Skip to main content

Full text of "The Journal of nervous and mental disease"

See other formats 


THE 


JOURNAL 


Nervous  and  Mental  Disease 


EDITED    BY 


J.  S.  JEWELL,  M.D. 

PROFESSOR    OF   NERVOUS   AND    MENTAL   DISEASE^   IN    CHICAGO    MEDICAL   COLLEGE 


H.   M.  BANNISTER,   M.D. 


ASSOCIATE   EDITORS 

W.  A.  HAMMOND,  M.D.        MEREDITH  CLYMER,  M.D. 
NEW   YORK 

S.  WEIR  MITCHELL,  M.D. 
PHILADELPHIA 


JANUARY— OCTOBER,    1881 


[whole    SERIES    VOL.    VIIl] 


AMS   PRESS,  INC. 
NEW  YORK 


Reprinted  with  permission  of 
The  JelUffe  Trust 


Abrahams  Magazine  Service,  Inc. 

A  division  of 

AMS  Press,  Inc. 

New  York,  N.Y.  10003 

1968 


,  j^a-L^^-  •    ^Jitk»atfS4  . 


FEB  11  1969       ]]  J?^ 

V.2 


Manufactured  in  the  U.  S.  A. 


Vol.  VIII.  JANUARY,    1881.  No.  i. 

THE 

Journal 

OF 

Nervous  and  Mental  Disease 


©rigtual  ^xticlts. 


INFLUENCE    OF    OUR    PRESENT    CIVILIZATION    IN 

THE  PRODUCTION  OF  NERVOUS  AND 

MENTAL  DISEASES.* 

By  J.    S.    JEWELL,    M.D. 

BY  the  phrase  nervous  and  mental  diseases  I  mean 
those  affections  which  have  their  organic  seat  in 
the  nervous  system,  and  are  manifested  by  derangements, 
either  in  kind  or  degree,  of  nervous  and  m.ental  functions. 

Among  such  affections  may  be  classed  all  forms  of 
paralysis,  however  limited  or  general,  however  partial  or 
complete,  is  the  loss  of  power.  Under  this  head  it  is  neces- 
sary to  remember  that  the  power  of  the  nervous  system  is 
not  exerted  upon  the  muscles  alone,  but  also  upon  glands, 
such  as  the  liver,  kidneys,  salivary  glands,  the  vast  number 
of  gland  structures  in  the  skin  and  the  mucous  mem- 
branes. The  power  of  the  nervous  system,  likewise,  is 
exerted  more  or  less  distinctly,  no  doubt,  in  or  upon  the 
intimate  process  of  nutrition  of  most  parts  of  the  body,  and 
among  the  rest  upon  that  of  the  nervous  system  itself. 

Side  by  side  with  paralysis  should  be  ranged  all  classes 
of  excessive  morbid  muscular  action,  as  in  convulsions  of 

*  A  Lecture  delivered  before  the  Chicago  Philosophical  Society,  December  11, 
1880. 

I 


2  J.   S.   JEWELL. 

all  forms  and  degrees,  like  epilepsy,  catalepsy,  all  forms  of 
jerkings  and  tremors,  all  forms  of  spasm,  with  or  without 
unconsciousness,  whether  permanent  or  transient.  Under 
this  head,  also,  should  be  included  all  those  higher  affec- 
tions of  motility  in  which  the  will  is  involved,  as  respects 
not  only  its  control  over  the  movements  of  the  body,  but 
also  over  the  actions  of  the  mind. 

As  correlative  to  disorders  of  motion,  we  must  include 
all  forms  of  disorder  of  sensibility,  such  as  its  exaltations, 
called  hyperaesthesias,  all  diminutions  or  losses  of  sensi- 
bility, classed  under  the  name  of  anaesthesias,  all  modifica- 
tions or  departures  from  the  normal  types  or  qualities  of 
sensibility,  gathered  under  the  head  of  paraesthesias.  Not 
only  must  we  include  here  the  physiological  sensibilities, 
such  as  those  of  touch,  of  the  pain  sense,  the  muscular 
sense,  the  space  sense,  the  visual  sense,  hearing,  smell,  and 
taste,  but  disorders  of  those  higher  forms  of  sensibility 
which  pass  under  the  name  of  emotions. 

Finally,  not  to  extend  the  list  too  far,  the  phrase  nervous 
and  mental  diseases  should  include  all  forms  of  disordered 
mental  action,  such  as  insanity  in  its  different  forms, 
whether  there  be  exaltations  or  depressions  of  feeling,  or 
unnatural  feeling,  or,  as  sometimes  happens,  a  want  of  it, 
and  so  on.  It  will  thus  be  seen  that  the  expression  I  have 
used  is  a  comprehensive  one,  much  more  so  than  is  or- 
dinarily supposed. 

My  object  this  evening  will  be  to  consider,  as  far  as  I 
can  in  a  discussion  limited  to  so  brief  a  space  in  time, 
whether,  as  a  whole,  the  classes  of  affections  referred  to  are 
more  common  as  civilization  advances  than  they  were 
among  men  in  the  more  primitive  stages  of  the  develop- 
ment of  society. 

This  question  has  been  frequently  discussed,  and  widely 
different    conclusions    have    been    reached.      Various    at- 


NERVOUS  AND  MENTAL  DISEASES.  3 

tempts  have  been  made  to  determine  by  the  statistics  of 
one  period  as  compared  with  those  of  another,  whether 
nervous  and  mental  diseases  are  more  prevalent  in  high  or 
advanced  than  in  low  states  of  civilization  of  a  people. 
This  would  be  an  unexceptionable  mode  of  proceeding  if 
reliable  statistics  of  the  present  generation,  not  to  mention 
past  ones,  were  in  existence.  But,  unfortunately,  such  sta- 
tistics do  not  exist,  except  within  very  limited  areas,  and 
even  in  such  cases  open  to  serious  criticism.  I  may  say 
that  by  the  use  of  such  a  method  the  conclusion  has  been 
arrived  at,  and  maintained  as  correct,  that  insanity  and 
nervous  diseases  are  probably  no  more  prevalent  at  the 
present  day  than  in  the  earlier  history  of  nations.  I  shall, 
therefore,  make  no  serious  endeavor  to  discuss  the  question 
before  us  in  the  light  afforded  by  such  unreliable  data.  I 
shall  approach  it  by  a  different  way. 

Without  further  preliminary  I  will  state  my  belief,  de- 
rived from  considerable  observation  and  study,  that,  taken 
as  a  whole,  nervous  and  mental  diseases  are  increasing,  and 
must,  as  things  now  stand,  increase  with  the  advance  of 
civilization. 

Civilization  has  its  advantages  and  its  disadvantages,  and 
among  the  latter  is  the  apparent  fact,  that  forms  of  disease 
multiply,  and  certain  diseases  become  more  prevalent  with 
an  advance  of  civilization  as  it  is,  rather  than  in  the  course 
of  that  which  is  imaginary  or  ideal. 

It  may  be  a  discouraging  fact,  but  I  am  firmly  convinced 
that  it  is  a  fact  that  civilization,  as  we  find  it  at  present  or 
in  the  past,  carries  with  it  the  causes  or  conditions  of  decay, 
or  even  of  its  final  destruction.  This  has  certainly  been 
the  history  of  its  particular  forms  in  the  past.  Without  a 
careful  study  of  its  causes  and  a  resolute  self-denying  appli- 
cation of  the  remedies,  I  think  it  may  be  considered  highly 
probable  that  such  will,  in  the  course  of  time,  be  the  inevi- 


4  J.   S.   JEWELL. 

table  fate  of  our  present  forms  of  civilization.  Further,  I 
think  it  may  be  shown  that  the  nervous  system  is  the  part 
of  the  organism  which  is  to  be  the  chief  theatre  of  the  ruin 
with  which  the  race  at  different  periods  seems  likely  to  be 
overtaken.  But  this  question  is  too  large  for  discussion  in 
one  evening.  Many  will  not  agree  with  me  in  my  belief 
that  as  civilization  advances  nervous  diseases  increase,  but 
upon  careful  study  and  after  a  long  experience,  most  would 
admit  as  correct  the  position  taken. 

I  would  not  have  you  think  I  am  alone  in  holding  to  the 
belief  I  have  just  declared,  or  that  it  is  novel.  Not  to  spend 
time  in  citing  authorities,  I  may  be  permitted,  however,  to 
refer  to  certain  recent  statements  of  one  of  the  highest  and 
most  cautious  of  living  authorities  on  the  subject  of 
nervous  diseases  in  all  their  relations.  I  now  refer  to  the 
statements  made  in  a  lecture  (July,  1880)  by  Professor  W. 
Erb  at  Leipsic,  in  which  he  declared  in  the  most  positive 
manner  the  fact — as  he  considers  it  to  be — of  an  increase  of 
insanity  and  nervous  diseases. 

With  these  simple  declarations,  I  will  proceed  to  give 
you  some  of  the  reasons  for  entertaining  the  belief  ex- 
pressed : 

In  the  first  place,  among  the  conditions  referred  to,  I 
believe  the  advance  of  civilization  is  favorable  to  an  increase 
of  nervous  and  mental  diseases,  because  such  advance  nec- 
essarily involves  a  higher  degree  of  specialization  and  re- 
finement in  function,  and,  hence,  in  structure  than  is  known 
to  exist  in  comparatively  uncivilized  states  of  the  race. 
No  physiological  law  is  more  firmly  established  than  the 
one  in  which  it  is  declared  that  a  high  degree  of  refine- 
ment and  complexity  in  activity  in  an  organ  or  class  of 
organs  implies  a  high  organization.  There  can  be  no  ques- 
tion as  to  whether  the  nervous  systems  of  highly  culti- 
vated and  refined  individuals  among  civilized  peoples  are 


NERVOUS  AND  MENTAL  DISEASES.  5 

more  complex  and  refined  in  structure  and  delicate  in  sus- 
ceptibility and  action,  at  least  in  their  higher  parts,  than 
the  nervous  systems  of  savages. 

This  may  be  an  extreme  statement  of  the  case,  but  on 
that  account  none  the  less  within  the  limits  of  our  ques- 
tion. 

As  civilization  advances,  the  occupations  increase,  which 
imply  a  cultivation  of  the  sensibilities,  more  especially  those 
comprehended  under  the  sense  of  beauty.  A  relatively  large 
number  of  persons  give  themselves  to  the  study  and  prac- 
tice of  art  in  its  various  forms, — to  polite  literature,  to  sed- 
entary occupations,  and  the  like.  The  more  a  part  of  the 
nervous  system  is  used  the  more  extended  its  develop- 
ment. In  highly  civilized  communities,  there  is  a  constant 
tendency  to  a  loss  of  balance  in  nerve  development,  in 
which  the  sensitive  side  of  the  nervous  system  preponder- 
ates over  the  motor  part  of  the  same.  All  disturbances  of 
symmetry  or  balance  in  development  tend  toward  dis- 
ease. This  is  one  disadvantage  of  a  high  civilization, 
as  compared  with  one  which  is  lower  and  in  which  the 
nervous  system  is  less  sensitive,  and,  in  consequence,  there 
is  a  narrower  range  of  feeling,  whether  for  pleasure  or  pain, 
and,  at  the  same  time,  less  intensity  as  well  as  less  range  of 
sensibility. 

This  state,  which  involves  an  increasing  loss  of  balance 
between  sensibility  and  power  in  the  nervous  systems  of 
highly  civilized  peoples,  is  a  grave  matter.  It  is  not  a  dis- 
eased state,  but  verges  in  that  direction.  Under  such  cir- 
cumstances, pleasures,  and,  pari  passu,  pains,  are  widened 
and  intensified.  This  state  of  things  certainly  belongs  to 
an  advanced  and  an  advancing  civilization,  and  involves  a 
world  of  minor  consequences,  both  for  the  weal  and  the  woe 
of  a  people. 

But  to  proceed  :  There  are  two   principal  ways  in  which 


6  y,  S.    JEWELL. 

the  nervous  system  may  be  diseased  ;  that  is,  by  overdoing 
by  any  unhealthy  kind  or  degree  of  exercise  of  the  nervous 
system  in  physical  and  mental  occupations,  and  by  over- 
excitation in  which  there  is  an  unhealthy  play  of  emotion, 
or  of  some  form  of  feeling,  whether  low  or  high.  Now,  it 
will  be  my  purpose  to  show  by  certain  examples  selected  al- 
most at  random,  that  an  advanced,  as  compared  with  a 
primitive  civilization,  leads  to  overdoing  and  to  overexcita- 
tion in  a  remarkable  degree,  and  that  in  these  ways  nerve 
and  mental  diseases  are  increased.  Then,  to  begin,  let  us 
consider  what  the  effects  in  the  aggregate  are,  of  those  oc- 
cupations which  call  for  prolonged  and  severe  exercise  of 
the  nervous  system,  such,  for  example,  as  is  seen  in  the 
workings  of  our  public-school  system  in  this  country,  es- 
pecially in  the  Northern  States. 

It  will  certainly  not  be  pretended  that  as  many  persons 
out  of  a  thousand,  taken  at  random,  attended  school 
fifty  or  one  hundred  years  ago  in  this  country  as  now  do 
out  of  a  thousand  persons  equally  taken  at  random.  It  is 
probably  a  fact  that  out  of  the  same  number  in  population 
at  the  present  day,  as  compared  with  the  condition  of 
things  fifty  or  one  hundred  years  ago,  three  persons  at 
present  to  one  at  the  earlier  periods  mentioned  attended 
schools  of  some  sort.  It  will  not  be  disputed,  either,  but 
that  the  courses  of  study  are  longer  and  the  range  of  sub- 
jects greater  at  present  than  they  were  even  fifty  years  ago 
in  this  country. 

The  graded  system  in  our  schools  represents  essentially  the 
average  of  practicable  attainment  within  stated  periods  as 
fixed  by  experience.  Many  could  easily  rise  above  a  grade 
in  the  allotted  period  ;  still  others,  with  rather  close  applica 
tion,  can  maintain  themselves  at  the  level  of  their  grades  ; 
while  a  very  considerable  number  reach  the  required  level 
only  by  systematically  overdoing ;  while  a  few  others  finally 


NERVOUS  AND  MENTAL  DISEASES.  7 

break  down  in  nerve  health  by  the  way,  and  are  hence 
obliged  to  abandon  their  course  of  study. 

It  is  my  opinion  that  a  very  great  number  of  cases  of 
nerve  disease  are  produced,  such  as  cerebral  congestions, 
undue  nerve  irritability,  sleeplessness,  or,  at  least,  imperfect 
sleep  troubled  by  dreams,  headache,  various  forms  of  neur- 
aesthenia,  not  to  speak  of  graver  forms  of  disorder,  by  sys- 
tematically overtaxing  children  in  our  public  schools.  This 
opinion  is  the  result  of  very  considerable  observation  and 
experience. 

It  must  necessarily  happen  that  a  great  many  children 
among  the  vast  number  in  annual  attendance  upon  the 
public  schools  in  this  country  have  very  moderate  abilities 
for  learning,  or  are  affected  by  hereditary  weakness  of  con- 
stitution in  various  ways,  so  that  in  the  rather  close  race  to 
keep  lip  with  their  more  fortunate  fellows,  they  suffer  in 
health. 

This  I  believe  to  be  a  more  serious  matter  than  is  com- 
monly supposed.  It  is  one  to  which  the  attention  of  pa- 
rents, school  inspectors,  boards  of  education,  teachers  and 
physicians  should  be  directed  with  great  emphasis. 

I  have  seen  in  the  course  of  my  observation  many  chil- 
dren who,  with  the  best  of  intentions  on  the  part  of  pa- 
rents, had  been  forced  along  in  their  studies  with  great 
damage  to  health.  The  school  year  includes  something 
like  nine  months  out  of  the  twelve,  and  in  many  in- 
stances the  hours  in-doors  are  long.  During  this  great 
period,  five  days  out  of  each  week,  children,  during  the  age 
in  which  confinement  is  borne  with  difficulty,  are  kept  too 
often  in  ill  ventilated  or  imperfectly  warmed  rooms,  with 
restraint  upon  their  all  but  spontaneous  activities,  and  at 
the  same  time  are  more  or  less  busily  engaged  in  brain 
work  ;  and  this  is  maintained  in  many  communities  during 
several  years  of  the  restless,  growing,  plastic  period  in  the 


8  y.  S.  JEWELL. 

life  of  the  individual.  It  is  the  period  in  which  physical 
exercise  in  the  open  air  is  simply  a  necessity,  and  almost  a 
passion. 

I  cannot  but  think  such  long  periods  of  repression  of 
physical  activity  at  an  age  when  there  is  a  strong  spon- 
taneous tendency  toward  it,  and  such  long  confinement  so 
often  in  imperfectly  heated  and  poorly  ventilated  rooms, 
while,  at  the  same  time,  the  brain  is  taxed  in  various  direc- 
tions— I  say,  I  cannot  but  think  in  this  direction  lie  the 
causes  of  a  vast  number  of  general  nervous  affections. 

Then,  the  fixed  use  of  the  eyes  at  a  tender  age  leads  fre- 
quently to  ill  consequences,  partly  by  exhausting  and  ren- 
dering irritable  the  visual  nerve  apparatus,  producing  asthe- 
nopia and  other  disorders.  These  affections  are  frequently 
overlooked  or  disregarded  by  those  who  have  the  care  of 
children,  and  with  disastrous  consequences.  It  often  hap- 
pens that  children  have  various  disorders  of  vision,  such  as 
defective  accommodation,  giving  rise  to  short  sight  or  long 
sight,  or  they  have  indistinct  vision  from  the  deformity 
called  astigmatism,  or  they  have  unusual  strain  upon  the 
muscles  of  the  globe  of  the  eye  which  are  used  to  produce 
accurate  convergence  of  the  axis  of  vision  upon  the  small 
objects  looked  at.  Such  conditions  lead  to  pain  in  the 
eyes,  frontal  and  other  headaches,  cerebral  congestions,  and 
a  variety  of  slighter  disorders  which,  as  a  rule,  pass  unob- 
served or  are  disregarded  until  a  case  becomes  alarm- 
ing. 

I  have  many  times  seen  cases  that  had  been  running  for 
years,  in  which  signal  defects  of  vision  existed,  making  it  al- 
most a  cruelty  to  keep  a  child  at  study,  its  complaints  be- 
ing unrecognized  or  disregarded  while  it  is  driven  to 
school. 

It  is  not  uncommon  for  children,  either  of  their  own  mo- 
tion or  as  compelled  by  their  parents  or  guardians,  to  study 


NERVOUS  AND  MENTAL  DISEASES.  9 

of  evenings  until  the  brain  becomes  excited,  its  circulation 
disturbed,  and  the  result  very  frequently  is  restless  and  un- 
refreshing  sleep,  headaches,  and,  sooner  or  later,  more  or 
less  marked  exhaustion  and  nervousness  in  various  degrees 
and  ways.  Statements  of  the  same  tenor  might  be  multi- 
plied, and  are  susceptible  of  practical  demonstration. 

Now,  it  will  scarcely  be  pretended  by  any  one  that  in  the 
earlier  periods  of  civilization  in  our  own  country,  rela- 
tively so  great  a  number  of  persons  were  engaged  in  study, 
or  that  the  courses  of  study  were  so  prolonged  and  elabo- 
rate as  we  now  know  to  be  true.  Within  fifty  or  one  hun- 
dred years  whole  sciences  have  been  created.  Knowledge 
has  been  extended  in  a  surprising  manner  in  almost  all 
directions,  and  courses  of  study  are  now,  as  a  rule,  very 
much  longer,  embrace  a  greater  variety  of  subjects  than  was 
true  in  earlier  times,  and  the  mind  of  the  student  is  taxed 
as  never  before. 

I  do  not  hesitate,  therefore,  to  say  that  from  this  source 
alone  certain  forms  of  nervous  disease,  notably  those  of  the 
brain,  are  relatively  much  increased  in  the  present  advanced, 
as  compared  with  a  more  primitive  condition  of  civilization. 
The  causes  of  brain  disease  in  this  case  are  multiplied,  and 
hence  such  diseases  are  increased. 

If  what  has  been  alleged  against  the  courses  pursued  in 
the  common  schools,  as  furnishing  causes  for  nervous  dis- 
eases, is  true,  how  much  more  true  are  similar  statements 
when  applied  to  our  higher  institutions  of  learning,  from 
the  ordinary  seminary  up  into  our  universities,  where  almost 
every  possible  means  for  exciting  the  student  forward  in 
the  race  for  an  education  is  brought  to  bear.  Courses  of 
study  are  laid  down  which  tax  to  the  utmost  even  the 
brighter  and  healthier  students  of  a  class,  and  in  which 
mediocre  students,  whether  in  mental  or  physical  health, 
find  it  difficult  or  impossible  to  maintain  themselves  with 


lO  y.   S.  JEWELL. 

credit.  This  is  to  be  seen  in  professional  schools  as  well  as 
in  those  devoted  to  the  broader  work  of  a  general  educa- 
tion. It  requires  from  three  to  seven  years  of  severe  effort 
to  accomplish  the  courses  laid  down  in  most  of  our  higher 
institutions  of  learning. 

Bad  as  the  results  are  upon  a  large  minority  of  those 
who  try  to  complete  the  courses  of  instruction  in  our  higher 
institutions  of  learning,  they  become  worse  in  some  special 
cases. 

