma,  Carcinoma,  Cholesteatoma,  etc.;  (2) 
the  Granulomata  and  (3)  tumors  of  parasitic  origin.  He  lays  some 
stress  upon  the  uitieiential  diagnosis  of  glioma  and  sarcoma,  the 
lormer  arising,  he  says,  from  neuroglia  tissue,  the  latter  being  of 
ectodermal  origin.  Ihe  second  chapter  deals  with  the  occurrence 
and  etiology  of  tumors,  and  here  as  an  etiological  factor  the  influence 
of  trauma  is  carefully  considered,  the  author  inclining  to  a  negative 
view  with  reference  to  this  factor.  The  following  chapters  on  the 
general  action  of  tumors  and  the  symptomatology,  both  general  and 
U)cal,  are  es])ecially  full  and  valuable.  Here  optic  atrophy  is  reck- 
oned as  tlie  most  constant  and  important. of- the  general  symptoms  of 
brain  tumor.  ( )f  more  than  general  value  is  the  portion  of  this  chap- 
ter bearing  upon  the  localization  of  brain  tumors,  which  in  the 
author's  experience  was  possible  in  at  least  80  per  cent,  of  all  his 
cases.  In  the  descriptions  of  cerebellar  tumors  with  cerebellar  ataxia 
the  author  distinguishes  two  types,  those  presenting  Romberg's 
sign  and  those  which  do  not.  In  chapter  seven  on  the  surgical  treat- 
ment of  brain  tumors  Bruns  would  seem  to  show  anything  but  an 
optimistic  feeling,  in  that  his  own  experience  has  given  few,  if  any. 
satisfactory  results,  yet  he  shows  a  broadmindedness  in  his  hearty 
support  of  operative  interference  in  tumors  w-hich  can  be  well  local- 
ized and  diagnosed. 

The  second  portion  of  the  book  on  tumors  of  the  spinal  cord  is 
as  accurate  and  careful  as  the  first.  Hdrc  operative  treatment  shows 
far  better  results. 

The  third  portion,  on  tumors  of  the  nerves  and  the  nerve  plexuses, 
is  treated  of  in  some  thirty  pages.  The  pathological  anatomy,  occur- 
rence, symptoms,  prognosis,  diagnosis  and  therapy  are  clearly  and 
fully  set  forth. 

The  work  is  sparingly  though  well  illustrated,  and  as  a  work  for 
study  and  reference  has  no  equal.  Jklliffe. 

Lks  hvdrocei'H.m.iks.     Par  le  Doeteur   Leon    d' Astros.     Medecin  des 
hopitaux  de  Marseille.     Paris,  G.  Steinheil,  Editeur,  1898. 

D' Astros  has  written  a  voluminous  treatise  on  hydrocephalus 
which  is  useful  as  giving  a  survey  of  the  whole  field  rather  than  as 
contributing  anything  new  to  our  knowledge  of  this  somewhat  obscure 
subject.  In  fact,  after  a  rather  careful  search  through  the  book,  we 
must  confess  to  a  feeling  of- disappointment  that  we  have  not  learned 
more  that  is  new  about  the  moot  points  of  hydrocephalus.  The  book 
has  simply  taken  us  over  the  ground  and  presented  us  wfth  a  resume 
of  facts  and  opinions.  In  this  sense  it  is  a  useful  work,  both  for  study 
and  for  reference,  but  it  is  not  a  work  of  much  originality. 

The  author  has  evidently  been  a  careful  student  and  investigator 
of  cerebral  pathology.  He  is  a  painstaking  examiner,  and  leaves  no 
detail  unexplored.  Thus  he  gives  not  only  anatomical  findings,  but 
:ilso  the  chemical  constituents  of  the  cerebro-spinal  fluid  as  a  means 
of  differentiation  between  the  several  forms  of  hydrocephalus.  By 
lumbar  puncture  he  not  only  secures  this  fluid,  but  he  also  estimates 
the  degree  of  intraventricular  pressure — an  exact  procedure  which  we 
imagine  is  not  very  generally  resorted  to  by  clinicia^^. 