A  vast  number  of  young  ladies,  for  example,  at  these 
times,  as  compared  with  the  same  number  of  fifty  or  one 
hundred  years  ago,  are  engaged  at  in-door  rather  than  out- 
door occupations.  From  six  or  seven  to  twelve  or  thirteen 
years  of  age,  they  are  in  our  common  schools.  Subse- 
quently, at  a  peculiarly  susceptible  period  in  life,  they  are 
sent  into  seminaries,  boarding-schools,  schools  of  music, 
embroidery,  painting,  or  to  the  colleges,  until  they  arrive  at 
a  period  in  life  from  seventeen  to  twenty.  In  many 
instances  these  girls  are  sent  away  from  home,  and  live 
more  or  less  irregularly  in  the  matters  of  diet,  exercise, 
sleep,  and  study.  Most  of  them  are  engaged  too  exclusively 
in  those  forms  of  study  or  action  which  cultivate  the  sensi- 
bilities rather  than  enlarge  and  fix  the  powers  of  the  nervous 
system.  All  this  happens,  as  already  said,  at  an  unusually 
sensitive  and  plastic  period  in  life,  whether  for  the  male  or 
female,  but  especially  so  for  the  latter,  and  the  result  is,  in 
an  astonishing  number  of  instances,  that  they  either  break 
down  before  they  get  through,  or  get  through  broken  in 
health  and  more  or  less  unfitted  for  any  useful  occupation, 
either  for  years  or  for  life. 

The  more  delicate  in  physical  health  is  the  boy  or  the 
girl,  the  more  is  it  thought  to  be  a  duty  on  the  part  of 
parents  or  guardians  to  keep  them  in  school.  It  is  thought 
they  are  unable  to  work  their  way  in  any  physical  or  manual 


NERVOUS  AND  MENTAL  DISEASES.  II 

employment.  They  are  physically  weak  or  exhausted,  or 
born  of  consumptive  or  sickly  parents,  and  they  must  be 
and  they  are  educated.  While  the  mind  is  becoming  in 
some  measure  trained,  too  often  in  useless  directions,  the 
physical  organization  is  being  gradually  worn  until  at  last 
there  is  little  left  but  a  physical  wreck,  or,  if  not  so  bad  as 
this,  impaired  physical  health  for  years  or  for  life,  as  might 
have  been  plainly  foreseen.  Many  times  I  have  observed  a 
young  man  or  a  young  woman  deliberately  started  on  an 
educational  career,  because  possessed  of  an  active  mind, 
though  joined  to  a  feeble  body,  only  to  complete  an  educa- 
tion, as  it  is  called,  immediately  to  die  or  to  enter  upon  a 
life  of  invalidism.     Unhappily  this  is  no  fancy  picture. 

It  is  a  fearful  responsibility,  so  often  ignorantly  and 
thoughtlessly  assumed  by  parents  and  guardians,  and  blind- 
ly permitted  by  teachers,  by  which  a  young  person  is  de- 
liberately placed  upon  what  might  have  been  foreseen  as  a 
career  straight  to  physical  destruction. 

The  time  is  coming,  I  hope,  when  these  matters  will  be 
more  intelligently  and  practically  considered  than  they 
have  ever  been.  When  it  shall  come  to  pass  that  a  student 
will  not  be  examined  simply  to  find  out  whether  he  or  she 
knows  so  much  arithmetic,  or  grammar,  or  geography,  or 
history,  but  side  by  side  with  this  as  practically  the  more 
important,  whether  he  or  she  has  a  healthy  organization, 
has  a  healthy  nervous  system,  has  a  large  or  a  small  chest, 
has  a  healthy  digestive  system,  has  any  important  heredit- 
ary bias  or  tendencies. 

In  hundreds  of  instances  have  I  seen,  during  the  later 
periods  of  student  life  in  our  higher  schools,  general  ner- 
vous exhaustion,  brain  exhaustion,  melancholia,  hysteria, 
vascular  irregularities,  cerebral  congestions,  headaches,  in- 
somnias, neuralgias,  tremors,  and  the  like,  the  direct  results 
of  over-study. 


12  y.   S.   JEWELL. 

It  will  hardly  be  pretended  that  such  causes  for  nervous 
diseases  are  more  prevalent  in  a  low  as  compared  with  an 
advanced  civilization. 

Again,  as  civilization  advances,  professions  multiply 
which  involve  life-long  brain  activity.  In  these  the  stand- 
ards of  attainment  are  more  elevated,  and  the  conditions  of 
success  become  gradually  more  difficult  to  fulfil,  with  the 
progress  of  civilization. 

In  the  clerical,  legal  and  medical  professions,  a  relatively 
increasing  number  of  persons  is  found,  who,  in  consequence 
of  the  operation  of  various  motives  in  the  fierce  race  for 
supremacy  and  professional  rewards,  are  exhausted  or  over- 
come. They  work  too  many  hours,  become  more  or  less 
irregular  as  to  the  times  of  taking  food,  maintain  for  un- 
usual periods  high  states  of  brain  activity,  have  produced 
gradually,  sometimes  suddenly,  cerebral  congestions,  unre- 
freshing  sleep,  or  sleeplessness,  impaired  digestion,  head- 
aches, and  besides  these  a  variety  of  other  more  or  less  pro- 
nounced nervous  and  mental  disorders,  differing  in  various 
cases,  a  large  proportion  of  which  are  traceable  to  over- 
work and  other  incidents  belonging  to  professional  life  as 
we  see  it. 

The  same  remarks  may  be  made  in  relation  to  the  literary, 
but  more  particularly  the  journalistic  profession. 

The  most  intense  nervous  and  mental  strain  is  maintained 
in  these  days,  as  never  before,  in  the  conduct  of  great  daily 
newspapers.  But  few  persons  unacquainted  with  the  facts 
of  this  case  are  aware  of  the  intense  and  continuous  labor 
the  conduct  of  these  enterprises  involves.  Every  faculty  is 
on  the  alert  in  watching  the  course  of  events,  in  collecting 
and  condensing  not  only  items  of  news,  but  in  watching  and 
exposing  to  the  reader  the  less  palpable,  though  not  less 
real  tides  of  thought  and  feeling  in  civil,  political,  com- 
mercial, monetary,  ecclesiastical,  and  other  affairs,  at  home 


NER  VO  US  A ND  MENTAL  DISEA  SES.  1 3 

and  throughout  the  world.  The  wonderful  extension  of 
the  telegraph,  which  places  the  whole  civilized  world  more 
or  less  distinctly  under  the  eyes  of  the  leading  workers 
upon  our  great  newspapers,  implies,  in  the  present  ad- 
vanced state  of  civilization,  a  breadth,  intensity,  and  rapid- 
ity of  nerve  and  mental  action  such  as  the  conductors  of 
newspapers  in  the  olden  times  were  strangers  to. 

Side  by  side  with  the  workers  in  these  exhausting  occu- 
pations must  be  placed  that  very  large  and  ever-increasing 
company  of  men  engaged  in  conducting  large  commercial 
and  financial  concerns.  Besides  the  almost  numberless  de- 
tails which  must  daily  pass  under  the  review  of  chiefs  of 
concerns  where  hundreds  of  thousands  and  millions  of  dol- 
lars are  involved,  a  wider  sweep  of  objects  or  of  relations 
must  be  made.  The  markets  must  be  watched  with  almost 
feverish  anxiety.  A  critical  and  tactful  study  must  be 
made  of  the  wants  of  customers,  or  of  sections  of  country, 
or  of  the  probable  future  demands  in  trade.  Then,  again' 
in  consequence  of  the  vast  extension  of  the  credit  system, 
a  sleepless  eye  must  be  kept  on  the  financial  standing  of 
widely  distant  customers.  Nice  perceptions  must  be  had  in 
which  there  is  an  element  of  uncertainty  or  hazard,  and 
upon  decisions  in  relation  to  which  purchases  are  made  or 
declined  which  may  involve  success  or  ruin.  Rival  firms  at 
home  and  abroad  must  be  closely  watched,  and,  in  general, 
everything  must  be  done  that  can  be  done  by  tireless  in- 
dustry, nice  calculation,  combined  with  close  attention  to 
details  down  to  their  finest  ramifications.  When  all  these 
things  are  taken  into  the  account,  it  is  not  to  be  wondered 
at  that  men  become  worn,  haggard,  nervous,  irritable,  sleep- 
less, and  finally  broken  in  nerve  health. 

These  forms  of  occupation  multiply  and  widen  as  civili- 
zation advances.  Any  one  whose  position  is  such  as  to  call 
him  to  see  the  results  to  which  such   nervous  and  mental 


14  y.  S.   JEWELL. 

strains  lead,  gains  the  firm  conviction  that  in  these  ways 
nervous  and  mental  diseases  are  increasing. 

In  the  next  place,  I  would  call  your  attention  to  another 
fact,  more  conspicuous  at  present,  especially  in  this  country, 
than  ever  before,  and  to  which,  within  my  certain  knowl- 
edge, a  vast  number  of  cases  of  nervous  and  mental  disease 
may  be  traced. 

It  is,  perhaps,  not  so  much  what  people  do  as  what  they 
endure  or  suffer  that  leads  to  nervous  and  mental  diseases. 
The  ceaseless  pressure  of  weighty  responsibilities  and  the 
consuming  fire  of  cares  and  anxieties,  which  can  not  be  laid 
aside  as  physical  or  mental  labor  may  be,  often  tell  more 
disastrously  upon  the  nervous  organization  than  any  over- 
work. 

Under  this  head,  from  among  the  many  striking  exam- 
ples that  might  be  cited,  I  wish  to  direct  attention  to  the 
following :  In  these  days,  more  than  ever  before,  there  has 
entered  into  almost  every  legitimate  branch  of  commerce 
a  purely  artificial  element  of  risk  or  hazard. 

It  is  speculation.  Even  so  tame  and  legitimate  an  occu- 
pation as  that  of  buying  and  selling  grain  has  been  per- 
meated, almost  obscured,  by  the  speculative  spirit.  It  has 
penetrated,  like  a  deadly  miasm,  almost  every  possible  line 
of  trade.  It  has  even  appeared,  in  one  form  or  another,  in 
the  house  of  God. 

Trade  in  all  natural  productions  of  the  earth,  such  as 
grains,  meats,  tissues,  fabrics,  of  all  forms  of  mining  proper- 
ties, real  estate  in  all  forms  of  corporate  property,  stocks, 
bonds,  everything  near  and  far,  from  the  greatest  to  the 
least,  from  the  least  to  the  greatest, — all  have  been  per- 
meated by  this  unhallowed  and  dangerous  spirit  of  specu- 
lation, which  thrives  only  upon  the  spoils  of  the  fortunes 
or  the  savings  of  untold  thousands. 

A  large  volume  of  the  business  done  in  our  boards  of  trade 


NER  VO  US  A  ND  MEN  TA  L  DISEA  SES.  1$ 

and  at  the  exchanges  is  speculative.  Mr.  A.  sells  one  hun- 
dred thousand  bushels  of  wheat  to  Mr.  B.,  to  be  delivered 
at  a  time  agreed  upon  in  the  future.  Mr.  A.  does  not  own 
a  single  grain  of  wheat,  never  did  and  probably  never  will 
have  the  means  wherewith  to  buy  a  hundred  thousand 
bushels  of  wheat.  Mr.  B.  is  aware  of  all  this,  does  not  ex- 
pect to  receive  the  wheat,  although  he  has  bought  it,  and 
would  be  surprised  and  alarmed  if  it  were  actually  de- 
livered. What  is  really  done  is  that  each  man  deposits  a 
certain  sum  of  money  at  some  bank  or  with  some  broker, 
which  sums  of  money  pass  under  the  name  of  "  margins." 
This  is  a  fair  outline  of  all  speculative  transactions,  no  mat- 
ter what  the  commodity  is,  from  a  bushel  of  grain  down  to 
a  raffle  for  some  object  at  a  church  fair. 

But  no  sooner  are  the  "  margins  put  up  "  than  each  man 
begins,  as  a  rule,  to  be  more  or  less  anxious  as  to  the  out- 
come three  months  hence.  In  nine  chances  out  of  ten 
one  of  the  parties  must  lose  his  money ;  that  is,  the 
other  party  takes  the  money  without  giving  anything 
whatever  as  a  consideration  in  return ;  he  simply  pock- 
ets it. 

This  speculative  mania  is  having  in  these  later  years 
an  extraordinary  increase.  It  has  extended,  at  last,  not 
only  to  almost  every  line  of  business,  but  to  all  ranks, 
and  both  sexes  in  society.  It  is  not  indulged  simply  by 
the  trained  operators  who  are  the  possessors  of  millions, 
who  sit  at  the  centres  of  business  and  manipulate  the 
markets,  swelling  their  ill-gotten  gains  upon  the  little 
contributions  of  thousands  of  the  "small  fry,"  but  it  has 
extended  so  as  to  involve  a  vast  array  of  persons  of 
small  means,  such  as  clerks  on  small  salaries,  and  other 
persons  of  very  limited  means.  This  is  not  confined  to 
cities,  but  has  extended  gradually  to  the  remotest  vil- 
lages   in    the   land.      These   furnish    their    pittances,    here 


1 6  y.   S.   JEWELL. 

and  there  a  few  dollars,  to  some  broker  or  other  party 
conducting  the  operation  in  the  distant  city. 

Tens  of  thousands  of  persons  in  these  United  States  in- 
vest a  certain  proportion  or  all  their  means  in  these  haz- 
ardous operations.  No  sooner  is  the  speculation  embarked 
in  than  the  individual  becomes  nervous,  anxious  night  and 
day,  until  the  result  is  made  known,  and  then  almost  in 
nine  cases  out  of  ten  his  anxiety  is  exchanged  for  the  dis- 
tressing certainty  that  the  money  invested  has  been  swal- 
lowed up  out  of  sight  forever. 

A  man  may  do  a  hard  day's  work  and  be  greatly  fatigued 
at  night.  After  eating  a  full  meal  he  may  then  He  down 
in  peace  and  recuperate  by  the  morrow.  But  not  so  with 
the  anxious  speculator.  The  individual  too  frequently  can- 
not withdraw  his  mind  long  at  a  time  from  the  illegitimate 
business  upon  which  he  has  entered.  He  becomes  preoc- 
cupied, inattentive  to  other  employments  or  interests,  and 
often  becomes  so  nervous  or  excitable,  especially  if  pos- 
sessed of  a  nervous  temperament,  as  to  make  a  resort  to 
stimulants  and  sedatives  an  apparent  necessity.  Unlike 
the  man,  tired  from  legitimate  work,  who  can  sleep,  he  has 
no  sooner  laid  down  than  he  begins  to  think,  stimulated  by 
his  hopes  or  fears  about  what  will  be  the  result  of  his  un- 
certain business.  What  will  he  do  if  he  succeeds?  What 
will  he  do  if  he  fails?  He  watches  the  course  of  the 
markets  in  the  line  in  which  he  is  engaged.  According  to 
the  natural  constitution  or  temperament  of  the  individual 
will  he  be  more  or  less  anxious  or  disturbed. 

Now,  in  the  advance  of  civilization,  in  our  own  country 
at  least,  nothing  is  plainer  than  that  the  speculative  phase 
of  business  has  relatively  increased  many  fold,  and  is  still 
increasing.  I  am  in  a  position  to  know  that  a  large  number 
of  cases,  of  especially  the  slighter  forms  of  nervous  and 
mental  disease,  arise  from  the  wear  and  tear  of  the  brain  in 


NERVOUS  AND  MENTAL  DISEASES.  1 7 

following  this  dangerous  and  unhealthy  form  of  so-called 
business.  What  the  end  is  to  be  it  is  difficult,  perhaps  im- 
possible, to  say. 

In  the  next  place,  I  would  call  your  attention  to  what  I 
look  upon  as  an  exceedingly  important  topic  in  the  present 
discussion,  that  is,  the  increasing  use,  as  civilization  ad- 
vances, at  least  in  this  country,  of  certain  stimulants  and 
sedatives.  I  cannot  now  delay  to  discuss  the  causes  of  the 
alleged  increase  in  the  use  of  such  agents.  I  shall  content 
myself,  for  the  present,  with  asserting  that  such  an  increase 
is  a  fact. 

Under  this  head,  I  would  direct  attention  especially  to  an 
increase  in  the  use  of  coffee  and  tea. 

In  the  earlier  history  of  this  country,  unless  in  the 
larger  cities  and  towns,  comparatively  little  of  these  stimu- 
lants was  used.  But  at  present,  owing  to  their  extraordi- 
nary cheapness  and  the  facilities  which  exist  for  distribu- 
ting these  as  well  as  other  commodities,  their  use  has  ex- 
tended to  almost  every  family  in  the  land. 

Coffee  and  tea  are,  taken  altogether,  the  purest  nerve  stim- 
ulants known.  They  are  not  tonics  in  any  sense  of  the 
word.  The  infusions  of  these  agents  contain  no  nutritive 
material  worthy  of  a  moment's  consideration.  They  do, 
however,  contain  a  certain  alkaloid,  and  perhaps  other  in- 
gredients, which  act  directly  upon  the  nervous  system. 

A  nerve  tonic  is  an  agent  the  proper  action  of  which  is 
to  quicken  and  perfect  those  intimate  nutritive  processes 
upon  which  the  growth  and  repair  of  the  nervous  system 
depend.  A  nerve  stimulant  acts  very  differently.  It  acts 
upon  the  nerve  structure  so  as  to  quicken  the  play  of  its 
own  proper  activities.  It  hastens  the  expenditure  of  nerve 
force,  and  hence  quickens  the  waste  of  nerve  substance. 
Nerve  action  becomes  quicker,  feeling  becomes  more 
acute,   the    play   of  emotion    more   vivid,  the    celerity   of 


1 8  %  S.   JEWELL. 

thought  is  greater,  but  the  power  of  the  nervous  system, 
especially  the  power  for  control,  is  not  augmented,  but 
rather  diminished. 

Back  of  these  phenomena  the  circulation  of  blood  in 
the  brain  is  quickened ;  nerve  cells  and  nerve  fibres  attenu- 
ate or  wear  away  faster ;  soon  the  effervescent  play  of 
nerve  activity  subsides,  and  there  results  a  period  of  com- 
parative exhaustion,  marked  by  loss  of  power,  increased 
reflex  excitability,  especially  in  respect  to  the  heart.  There 
is  increased  nerve  irritability,  and  exaltations  in  acuteness 
of  the  pain  sense.  If  the  dose  of  the  stimulant  has  been 
rather  large,  the  ill  results  just  enumerated  become  quite 
marked.  The  tongue  becomes  coated  ;  the  appetite  for  the 
first  meal  in  the  day  is  almost  gone ;  dyspeptic  symptoms 
are  apt  to  appear  ;  sleep  is,  in  a  measure,  unrefreshing,  and 
feelings  of  exhaustion  or  depression  are  experienced  in  the 
morning.  Headaches,  and  slight  or  at  times  severe  neural- 
gic symptoms  are  likely  to  appear,  especially  of  mornings, 
and  to  continue  during  the  day,  unless  the  individual  takes 
his  ordinary  dose  of  coffee  infusion. 

It  is  customary  to  hear  an  expression  like  this:  "I 
would  rather  go  without  everything  else  at  breakfast  than 
my  cup  of  coffee.  If  I  do  not  take  it,  I  feel  out  of  sorts 
the  entire  day.  But  with  it,  even  if  I  take  nothing  else,  I 
can  work  along  contentedly  until  dinner.  Take  anything 
else  away,  but  do  not  take  away  my  coffee." 

As  the  result  of  long  observation  and  of  personal  ex- 
perience, I  am  ready  to  declare  that  I  know  of  no  other 
way  in  which  moderate  harm  to  the  nervous  system  is  done 
to  the  same  extent  as  by  the  use  and  abuse  of  coffee  and 
tea.  An  immense  number  of  cases  of  moderate  digestive 
disorder,  of  the  slighter  trigeminal  neuralgias,  headaches, 
unrefreshing  sleep,  palpitations  of  the  heart,  irritability, 
moderate   nervous  exhaustions,  moderate  nervous  depres- 


NERVOUS  AND  MENTAL  DISEASES.  I9 

sions,  or  the  "blues,"  are  met  with,  caused  by  the  abuse  of 
these  stimulants. 

I  am  aware  that  many  persons  hold  to  a  different  opin- 
ion, but  my  own  opinions  have  not  been  adopted  hastily. 
I  have  been  giving  this  subject  special  attention  for  years 
past,  and  can,  if  necessary,  produce  hundreds  of  cases  in 
which  various  nervous  disorders  have  been  found  directly 
traceable  to  the  source  now  indicated.  An  emphatic  warn- 
ing needs  to  be  given  on  this  subject,  as  one  of  interest  to 
nearly  every  person  throughout  our  land. 

In  this  connection  I  should  be  glad  to  speak  of  the  influ- 
ence of  certain  sedatives,  especially  of  tobacco,  but  time 
will  not  permit.  I  cannot,  however,  pass  without  referring 
to  the  enormous  increase  in  the  use,  both  in  medical  prac- 
tice and  out  of  it,  of  pain-allaying  and  sleep-producing 
agents,  of  opium  and  its  salts,  and  the  hydrate  of  chloral. 

These  agents  have  not  only  become  serious  causes  of  ner- 
vous and  mental  disease,  but  their  use  is  partly  a  conse- 
quence of  nervous  and  mental  disease.  The  increase  in 
their  use  implies  an  increase  of  those  nervous  disorders  to 
the  palliation  of  which  they  are  applicable. 

Side  by  side  with  the  agents  already  mentioned  should  be 
placed  that  most  gigantic  of  all  evils  of  its  class,  affecting 
high  as  well  as  low  conditions  of  civilization. 

I  mean  the  abuse  of  alcohol.  It  is  probable  that  its  use 
is  permeating  more  and  more  widely  the  various  ranks  of 
society.  Its  forms  are  multiplied  ;  the  means  for  dissemi- 
nating them  are  becoming  more  perfect  as  the  years  pass, 
and  with  an  increase  of  wealth,  and  in  the  perfection  and 
refinement  of  civilized  society,  the  incentives  and  occasions 
for  their  use  are  increased.  I  know  of  no  more  patent 
source  of  the  graver  forms  of  nervous  and  mental  disease. 
I  have  omitted  its  discussion,  partly  because  it  has  been 
more  thoroughly  held  up  before  the  public  by  temperance 


20  y.   S.   JEWELL. 

workers  and  in  the  movements  for  temperance  reform,  than 
the  other  subjects  to  which  I  have  alluded. 

But,  take  it  as  a  whole,  I  think  it  cannot  be  successfully- 
disputed  that,  in  the  ways  just  described,  nervous  and  men- 
tal diseases  not  only  are  produced  but  increased  with  the 
advance  of  civilization. 

I  would  next  turn  to  another  aspect  of  our  subject  of 
high  importance  ;  that  is,  the  progressive  specialization  and 
refinement  of  labor.  This  is  one  of  the  special  marks  of 
an  advanced  civilization  as  compared  with  one  that  is  prim- 
itive. 

For  example,  it  is  only  a  few  years  since  the  discovery  of 
the  telegraph.  It  has  now  extended  in  the  most  surprising 
manner  into  almost  every  phase  of  active  life.  The  mental 
state  of  attention  on  the  part  of  the  telegrapher  is  tense 
and  wearying  when  it  is  long  kept  up,  especially  in  offices 
where  a  large  amount  of  business  is  done.  Then,  in  the 
transmission  of  dispatches,  there  is  a  rapid,  peculiar,  and 
monotonous  movement  of  the  right  hand  and  arm,  espe- 
cially in  the  case  of  the  expert  transmitter.  The  special 
nerve  apparatus  which  stands  between  the  mind,  whatever 
that  may  be,  and  the  muscles  which  are  put  in  action,  be- 
comes highly  developed,  or  specialized,  so  as  to  act  almost 
automatically.  In  the  pursuit  of  this  occupation,  it  is  not 
at  all  uncommon  to  find  persons  with  exhaustion  of  the 
special  nerve  apparatus  allotted  to  the  right  arm,  and  the 
results  are  very  frequently  subacute  inflammatory  affec- 
tions of  the  nerves  or  muscles,  spasmodic  affections,  such  as 
telegrapher's  cramp,  tremors,  and  paralysis. 

These  disorders,  in  most  instances,  are  plainly  seen  to 
grow  out  of  a  pursuit  of  the  occupation,  and  are  limited  to 
the  special  parts  used.  In  the  advance  of  civilization  such 
occupations  multiply  on  every  hand. 

Under  this  head  I  wish  to  speak  of  a  matter  of  much 


NERVOUS  AND  MENTAL  DISEASES.  21 

practical  importance.  I  now  have  in  mind  piano  practice 
by  the  young,  especially  by  girls  of  a  tender  age.  In  these 
days  this  accomplishment  has  been  carried  to  an  extraor- 
dinary degree  of  complexity  and  perfection.  Years  of  the 
most  persistent  effort  are  given  to  the  acquirement  of 
"  styles  of  fingering."  The  most  elaborate  "  studies  "  are 
invented  with  the  design  of  training  the  nervo-muscular 
mechanism  to  the  point  of  the  automatic  production  of 
every  possible,  and,  I  was  about  to  say,  impossible  move- 
ment the  hand  can  execute.  To  become  moderately  expert 
requires  daily  from  one  to  four  hours  of  continuous  fatigu- 
ing practice  for  years.  The  pupil  must  sit  upright  on  a 
stool,  and  use  both  arms,  and  all  the  fingers,  the  muscles  of 
the  upper  members,  the  nerves  which  go  to  them,  the  nerve 
cells  in  the  spinal  cord,  out  from  which  the  nerves  go,  and 
finally,  above  these,  a  limited  part  of  the  brain.  When  the 
practice  is  overdone,  as  it  so  often  is,  the  arms  become  fa- 
tigued, the  upper  part  of  the  spine  tired,  tender  and  pain- 
ful. There  is  pain  in  the  back  of  the  neck  and  up  into  the 
base  of  the  brain,  and  various  other  slight  nervous  disor- 
ders caused  by  protracted  overuse  of  certain  parts.  This 
matter  has  gone  to  an  irrational  and  harmful  extent,  and 
deserves  a  vigorous  rebuke.  Children  are  often  cruelly 
driven  to  these  exercises. 

Take  the  matter  of  type-setting,  using  the  pen,  and  many 
other  occupations.  These  lead  in  very  many  instances  to 
overuse,  particularly  of  the  right  arm,  giving  us  scrivener's 
and  type-setter's  paralysis. 

In  the  great  manufacturing  interests  of  the  country,  and 
in  the  specialization  of  labor  within  their  limits,  persons  are 
now  employed  to  perform  some  limited  and  special  task,  to 
the  exclusion  of  all  other  kinds  of  work,  to  an  extent  never 
before  known.  In  this  way,  in  almost  all  forms  of  labor, 
persons  overuse,  so  as  to  lead  to  disorder  or  even  to  seri- 


22  J.   S.   JEWELL. 

ous  disease,  particular  parts  of  the  nervous  system.  As 
civilization  advances,  there  is  reason  for  supposing  that 
this  work  of  specialization  of  labor  within  more  and  more 
restricted  areas  will  go  on  to  a  degree  not  attained  at 
present. 

In  these  ways,  then,  does  an  advanced  civilization,  as 
compared  with  a  lower  condition  of  the  same,  lead  to  a  rel- 
ative increase  in  nervous  and  mental  affections. 

Finally,  to  terminate  the  present  discussion  of  this  as- 
pect of  our  subject,  it  may  be  remarked  that  the  forms  and 
customs  of  highly  civilized  society,  by  which  night  is  turned 
into  day  and  day  into  night,  in  which  there  are  parties,  late 
suppers,  highly  seasoned  food,  irregular  eating,  too  much 
excitement,  numberless  ill  results  of  social  friction,  such  as 
jealousies,  envies,  and  disappointments,  in  which  there  are 
inordinate  machinations  and  struggles  to  attain  and  main- 
tain position  in  a  highly  artificial  and  unnatural  form  of 
society, — all  these  things  tell  in  a  thousand  ways  on  nerve 
and  mental  health.  But  I  can  not  tarry  to  speak  of  them 
to-night. 

Now,  as  a  proof  of  the  correctness  of  the  assertion,  that 
highly  developed  and  specialized  nervous  systems  are  more 
liable  to  disease  than  those  of  a  simpler  and  less  specialized 
structure  and  action,  I  would  refer  to  the  curious  fact  that 
the  lower  animals  seldom  are  affected  by  manifest  nervous 
diseases,  and  are  almost  never  insane,  as  compared  with 
highly  civilized  men.  The  chief  reason  for  this  difference 
seems  to  lie  in  certain  differences  in  nerve  organization. 
That  condition  of  things  which  makes  the  wide  differences 
in  liability  to  nerve  and  mental  disease  between  men  and 
the  lower  animals,  it  would  seem  probable,  holds  good,  for 
the  same  reasons,  as  between  the  savage  and  the  highly  cul- 
tivated individual  belonging  to  a  high  state  of  civilization. 
This  statement  receives  some  support  from  the  fact  that  in- 


NERVOUS  AND  MENTAL  DISEASES.  23 

sanity,  at  least,  is  far  less  common  in  children  than  in 
adults.  This  fact  is  to  be  explained  by  a  consideration  of 
the  differences  in  structure,  development,  and  action  of  the 
nervous  system  of  children  as  compared  with  that  of  adults. 
The  child  has  a  more  primitive  brain  and  represents,  to 
some  degree,  that  state  of  brain  characteristic  of  individuals 
belonging  to  a  low  state  of  civilization,  when  compared 
with  that  of  the  highly  cultivated  adult  brain. 

But  I  have  no  time  at  present  in  which  to  discuss  these 
suggestive  topics.     I  can  only  allude  to  them. 

Finally,  I  would  direct  attention  to  one  other  probable 
cause  of  the  increase  of  nervous  and  mental  diseases,  which 
lies  by  the  side,  rather  than  in  the  direct  line,  of  my  sub- 
ject this  evening ;  I  refer  now  to  the  part  played  by  hered- 
ity. I  can  not  enter  into  a  recital  and  discussion  of  par- 
ticular facts,  however  interesting  such  a  course  would  be. 
It  has  been  done  at  length  by  various  writers,  especially  by 
Dr.  Prosper  Lucas  in  his  great  work,  in  two  volumes,  on 
"  Natural  Heredity." 

But  it  may  be  remarked  in  general  terms  that  whatever 
is  acquired,  whether  in  health  or  disease,  in  the  way  of  de- 
velopments or  accidents  in  the  nervous  system,  is  liable  to 
be  perpetuated  in  a  measure  by  hereditary  transmission 
from  one  generation  to  that  which  comes  after.  It  must 
necessarily  happen  that  many  persons  born  of  healthy  par- 
ents will  in  various  ways  acquire  disease  which,  when  ac- 
quired, is  often  transmitted  in  some  form  or  other  to  their 
offspring.  This  is  one  of  the  most  important  and  infallible 
modes  of  an  increase  of  nervous  and  mental  diseases.  The 
stream  widens  as  it  advances.  It  begins  in  one  and  may 
spread  to  many,  if  it  spreads  at  all. 

A  vast  number  of  instructive  facts  and  considerations 
based  upon  them  could  be  placed  before  you  under  this 
head.     To  their  discussion  an  evening  might  profitably  be 


24  y.  S.   JEWELL. 

devoted.  You  all  know  that  insanity,  or  the  insane  tem- 
perament, may  be  and  is  transmitted.  The  same  may  be 
said  of  epilepsy,  neuralgia,  migraine,  tendencies  to  paral- 
ysis, chorea,  idiocy,  criminal  tendencies,  nervous  weakness, 
and  besides  these  many  other  morbid  conditions  or  species. 
If  it  shall  be  learned,  after  due  inquiry,  that  the  causes  of 
nervous  and  mental  diseases  are  more  prevalent  in  our  own 
country  to-day  than  they  were  fifty  or  one  hundred  years 
ago,  then  the  question  is  settled  that  heredity  plays  an 
important  part  in  an  increase  of  such  disorders. 

This  is  a  subject  destined  hereafter  to  occupy  much  more 
serious  public  and  private  attention  than  ever  before  in  the 
history  of  the  world.  The  time,  let  us  hope,  is  not  far  dis- 
tant when  marriage  may  be  in  some  way  regulated  so  as  to 
prevent  what  should  be  foreseen, — that  is,  that  the  union  of 
two  persons  in  marriage,  with  certain  known  or  easily  dis- 
coverable hereditary  tendencies,  will  be  the  means  of  bring- 
ing into  existence  insane,  or  physically  feeble  and  worth- 
less, or  morbidly  nervous,  or  criminally  inclined  offspring. 
The  time  is  coming  when  this  subject,  delicate  and  unman- 
ageable as  it  is,  will  be  carefully  pondered  by  parents,  or 
by  those  who  are  to  become  such.  This  is  one  way  in 
which,  under  certain  circumstances,  nervous  and  mental 
diseases  may  be  and  are  increased. 

These  are  a  few  of  the  considerations  which  have  led 
me  to  the  conclusion  expressed  at  the  beginning  of  my 
paper,  namely,  that  as  civilization  advances,  nervous  and 
mental  diseases  increase. 


INSANE  DELUSIONS:  THEIR  MECHANISM  AND 
THEIR  DIAGNOSTIC  BEARING. 

By  EDWARD  C.  SPITZKA,  M.D. 

TO  probably  no  other  class  of  symptoms  of  mental  de- 
rangement does  so  much  interest,  and  interest  of 
so  manifold  a  character,  attach,  as  to  the  delusions  of  the 
insane. 

These  perversions  of  the  apperceptional  and  conceptional 
sphere  have,  indeed,  had  the  high  medico-legal  importance 
assigned  to  them  (I  need  not  add,  erroneously)  of  consti- 
tuting the  criterion  of  insanity,  and  from  the  days  of  Willis, 
Haslam  and  Esquirol  down,  practical  alienists  have  based 
many  important  indications  for  the  prognosis  and  treatment 
of  mental  diseases  on  the  special  character  of  the  delusions 
accompanying  them. 

Notwithstanding  the  admitted  importance  of  these  symp- 
toms, none  of  the  classical  writers  on  insanity  have  at- 
tempted to  range  all  the  various  forms  of  insane  delusion 
side  by  side  before  the  student's  eye,  to  analyze  their  bases 
comparatively,  and  to  formulate  their  differential  diagnostic 
significance.  Certain  special  forms  of  insane  delusion,  and 
certain  other  conceptional  disturbances  which  are  allied 
thereto,  have  been  well  studied  by  continental  alienists, 
but  the  entire  field  has  not  been  gone  over  with  that  pre- 
cision and  that  unity  of  plan  which  the  student  of  the  sub- 
ject requires. 

25 


26  EDWARD   C.   SPITZKA. 

In  my  opinion,  there  is  no  evidence  of  insanity  which 
constitutes  as  proper  a  starting-point  for  study  as  the  in- 
sane delusion.  On  first  sight,  the  most  complex  of  insane 
symptoms,  it  is  yet  that  manifestation  which  strikes  the 
mind  of  the  novice  with  greatest  force.  It  is  the  symptom 
to  which  the  readiest  expression  is  given  by  the  patient 
himself,  the  ^ne  which  can  be  most  readily  laid  bare  before 
a  class  in  the  course  of  clinical  demonstration,  and  the  one 
which  offers  to  the  beginner  in  psychiatry  that  obvious  con- 
trast with  sanity,  which  is  the  most  satisfactory  as  it  is  the 
most  tangible  to  his  mind.  For  the  very  reason  that  insane 
delusions  are,  however  erroneously,  considered  by  the  laity 
as  the  criterion  of  insanity,  they  should  constitute  the  in- 
troduction to  the  study  of  insanity.  The  lay  conception  of 
a  lung  disorder  associates  it  with  cough  and  expectoration  ; 
now  while  cough  and  expectoration  do  not  constitute  cri- 
teria of  lung  affections,  yet  the  clinical  teacher  who  will 
analyze  these  phenomena  before  the  new-comer,  and  point 
out  their  true  meaning  previous  to  proceeding  to  the  phys- 
ical signs,  whose  recognition  and  interpretation  require 
experience  and  acumen,  does  that  new-comer  a  far  greater 
service  than  he  who  endeavors  to  override  the  untutored 
mind  by  ignoring  all  which  the  latter  has  hitherto  been 
cognizant  of,  and  presenting  at  once  those  abstractions 
which  the  beginner  is  altogether  unfitted  to  comprehend ! 
For  like  reasons  is  it  to  be  considered  unfortunate  that 
some  modern  text-books  and  teachers  open  the  subject  of 
insanity  with  an  abstract  analysis  of  the  variations  in  the 
intensity  of  the  mental  processes,  which,  while  they  are 
perhaps  more  constantly  found  in  the  insane  than  insane 
delusions,  are  far  less  evident,  nay,  at  first  even  unrecog- 
nizable, to  the  novice.  My  individual  experience  has  taught 
me  that  nothing  serves  to  initiate  the  student  so  rapidly  in 
the  mysteries  of  the  insane  mind,  as  an  analysis  of  the  in- 


INSANE  DELUSIONS.  27 

sane  delusion,  for  perversions  of  the  conceptional  faculties 
are  far  more  readily  understood  than  those  involving  the 
moral,  emotional  and  volitional  states. 

In  the  present  paper,  I  shall  first  detail  the  principal 
kinds  of  delusion  encountered  among  the  insane,  irrespec- 
tive of  the  form  of  insanity  with  which  they  are  found. 
Next,  I  shall  proceed  to  analyze  the  morbid  psychological 
character  of  the  insane  delusion  and  its  mode  of  origin. 
Finally,  I  shall  endeavor  to  point  out  the  diagnostic  infer- 
ences which  can  be  drawn  from  the  character  of  insane  de- 
lusions/^r  se. 

§  I.  At  the  outset,  the  question  arises  :  How  shall  insane 
delusions  be  classified  ?  In  many  treatises  we  find  them 
divided  according  to  their  accidental  character,  as  to 
whether  they  are  expansive  or  depressive,  and  the  funda- 
mental distinction  has  thence  been  made  of  expansive  and 
depressive  delusions.  The  further  subdivisions  have  been 
added,  of  ambitious,  religious  and  erotic  delusions  under 
the  former,  and  of  hypochondriacal  delusions  and  delusions 
of  persecution  under  the  latter  head.^ 

All  these  terms  are  admissible  as  terms,  but  the  principle 
of  classification  which  adopts  them  as  fundamental  distinc- 
tions is  faulty.  A  paretic  may  entertain  the  delusion  that 
he  is  a  king,  so  may  a  monomaniac,  and  so  may  an  imbecile 
or  dement,  but  nowhere  does  an  old  German  saying  "  Wenn 
Zwei  Dasselbe  thun,  so  ist  es  darum  nicht  Dasselbe,''  apply 
so  well  as  here.  In  the  three  cases  mentioned,  although  the 
conclusion  of  the  delusion  is  formally  the  same,  yet  its 
logical  foundation  and  structure  is  in  all  a  widely  different 
one.  To  study  that  difference  is  to  analyze  the  actual 
character  of  the  insanity  with  which  the  delusion  is  found, 
and  right  here  it  is  to  be  insisted  that  the  formal  contents 
of  delusions  are  of  but  a  secondary  importance,  as  com- 
pared with  their  method  of  origin  and  building  up. 


28  EDWARD   C.   SPITZKA. 

§  2.  Delusions  may  be  divided  into  the  GENUINE  and 
the  SPURIOUS.  The  former  group  consists  of  those  delu- 
sions which  have  been  the  creation  of  the  patient  himself ; 
the  latter  consists  of  those  which  have  been  adopted  from 
other  sources.  The  former  have  an  intrinsic  importance, 
and  characterize  the  form  of  insanity  with  which  they  are 
found ;  the  latter  have  only  a  collateral  significance,  due  to 
their  differential  diagnostic  relations. 

§  3.  The  genuine  delusions  of  the  insane  are  to  be  classi- 
fied according  to  their  synthesis.  We  find  that  certain  de- 
lusions are  of  a  complex  logical  organization,  and  that  others 
are  devoid  of  such  an  organization.  The  first  differentia- 
tion will  therefore  be  that  of  SYSTEMATIZED  DELUSIONS 
as  contrasted  with  UNSYSTEMATIZED  DELUSIONS. 

§  4.  All  the  various  forms  of  insane  delusions,  hitherto 
admitted,  may  fall  under  both  of  these  heads,  that  is,  we 
may  have  delusions  of  persecution  which  are  systematized 
and  such  which  are  unsystematized,  and  the  same  applies 
to  delusions  of  grandeur  and  to  hypochondriacal  delusions. 
It  will  therefore  be  desirable  in  describing  a  given  case, 
and  in  order  to  fully  characterize  the  delusions  present,  to 
speak  of  a  "systematized  delusion  of  persecution"  or  an 
"  unsystematized  delusion  of  grandeur,"  etc. 

To  answer  the  question  whether  a  delusion  is  systema- 
tized or  unsystematized,  is  of  vastly  greater  importance 
than  to  determine  its  accidental  features,  if  I  may  so  term 
them.  Take  a  delusion  of  persecution,  for  example.  If  it 
is  systematized  ^&  maybe  absolutely  certain  that  we  have 
to  deal  with  a  case  of  that  primary  "  partial "  insanity,  for 
which,  in  default  of  any  other  admissible  English  term,  I 
have  recently^  proposed  the  reestablishment  of  the  term 
"•Monomania."  If,  on  the  other  hand,  it  is  unsystematized, 
we  know  with  equal  certainty,  that  it  is  a  symptom  of  mel- 
ancholia, of  senile  insanity,  or  of  the  first  stage  of  progress- 


INSANE  DELUSIONS.  29 

ive  paresis.  Thus  this  mode  of  inquiry  gives  the  delusion 
itself  a  diagnostic  weight  which,  under  the  older  view,  it 
could  not  possess. 

§  5.  The  SYSTEMATIZED  EXPANSIVE  DELUSION  is  the 
one  which  has  had  most  attention  directed  to  it.  It  is  the 
prominent  symptom  of  that  form  of  primary  partial  insanity 
which  the  French  designate  "  Megaloinanie.'"  I  shall,  how- 
ever,  endeavor  to  show  that  the  expansive  delusion  is  not 
suf^ciently  distinct  from  other  systematized  delusions  to 
justify  the  ranking  of  the  mental  affection  with  which  it  is 
found  under  a  separate  name.  The  more  modern  French 
writers  divide  "  Megalomanie  "  into  the  simple,  the  religi- 
ous and  the  erotic  form.'*  The  German  writers^  speak  of 
monomania  with  expansive  delusions,  and  its  two  sub-groups 
of  religious  and  erotic  monomania.  (Primaere  Verrueckt- 
heit  mit  Groessenwahn,  Religioese  Verruecktheit,  Erotische 
Verruecktheit.) 

In  all  these  divisions,  the  special  direction  in  which  the 
delusion  has  developed  has  given  the  name  to  the  forms  of 
insanity  enumerated. 

It  may  be  readily  imagined  that  if  the  world  were  atheis- 
tical and  had  been  so  for  several  centuries,  and  every  trace 
of  religion  had  been  obliterated  from  the  human  mind,  that 
the  insane  developing  systematic  delusions  of  grandeur,- 
would  not  develop  that  form  which  we  term  religious.  To 
use  the  additional  adjectives  religious,  erotic,  etc.,  in  the 
nomenclature  of  the  expansive  systematized  delusions,  is, 
therefore,  merely  done  for  convenience'  sake,  and  does  not 
presuppose  an  essential  character  of  the  delusion. 

§  6.  When  we  proceed  a  little  later  on  to  analyze  the 
mechanism  of  the  three  principal  varieties  of  expansive 
systematized  delusions,  we  shall  find  that  they  indicate 
each  of  them  a  certain  grade  of  logical  enfeeblement,  and 
that  the  enfeeblement  is  the  more  pronounced  as  we  leave 


30  EDWARD    C.   SPITZKA. 

those  delusions  which  involve  mundane  relations  and  pro- 
ceed to  those  involving  sexual  and  religious  matters. 