D'.\stros  practically  limits  the  term  hydrocephalus  to  the  chronic 
internal  variety  of  the  older  authors,  i.  e.,  an  effusion  of  fluid  in  the 
ventricles,  distending  them  and,  as  a  secondary  consequence,  dis- 
tending the  cranium.  This  effusion,  of  course,  spreads  to  the  sub- 
arachnoid space,  unless  some  of  the  natural  foramina  of  the  ventricles 
are  pathologically  closed.  An  external  hydrocephalus  in  the  older 
^ense,  1.  e..  an  effusion  limited  to  the  subarachnoid  space,  but  not  com- 


BOOK  REVIEWS.  903 

nnn.icatiiig  with  the  ventricles,  must  be,  in  the  author's  opinion, 
cxTcnitlv  rare,  for  reasons  that  are  easily  apparent  to  every  one. 
liencc  he  views  with  disfavor  an  attempt  to  describe  an  external  hy- 
drovTCphalus  in  the  older  sense.  This  term,  if  admitted  at  all,  should 
be  ust-d  for  those  very  rare  cases  in  which  the  effusion  is  subdural, 
and  does  not  communicate  at  all  with  the  ventricular-arachnoid  sac. 
In  such  casts,  of  course,  the  condition  is  radically  distinct  from  hydro- 
cephalus as  ordinarily  understood. 

Beginning  thus  with  a  clear  definition  of  his  subject,  d' Astros 
takes  up  seriatim  all  the  various  morbid  states  that  cause  or  are  asso- 
ciated with  effusion  into  the  ventricles. 

Congenital  hydrocephalus  is  admittedly  the  most  characteristic 
and  at  the  same  time  the  most  obscure  iorm  of  the  disease.  The 
author  distinguishes  a  true  teratological  and  a  pathological  variety, 
but  the  distinction  is  not  satisfactory,  for  even  in  the  teratological 
form  there  must  be  practically  something  pathological,  since  this  form 
arises  from  errors  in  the  development  of  the  embryo  that  arc  essen- 
tially morbid.  This  is  shown  by  the  fact  that  this  variety  is  often 
associated  with  spina  bifida  and  encephalocele.  In  fact,  the  hydro- 
cephalus is  probably  due,  just  as  is  spina  bifida,  to  a  faulty  develop- 
ment of  the  walls  of  the  primitive  neural  tube  in  the  embryo.  It  is 
here  especially  that  we  need  new  light  on  the  radical  causation  of 
hydrocephalus,  and  the  author,  in  common  with  others,  fails  to  give 
such  light.  This  is  a  chapter  in  embryonal  pathology  that  is  still 
uncompleted. 

Among  the  various  causes  of  acquired  hydrocephalus  (post-natal) 
d'Astros  recognizes  certain  mfections,  rachitis,  serous  meningitis, 
gross  lesions,  such  as  tumors,  tuberculosis,  and  hereditary  syphilis. 
These  causes  act  to  produce  ventricular  effusion  in  one  of  two  ways, 
either  by  stasis  or  by  irritation.  Stasis  may  be  venous  or  lymphatic. 
Irritation  acts  especially  in  the  vessels  of  the  choroid  plexus  or  in  the 
ependyma.  Effusion  from  a  mere  blocking  up  of  the  foramina  of 
the  ventricles  (the  foramen  of  Monro,  the  aqueduct  of  Sylvius,  or  the 
foramen  of  Magendie)  is  not  accepted  without  great  reserve  by  -the  1 
author,  for,  as  he  says  truly,  agy  lesion  acting  to  obstruct  these 
natural  orifices  would  probably  act  also  to  obstruct  the  venous  out- 
flow. This  obstruction  of  the  veins  and  lymphatics  is  a  much  more 
probable  cause  of  effusion  than  a  mere  obstruction  of  the  various 
foramina  of  the  ventricles,  through  which  the  circulation  of  the 
cerebrospinal  fluid  is  probably  not  very  active. 

Quincke's  view  of  a  serous  meningitis  is  criticized  by  d'Astros, 
who  does  not  altogether  deny  the  existence  of  this  disease,  but  very 
properly  points  out  that  in  some  recorded  cases,  including  those  of 
Quincke  himself,  the  lesion  is  susceptible  of  other  explanations,  as, 
for  instance,  the  action*  of  tubercles  or  some  other  infection. 

D'Astros  concludes  his  book  with  a  chapter  on  treatment,  in 
which  he  reviews  especially  the  various  surgical  procedures  that  have 
been  advised  for  the  relief  of  hydrocephalus.  This  is  an  especially 
important  chapter  for  those  who  are  interested  in  the  surgical  aspects 
of  the  subject,  as  it  presents  a  complete  view  of  this  somewhat  forlorn 
field  of  practice.  James  Hendrie  Lloyd. 

Festschrift  ani.aesslich  des  funfzigjaehrigen  BESTEHENfr  der  Pro- 
vinziai.-Irren-Anstalt  zu  Nietlbben  bei  Hallf.     A.  S.  Von  friih- 
eren  und  jetzigen  Aertzten  der   Anstalt.     F.  C.  W.  Vogel,  Leip- 
zig.    1897. 
This  volume  contains  a  number  of  contributions  to  psychiatry, 

.both  interesting  and  able,  by  alienists  of  international  reputation. 


904  ^OOK  REVIEWS. 

Ueber  den  Querulanten-Wahnsinn,  by  E.  Hitzig;  Clinical  Con- 
tributions to  Forensic  Psychiatry,  by  E.  Siemerling;  Reflex  Epilepsy, 
by  A.  Seeligmuller ;  Psychical  Disturbances  following  Attempted  Sui- 
cide by  Hanging,  by  R.  Wollenberg;  Uraemia  Presenting  the  Pictures 
of  General  Paresis,  by  L.  Bruns;  Herpes  Zoster,  by  G.  Peters;  Epi- 
lepsy as  a  Symptom  of  Withdrawal  of  Morphine,  by  C.  Heimann; 
Chronic  Paranoia  in  Epileptic  Individuals,  by  A.  Bucholz.  These,  with 
a  few  others,  make  up  the  contents  of  this  excellent  report.  In  the 
United  States  reports  of  this  type  are,  unfortunately,  the  great  excep- 
tion to  the  rule,  those  usually  issued  from  our  institutions  consisting 
for  the  main  part  of  useless  pages  of  figures.  Jelliffe. 


BOOKS   RECEIVED. 

'•The  Care  of  the  Baby,"  by  J.  P.  Crozcr  Griffith,  M.  D.  \V.  B. 
Saunders,  Philadelphia. 

"A  Text-Book  of  Pathology,"  by  Alfred  Stengel,  M.  D.  W.  B. 
Saunders,  Philadelphia. 

"The  American  Pocket  Medical  Dictionary,"  by  W.  A.  Newman 
Dorland,  A.  M.,  M.  D. 

"Cleft  Palate;  Treatment  of  Simple  Fractures  by  Operation: 
Diseases  of  Joints,  Antrectomy,  Hernia,"  etc.,  by  W.  Arbuthnot 
Lane.  M.  D.    The  Medical  Publishing    Company,  Limited,  London. 

"Essentials  of  Materia  Medica,  Therapeutics  and  Prescription- 
Writing,"  by  Henry  Morris,  M.  D.     W.  B.  Saunders,  Philadelphia. 

"Ueber  das  Pathologische  bei  Goethe,"  by  P.  J.  Mobius.  J,  A. 
Barth,  Leipzig,  1898. 

"Annaurie  des  Eaux  Minerales  Stations  Climatique  et  Sanatoria," 
Paris.     Gaz.  des  Eaux. 

"Klinische  und  pathologische  Beitrage  zur  Lehrc  von  der  beider- 
seitigen  ccrebralen  Lahmung  im  Kindesalter,"  by  W.  Muratow. 
From  Deutschcn  Zeitschrift  f.  Nervenheilkunde,  1897. 

"De  la  Constitution  des  Noyaux  moteur  medullaircs,"  by  F.  Sano. 

"Abolition  du  reflexe  rotulien  malgre  Tintegritc  relatif  de  la 
moelle  lombo-sacree,"  by  F.  Sano.  From  Journal  de  Neurologic, 
^898. 

"Lcs  Etats  Neurasth^niques,"  by  Dr.  Gilles  de  La  Tourette. 


^Bensolyptus  (schkffeim's) 

Bensolyptus  is  an  agreeable  alkaline  solution  of  various  highly 
approved  antiseptics,  all  of  which  are  of  recognised  value  in 

Catarrhal  Affections 

because  of  their  cleansing,  soothing  and  healing  properties. 
Bensolyptus  is  highly  recommended  in  all  inflammations  of 
mucous  membranes,  especially  in  diseases  of  the 

Nose  and  Throat  and  as  a  Mouth-Wash  and  Dentifrice. 