§  7.  The  highest  general  mental  development  among 
constitutional  lunatics  is  found  with  those  who  cherish  sys- 
tematized delusions  of  social  ambition.  These  patients  are 
the  kings,  emperors,  social  reformers,  inventors  of  flying 
machines,  the  perpetuum  mobile,  great  poets,  military  gen- 
iuses, etc.,  of  asylums.  The  delusion  frequently  has  grown 
out  from  a  dream,  or  from  an  actual  hallucination.  The 
patient  acts  consistently  with  his  assumed  character,  and  in 
most  instances  the  existence  of  a  certain  grade  of  mental 
energy  and  ability  is  documented  by  the  formation  of  proj- 
ects which,  whatever  their  ultimate  feasibility,  are  under- 
taken with  some  attention  to  detail  and  to  the  patient's 
worldly  circumstances.  More  frequently,  I  find,  has  the 
idea  of  grandeur  gradually  developed  from  a  delusion  of 
persecution,  and  it  is  not  rare  to  find  the  original  delusion 
of  persecution  and  the  resulting  delusion  of  grandeur  ex- 
isting side  by  side. 

Often,  especially  with  patients  of  high  culture,  are  the 
delusions  not  so  monstrous  as  to  lead  to  an  error  in  the 
patient's  sense  of  identity,  but  limited  to  his  self-esteem  in 
the  abstract.  He  writes  doggerel  or  mediocre  verse,  for 
example,  and  imagines  himself  as  great  a  poet  as  Byron, 
or  he  invents  some  unimportant  mechanical  contrivance, 
and  lays  claim  to  the  gratitude  of  a  nation  or  a  king. 

§  8.  Systematized  delusions  of  an  expafisive  erotic  character 
have  given  the  name  to  the  so-called  "  Erotomania."  In 
the  text-book  of  Bucknill  and  Tuke,  this  term  is  used  as 
synonymous  with  nymphomania,  which  is  calculated  to 
lead  to  a  serious  confounding  of  two  widely  different  forms 
of  derangement.  As  Krafft-Ebing**  and  the  modern 
French  authors  correctly  remark,  the  perversion  in  erotic 
delusional  insanity  is  not  necessarily  accompanied  by  sex- 


INSANE  DELUSIONS.  31 

ual  desire,  and  it  is  to  be  added  that  nymphomania  is  not 
generally  accompanied  by  those  delusions  which  are  termed 
erotic.  Here  the  word  erotic  is  used  in  its  higher  and 
strictly  classical  sense. 

The  patient,  noted  in  his  adolescence  for  his  romantic 
tendencies,  constructs  an  ideal  of  the  other  sex  in  one  of 
his  day-dreams,  and  on  some  occasion  or  other  discovers 
the  incorporation  of  his  ideal  in  an  actual  personage,  usu- 
ally in  a  more  exalted  social  station  than  his  own.  He  or 
she  then  spins  out  a  perfect  romance  with  the  adored  per- 
son for  its  subject,  and  according  as  the  surrounding  cir- 
cumstances may  be  momentarily  favorable  or  not,  delusions 
of  self-exaltation  or  of  persecution  may  be  added  to  the 
erotic  one, 

§  9.  Systematized  delusions  of  an  expansive  religious  char- 
acter are  rooted  in  a  devotional  tendency  of  the  patient, 
and  brought  to  their  full  bloom  by  incidental  circum- 
stances either  actual  or  in  the  shape  of  hallucinations.  It 
is  not  uncommon  to  hear  such  patients  designated  as  cases 
of  religious  melancholia,  for  supposing  themselves  assailed 
by  inimical  and  diabolical  forces  they  become  depressed, 
and  even  refuse  food.  But  to  call  an  individual  who,  aside 
from  these  actions  (all  consistent  with  his  or  her  delusions), 
believes  himself  to  be  God,  Christ,  a  saint,  the  Messias,  a 
religious  reformer,  or  herself  the  Virgin  Mary,  and  who, 
the  very  next  day,  passes  into  visionary  or  ecstatic  states,  a 
melancholiac,  is  to  involve  one's  self  in  a  profound  contra- 
diction with  the  established  use  of  psychiatrical  terms  ! 

§  10.  Systematized  Delusions  of  a  Depressive 
Character  have  also  long  attracted  the  attention  of  alien- 
ists. Unfortunately  Esquirol^  failed  to  perceive  their  great 
analogy  to  the  systematized  expansive  delusions,  and  placed 
the  cases  of  insanity  in  which  the  former  were  prominent 
symptoms   under  his   group   of  lypemania.     Other   French 


32  EDWARD    C.    SPITZKA. 

writers  discovered  a  relation,  and  hence  the  term  "  mono- 
manie  triste  "  in  contradistinction  to  the  "  monomanie  gaie," 
or  that  in  which  expansive  delusions  predominate.  But 
none  perceived  the  true  relation  as  distinctly  as  Marce,'' 
whose  remarks*  on  this  head  have  not  received  that  atten- 
tion which  they  merit.  I  therefore  seize  the  present  oppor- 
tunity to  do  justice  to  one  of  the  greatest  thinkers  in  the 
field  of  psychological  medicine,  and  who,  unnoticed  by  the 
alienists  of  his  own  land,  evolved  those  principles  which,  a 
few  years  later,  were  independently  announced  by  Snell, 
Kahlbaum  and  Sander,  and  which  are  destined  to  universal 
acceptance. 

Speaking  of  the  term  lypemania,  as  employed  by  Esqui- 
rol,  he  objects  to  its  use  and  to  the  principle  of  classification 
that  is  associated  with  its  use.  He  divides  the  patients 
classed  by  Esquirol  as  lypemaniacs  into  two  entirely  distinct 
groups,  namely,  melancholia  proper,  and  monomania  with 
depressive  delusions  {inonomanie  triste).  The  latter  division 
corresponds  in  every  detail  of  Marce's  description  to  the 
"  Primaere  Verruecktheit  mit  Wahnideen  depressiven 
Inhaltes  "  of  the  Germans,  just  as  the  former  corresponds 
to  the  true  melancholias  of  Krafft-Ebing,  Meynert  and 
Schuele. 

Our  author  continues:  "  In  sad  monomania  the  patient 
will  exhibit  fixed  ideas  of  a  melancholic  nature,  but  he  will, 
while  regulating  his  actions  by  his  delusive  conceptions, 
yet  be  able  to  pay  attention  to  the  actual  affairs  of  life, 
while  in  melancholia,  on  the  contrary,  the  delusion  invades 
the  whole  intellectual  field  and  leads  to  a  state  of  depres- 
sion, to  inertia  and  to  stupor."' 

§  II.  Under  the  head  of  the  depressive  systematized  de- 
lusion, we  shall  find  the  antithesis  of  almost  every  form 
found  under  the  head  of  the  expansive  delusion.     We  have 

*  Quoted  from  Dagonet*. 


INSANE  DELUSIONS.  33 

systematized  dehisions  of  depressed  social  ambition,  of  worth- 
lessness,  of  moral  monstrosity,  or  of  criminality  ;  again  we 
have  such  of  a  depressive  erotic  character,  usually  persecu- 
tory, while  the  list  is  completed  by  depressive  religions  delu- 
sions of  the  most  varied  kind.  How  very  circumstantial  the 
line  of  demarcation  between  the  expansive  and  depressive 
delusion  really  is,  must  be  apparent  from  the  fact  that  a 
systematized  depressive  religious,  erotic  or  personal  delu- 
ion,  may  within  a  few  days  (yes,  I  know  of  one  instance 
where  this  occurred  within  a  few  hours)  become  expansive. 
In  fact,  as  I  have  already  hinted,  expansive  and  depressive 
conceptions  often  exist  side  by  side  as  component  elements 
of  the  same  delusion. 

From  this  it  will  be  evident  that  a  subdivision  of  the  sys- 
tematized delusion  must  necessarily  be  arbitrary.  When, 
therefore,  I  proceed  to  describe  later  on  the  salient  features 
of  some  more  common  forms  of  delusion,  I  shall  not  de- 
vote much  attention  to  that  incidental  circumstance,  their 
depressive  or  expansive  character. 

§  12.  When  we  see  an  individual  without  any  man- 
ifest disturbance  of  his  emotional  and  effective  states,  in 
full  possession  of  the  memories  accumulated  in  the  recep- 
tive sphere,  and  able  to  carry  out  most  or  all  of  the  duties 
incident  to  his  social  position,  who  cherishes  such  a  gross 
error  as  a  delusion,  firmly  believing  in  the  reality  of  that 
which,  from  his  education  and  surroundings,  we  should  ex- 
pect him  to  recognize  as  absurd,  we  are  naturally  puzzled  to 
account  for  the  phenomenon,  and  numerous  have  been  the 
theories  advanced  to  explain  the  systematized  delusion. 
The  older  view  that  a  delusion  is  based  on  an  exaggerated 
excitation  of  certain  cell  groups  in  the  cortex^,  must  be 
abandoned,  for  such  excitation  could  not  be  so  distributed 
anatomically  as  to  involve  the  cell  groups  which,  in  the 
light  of  our  modern  theories  of  cerebration,  are  involved  in 


34  EDWARD  C.   SPITZKA. 

any  one  special  set  of  intellectual  functions  without  involv- 
ing so  much  of  the  cortex  as  would  lead  to  generally  exag- 
gerated mental  action.  Excitation  beyond  the  normal 
bounds  does  sometimes  occur  in  these  patients,  but  such 
excitation  partakes  of  the  character  of  a  delirium,  has  no 
fixed  relation  to  the  systematized  delusion,  and  is  episodical. 
§  13.  Instead  of  an  exaggerated  cell  action,  we  shall  find 
that  actually  a  contrary  state  of  things  is  at  the  root  of  the 
systematized  delusions.  The  only  explanation  of  these  cre- 
ations, which  is  in  accord  with  anatomical,  physiological, 
and,  I  think  I  may  add,  pathological  principles,  is  that  of 
Meynert.^  This  writer  had,  many  years  ago^°,  called  at- 
tention to  the  presumptive  physiological  role  of  certain 
arched  fibres  which  are  known  to  unite  adjoining  as  well  as 
distant  cortical  areas  with  each  other.  He  claims  that  if 
we  are  justified  in  asserting  a  nerve  bundle,  which  unites  a 
peripheral  surface  like  the  retina  to  the  cortex,  to  be  a  tract 
of  functional  projection,  another  tract  which  unites  two  cor- 
tical areas  must  be  looked  upon  as  an  associating  mechan- 
ism. I  have  since  then  ascertained  that  as  we  examine 
an  ascending  series  of  animal  brains,  culminating  with 
the  human,  the  white  centre  of  Vieussens,  which  in  the 
reptilia  and  marsupials  is  almost  exclusively  devoted  to 
"projection,"  grows  with  far  greater  rapidity  than  the  corti- 
cal area  and  cortical  thickness  and  richness  in  cells. ^^ 
This  increase  is  largely  and  mainly  due  to  the  increased 
number  and  extent  of  the  associating  tracts.  In  fact,  I 
should,  if  asked  to  point  to  the  chief  factor  on  which  the 
higher  powers  of  the  human  brain  depend,  lay  less  stress  on 
the  cortical  development,  as  such,  than  on  the  immense  pre- 
ponderance of  the  white  substance  due  to  the  massive  asso- 
ciating   tracts.*     Although   the  projecting    tracts   are    also 

*  If  transverse  vertical  sections  be  made  of  a  monkey's  and  a  lium.iii  brain, 
the  chief  contrast  noticeable  is  afforded  by  the  more  than  double  massiveness, 
proportionately,  of  the  white  centre  of  Vieussens  in  the  latter. 


INSANE  DELUSIONS.  35 

larger  in  man  than  in  any  other  animal,  yet  so  great  is  the 
preponderance  of  the  associating  mechanism  that  the  elim- 
ination of  the  former  would  not  reduce  the  white  substance 
of  the  hemisphere  by  one-half  of  its  bulk.  Both  project- 
ingi2  and  associating  fibre  masses  increase  in  a  nearly  geo- 
metrical progression  as  we  pass  from  the  lower  animals  to 
man  ;  but  the  ratio  of  progression  of  the  associating  fibre 
masses  exceeds  that  of  the  projecting  tracts. 

There  are  certain  convolutions,  which  are  almost  exclu- 
sively connected  •wiX.h.  fibrce  arctcatcs,  that  is,  with  associating 
tracts,  and  which  enjoy  but  little  direct  connection  with 
the  bodily  periphery.*  It  is  reasonable  to  suppose  that 
the  cortical  areas  so  connected  play  an  important  role  as  a 
substratum  of  the  abstractions.  Like  a  polyp,  such  an  area 
sends  out  its  arms,  the  associating  fasciculi,  to  those  gyri 
which  have  received  the  simpler  registrations  transmitted 
by  the  projecting  tracts,  seizes  them  and  utilizes  tliem  in 
the  construction  of  its  organic  unity  (to  use  a  perhaps 
rather  coarse  simile). 

§  14.  Such  cortical  areas  and  their  subsidiary  associating 
tracts,  bound  into  the  still  higher  unity  of  the  entire  hemi- 
sphere, constitute  the  substratum  of  the  metaphysician's 
Ego. 

A  disturbance  of  the  intricate  anatomical  relations  which 
are  involved  in  the  material  basis  of  the  Ego,  must  be  ac- 
companied by  a  disturbance  of  the  Ego,  or  may  even  render 
an  Ego  an  impossibility. 

It  is  on  the  accurate  connection  of  projection  areas  with 
projection  areas,  and  of  these  with  the  "  abstraction  "  areas, 
and  of  these  again  with  each  other,  that  the  faculty  of  logi- 
cal correlation,  which  after  all  is  the  keystone  of  the  meta- 
physical arch,  must  be  supposed  to  depend.    The  correction 

*  Rroadbent,  I  believe,  has  expressed  the  view  that  there  are  gyri  winch  have 
no  peripheral  connections.  The  correctness  of  this  has  not  yet  been  demon- 
strated. 


36  EDWARD  C.   SPITZKA. 

of  the  countless  errors  which  a  person  naturally  commits 
in  a  lifetime  is  possible  only  by  the  influence,  analogous  to 
the  inhibitory,  exercised  by  the  associating  fasciculi,  and 
the  proper  aim  of  every  healthy  educational  system  is  to 
develop  this  control  of  the  various  cortical  "  screen  "  fields 
on  each  other,  a  correction  which,  with  progressing  maturity, 
is  delegated  to  the  "abstraction  "  fields. 

Quite  confirmatory  of  these  presumptions,  is  the  fact  that 
we  so  frequently  discover  aberrations  in  the  development 
of  the  gyri,  in  the  proportion  of  the  cerebral  lobes  to  each 
other,  and  in  the  symmetry  of  the  hemispheres,  on  exam- 
ining the  brains  of  those  constitutional  lunatics  with  whom 
the  systematized  delusions  are  found.* 

Both  the  anatomico-pathological  theory,  as  well  as  meta- 
physical analysis,  lead  us,  then,  to  the  result  that  the  insane 
systematized  delusion  is  not  the  result  of  exaggerated  cell 
action,  but  is  due  to  defective  association,  in  other  words, 
to  a  weakness  of  the  logical  inhibitory  power." 

§  15.  The  component  elements  of  the  systematized  de- 
lusion are  the  same  which  coristitute  normal  conceptions  ; 
such  as  the  day-dreams,  or  the  errors  of  every-day  life.  But, 
as  Meynert  happily  remarks,  the  systematized  delusion 
differs  from  the  same  error,  which  it  resembles  in  some  re- 
spects, by  the  utter  incapacity  of  the  logical  apparatus  for 
the  time  being  to  correct  the  delusion  by  the  same  pro- 
cess which  enables  the  sane  individual  to  recognize  that  his 
error  is  an  error. 

*  This  applies  also  to  the  moral,  the  constitutional  affective,  the  impulsive, 
and  other  organically  insane  subjects.  This  view  was  first  announced  by  my- 
self in  the  W.  and  S.  Tuke  Prize  Essay,  and  provisionally  published  in  a  re- 
view appearing  in  this  JOURNAL,  1878.  Since  then,  it  has  been  advanced  by 
Schuele  in  his  Handbook,  and  is  credited  to  that  author  by  v.  Krafft.  I  lay 
stress  on  the  priority  of  the  views  announced,  as  I  cannot  be  expected  to  quote 
Schuele  as  the  author  of  a  theory  which  is  original  with  myself,  and  which  is 
the  outgrowth  of  the  principles  promulgated  by  Th.  Meynert,  in  his  lectures 
delivered  at  the  University  of  Vienna,  1874-75.  The  first  observations  on  cor- 
tical malformation  with  the  insane  of  this  class  as  well  as  certain  imbeciles, 
were  made  by  Jensen  ^^  in  1875.  and  on  these  Schuele  seems  to  have  based  his 
views.     One  of  the  finest  cases  in  point  is  that  of  Muhr.  ^* 


INSANE  DELUSIONS.  37 

Much  of  the  difficulty  involved  in  a  thorough  apprecia- 
tion of  the  systematized  delusion,  can  be  obviated  by  re- 
garding the  systematized  delusional  lunatic  as  a  member  of 
a  large  family,  whose  other  members  are  the  subjects  of  va- 
rious forms  of  hereditary  degenerative  insanity.^  Actually 
his  insanity  reduces  itself  to  a  partial  imbecility.  The  men- 
tal weakness  does  not  involve  the  entire  horizon  as  in  the 
imbecile  or  idiot,  but  only  certain  of  the  higher  combina- 
tions. It  is  not  even  necessary  that  all  these  higher  combi- 
nations be  impossible,  nay,  some  of  these  may  be  so  per- 
fect that  by  a  collateral  process  of  reasoning,  such  lunatics 
may  correct  their  delusions.* 

§  i6.  The  one  fundamental  character  which  distin- 
guishes the  delusions  of  systematic  delusional  lunatics 
is  the  correlation  with  their  surroundings,  or  of  their  indi- 
vidual physical  states.  However  falsely  the  patient's  sen- 
sations and  external  circumstances  may  be  interpreted,  yet, 
after  all,  there  is  a /i'^z/fl'f?  logical  chain  running  from  them 
to  the  delusion  which  they  help  to  create  and  to  sustain. 
This  is  absent  in  the  case  of  patients  exhibiting  unsyste- 
matized delusions. 

Up  to  a  certain  stage,  the  systematized  delusion  is  analo- 
gous to  a  healthy  conception ;  this  is  never  the  case  in  an 
unsystematized  delusion.  It  would  be  difficult  to  draw 
the  line  between  the  delusion  of  Martin  Luther  that  the 
devil  was  persecuting  him,  based  on  a  hallucination  of 
vision  and  never  corrected  by  him,  on  the  one  hand,  and 
that  of  a  religious  monomaniac  who  believes  himself  re- 
ferred to  by  the  Pope  as  the  coming  Saviour,  based  likewise 
on  a  hallucination  of  vision.  In  fact,  there  is  no  other 
discrimination  to  be  made  than  that  the  delusion  of  Martin 
Luther  was  in  full  consonance  with  the  belief  of  his  day, 

*  Thus  the  dictum  that  "  an  insane  delusion  is  a  delusion  out  of  which  the 
subject  can  not  be  reasoned,"  falls  to  the  ground,  unless  the  words  "  for  the 
time  being"  be  added. 


3 8  EDWARD  C.   SPITZKA. 

while  the  delusion  of  the  religious  monomaniac  of  to-day  is 
in  conflict  with  that  which  from  his  education  and  the  time 
in  which  he  lives,  he  should  recognize  as  rational  and  pos- 
sible. Nothing  could  better  illustrate  the  great  analogy- 
existing  between  the  conceptions  possible  in  health  and  the 
systematized  delusions  of  the  insane,  than  this  instance. 
Imagine  the  religious  monomaniac  living  in  the  sixteenth 
century,  and  entertaining  the  delusion  that  the  devil  was 
interfering  with  a  task  on  which  he  was  engaged,  having  ap- 
peared to  him  in  person  (hallucinated) !  In  no  court  of  law 
could  his  insanity  be  maintained  on  the  strength  of  that 
one,  or  even  a  number  of  such  delusions  ! 

As  examples  of  the  manner  in  which  the  subjects  of  sys- 
tematized delusions  utilize  casual  occurrences  in  the  con- 
struction and  defence  of  their  delusions,  I  need  but  refer  to 
the  common  case  where  such  patients  detect  a  connection 
between  their  delusive  hopes  or  fears  and  an  advertisement 
or  a  bill-poster  containing  their  initials.  That  others  sus- 
tain their  royal  birth  by  a  fancied  resemblance  in  their  feat- 
ures to  some  member  of  the  royal  family.  That  another 
appears  at  Washington  to  be  inaugurated  as  President  of  the 
United  States,  because  he  was  born  in  the  same  town  and 
was  brought  up  in  the  same  circumstances  and  had  the 
same  opportunities  as  the  President-elect.  That  another 
bases  a  memorial  to  the  Lord-Chancellor  of  England,  claim- 
ing a  great  estate  as  his  own,  on  the  fact  that  his  niece  is 
married  to  some  relative  of  the  legatee. 

A  lady  whom  I  treated  recently,  from  one  of  the  British 
colonies,  had  built  up  an  elaborate  series  of  delusions  cul- 
minating in  the  general  conclusion  that  everything  about 
her  was  changed — even  her  husband,  who  had  from  an 
Englishman  become  a  Spaniard  (because  he  was  of  a  dark 
complexion),  on  the  single  fact  that  the  nursery-maids  of 
her  family  and  a  neighboring  one  had  played  with  her  in- 


INSANE  DELUSIONS.  39 

fant  and  another's,  and  must  have  got  them  mixed  up, 
because,  when  a  few  days  after,  she  looked  at  her  child's 
eyes,  the  irides  were  of  a  different  color  than  when  it  was 
new-born.  This  observation  was  no  doubt  correct,  for  it 
was  corroborated,  but  the  inference  that  her  child  was 
changed  was  faulty,  as  its  grandmother  had  observed  it 
from  day  to  day ;  had  noticed  the  change  in  color  to  be 
more  decided  than  is  usual,  and  the  child  suffering  cholera 
infantum,  changing  greatly  in  appearance  otherv/ise ;  but 
she  was  able  to  prove  its  identity  by  a  number  of  circum- 
stances which  would  have  convinced  a  sane  person.  My 
patient,  however,  went  on,  interpreted  the  arguments  of 
her  relatives  to  a  desire  on  their  part  to  make  the  best  of 
what  could  not  be  remedied,  and  became  satisfied  that  her 
husband  was  indifferent  to  his  family.  A  few  attentions 
shown  by  him  to  some  young  ladies  convinced  her  of  his 
infidelity,  and  ready  to  believe  anything  of  him  that  was 
bad,  a  few  robberies  occurring  in  the  neighborhood  were 
also  attributed  to  him,  as  he  happened  to  come  home  late 
on  the  evenings  when  they  took  place,  and  one  night  she 
found  a  large  negro  peering  over  the  garden  wall,  at  whom 
the  watch-dog,  recognizing  the  alleged  accomplice  of  her 
husband,  did  not  bark.  Her  parents,  removing  her  to  their 
own  home,  previous  to  taking  her  to  New  York  for  medical 
advice,  she  here  found  that  a  cousin  changed  her  wardrobe, 
and  abstracted  articles  therefrom,  because  a  half  dozen 
packages  of  chemises  contained  only  four  such.  On  land- 
ing at  New  York  she  advanced  similar  charges  against  the 
custom-house  officers. 

§  17.  In  how  striking  a  contrast  with  the  imbecility  of 
judgment  involved  in  the  existence  of  such  delusions  is  the 
mental  calibre  of  these  patients  in  other  respects?  The 
chronic  presidential  candidate,  Piatt,  was  a  fair  and  logical 
orator  and   had   sound  views   on   many  points   of  political 


40  EDWARD  C.   SPITZKA. 

economy,  though  the  sport  of  sophomores  when  I  saw  him. 
The  claimant  of  the  estates  of  Lord  Camperdown  was  a 
skilful  surgeon  and  a  popular  dentist,  familiar  with  the  re- 
searches of  Magendie,  and  occupying  and  maintaining  a 
position  at  the  English  court  for  many  years;  a  man  who, 
after  the  actual  outbreak  of  his  disease,  imposed  himself  on 
Cavaignac  as  a  general,  and  losing  his  practice  as  a  surgeon 
and  dentist,  and  after  organizing  a  riot  in  Australia,  earned 
a  support  as  a  newspaper  correspondent.  The  lady,  part  of 
whose  history  I  detailed  above,  had  qualities  which  would 
have  made  her  an  ornament  of  what  is  called  "  society," 
and  neither  society  nor  the  alienist  would  have  detected 
the  first  evidence  of  her  insanity  unless  attention  had  been 
thereto  directed  by  the  few  relatives  initiated  in  her 
secret. 

§  1 8.  The  absurdity  of  the  delusion  is  not  so  much  a 
test  of  the  absolute  mental  rank  of  the  patient  as  is  its 
synthesis.  A  very  absurd  conclusion  may  be  reached  by  a 
very  elaborate  ratiocination,  and  a  less  absurd  conclusion 
be  reached  by  a  very  crude  process  of  reasoning.  It  is  in 
studying  this  aspect  of  the  subject  that  we  become  con- 
vinced of  the  close  relation  of  insane  projects  cind  insane 
systematized  delusions.  Elaborate  projects,  some  of  them 
actually  feasible,  are  evolved  by  these  insane,  along  with 
very  absurd  delusions,  while  the  more  stupid  class  of  these 
lunatics  either  evolve  no  projects,  or  very  stupid  ones, 
along  with  their  delusive  conceptions. 

§  19.  The  factors  engaged  in  producing  the  systematized 
delusion  are  two-fold.  One,  the  predisposition  we  have 
recognized  as  presumably  based  upon  an  anomaly  of  the 
cerebral  architecture,  the  other  or  exciting  causes  we  shall 
now  proceed  to  study. 

I.  The  general  mental  tone  of  the  patient.  If  he  be  of 
a  sanguine  disposition,  the  delusion   is  often  the  outgrowth 


INSANE  DELUSIONS.  4 1 

of  a  day-dream,  on  the  plan  of  the  saying,  that  the  wish  is 
father  to  the  thought.  If  he  be  of  a  suspicious  turn,  de- 
lusions of  persecution  are  apt  to  arise. 

2.  The  physical  state.  If  this  is  fair,  delusions  are  apt 
to  be  expansive,  and  to  involve  social  and  sexual  matters. 
If  somatic  disease  exists,  the  disordered  condition  of  the 
viscera  will  give  rise  to  visceral  illusions  with  consequent 
delusions  of  a  hypochondriacal  tinge. 

3.  The  circumstances  of  the  patient.  The  age  in  which 
he  lives,  the  education  he  receives,  his  social  condition, — all 
these  seriously  modify  the  character  of  the  delusions  of  this 
class  of  the  insane. 

While  the  factors  enumerated  under  these  three  heads 
are  of  considerable  importance,  it  must  be  insisted  here 
that  they  all  in  combination  will  rarely  create  a  systema- 
tized delusion,  unless  the  cerebral  predisposition  exists. 
Even  in  the  few  cases  ^^  where  systematized  delusions  were 
observed,  in  subjects  devoid  of  a  hereditary  or  acquired 
taint,  the  presence  of  soihe  autochthonous  aberration  is  not 
excluded.  The  fact  that  the  delusions  do  not  appear  in 
early  life,  as  a  rule,  is  to  be  explained  on  the  very  simple 
basis,  that  the  mind  requires  a  given  time  to  collect  the 
conceptions  which  even  insane  ideas  require  as  their  build- 
ing material.  This  observation  constitutes  an  important 
guide  to  treatment.  It  shows  us  that  after  all  the  best 
treatment  of  these  cases  is  preventive,  that  the  object  of 
the  education  of  these  subjects  ought  to  be  to  counteract 
the  vicious  tendencies  implanted  in  the  cerebral  organiza- 
tion. Their  treatment,  therefore,  necessarily  must  be  edu- 
cational. Every  day  we  hear  of  gastric  catarrh,  constipa- 
tion, dysmenorrhoea  and  other  ills,  assigned  as  the  cause  of 
hypochondriacal  and  erotic  delusional  insanity.  The  con- 
stipation is  removed,  the  dysmenorrhoea  relieved,  but  the 
delusion   persists   unmodified.     One  might  just  as  well  ex- 


42  EDWARD    C.   SPITZKA. 

tirpate  the  ribs,*  or  cut  off  the  haematomatous  ear  of  a 
paretic,  with  the  hope  of  influencing  his  disease  thereby. 

§  20.  The  unsystematized  delusion  is  characteristic 
of  the  acuter  insanities.  They  may  be  ranged  in  two  great 
groups :  those  due  to  actual  destruction  of  logical  associat- 
ing power,  and  those  due  to  the  overwhelming  of  the 
mental  sphere  by  a  powerful  emotional  or  other  disturb- 
ance. The  delusions  of  grandeur,  of  progressive  paresis  are 
types  of  the  first  class;  the  delusions  of  persecution  in  the 
acute  melancholiac  and  epileptic  are  types  of  the  second 
class. 

§  21.  In  the  former  case,  the  patient  says  he  is  a  king 
or  a  president,  or  has  a  million  dollars,  because  it  is  a  de- 
sirable thing  to  have  these  positions  and  moneys.  But  he 
can  not  tell  you  how  he  can  be  a  king  and  yet  be  named 
Dennis  Maginnis.  He  can  not  tell  you  how  it  is  that  he 
had  twice  as  much  yesterday  as  he  has  to-day.  He  never 
acts  in  that  strict  accordance  with  his  assumed  character 
which  one  suffering  from  systematized  delusions  of  gran- 
deur does.  A  systematic  delusional  lunatic,  if  claiming 
great  personal  attractions  (which  is  rare),  will  demonstrate 
the  claim  by  letters  received,  by  poems  which  he  will  state 
refer  to  him,  and  by  the  fact  that  certain  people  have 
looked  at  him  in  a  peculiar  way  and  have  made  comments 
on  him.  The  paretic,  however,  will  simply  boast  that  he 
is  good  looking,  and  it  is  not  always  impossible  to  prove 
that  his  statements  are  not  based  upon  a  deep  conviction, 
but  are  mere  braggadocio.  ^^ 

A  systematic  hypochondriacal  lunatic  will  argue  that  his 
body  is  indestructible,  and  complain  that  he  is  condemned 
to  live  forever,  and  he  will  explain  to  you  that  his  idea  must 
be  correct,  because  with  the  physical  ailments  from  which 

*  At  no  very  remote  period,  it  may  be  confidently  predicted,  oophorectomy 
will  cost  a  couple  of  lives  before  it  will  dawn  upon  enthusiasts  that  erotic  mono 
mania  is  not  located  in  the  ovaries. 


INSANE  DELUSIONS.  ~  43 

he  is  suffering,  and  which  are  incompatible  with  life  in 
ordinary  people,  it  must  be  evident  that  he  cannot  die.* 
The  paretic,  who  is  sometimes  hypochondriacal  in  the  first 
stage  of  his  disease,  has  occlusion  of  tne  rectum  to-day, 
rocks  in  his  head  to-morrow,  a  clockwork  in  his  chest  the 
day  after.  In  short,  the  unsystematized  hypochondriacal 
delusion,  like  the  unsystematized  delusion  of  grandeur,  is 
lacking  in  that  consistency  and  that  elaborate  constitution 
characteristic  of  the  corresponding  systematized  delusion. 

A  paretic  rells  me  that  he  is  five  thousand  three  hundred 
and  seventy-two  feet  high,  his  actual  height  being  rather 
under  five  feet.  I  place  him  side-by-side  with  a  man  of  six 
feet  and  ask  him  how  high  he  is;  he  correctly  answers  about 
six  feet.  I  ask  him  whether  he  has  to  look  up  or  down  to 
tax  that  man's  height ;  he  answers  without  hesitation  that 
he  has  to  look  up.  On  my  now  interpellating  him  as  to  his 
inconsistency,  he  simply  repeats  in  a  random  way,  that  he 
is  six  thousand  feet  higher  than  any  other  man.  Such 
inconsistencies  are  not  found  with  systematized  delusions. 
Another  paretic  claims  that  he  is  General  Grant.  The  week 
before  he  claimed  that  he  was  Rothschild,  but  abandoned 
that  idea  when  told  that  the  great  Rothschild  was  dead. 
He  is  unable  to  say  when  the  war  began,  what  his  business 
was  before  he  became  General,  what  battles  he  fought  in, 
and,  finally,  what  country  he  is  president  of.  A  systema- 
tized delusion  would  have  incorporated  all  these  facts. 

§  22.  There  are  also  unsystematized  delusions  of  perse- 
cution, of  subjective  worthlessness  and  criminality.  These 
are  found  in  melancholia  (true  lypemania,  acute  melan- 
cholia). 

Here  the  emotional  state  has  overwhelmed  the  entire 
intelligence,  and  thrown  the  logical  faculties  into  the  back- 

*  The  legend  of  the  Wandering  Jew  is  based  upon  the  statements  of  such 
lunatics  (Ahasuer,  etc.). 


44  EDWARD  C.   SPITZKA. 

ground.  The  patient  believes  he  is  bad  because  he  feels 
unworthy  in  a  general  way ;  because  he  is  bad  he  has  com- 
mitted the  unpardonable  sin,  and  cannot  tell  you,  when  nor 
why,  nor  what  the  unpardonable  sin  is.  Or  he  is  despised, 
he  is  hated  because  despised,  he  is  pursued  because  hated, 
and  whispers  from  all  sides  drive  him  to  seek  relief  from  a 
danger  which  was  never  clear  in  his  own  mind,  by  suicide. 

Here  again  there  is  found  the  great  demarcation  between 
the  systematized  and  the  unsystematized  delusion.  In  the 
systematized  delusion,  such  partial  logical  power  and  such 
other  mental  qualities  as  the  patient  ever  had  are  utilized 
by  him  in  the  construction  and  defence  of  his  delusion,  and 
what  is  of  great  medico-legal  importance,  also  utilized  in  the 
carrying  out  of  his  schemes  of  defence,  of  revenge  *  or  of 
suicide  (which  is  rare  here).  The  melancholiac,  however,  is 
deprived  of  such  logical  power  as  he  naturally  possesses  for 
the  time  being  ;  aside  from  his  hallucinations  he  is  unable 
to  specify  any  support  for  his  morbid  idea,  and  his  actions 
betray  that  same  lack  of  system  which  his  delusions  do, 
except  in  the  case  of  the  suicidal  attempts;  where  the  latter 
are  the  direct  result  of  the  delusions,  they  are  as  unsyste- 
matized as  these. 

§  23.  Very  transient  unsystematized  delusions  of  grandeur 
crop  out  occasionally  with  violent   cases  of  acute  mania.f 

*An  example  of  this  kind  is  furnished  by  the  incendiary  of  the  St.  Peter's 
Asylum. 

f  The  first  case  of  puerperal  mania  I  saw  in  the  Vienna  Asylum,  exemplified 
this  better  than  any  case  1  have  since  seen.  Isolated  on  account  of  her  vio- 
lence, the  patient  tore  every  shred  of  clothing  from  her  body,  and  then  in  an 
incredibly  short  space  of  time  picked  the  matting  to  pieces,  and  made  from  the 
strands  a  most  perfect  and  tasteful  dress,  including  every  article  of  wearing 
apparel  from  the  hat  and  shoes  to  a  satchel.  This  she  wore  for  a  long  period  ; 
I  believe  her  abandonment  of  it  was  the  first  sign  of  recovery.  She  claimed  to 
be  a  princess  ;  asked  which  one,  she  mentioned  a  name  not  in  the  list  of  Aus- 
trian princesses,  and  she  repudiated  the  attentions  of  a  secondary  chronic 
maniac  who,  claiming  to  be  the  empress,  acted  the  part  of  her  mother.  Later 
on  she  accepted  the  relation,  but  the  manner  in  which  she  did  it,  was  evidence 
of  her  insincerity.  It  was  evidently  entered  into  with  the  same  spirit  that  chil- 
dren will  enter  into  assumed  relations  toward  each  other,  in  play,  not  with  that 
earnestness  characteristic  of  systematic  delusions. 


INSANE  DELUSIONS.  45 

but  they  partake  of  the  same  flightiness  aVid  confusion  that 
is  characteristic  of  all  the  intellectual  acts  of  the  violent 
acute  maniac.  Delusions  of  conspiracy  and  persecution 
sometimes  occur  with  senile  insanity,  but  the  constructive 
element  so  prominent  in  systematized  delusions  of  persecu- 
tion, and  that  consistency  of  action  found  with  the  latter 
are  conspicuously  absent.  The  defence  of  the  morbid  idea 
is  not  as  skilful. 

§  24.  On  the  whole,  then,  we  are  justified  in  saying  that 
the  fundamental  criterion  of  the  insane  delusion  from 
psychological  and  pathological  points  of  view,  is  its  organi- 
zation, and  that  this  organization  reflects,  to  a  certain  de- 
gree, the  form  of  insanity  of  which  it  is  a  symptom. 

A  systematized  delusion,  no  matter  whether  it  be  one  of 
grandeur,  of  persecution  or  hypochondriacal,  means  a  bad 
prognosis,  chronicity,  and  leads  us  to  look  for  a  hereditary 
or  other  taint.  I  may  say  here  that  with  the  delusion  of 
personal  ambition  that  correction  of  the  delusion  which 
alone  holds  forth  a  hope  of  recovery  is  most  possible,  that 
the  chances  are  next  most  favorable  with  the  delusion  of 
persecution,  less  favorable  with  the  religious  and  hypochon- 
driacal, and  null,  I  think,  with  the  erotic  variety. 

An  unsystematized  delusion  of  persecution,  means  either 
acute  melancholia,  senile  insanity,  the  first  stage  of  pro- 
gressive paresis  (rarely)  or  alcoholism.  The  narrower  diag- 
nosis between  these  three  states  is  not  difficult.  It  may  be 
well  to  note  the  frequency  with  which  delusions  of  marital 
infidelity  and  of  poisoning  occur  with  alcoholic  subjects. 
The  delusions  here  stand  by  themselves,  are  never  circum- 
stantially supported,  and  are  probably  not  unrelated  to  the 
effect  of  the  alcoholic  poison  on  the  sexual  and  gustatory 
apparatus. 

An  unsystematized  delusion  of  grandeur  is  the  charac- 
teristic   feature    of    progressive    paresis,    and    found    in    all 


46  EDWARD    C.   SPITZKA. 

the  other  paralytic  insanities.*  It  rarely  occurs,  and 
then  very  vaguely  expressed  and  undefended,  in  violent 
mania. 

In  addition,  all  kinds  of  unsystematized  delusions  are 
found  in  chronic  secondary  mania,  as  relics  of  the  primary 
insanity  which  preceded  it.  They  resemble  fragments  in 
the  chaos  which  represents  the  ruins  of  the  intellectual 
structure;  they  are  disconnected,  stupidly  expressed,  and 
differ  from  the  delusions  of  progressive  paresis  by  their 
slighter  variability,  and  lesser  expansiveness  when  expan- 
sive. 

§  25.  In  asylums  and  in  prisons,  we  not  infrequently  dis- 
cover subjects  of  imbecility  or  of  otherwise  stunted  mental 
growth,  who  display  insane  delusions.  These,  from  the 
mental  grade  of  the  patients,  it  might  be  anticipated,  are 
of  the  simplest  character.  They  occupy  that  relation  to 
the  systematized  delusion,  which  the  notions  of  an  igno- 
rant navvy  bear  to  the  conceptions  of  a  sage.  The  Ego  of 
these  patients  is  so  feebly  pronounced,  that  it  is  difficult  to 
determine  whether  they  have  identified  themselves  with 
their  delusional  character  in  the  same  sense  that  the  sub- 
jects of  systematized  delusions  have.  While,  therefore,  I 
am  not  able  to  say  that  the  delusions  of  these  imbeciles 
should  be  classed  as  systematized,  I  would  be  very  un- 
willing to  put  them  in  a  category  with  the  unsystematized 
delusions. 

The  patients  with  whom  they  are  found  appertain  to  the 
hereditary  and  degenerative  group,  and  the  delusions  have 
an  analogous  relation,  signification  and  mechanism,  as  far 
as  we  can  speak  of  a  mechanism,  as  in  these  other  heredi- 
tary degenerative  states  with  which  the  elaborate  syste- 
matized delusions  are  found.    The  importance  of  these  con- 

*  Non-paralytic  dementia  after  meningitis,  syphilis,  etc.,  sometimes  manifests 
these  delusions. 


INSANE  DELUSIONS.  47 

ditions  which  are  not  infrequently  discovered  in  company 
with  imperative  conceptions  and  impulses,  and  sometimes 
with  epileptiform  states,  is  chiefly  medico-legal.  As  my 
friend  Dr.  Hazard  will,  within  a  short  period,  lay  his  ob- 
servations on  a  pertinent  case,  that  of  the  executed  homi- 
cide Redemeier,  before  the  profession,  and  as  I  wish  in  that 
connection  to  make  a  special  report  on  a  similar  subject, 
the  homicide  Munzberger,  in  whose  case  the  judge  recog- 
nized the  insanity  from  the  bench,  I  will  defer  the  consid- 
eration of  these  states  for  the  present. 

As  the  subject  of  spurious  delusions  has  been  ably  dis- 
cussed in  the  last  number  of  this  Journal^'  it  will  not  be 
necessary  to  go  over  that  subject  here,  especially  as,  like 
other  subsidiary  themes,  it  could  not  be  adequately  dis- 
cussed otherwise  that  in  a  separate  paper. 

My  main  object  was  to  show  the  grave  significance  of 
the  systematized  delusion,  leaving  it  to  the  reader  to  draw 
such  deductions  as  may  suggest  themselves  in  reference  to 
the  rationale  of  driving  out  delusions  from  the  ovaries, 
uterus  and  rectum  when  they  are  rooted  iu  the  brain  struc- 
ture, and  the  justifiability  of  classing  every  patient  with  ex- 
pansive delusions,  as  an  acute  or  chronic  maniac,  and  one 
with  depressive  delusions  as  an  acute  or  chronic  melancho- 
liac,  to  which  classification,  with  the  exception  of  the  re- 
cent importation  of  paralytic  dementia,  our  asylum  nom- 
enclature has  been  limited  thus  far. 

REFERENCES. 

1.  Le  Grand  DU  Saulle.     Le  delire  des persecutions.     Paris,  1870. 

2.  Flemming.  Zur  Genese  der  Wahnsinnsdeliriem.  Allg.  Zeitschfi/t  fiir 
Psychiatf  ie. 

3.  Spitzka.      Monomania.      St.  Louis  Clin.  Record.     December,  1 880. 

4.  Dagonet.     Nouveau  Traite  des  Maladies  Mentales. 

5.  V.  Krafft-Ebing.      Lehrbuch  der  Psychiatric. 

6.  ESQUIROL.      Traite  des  Maladies  Mentales. 


48  EDWARD   C.   SPITZKA. 

7.  Marce.      Traite  Pratique  des  Maladies  Mentales. 

8.  Hagen.      Studien  auf  dein  Gebiete  der  csrztlichen   Seelenkunde. 

9.  Meynert.  Ueber  Fortschriite  in  der  Lehre  von  den  Psychiatrischen 
Krankheiten,     Psychiatrisches  Centralblatt,   1878.      I. 

10.     Article  in  Strieker's   Histology. 

rr.  Spitzka.  Contributions  to  Encephalic  Anatomy.  Journ.  of  Mental 
and  Nervous  Disease,  July,  187S. 

12. The  Peduncular  Tracts  of  the  Anthropoid  Apes.       Journ.  of 

Mental  and  Nervous  Disease,  1879. 

13.  Jessen.     Archiv  ftir  Psychiatrie,  -v. 

14.  MUHR.  Anatomische  Befunde  bei  einem  Falle  von  Verruecktheit. 
Archiv  ftir  Psychiatrie,  vi. 

15.  BiLLOD.     Annales  Med.  Psychologiques,  1879. 

16.  Spitzka.  Psychological  Pathology  of  Progressive  Paresis,  jfournal  of 
Nervous  and  Mental  Disease,  April,  1877. 