It  is  also  of  value  for  internal  use  in  affections  of  the  alimen- 
tary tract  attended  with  fermentation  of  food,  eructations, 
and  heart  burn. 

Send  for  pamphlet  to       ScHeffelin  &  Co.,  Ncw  YofL 


Needs  no  Disguise, 


Because  It  b  FREE  from  all 
Disagreeable  Taste  or  Odor. 


Peter  Moller's 


Hydroxyl-Free 


Cod  Liver  Oil. 


Always  of  the  highest  standard  of  quality,  is  now  prepared  by  a  new  process,  the 
result  of  years  of  scientific  investigation,  whereby  the  oil  is  kept  from  atmospheric 
contact  from  the  beginning  of  the  process  of  manufacture  until  it  is  safely  corked  up 
in  bottles,  thus  preventing  contamination  of  any  kind  and  excluding  all  impurities. 

rtl         -tf-kl      ^^  ^^^  PETER  MOLLER'S  OIL,  and  see  that  the  bottle—a  fiat. 

ClI  VC  tniS   oval  one — ^bears  our  name  as  agents.   Notice  the  date  in  perforated 

M^w  Q[|     letters  at  bottom  o£  the  label.    We  shall  be  glad  to  forward  speci- 

rws   •    •       mens  of  Moller's  Oil  to  members  of  the  medical  profession,  either 

A   1  riAl*     for  chemical  inve.stigation  or  practical  '*  exhibition,"  and  we  shall 

also  be  glad  to  supply  full  information  regarding  Moller's  New  Process. 

5chieffelin  &  Co.,  New  York. 


•  •  •  • 


WM.  R.  WARNER  &  GO'S 


I 
•  •  •  •         y. 


Easily  assimilable 

......foriD  of 

FerroBB  Carbonate. 

Useful  in 

Anemia 

Chlorosis 

Phthisis 


We  claim  there  is  no  superior  method  of  prescribing  iron 
than  by  Pil.  Chal3rbeate  and  PiL.  Chalybeate  Comp.  We 
haye  combined  Peni  Sulph.  i}i  gr.  and  Potass.  Carb.  i}4  gr. 
so  that  upon  disintegration  of  the  pill  in  the  visceral  fluids, 
the  contents  are  released  as  protocarbonate  of  iron^  one  of 
the  most  assimilable  forms  of  tiiis  remedy.  They  are  pills 
requiring  skilful  manipulation  during  their  manufacture  on 
account  of  possible  oxidation.  An  iron  pill  that  oxidizes 
while  being  prepared  is  of  very  little  value.  To  distinguish 
the  value  of  an  iron  pill,  dissolve  it  in  water.  A  light  green 
color  indicates  protocarbonate,  while  a  reddish  brown  denotes 
the  ferric  salt,  decomposed  by  oxioation. 


'  ¥^f*0^0^^^^^0*^0^0^0^0^0*0^t0*0^0t0t^t^*^^0^0^0^0^0^^^m0^0^l^^0^^^l^^0^0^^l^^f^^t^^/^^^l^*^f^^^0^l^l^t^ 


SUPERIOR  TO  PEPSIN  OP  THE  HOG 


INCLUYIN 


A  Powdetw-prescribed  ia 
the  same  manner,  doses 
and  combinations  aa 
pepsin. 


w.i.iuiiEiseo.| 

PHILADELPHIA  ^l 

NEW  YORK  f 

CHICAGO  ^ 


r; 


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Predigested  Beef 

Is  the  basis  of  Armour's  Nutrient  Wine  of 

Beef  Peptone,  a  preparation  presenting  the 
entire  digestible  substance  of  prime,  lean  Beef, 
in  a  form  requiring  no  effort  of  the  digestive 
organs  to  render  it  diffusible. 

Nutrient  Wine 

Is  especially  indicated  in  the  treatment  of  all 
cases  of  faulty  nutrition  occasioned  by  gastric 
weakness,  Ulceration  of  the  Stomach,  Phthisis, 
Typhoid  Fever,  and  wherever  a  readily  assim- 
ilable food  is  required. 


L 


Manufactured  by 

ARMOUR  &  COMPANY,  CHICAGO. 


J