17.  KlERNAN.  Folie  a  deux.  Journ.  of  Nervous  and  Mental  Disease,  Oc- 
tober, 1880. 


ON    SOME    POINTS    IN    REGARD  TO  COLOR- 
BLINDNESS. 

By  H.   M.   bannister,  M.  D. 

THE  practical  questions  connected  with  color-blindness 
have  been  brought  very  prominently  before  the 
public  within  the  past  two  years,  and  have  been  acted  upon 
by  state  legislatures  and  the  general  government  as  well  as 
by  various  private  corporations.  The  necessity  of  distin- 
guishing signals  correctly  is  of  such  obvious  importance  in 
railway  operating  and  in  navigation  that  it  is  no  wonder 
that  the  subject  has  attracted  public  attention.  It  is  more 
a  matter  of  surprise  that  the  practical  importance  of  an  in- 
firmity that  has  been  recognized  for  a  hundred  years  or 
more,  and  that  has  been  studied  more  or  less  by  physiolo- 
gists for  half  that  period,  and  the  common  occurrence  of 
which  has  been  well  known,  should  not  have  been  earlier 
recognized.  Men  had  been  sailing  ships  and  running  loco- 
motives many  years  under  the  present  systems  of  colored 
signals,  and  their  capacity  had  never  been  questioned  until, 
under  the  present  tests,  they  were  found  defective  and  dis- 
qualified. It  cannot,  nevertheless,  be  assumed  from  this 
that  the  present  agitation  of  the  subject  is  needless ;  it  may 
be  that  only  one-tenth  of  one  per  cent,  of  accidents  by  rail 
or  sea  has,  amongst  its  causal  factors,  this  defect  of  color- 
vision,  and  yet  the  public  has  the  right  to  claim  protection 
against  even  this  remote  possibility  of  danger.     The  ques- 

49 


50  H.  M.  BANNISTER. 

tion  only  remains  as  to  just  what  is  necessary  for  this  pro- 
tection and  how  it  is  to  be  afforded.  If  color-bhndness  of 
certain  kinds  and  degrees  does  not  disqualify  the  individual 
from  correctly  distinguishing  signals,  as  is  claimed  by  Mr. 
William  Pole,*  then  the  practical  importance  of  the  defect 
is  greatly  diminished,  if  not  altogether  destroyed,  as  regards 
these  occupations.  Again,  if  this  infirmity  is  curable  by 
exercise  or  education,  as  is  held  to  be  the  case  by  Dr.  Favre, 
who  was  himself  one  of  the  first  to  call  attention  to  the 
practical  points  involved,  then  the  whole  subject  is  deserv- 
ing of  far  less  importance  than  is  nowadays  attributed  to  it. 
If  either  of  these  views  is  correct,  it  is  a  reasonable  pre- 
sumption that  a  person  in  constant  exercise  of  his  percep- 
tive powers  on  the  distinction  of  colored  signals  would  be 
able  to  overcome  or  compensate  for  this  particular  defect, 
so  far  as  all  practical  purposes  are  concerned,  while  still,  it 
may  be,  exhibiting  it  in  the  plainest  manner  to  the  usual 
tests.  Some  facts  point  very  strongly  in  this  direction  ;  the 
recent  examinations  of  pilots  and  engineers  have  revealed 
cases  of  color-blindness  where  it  was  utterly  unsuspected, 
and  in  persons  who  had  acceptably  filled  positions  for  many 
years  that  required  daily  and  almost  hourly  exercise  and 
test  of  their  ability  to  correctly  distinguish  colored  sig- 
nals. 

The  object  of  this  paper  is  to  discuss  certain  practical 
points  in  relation  to  color-blindness  that  appear  to  have 
been  heretofore  too  little  noticed.  First  among  these  is 
what  I  may  call  the  psychic  element  in  the  disease  or  de- 
fect, which,  I  think,  is  quite  an  important  one  in  many 
cases.  The  seat  of  color-blindness  has  been  commonly 
spoken  of  as  in  the  retina  or  conducting-fibres  to  the  brain, 
and  many  writers  have  apparently  acted  entirely  on  this  as- 
sumption.    The  usual  way  of  stating  the  Young-Helmholtz 

*  Contemporary  Review,  May,  1 880. 


SOME  POINTS  IN  REGARD  TO  COLOR-BLINDNESS.         5  I 

theory  of  color-perception  is  that  there  are  three  sets  of 
nerve  fibres,  conveying  respectively  impressions  of  red, 
green,  and  violet,  or  that  there  are  three  sets  of  retinal  per- 
ceptive elements  with  such  functions.  The  Hering  theory 
is  commonly  stated  as  if  there  were  three  kinds  of  physio- 
logico-chemical  changes  taking  place  in  the  retina,  and  pro- 
ducing, according  to  their  stage  and  degree,  the  shades  and 
tints  of  black  and  white,  blue  and  yellow,  and  red  and 
green.  Nerve  fibres  cannot  be  considered,  in  the  light  of 
our  present  knowledge  of  physiology,  as  anything  more 
than  mere  conductors;  their  functions  depend  solely  upon 
their  terminal  apparatuses,  and  of  these  the  central  ones 
are  as  essential  and  more  important  than  those  of  the  pe- 
riphery. We  can  follow  the  light  through  the  dioptric  mech- 
anism of  the  eye  to  the  rods  and  cones  of  Jacob's  mem- 
brane, and  then  the  process  changes  from  a  physical  to  a 
physiological  one,  and,  however  much  we  may  speculate  in 
regard  to  the  function  of  the  rods  and  cones,  the  exact 
manner  in  which  the  luminous  impressions  are  received  by 
them  to  be  converted  into  nervous  impulses,  is  absolutely 
unknown.  From  this  point  on,  the  visual  mechanism  is  a 
sort  of  physiological  telegraph,  the  retina  being  simply  the 
sending  apparatus,  the  optic  nerve  the  conductor,  and  the 
receiving  of  the  message  and  its  delivery  to  consciousness 
are,  of  course,  accomplished  somewhere  within  the  cere- 
brum. The  process  may  be  interrupted  at  any  point  of  the 
route,  the  retina  may  be  an  imperfect  instrument,  the  con- 
ducting fibres  may  be  out  of  order,  the  centre  at  the  base 
of  the  brain  may  be  defective,  or,  finally,  the  conveyance  to 
the  centres  where  the  impression  is  taken  cognizance  of  by 
consciousness  may  be  retarded  or  obstructed.  This  is  the 
case  as  regards  all  sensations,  and  errors  and  delays  are 
much  the  most  likely  to  occur  with  our  more  complex  ones, 
such   as   that  of  color,  which   is  so  often  found  deficient  in 


52  H.  M.  BANNISTER. 

otherwise  normal  individuals.  The  exact  locality  of  this 
defect  of  color-perception  is  of  some  practical  as  well  as 
theoretical  importance.  In  pathological  cases  it  is  some- 
times accompanied  with  retinal  disease,  but  this  is  not  so 
with  the  congenital  forms  of  color  deficiency.  If  there  is 
in  these  latter  any  retinal  defect,  we  might  hope,  with  the 
modern  appliances  for  microscopic  research,  to  find  some 
structural  alteration.  A  case  of  the  post-mortem  examina- 
tion of  a  congenitally  color-blind  eye,  has  not,  so  far  as  I 
know,  occurred  since  the  death  of  Dr.  Dalton,  and  then, 
the  minute  anatomy  of  the  retina  being  at  the  time  un- 
known, the  investigation  was  confined  to  the  humors  of  the 
eye,  with,  of  course,  a  negative  result.  But  if  the  retina  is 
the  part  usually  involved  in  color-blindness,  or,  rather,  if 
correct  color-perception  usually  depended  on  the  healthy 
condition  of  the  retina  or  the  rods  and  cones,  we  might  ex- 
pect to  see  it  impaired  with  whatever  affected  their  nutri- 
tion, while,  in  fact,  we  do  not  find  it  necessarily  abnormal 
with  either  an  anaemic  or  a  congested  retina,  or  even  with 
some  serious  retinal  alterations  that  may  affect  the  general 
visual  power.  The  fact  that  color-perception  varies  in  dif- 
ferent portions  of  the  retinal  field,  and  especially  decreases 
toward  the  periphery,  does  not  appear  particularly  signifi- 
cant in  this  connection,  for  all  the  other  niceties  of  vision 
follow  similar  rules.  That  the  retina  is  a  mechanism,  the 
perfection  of  which  is  essential  to  correct  color-vision  as  it 
is  to  all  sight,  is  beyond  question,  but  that  color-blindness 
necessarily,  or  even  generally,  is  due  to  its  defects  is  ex- 
tremely doubtful. 

The  grounds  for  referring  the  defect  of  color-perception 
to  the  higher  cerebral  centres  seem  much  stronger.  But 
there,  also,  direct  anatomical  evidence  is  lacking;  we  have 
no  pathological  facts,  so  far  as  known  to  me,  of  cerebral  le- 
sions directly  connected  with   color-blindness.     There  are, 


SOME  POINTS  IN  REGARD  TO  COLOR-BLINDNESS.         5  3 

however,  numerous  clinical  observations  that  point  strongly 
in  this  direction,  and  some  that  are  scarcely,  if  at  all,  intel- 
ligible with  any  other  interpretation.  Such  are  the  cases  of 
colorblindness  in  hysterical  and  hypnotic  conditions,  and 
those  observed  in  certain  cerebral  diseases  in  which  there 
is,  so  far  as  we  know,  no  retinal  or  optic  abnormality.  Such 
a  case  as  one  mentioned  by  Charpentier  in  a  recent  paper,* 
as  observed  by  him  in  Landolt's  clinic,  in  which  there  was 
hemiopia  limited  to  the  color-vision,  is  very  positive  evidence 
in  this  direction,  though  it  does  not  necessarily  indicate  a 
disorder  as  high  as  the  perceptive  centres.  In  addition,  we 
have  the  facts  of  colored  phantasms  in  cerebral  disease.  A 
lady  of  my  acquaintance,  who  is  subject  to  occasional  se- 
vere migrainous  attacks,  has  them  sometimes  preceded  by 
a  loss  of  power  to  perceive  any  color  except  red,  which 
tinges  all  objects;  and  Dr.  J.  S.  Jewell  has  described  to  me 
a  case  of  a  patient  of  his  own  who  has,  preceding  his  head- 
aches, a  brilliant  play  of  colors  occupying  just  one-half  the 
visual  field,  the  other  half  being  normal.  We  have  also,  as 
instances,  the  color  auras  of  certain  epileptics,  and  it  is  need- 
less to  further  multiply  instances  of  this  kind. 

If  we  could  obtain  the  testimony  in  full  of  all  intelligent 
partially  color-blind  individuals,  we  could  probably  obtain 
some  quite  significant  facts.  My  own  experience  seems  to 
me  somewhat  to  the  point.  I  am  partially  red-green-blind, 
not  very  much  so,  but  to  a  slight  extent.  My  eyesight  is 
excellent,  V.  |-^;  a  slight  myopic  astigmatism,  -J-g-,  or  less,  in 
the  vertical  meridian,  is  of  no  practical  importance  as  a  de- 
fect. The  optic  nerve  and  retina  are  healthy.  I  see  a  con- 
tinuous colored  spectrum  from  beyond  the  potash  line  to 
the  extreme  violet.  The  lithium  line  is  a  very  beautiful  and 
typical  red,  and  if  any  portion  of  the  spectrum  is  cut  off  or 
uncolored  at  the  red  end  it  must  be  extremely  slight.     I 

*  Read  before  French  Assn.  Adv.  Sci.  (Rep.  in  Progres  Mddical,  1880).  This 
Journal,  Oct.,  1880. 


54  H.  M.  BANNISTER. 

recognize  all  the  spectral  colors  as  distinct  in  tint,  except, 
perhaps,  indigo,  which  seems  only  a  variety  of  blue.  I  do 
not  see  any  gray  or  uncolored  stripe  in  the  blue-green  ;  in 
fact,  my  perception  of  spectral  colors  seems  to  be  only 
weakened,  not  in  any  important  respect  lost.  Yet,  in  pig- 
ments I  am  constantly  liable  to  confusion,  and  frequently 
confound  colors  that  to  other  persons  are  quite  distinct. 
Sometimes,  in  using  Holmgren's  first  test  with  the  green 
skein,  I  put  in  all  the  usual  confusion  colors,  and  some  that 
are  not  usually  given  as  such.  There  is  a  special  tendency 
to  confuse  certain  browns  with  dark  yellow-greens.  The 
peculiar  feature,  however,  that  bears  upon  the  point  now 
under  consideration,  is  that  when  I  see  two  colors  as  alike, 
a  closer  inspection,  requiring  sometimes  only  a  few  seconds, 
sometimes  even  a  minute  or  more,  brings  out  a  difference,  not 
in  shade  or  tone,  but  in  tint,  and  I  can  generally  correctly 
name  the  color.  Then,  again,  in  using  Holmgren's  test  No. 
I,  I  have  to  give  my  whole  attention  to  the  nuances  of  green, 
at  one  end  or  the  other  of  the  series,  separately — that  is,  I 
am  obliged  to  sort  out  the  blue-greens  by  themselves,  and 
in  so  doing  I  scarcely  notice  the  yellow-greens,  and  vice 
versa.  If  this  is  not  done,  I  leave  in  the  pile  of  mixed 
skeins  either  a  number  of  well-marked  blue-greens  or  yellow- 
greens,  which  I  readily  recognize  by  themselves.  It  appears 
that  my  color-perception  is  not  equal  to  covering  the  whole 
range  of  greens  at  once,  though  recognizing  their  common 
character  when  taken  separately. 

Again,  in  looking  at  a  cherry-tree,  or  other  dark  foliaged 
tree  with  red  fruit,  I  first  see  only  a  uniform  dark  green,  but 
longer  observation  brings  out  the  red  color  of  the  ripe  fruit. 
This  is  independent  of  the  form,  for  the  color  can  be  seen 
without  my  taking  note  of  the  form,  and  when  the  fruit  is 
abundant  and  clustered,  at  a  distance  too  great  to  well  dis- 
tinguish the  form.     Another  instance  of  this  peculiarity  of 


SOME  POINTS  IN  REGARD  TO  COLOR-BLINDNESS.         5  5 

my  color-vision  is,  that  in  looking  at  a  certain  painted  glass 
window,  a  rosette  of  alternate  leaflets  of  a  yellowish-green 
and  a  tint  of  red  of  very  nearly  the  same  illumination  and 
pattern,  appears  to  me  at  first  of  all  one  color,  but  con- 
tinued observation  brings  out  the  red,  and  afterward,  as  long 
as  I  continue  to  look  at  it,  it  is  not  possible  for  me  to  make 
the  same  confusion.  I  have  frequently  repeated  this  ex- 
periment, and  generally  with  the  same  result.  I  say 
"  generally,"  for  I  find  my  color-sense  varies  from  day  to 
day,  and  at  times  I  distinguish  colors  more  quickly  than 
at  others.  On  one  occasion,  with  a  perfectly  new  set  of 
worsteds  that  I  had  never  before  tried,  I  was  able  to 
pass  all  of  Holmgren's  tests  without  making  any  notable 
mistakes  or  exhibiting  anything  more  than  a  tendency  to 
them.  This,  however,  does  not  often  happen,  and  more 
frequently  this  test  would  indicate,  I  think,  a  much  more 
deficient  color-sense  than  I  really  possess.  I  constantly 
observe  this  variability  of  my  power  to  perceive  colors, 
and  have  tried  to  make  out  its  cause,  or  some  rule  by 
which  it  is  governed,  but  so  far  with  no  result.  I  have  a 
good  faculty  of  mental  imagery,  and  can  generally  recall 
rather  vividly  the  color  of  any  familiar  object,  and 
have  sometimes  thought  that  this  might  also  be  at  fault 
when  color-perception  is  at  its  worst,  but  careful  observa- 
tions in  this  regard  have  not  verified  the  supposition.  In 
fact,  color-memory  and  color-perception  appear  to  be  some- 
what independent  of  each  other  in  my  case,  or,  rather,  the 
former  does  not  fully  reproduce  the  latter. 

The  fact  that  in  the  cases  I  have  described  I  see  the 
color  or  nuance  and  not  the  shade  or  tone,  is  to  me  a 
subjective  certainty.  The  only  way  I  can  easily  demon- 
strate it  to  others  is  by  correctly  naming  the  tint  after  it 
has  impressed  itself  upon  me,  which  I  have  often  done. 
Indeed,  the  fact  that  two  colors  sometimes,  at  first  sight, 


56  H.   M.  BANNISTER. 

look  exactly  alike  to  me,  though  afterward  they  appear 
different  in  tint,  would  seem  to  indicate  that  they  were  the 
same  in  shade,  especially  if  I  am  to  be  credited  with  the 
usual  acuteness  in  that  direction  of  the  partially  or  wholly 
color-blind.  My  power  of  discrimination  in  this  respect  is 
said  to  be,  in  reality,  quite  acute. 

It  appears  highly  probable  that  this  psychic  element  en- 
ters much  more  largely  into  partial  color-blindness  than  has 
been  generally  supposed.  All  of  our  senses  have  to  be 
educated  in  infancy,  and  to  this  is  possibly  due,  to  a  very 
great  extent,  the  absolute  vacancy  in  our  minds  in  regard 
to  the  earlier  months  and  years  of  our  existence.  The  in- 
fant sees,  that  is,  the  light  affects  its  optic  nervous  mechan- 
ism, but  it  conveys  no  adequate  idea  to  its  mind  till,  by  the 
cooperation  of  its  other  senses,  a  true  perception  of  the  na- 
ture and  relationship  of  things  is  evolved.  Most  people  are 
still  in  the  condition  of  infancy  as  regards  the  refinements 
of  certain  of  their  senses,  the  auditory  sense,  for  example, 
which  in  some  respects  is  so  comparable  to  that  of  sight. 
In  all  these  cases  it  is  the  higher  centres  that  are  at  fault, 
and  if  there  is  any  defect  in  the  lower  mechanism  for  receiv- 
ing impressions,  it  will  be  likely  to  exaggerate  itself  in  the 
cortical  changes  that  are  correlated  with  conscious  percep- 
tion. It  may  easily  be,  and  indeed  it  appears  highly  prob- 
able, that  a  deficient  early  training  and  a  lack  of  special 
observations  of  colors  in  early  life,  when  the  cerebral  cen- 
tres are  receiving  those  first  impressions  that  most  strongly 
influence  their  organization,  may  have  as  their  result  in 
adult  life  a  defect  of  color-sensibility,  varying  in  degree  from 
scarcely  perceptible  enfeeblement  to  pronounced  partial 
color-blindness,  or  to  dyschromatopsia,  as  in  my  own  case. 
Disuse  abolishes  or  weakens  functions  in  the  brain  as  in 
other  organs,  and  there  is  no  good  physiological  reason  why 
special  cerebral   organs  or  centres  may  not  be  thus   affected. 


SOME  POINTS  IN  REGARD  TO  COLOR-BLINDNESS.         5 7 

It  may  even  be  that  to  this,  combined  with  heredity,  is  due 
the  relatively  greater  frequency  of  the  defect  in  the  male 
sex. 

I  have  not  met  with  much  mention  in  medical  literature 
of  this  retardation  of  color-perception,  which  I  myself  ex- 
perience. In  his  work  on  color-blindness.  Dr.  B.  Joy 
Jeffries  mentions  incidentally,  in  one  place,  a  slowness  of 
color-perception  which  cannot,  however,  be  very  marked,  for 
it  is  plain  that  by  the  test  he  usually  employs,  any  hesita- 
tion or  actual  tendency  to  put  in  confusion  colors  is 
counted  as  color-blindness.  He  also  gives  an  account  of 
the  examination  of  some  pupils  in  an  institute  for  the  blind, 
who  had  still  an  ability  to  perceive  colors.  One  lad,  the 
least  blind  of  them  all  as  to  form,  etc.,  was  able  to  name  the 
colors  of  various  objects  correctly,  but  with  hesitation;  he 
said  "  he  did  not  get  hold  of  colors  very  well."  The  ac- 
count is  suggestive  of  the  same  difficulty  that  I  myself  have 
experienced,  but  the  boy's  partial  blindness  in  other  re- 
spects affects  its  value  in  this  relation. 

Ott  and  Prendergast,^-  in  a  paper  on  the  rapidity  of  per- 
ception of  colored  lights,  briefly  allude  to  some  practical 
points  involved.  The  differences  they  noted  in  this  respect 
are  too  slight  to  be  exactly  comparable  with  those  I  have 
described.  They  simply  observed  the  differences  of  per- 
sonal equation  that  probably  exist  more  or  less  in  every  in- 
dividual, while  in  my  own  case  there  seems  to  be  a  slowness 
of  cortical  functioning  in  the  perception  of  certain  tints, 
which  can  be  to  some  extent  overcome  by  conscious  mental 
effort,  and  which,  as  I  shall  attempt  to  show,  can  be  im- 
proved by  education. 

All  these  facts  appear  to  indicate  that,  in  some  cases  at 
least,  the  perception  of  color  is  largely  a  mental  process  in- 
volving a  considerable   element  of  time  and  attention,  and 

♦This  Journal,  April,  1880. 


58  H.  M.  BANNISTER. 

not  a  simple  sensation.  The  higher  cortical  centres,  there- 
fore, must  be  the  seat  of  the  defect.  The  mental  effort 
that  is  required  is  much  like  that  needed  to  select  a  certain 
sound  out  of  a  number,  such,  for  example,  as  that  of  a  cer- 
tain instrument  or  part  out  of  an  orchestra  or  chorus.  The 
loud  ticking  of  a  clock  may  be  as  distinct  as  any  other 
sound  in  a  room,  and  yet  make  no  impression  upon  con- 
sciousness until,  by  what  is  sometimes  a  labored  direction 
of  the  attention,  the  nervous  impulse  reaches  the  seat  of 
consciousness  from  the  auditory  apparatus,  upon  which  the 
vibrations  have  all  the  while  been  acting.  It  appears  to  be 
in  much  such  a  way  as  this  that  my  perception  of  certain 
colors,  or  rather  of  certain  tints  and  shades  of  color,  takes 
place  ;  they  do  not  impress  themselves  upon  my  conscious- 
ness until  by  a  special  effort  my  higher  perceptive  cen- 
tres have  been  particularly  devoted  to  their  recognition. 
And  when  this  concentration  of  attention  is  given  I  am 
all  the  more  blind  to  other  tints ;  I  cannot  see  the  yellow- 
greens  well  when  looking  for  the  blue-greens,  and  vice 
versa. 

It  is  not  an  unnatural  or  unjustifiable  inference  that  this 
perception,  requiring  a  mental  effort,  may  be  modified  by 
education  ;  it  is  the  rule  that  the  mental  powers  improve 
by  exercise.  This  brings  me  to  the  second  point  to  which  I 
wish  to  call  attention, — that  of  the  curability  or  modifiabil- 
ity  of  color-blindness. 

It  is  generally  assumed — there  are  very  few  who  hold  to 
the  contrary — that  congenital  color-blindness  is  incurable. 
It  may,  perhaps,  be  admitted  as  highly  probable  that  when 
absence  of  power  to  distinguish  all  colors,  or  any  one  fun- 
damental color,  is  complete,  that  there  is  very  little  or  no 
possibility  of  a  change  taking  place.  In  this  case  there  is 
no  basis  upon  which  to  work  ;  if,  for  example,  the  case  is 
one  of  complete  red-blindness,  there  is  then  no  original  sen 


SOME  POINTS  IN  REGARD  TO  COLOR-BLINDNESS.         59 

sation  or  perception  of  red  to  be  cultivated  or  educated.* 
But  when  this  dictum  of  the  incurability  of  color-blindness 
is  so  extended  as  to  apply  to  all  the  partial  phases  of  the 
defect,  it  seems  to  me  unphilosophical  and  unphysiological. 
If  the  defect  is  only  an  imperfect  or  retarded  perception,  as 
in  my  own  case,  located  in  the  higher  cerebral  centres  and 
partially  compensated  for  by  mental  effort,  the  case  is  quite 
different  from  that  of  a  complete  absence  of  any  fundamen- 
tal color,  both  in  its  nature  and  its  prognosis.  There  is,  in 
such  a  case,  no  good  ground  for  denying  the  possibility  of 
an  improvement  or  modification  of  the  condition,  and  there 
are  abundant  reasons  to  the  contrary.  It  would  be  against 
all  analogies  if  it  were  not  so.  I  will,  however,  here  again 
cite  my  own  experience. 

Ever  since  childhood  I  have  been  aware  of  a  difference 
in  color-perception  between  myself  and  others.  My  earlier 
recollections  in  this  line  are  of  inability  to  see  more  than 
two  colors — yellow  and  blue — in  the  rainbow,  and  of  being 
a  rather  notable  failure  in  the  strawberry  excursions  of  boy- 
hood. The  redness  attributed  to  the  rose  and  certain  other 
flowers  was  also  a  puzzle  to  me.  I  did  not  come  to  a  full 
appreciation  of  my  defect  till  I  was  nearly  twenty  years  old, 
when  I  had  one  day  a  dispute  about  the  colors  of  a  certain 
area  of  a  map.  Then  I  began  to  notice  my  color-sense  and 
exercise  myself  on  colors.     Red,  or  what  was  called  such, 

*The  statement  of  Cohn  {Deutsch.  Med.  Wochenschr.,  1880,  No.  16)  that  by 
hypnotism  he  was  able  to  produce  correct  color-perception  in  two  totally  color- 
blind persons,  and  in  one  partially  color-blind,  appears  to  contradict  this  view, 
and  to  show  that,  even  in  these  cases,  there  is  a  latent  capacity  for  color-percep- 
tion. That  is,  if  there  was  no  error  in  Cohn's  observation.  I  have  as  yet  seen 
only  his  preliminary  communication,  and  do  not  know  the  full  details  of  his  ex- 
periment. All  the  subjective  phenomena  of  hypnotism  have,  so  far  as  I  have 
been  able  to  observe  in  my  own  experiments,  apparently  depended  upon  ex- 
ternal suggestion  for  their  incitation  at  least.  If,  therefore,  I  am  allowed  to 
offer  a  hypothesis  to  account  for  these  cases,  I  should  say  that  there  was,  from 
his  suggestion,  either  verbal  or  inferred,  that  iheir  color-sense  would  be  modified 
by  warming  the  eye,  such  a  concentration  of  attention  on  this  special  faculty  on 
the  part  of  these  three  persons  that,  with  the  usual  intensification  of  single 
faculties  thus  excited  in  the  hypnotic  state,  their  latent  color-sense  was  excited 
into  action.  Their  total  color-blindness  can  be  regarded,  therefore,  as  only 
aggravated  psychic  dyschromatopsia  or  normal  slowness  of  color-perception. 


6o  H.  M.  BANNISTER. 

seemed  to  me  to  include  a  large  range  of  colors  from  scar- 
let, which  appeared  to  me  as  the  type,  to  certain  tints  that 
seemed  to  me  much  more  blue  than  red.  Indeed,  some  tints 
called  red  by  others  appeared  to  me  almost  typically  blue. 
I  have  no  recollection  of  ever  recognizing  purple  and  violet 
in  my  childhood,  and  I  do  remember  wondering  why  they 
were  called  anything  more  than  varieties  of  blue.  The  ex- 
ercise in  colors  which  I  gave  myself  taught  me  to  recognize 
purple  in  some  of  its  varieties  when  I  was  about  twenty-one 
years  of  age.  Shortly  after  this  I  had  occasion  to  make  a 
trip  by  water,  and  the  importance  of  the  recognition  of 
colored  signals  in  navigation  occurring  to  me,  I  took  pains 
to  notice  the  side-lights  of  vessels,  and  I  found  my  vision 
quite  defective.  I  also  noticed  particularly  that  while  at 
this  time  I  could  distinguish  purple  tints  if  I  gave  my 
attention  to  them,  I  had  a  very  strong  tendency  to  confuse 
them  with  the  blues.  I  also  noticed  the  variability  of  my 
color-sense  at  this  time.  I  cannot  say  just  when  the  change 
in  my  vision  occurred;  it  must  have  been  gradual,  but  at  the 
present  time  I  readily  distinguish  the  purples  and  violets, 
and  have  only  a  very  slight  tendency  to  confound  the  light- 
est and  least  saturated  of  them  with  the  blues,  excepting  at 
times  when  my  eye  for  colors  is  unusually  bad.  The  various 
tints  of  red  are  all  distinguishable  and  quite  different  in  ap- 
pearance to  what  they  were  formerly ;  this  is  especially  the 
case  with  the  crimsons  and  rose  tints.  Within  the  past  two 
years  I  have  repeatedly  tested  myself  with  colored  lights 
under  practical  conditions,  and  find  that  I  make  very  few, 
if  any,  mistakes.  There  seems,  in  fact,  to  be  a  very 
marked  improvement  in  my  color-vision  over  what  it  was 
formerly. 

It  may  be  said  ',by  objectors  that  my  present  ability  to 
distinguish  colors  that  I  formerly  confounded,  is  due,  not 
to  any  actual   improvement  or  change  in  my  power  to  per- 


SOME  POINTS  IN  REGARD  TO  COLOR-BLINDNESS.         6  [ 

ceive  them,  but  to  practice  with  light  and  shade.  All  I  can 
say  to  this  objection  is  that  any  such  assertion  is  not  true, 
if  I  am  to  take  the  testimony  of  my  own  consciousness, 
rather  than  accept  the  a  priori  assumptions  of  others,  who 
can  by  no  possibility  share  it.  I  perceive  light  and  shade  at 
once,  and  better,  I  think,  than  the  average  individual,  but 
the  difference  in  tint  between  two  colors  that  I  am  likely 
to  confuse,  such  as  very  pale  green  and  drab,  and  dark-yel- 
low green  and  certain  browns,  only  reveals  itself  to  my  eye 
slowly,  and  sometimes  only  after  careful  comparison,  the  il- 
lumination remaining  all  the  while  the  same. 

The  practical  importance  of  the  slighter  degrees  of  color- 
blindness, in  some  cases  at  least,  is  very  much  lessened,  if 
it  is  admitted  that  the  defect  is  located  in  the  higher  cen- 
tres of  the  brain  ;  that  it  amounts  in  some  instances  only  to 
a  functional  defect  of  cortical  cerebration,  to  be  compen- 
sated for  to  a  great  extent  by  mental  effort  and  attention  ; 
and  that  it  is  improvable  by  education  and  exercise.  The 
usual  test  employed  in  this  country  for  the  examination  of 
railway  employees  and  pilots,  that  of  Holmgren,  makes, 
however,  no  allowance  for  this  variety  of  color-defect.  Dr. 
Jeffries,  the  principal  authority  on  the  subject  in  this  coun- 
try, says,  in  his  directions  for  the  use  of  this  test,  referring 
to  the  colored  plate  accompanying  it  :  "  If  the  person  ex- 
amined takes  any  of  the  confusion  colors  (1-5)  to  put  with 
the  green,  he  proves  himself  color-blind  ;  or  even  if  he  seems 
to  want  to  put  them  together."  This  rules  out  all  hesita- 
tion, and  condemns  at  once  as  defective  any  one  who  ex- 
hibits any  uncertainty  requiring  mental  effort  or  com- 
parison. Holmgren's  test  has  the  advantage  of  detecting 
very  slight  abnormalities  of  color-vision,  but  it  also  has  the 
defect  of  exaggerating  them.  As  it  is  often  used  in  this 
country,  the  person  to  be  examined  is  required  to  select  out 
all  tints  and  shades  of  the  color  of  the  test  skein,  and  in  this 


62  H.   M.   BANNISTER. 

case,  if  it  is  not  supplemented  by  some  other  test,  it  is  lia- 
ble to  do  injustice.  There  are  many  persons  whose  vision 
for  colors  is  as  good  as  the  average,  who  still  have  idiosyn- 
crasies in  regard  to  the  relationship  of  colors  to  each  other, 
for  instance,  as  to  the  exact  limits  between  blue-greens  and 
greenish-blues,  yellow-greens  and  greenish-yellows,  etc.,  and 
without  going  so  far  as  to  say  with  Stilling,^  that  by  it  a 
perfectly  normal-eyed  person  may  be  made  out  color-blind, 
there  is  no  question  but  that  there  is  in  it,  when  thus  made, 
between  examiner  and  examinee,  a  very  large  chance  for 
erroneous  diagnosis.  Although  my  own  defect  is  now,  as 
nearly  as  can  be  ascertained  from  all  the  various  tests  em- 
ployed, a  slightly  feeble  or  retarded  perception  of  red  and 
green,  Holmgren's  test  No.  i,  thus  applied,  may  make  me 
out  as  completely  color-blind  as  the  man  who  has  no  per- 
ception or  sensation  of  red  and  green  whatever. 

When  we  consider  that  a  man's  whole  livelihood  may  de- 
pend upon  the  result  of  the  examination,  the  advisability  of 
avoiding  unnecessary  mistakes  is  sufficiently  obvious. 
Therefore,  Holmgren's  test  should,  I  claim,  be  always  care- 
fully supplemented  with  some  other  that  approaches  more 
nearly  the  practical  conditions  that  the  color-sense  must 
meet,  in  cases  of  incomplete  color-blindness.  Bonder's  test 
with  lights  seen  through  colored  media  in  apertures  of  vari- 
ous sizes,  appears  to  me  much  more  satisfactory  for  practical 
purposes  than  the  generally  employed  one  of  Holmgren. 

I  might  discuss  here  at  length  the  vision  of  the  color- 
blind, and  examine  the  claim  made  by  Mr.  Pole,  that  the 
red-blind  individual,  seeing  red  light  as  a  dark  saturated 
yellow,  could  yet  distinguish  it  from  the  green,  especially 
if  the  blue-green,  the  complementary  color  to  red,  and  the 
tint  advised  by  M.  Redard  in  a  recent  report  to  the  French 
government,  is  used  instead  of  the   manifold  tints  now  em- 

*  Ueber  das  Sehen  der  Farbenblinden,   p.  77. 


SOME  POINTS  IN  REGARD  TO  COLOR-BLINDNESS.         63 

ployed.  My  object  in  this  paper,  however,  has  been  to  no- 
tice the  psychic  element  in  partial  color-blindness  and  its 
necessary  consequence,  the  possibility  of  cure  or  modifica- 
tion of  the  defect.  The  following  conclusions  appear  to  me 
to  be  logically  justified  by  the  facts  : 

1.  Color-blindness,  when  partial  and  incomplete,  is,  in 
some  instances  at  least,  a  functional  defect  of  the  higher 
cortical  centres  concerned  in  sight.  It  amounts  in  some 
cases  to  merely  a  retardation  of  perception  of  certain  colors, 
and  may  be  compensated  for  to  some  extent  by  mental  ef- 
fort and  attention. 

2.  Inasmuch  as  this  form  of  color-defect  is  a  mental  one 
that  can  be  more  or  less  overcome  by  effort,  there  is  a  pos- 
sibility of  its  modification,  if  not  of  its  complete  cure,  by 
exercise  and  education,  as  it  is  the  rule  that  the  mental 
powers  are  improved  by  exercise.  Its  practical  importance 
is,  therefore,  somewhat  modified  by  this  fact. 

3.  Holmgren's  test,  while  revealing  very  slight  defects  of 
the  color-sense,  also  magnifies  them,  and,  as  usually  em- 
ployed in  this  country,  takes  no  account  of  this  mental  ele- 
ment. It  should,  therefore,  in  justice  to  the  examined,  be 
supplemented  in  all  cases  of  partial  color-blindness  by  other 
and  more  practical  tests. 


THE  NATURE  AND  TREATMENT  OF  HEAD- 
ACHES* 

By  J.   S.  JEWELL,   M.  D. 

GENTLEMEN  :  There  are  but  few  forms  of  disorder 
which  you  will  be  called  upon  more  frequently  to 
study  and  treat  in  the  practice  of  your  profession  than 
those  passing  under  the  general  name  headache.  In  this 
lecture  it  will  not  be  possible  to  treat  the  subject  ex- 
haustively. All  the  clinical  varieties  of  headache  cannot 
be  described  for  want  of  time.  Some  of  the  more  impor- 
tant forms  of  this  class  of  disorders  will  be  mentioned  with 
sufficient  fulness  to  enable  you  to  recognize  them,  and 
such  reference  to  their  treatment  will  be  made  as  time 
may  allov^ 

By  headache  (or  cephalalgia)  is  meant  pain  in  the  head, 
not  due  immediately  to  any  external  cause,  but,  on  the  con- 
trary, apparently  depending  on  some  internal,  and,  to  com- 
mon apprehension,  obscure  cause.  The  pain  in  headache 
may  be  persistent  or  occasional  ;  it  may  be  dull  or  lanci- 
nating;  it  may  be  steady  or  throbbing.  It  may  be  at- 
tended with  abnormal  heat  of  the  head  or  not.  It  may  be 
aggravated  or  ameliorated  by  either  the  upright  or  by  the 
recumbent  posture.  It  maybe  periodic  or  irregular;  it  may 
be  unilateral  or  bilateral,  and,  if  either,  it  may  be  regional, 
— that  is,  it  may  occupy  the  front,  or  vertex,  or  base  ;   or  it 

*  A  lecture  delivered  in  the  Chicago  Medical  College. 

64 


NATURE  AND   TREATMENT  OF  HEADACHES.  65 

may  be  general.  It  may  be  or  not  aggravated  by  mental 
or  physical  effort.  It  may  be  or  not  accompanied  by 
vertigo,  or  by  nausea,  or  by  decided  changes  in  vascular 
tension,  or  by  other  phenomena ;  all  of  which  points  are 
important  to  be  observed  and  studied  in  relation  to  each 
particular  case.  Headaches  differ  as  regards  their  nature, 
mode  of  origin,  and  proper  methods  of  treatment,  almost 
as  widely  as  possible. 

Your  success  in  treating  them  will  depend  of  course 
upon  your  ability  first  of  all  to  recognize  their  true  nature, 
and  next  upon  the  application  of  the  proper  remedies 
whether  hygienic  or  medical. 

Without  further  preliminary  I  will  name  and  describe  for 
practical  or  clinical  purposes  the  more  important  forms  of 
headache  with  which  you  are  likely  to  meet.  Then,  in  the 
first  place,  I  would  point  you  to  those  headaches  which  de- 
pend upon  disease  of  the  dura  mater.  Headaches  depend- 
ing upon  acute  but  much  more  frequently  subacute 
forms  of  disease  of  this  sensitive  membrane  are  very  much 
more  common  than  is  ordinarily  supposed.  It  is  subject  to 
various  affections.  Disease  may  be  caused  in  it  by  the 
extension  to  it  of  diseases  of  the  bones  of  the  skull,  such  as 
result  from  injuries  of  various  kinds,  produced  in  falls  on 
the  head,  or  by  blows,  or  by  all  kinds  of  mechanical  injury. 
Affections  of  the  dura,  which  are  accompanied  by  pain, 
may  occur  suddenly  or  in  varying  periods  of  time,  months 
or  even  years  after  an  injury. 

Affections  of  the  dura  may  be  caused  by  various  consti- 
tutional conditions,  as  by  the  deposit  of  tubercular  matter, 
especially  along  the  course  of  its  vessels,  or  by  rheumatic 
action,  and  especially  by  syphilis.  Essentially  the  same 
form  of  disorder  as  that  which  appears  in  the  periosteum  of 
the  bones  may  affect  the  dura,  giving  rise  to  low  grades  of 
inflammation  accompanied  by  pain.     It  sometimes  follows 


66  y.  S.   JEWELL. 

in  the  wake  of  sunstroke,  severe  exposures  to  cold,  or 
arises  from  the  extension  of  disease  from  the  nasal  to  the 
cranial  cavity,  through  the  cribriform  plate  of  the  ethmoid 
bone,  or  from  the  middle  ear  as  in  otitis  media.  Affec- 
tions of  the  dura,  accompanied  by  pain  from  unknown 
causes,  may  occur,  as  happens  in  epidemic  cerebro-spinal 
meningitis. 

Various  other  forms  of  disease  either  of  the  bones  of  the 
skull  or  of  the  dura,  in  the  way  of  tumors  or  growths  of 
various  kinds,  may  lead  to  affections  of  the  dura  of  a  pain- 
ful nature.  The  Pacchionian  bodies  may  themselves  be  the 
starting-points  of  inflammatory  disorder  of  varying  degrees 
of  acuteness  accompanied  by  pain.  Disease  of  the  brain  or 
of  the  sinuses  at  its  base  may  be  the  starting-points  for 
painful  affections  of  the  dura.  In  this  connection  it  is  nec- 
essary to  remember  that  painful,  especially  inflammatory 
affections  of  this  membrane  are,  as  a  rule,  localized  rather 
than  general.  Small  patches  of  the  membrane  may  be  the 
seats  of  disease,  either  in  that  part  of  the  membrane  which 
covers  the  floor  or  base  of  the  skull,  or  its  sides,  or  the  ver- 
tex, or  may  be  limited  to  one  side,  as  so  frequently  is 
observed.  It  is  the  exception  to  have  a  general  meningitis. 
Painful  affections  of  the  dura  may  occur  at  all  ages,  from 
infancy  to  the  latest  period  in  life.  They  generally  occur, 
however,  during  later  childhood,  youth,  and  the  middle 
periods  in  life. 

I  desire  next  to  call  your  attention  to  the  peculiar  char- 
acteristics of  the  pain  depending  upon  acute  or  subacute 
affections  of  the  dura.  The  headache  which  results  from 
acute,  but  much  more  often  from  subacute,  affections 
of  the  dura  is,  in  the  first  place,  more  or  less  definitely 
localized.  This  is  not  always  the  case,  but  such  is  the  rule. 
In  the  second  place,  the  pain  continues  to  occupy  the  same 
part  of  the  head.     It  does   not  shift  from   place  to  place  as 


NATURE  AND  TREA  TMENT  OF  HEADACHES.  67 

it  does  in  many  of  the  circumscribed  pains  of  neuralgia.  In 
the  third  place,  the  headache  which  results  from  the  dis- 
orders now  under  consideration  is  persistent.  Unlike  the 
pain  in  many  other  forms  of  headache,  it  seldom  entirely 
ceases  long  at  a  time  so  long  as  the  meningitis  continues. 
It  seldom  begins  suddenly  ;  as  a  rule,  gradually.  It  almost 
never  disappears  suddenly,  but,  as  a  rule,  slowly.  It  is  gen- 
erally aggravated  by  anything  which  increases  the  activity 
of  the  intracranial  circulation.  It  is  aggravated  by  shocks 
to  the  head.  It  is  not  relieved  in  assuming  the  lying-down 
posture.  It  is  aggravated  when  the  head  is  permitted  to 
hang  down.  As  a  rule,  it  is  made  worse  by  increased 
barometric  pressure,  and  by  the  sudden  occurrence  of  cold 
weather,  or  by  exposures  of  the  surface  to  cold  by  which 
the  cutaneous  vessels  are  contracted,  or  by  any  other 
means  by  which  vascular  tension  is  increased,  or  by  any 
means  by  which  the  cutaneous  circulation  is  diminished  in 
activity  or  repressed.  It  is  occasionally  throbbing  in  char- 
acter where  cardiac  pressure  and  activityare  increased.  It 
is  accompanied  generally  by  more  or  less  mental  depression, 
and  by  nervous  irritability,  discouragement,  and  disinclina- 
tion for  mental  and  physical  labor.  Such  are  the  more 
prominent  signs  of  this  form  of  headache.  It  is  rarely, 
though  sometimes  it  is,  accompanied  by  nausea.  It  may  or 
may  not  be  accompanied  by  increased  temperature  of  the 
head,  though  it  very  frequently  is  by  an  increase  of  temper- 
ature in  that  part  of  the  scalp  or  skull  which  corresponds  to 
the  site  of  internal  disease.  This  depends  greatly,  however, 
upon  the  seat  or  degree  of  acuteness  of  the  disease. 

This  form  of  headache  may  be  complicated  or  even  in  a 
measure  obscured  by  others,  for  it  is  not  uncommon  to 
meet  with  complex  cases.  Headache  of  the  kind  I  have 
just  described  is  not  only  persistent,  but  difificult  to  re- 
move by  treatment.      The   management   which   has   been 


68  y.  S.   JEWELL. 

most  effective  upon  the  whole,  in  my  experience,  is  the  fol- 
lowing : 

In  the  first  place  it  is  necessary  for  the  patient  to  be  kept 
as  quiet  as  possible.  Loud  noises,  bright  lights,  exciting 
circumstances  of  any  or  all  kinds,  as  far  as  possible,  are  to 
be  avoided.  All  exercise,  whether  physical  or  mental,  ex- 
cept the  most  moderate,  should  be  avoided.  It  is  best  for 
the  patient  to  be  separated  from  company,  and,  if  practica- 
ble, confined  to  the  room  and  to  the  bed.  If  taken  out-of- 
doors,  it  is  best  for  the  patient  to  walk  quietly  or  ride  in  an 
easy  conveyance,  so  as  to  avoid  excitations  and  fatigue. 
The  diet  should  be  very  unstimulating,  and,  though  nutri- 
tious, simple  in  kind  and  very  moderate  in  quantity.  All 
disturbance  of  the  stomach  should  be  avoided.  If  an  un- 
due amount  of  acid  should  appear  in  the  stomach,  it  should 
be  immediately  neutralized.  The  bowels  should  be  kept 
entirely  free.  If  there  is  irritation  of  the  bladder,  measures 
should  be  taken  to  allay  it.  All  sexual  indulgence  or  ex- 
citement should  be  avoided.  All  the  sleep  that  can  be  se- 
cured should  be  had.  The  patient  should  sleep  upon  a 
gently  inclined  plane  formed  by  putting  blocks  of  wood  un- 
der the  headposts  of  the  bed,  from  four  to  eight  inches  in 
height.  By  this  means  the  blood  is  made  to  gravitate  away 
from  the  head  and  relief  is  obtained.  A  warm  climate 
should  be  secured  rather  than  a  cold  one.  By  this  means  a 
free  circulation  of  blood  in  the  surface  is  more  easily 
maintained.  A  climate  situated  some  distance  above  the 
sea  level  where  barometric  pressure  is  habitually  low,  is  bet- 
ter than  at  the  sea  level,  and  in  general,  a  warm,  steady 
climate  is  most  favorable.  The  surface  should  be  thor- 
oughly protected  from  exposures  to  cold  air.  Alcoholic 
stimulants  and  strong  coffee  and  tea,  as  a  rule,  .should  be 
avoided  in  this  form  of  headache.  Protracted  hot  foot 
baths  are  in  order. 


NATURE  AND   TREATMENT  OF  HEADACHES.  69 

As  regards  medical  treatment,  much  depends  upon 
the  stage  and  conditions  of  the  disorder,  and  in  gen- 
eral, it  may  be  said  that,  from  the  epidemic  cerebro- 
spinal meningitis  down  to  an  ordinary  localized  sub- 
acute pachymeningitis,  one  of  the  best  remedies,  as 
well  as  palliatives,  is  opium,  either  in  the  watery  pillular 
extract  or  the  deodorized  tincture.  In  this  class  of  cases 
these  preparations  of  opium  are  to  be  preferred  to  any 
others.  The  opium  should  be  given  in  doses  of  such  size 
and  frequency  as  to  subdue  the  pain,  and  continued  until, 
in  conjunction  with  other  measures,  the  pain  subsides,  when 
the  use  of  the  anodyne  may  be  gradually  withdrawn.  Side 
by  side  with  this,  it  is  necessary  to  employ  large  doses  of 
the  iodide  of  potassium.  For  an  adult,  ten  grains  may  be 
given  three  times  a  day  to  begin  with.  Each  day  the  dose 
may  be  augmented  by  five  grains,  until  decided  evidences 
are  given  that  the  remedy  has  produced  results.  If  duly 
diluted  with  water  from  fifty  to  one  hundred  grains  may  be 
given  three  times  a  day,  if  necessary.  In  connection  with 
this,  more  especially  if  the  disorder  is  syphilitic  in  origin, 
inunctions  of  mercury  may  be  employed.  For  this  purpose 
the  oleate  is  to  be  preferred.  Ten  grains  of  the  stronger 
oleate  to  an  ounce  of  cosmoline,  which  may  have  an  agree- 
able odor  imparted  to  it  by  a  di'op  or  two  of  the  oil  of  roses, 
if  thoroughly  mixed,  makes  an  eligible  form  for  the  inunc- 
tion, which  may  be  employed  once  or  twice  daily,  until  the 
effect  of  the  mercury  is  unmistakably  perceived.  Counter- 
irritation  behind  the  ears  and  along  the  back  of  the  neck  by 
means  of  the  actual  cautery  or  by  blistering  collodion  I  have 
found  useful. 

Under  this  treatment,  in  the  course  of  a  few  days  or  at 
most  a  few  weeks,  the  pain  abates.  In  the  later  progress 
of  the  case  tonics,  such  as  acid  solutions  of  strychnia  and 
quinine,  may  be  given,  according  to  the  exigencies  of  the 


J*^  y.  S.   JEWELL. 

case.  Such  is  an  outline  of  the  management  of  headaches 
depending  on  meningitis  either  general  or  localized.  In  the 
progress  of  different  cases,  many  other  points  will  arise  re- 
quiring attention,  but  these  need  not  be  discussed  at 
present. 

In  the  second  place  I  wish  to  call  your  attention  to  head- 
aches of  the  vaso-niotor  type. 

This  class  is  the  widest  and  most  important  of  all.  It 
includes  two  features :  abnormal  sensitiveness  of  certain 
parts  of  the  nervous  system,  and  violent  fluctuations  in 
blood  supply,  especially  in  certain  parts  of  the  nervous  sys- 
tem. It  may  be  divided  at  once  into  two  grand  classes : 
First,  the  pure  migraine  or  hemicrania,  which  recurs  at 
more  or  less  regular  intervals  and  is  capable  of  hereditary 
transmission.  Secondly,  a  class  of  headaches  in  healthy 
persons  that  depend  on  vaso-motor  disorders  which  follow 
in  the  wake  of  digestive  affections,  loss  of  sleep  and  a  vari- 
ety of  other  circumstances  which  recur  irregularly,  are  easily 
cured  by  removing  or  avoiding  their  causes,  and  are  not 
transmissible  by  heredity. 

I  will  direct  attention  first  to  the  true  migraine  or  hemi- 
crania. These  headaches  recur  at  more  or  less  regular 
intervals,  say  once  in  one  or  two  weeks,  or  in  a  month. 
The  intervals  are  sometimes  longer.  In  a  few  instances 
they  exhibit  a  true  periodicity.  The  intervals  between  the 
attacks  are  usually  free  from  pain.  They  occur,  as  a  rule, 
in  persons  having  a  decidedly  nervous  or  neuro-sanguine 
temperament.  They  are  most  frequently,  perhaps,  con- 
fined to  one  side  of  the  head,  especially  in  that  part  which 
lies  in  front  of  a  line  drawn  over  the  top  of  the  head  from 
one  ear  to  the  other.  They  may,  however,  affect  both 
sides  of  the  head  simultaneously,  in  the  front  or  top,  or  in 
the  occiput  and  base,  or  they  may  be  generalized.  They 
seldom    begin    suddenly,  generally  with   initial    symptoms 


NA  TURE  AND  TREA  TMENT  OF  HE  AD  A  CHES.  7  I 

which  vary  in  different  cases.  In  the  majority  of  instances 
there  are  certain  gastric  symptoms,  such  as  variations  from 
the  ordinary  character  of  the  appetite,  generally  some  loss 
of  the  same,  a  coated  tongue,  the  coat,  as  a  rule,  being  of 
the  white  epithelial  sort.  There  is  often  nausea,  mental  de- 
pression, occasionally  vertigo,  disinclination  for  mental  or 
physical  labor  in  a  majority  of  cases,  chilliness,  coolness 
of  the  extremities,  abnormal  variations  in  vascular  ten- 
sion, increased  sensitiveness  of  the  vaso-motor  reflexes, 
sometimes  a  pallid  face  and  cool  surface,  at  other  times  a 
flushed  face  with  elevated  temperature  about  the  head,  and 
if  confined  to  one  side  of  the  head  there  is  often  a  marked 
change  in  vascularity  in  the  skin  and  conjunctiva,  state  of 
the  pupil,  etc.,  on  the  affected  side.  In  true  hemicrania 
there  are  at  least  two  particular  varieties  as  distinguished 
by  superficial  symptoms.  The  one  noticed  first,  perhaps, 
by  DuBois  Reymond  in  which  there  is  pallor  and  coldness 
of  the  skin  on  the  affected  side  of  the  head,  with  a  local  in- 
crease in  vascular  tension,  which  form  passes  under  the 
name  given  it  by  the  author  just  mentioned, — hemicrania, 
sympathicO'tonica  ;  and  the  other  in  which  there  is  in- 
creased redness  and  an  elevated  temperature  in  the  skin  of 
the  affected  side  of  the  head.  This  variety  was  first  de- 
scribed by  Moellendorf  under  the  title  of  heinicrania  neuro- 
paralytica.  There  are  other  cases  in  which  there  does  not 
seem  to  be  any  change  from  a  healthy  average  in  vascular- 
ity or  temperature.  These  varieties  have  only  a  superficial 
importance,  and  in  my  judgment  deserve  nothing  more 
than  a  passing  notice.  When  the  attack  is  once  ushered  in 
the  pain  is  usually  very  severe.  As  a  rule  it  unfits  the  suf- 
ferer for  all  occupation.  The  pain  is  often  of  a  throb- 
bing character,  the  throbbing  corresponding  to  cardiac  im- 
pulses. This  is  a  significant  fact  as  I  will  try  to  show  you 
later.     The  patient,  as  a  rule,  retires  to  the  quiet  of  the  bed- 


72  J.   S.   JEWELL. 

chamber,  lies  down,  closes  the  eyes,  avoids  as  far  as  possi- 
ble every  cause  for  excitement  or  annoyance,  endeavors  to 
secure  the  most  perfect  mental  and  physical  quietude  un- 
til relief  shall  come. 

In  the  vast  majority  of  cases  there  is  more  or  less  pro- 
nounced nausea,  and  in  many,  vomiting.  Asa  rule  nothing 
is  ejected  from  the  stomach,  aside  from  the  food  which  may 
happen  to  be  present,  or  a  little  acid  mucus  at  times  tinged 
with  bile.  In  many  cases  the  attacks  of  vomiting  are  re- 
peated and  exceedingly  distressing  in  character  ;  the  pain 
meanwhile  may  be  almost  unbearable.  In  the  majority  of 
cases  there  are  rigors  or  decided  chilly  spells,  and  in  a  few 
instances,  in  the  middle  and  later  stages  of  the  attack,  some 
fever.  As  might  be  expected,  from  what  has  been  said,  the 
force  of  the  pulse  is  often  diminished  and  its  rapidity  vari- 
able. 

Such  are  the  more  important  surface  symptoms  belong- 
ing to  this  class  of  headaches.  They  occur  in  both  sexes, 
more  frequently  perhaps  in  the  female,  especially  just  be- 
fore the  occurrence  of  or  during  the  menstrual  period. 
These  headaches  appear  more  frequently  from  later  child- 
hood until  about  or  after  the  close  of  the  middle  period  in 
life.  In  some  instances,  however,  they  may  occur  in  quite 
young  children  or  continue  into  old  age. 

There  are  certain  points  in  regard  to  this  class  of  head- 
aches to  which  especial  attention  should  be  directed.  In 
the  first  place,  it  is  to  be  noticed  that  in  the  majority  of 
cases,  during  the  interval  between  attacks,  the  individual  is 
absolutely  free  from  headache.  In  many  instances  the 
health  seems  perfect,  except  during  or  about  the  time  of 
the  attack.  In  the  second  place,  it  is  to  be  noticed  that 
such  cases  always  involve  circulatory  disorder.  At  least,  so 
far  as  my  own  observation  extends,  this  is  true.  In  the 
third  place,  it  is  to  be  observed  that  they  occur  almost  en- 


NA  TURK  AND  TREA  TMENT  OF  HEADACHES.  73 

tirely  within  the  sphere  of  the  trigeminus,  especially  its 
upper  division,  that  is,  the  part  which  is  distributed  to  the 
orbit — its  deep  temporal  branches, — but  above  all  others  the 
pain  appears  to  have  its  peripheral  seat  in  those  branches  of 
the  nerve  in  question  distributed  to  the  dura.  In  the  fourth 
place,  all  measures  for  relief,  whether  hygienic  or  medical, 
which  have  led  to  good  results  so  far  as  palliation  is  con- 
cerned, are  almost,  without  exception,  such  as  diminish  or 
remove  excitation,  blunt  the  pain  sense,  and  steady  and 
equalize  the  action  of  the  vascular  system.  Any  measure 
adopted  by  which  these  results  are  secured  usually  leads  to 
good  results.  And  lastly,  it  is  worthy  of  note  that  the 
affection  is  capable  of  hereditary  transmission. 

All  these  points  should  be  inquired  after  in  the  history 
of  the  case.  Without  occupying  time  in  discussing  the 
various  steps  in  the  process  of  reasoning  by  which  the  con- 
clusions have  been  reached,  I  may  say  to  you  at  once  that 
two  points  are  made  rather  clear  in  the  analysis  of  facts. 
One  is,  that  there  fs  an  abnormal  increase  in  the  pain  sense 
in  certain  divisions  of  the  trigeminus,  and  second,  the  oc- 
currence of  certain  violent  vaso-motor  disorders  in  the  limits 
of  the  same  parts.  It  is  difficult,  perhaps  impossible,  in  view 
of  our  present  knowledge  of  the  structure  and  modes  of  ac- 
tion of  the  nervous  system,  to  understand  how  these  head- 
aches can  occur  and  be  limited  strictly  to  certain  parts  of 
the  nervous  system,  without  admitting  an  exaltation  of  the 
pain  sense,  in  the  parts  involved  in  disease,  as  the  necessary 
undertone  or  background  of  the  morbid  picture.  All  ex- 
tended reasoning  on  the  facts  of  the  case  seems  to  make 
some  such  conclusion  necessary. 

In  connection  with  this  it  is  to  be  noticed  that  individu- 
als who  suffer  from  this  form  of  headache  have  usually 
what  is  called  a  nervous  temperament,  in  which  the  sensi- 
bilities  of   the   nervous   system    are,  as   a   whole,  morbidly 


74  7-  S.   JEWELL. 

acute.  They  are  found  often  to  have  an  unfortunate 
hereditary  strain  or  bias.  The  parents  have,  one  or  both, 
been  afBicted  with  sinailar  headaches,  or  with  neuralgias, 
melancholias,  paralyses,  or  some  other  nerve  disorders. 

The  real  seat  of  the  organic  affection  upon  which  the  ex- 
altation of  the  pain  sense  depends,  is  the  nerve  centre,  or 
that  portion  of  the  trigeminal  nucleus,  back  to  which  the 
nerve  fibres  go  which  are  distributed  in  the  neuralgic  area. 
It  is  not  in  the  nerve  trunks  themselves  distributed  to  the 
dura. 

The  organic  condition  of  the  portion  of  the  trigeminal 
nucleus  in  question  is,  probably,  much  the  same  as  it  is  in 
ordinary  trigeminal  neuralgias  of  long  standing,  and  in 
which  it  often  happens  that  a  touch  on  the  skin  of  the  face, 
or  the  play  of  a  current  of  air  on  the  same,  is  sufficient  to 
provoke  a  severe  neuralgic  attack. 

The  abnormal  exaltation  of  the  pain  sense  being  given 
as  a  more  or  less  constant  factor,  the  exciting  causes  of  the 
attacks  are  sudden  and  violent  fluctuations  in  blood  supply 
in  certain  parts  of  the  affected  regions. 

In  one  class  of  these  cases  of  hemicrania,  DuBois  Rey- 
mond  supposed  that  the  pain  is  due  to  contraction  of  the 
arterial  walls  of  the  temporal  artery  and  its  branches.  The 
contraction,  in  his  opinion,  gave  rise  to  pinching  or  some 
similar  condition  of  the  nerve  distributed  to  the  vessels, 
and  hence  the  pain.  In  the  opinion  of  Moellendorf,  the 
pain  was  due,  not  to  contraction,  but  to  distension  of  the 
vessels  in  the  same  region.  Distension  of  the  blood-vessels 
led  to  painful  stretching  or  tension  of  nerves  in  the  affected 
region,  and  hence  the  pain. 

As  I  have  said  to  you  already,  there  are  many  cases  in 
which  neither  of  these  conditions  are  present  in  noticeable 
degree,  and  yet  the  pain  exists.  It  cannot  always,  there- 
fore, depend  upon  the  conditions  of  the  external  circulation 


NATURE  AND   TREATMENT  OF  HEADACHES.  75 

mentioned  by  these  observers.  But  they  may  well  cause 
certain  attacks,  when  it  is  remembered  how  fluctuations  in 
blood  supply  cause  pain  in  other  parts.  If  a  foot  or  a  hand 
is  permitted  to  hang  down  when  inflamed,  or  when  the 
head  is  hung  down  during  the  existence  of  some  acute  or 
painful  intracranial  affection,  the  change  in  vascular  tension 
gives  rise  to  acute  pain.  Local  changes  in  vascular  tension, 
though  produced  by  local  vaso-motor  irregularities  instead 
of  by  changes  in  posture,  if  the)'  occur  in  an  area  the  nerves 
of  which  lead  back  to  a  painfully  sensitive  centre,  may  in 
this  way,  as  readily  as  in  any  other,  be  the  occasion  of 
pain. 

It  is  probable,  however,  that  the  seat  of  these  extreme 
vascular  changes  is  chiefly  intracranial, — in  certain  portions 
of  the  dura  itself,  or,  it  may  be,  in  the  hyperalgic  centre  it- 
self. All  this  may  be,  and  yet  similar  morbid  circulatory 
phenomena  be  at  times  manifested  externally  as  well  as  in- 
ternally. 

Then,  again,  it  is  found  that  many  forms  of  pain,  es- 
pecially what  are  called  weather  pains,  depend  upon 
changes  in  barometric  pressure,  which,  in  their  turn,  im- 
ply changes  in  vascular  pressure.  If,  in  any  case,  there 
should  exist  in  the  central  nervous  system,  as,  for  example, 
at  the  central  termination  of  the  trigeminus,  some  weakened 
vascular  area,  there  is  almost  uniformly  augmented  pain  as 
a  result  under  the  conditions  mentioned. 

It  is  also  well  known  that  in  the  head  itself,  as  well  as  in 
other  parts,  every  heart-throb  often  gives  rise  to  an  in- 
crease in  pain,  which  continues  during  the  existence  of  the 
cardiac  impulse,  and  terminates  with  it.  All  these  and 
other  facts  go  to  show  that  more  or  less  violent  or  sudden 
changes  in  vascular  pressure  give  rise  to  increased  pain,  and 
by  parity  of  reasoning,  may  give  rise  to  pain  where  it  had 
not  existed  before.     This  class  of  cases  presupposes  an  in- 


^^  y.  S.  JEWELL. 

herited  or  at  least  a  morbid  facility  in  particular  zones  of 
the  vaso-motor  nerve  apparatus  to  irregularities  in  action. 
This  condition  of  affairs  is  observed  in  certain  other  disor- 
ders, chief  among  which  is  epilepsy.  The  chief  difference 
between  migraine  and  epilepsy,  it  has  long  seemed  to  me, 
is  this  :  The  vaso-motor  disorders  are  the  same  in  kind,  but 
do  not  occur  in  the  same  regions. 

The  one  in  epilepsy  occurs  in  the  cortex  of  the  brain,  and 
hence  leads  to  a  disturbance  or  to  a  loss  of  consciousness, 
accompanied  usually  by  certain  morbid  muscular  phenom- 
ena. The  same  kind  of  a  disorder,  or  one  similar,  however, 
occurs  in  migraine,  but  in  a  quite  different  region.  The 
dura  and  that  part  of  the  trigeminal  nucleus  back  to  which 
fibres  from  the  dura  extend,  appear  to  me  to  be  the  chief 
seats  of  disorder. 

The  cortex  itself  is  not  involved,  at  least  not  to  any  con- 
siderable extent.  For  a  long  time  various  observers  have 
noted  the  close  relation  which  exists  between  migraine  and 
epilepsy.  That  relation  appears  to  me  to  be  the  one  to 
which  I  have  just  referred.  The  disorders  are  the  same, 
but  occupy  different  horizons  in  the  central  and  periph- 
eral nervous  system.  The  disorder  in  question  may 
extend  in  one  direction  so  as  to  produce  an  epilepsy 
in  another  so  as  to  produce  a  migraine,  or  finally  to 
produce  both  in  the  same  case,  as  I  have  frequently 
observed.  So  much,  then,  for  those  vaso-motor  head- 
aches, which  depend  principally  or  chiefly  upon  an  un- 
stable state  of  certain  parts  of  the  nervous  system.  Of 
course  the  vaso-motor  action  is  reflex,  and  its  occurrence 
depends  less  upon  the  exciting  than  upon  the  predisposing 
causes.  The  latter  preponderate.  What  the  causes  of  peri- 
odicity are,  why  a  patient  remains  well  for  a  month  and 
then  has  a  severe  attack  of  migraine,  and  then  recovers  and 
appears  perfectly  well  for  a  season,  and  so  on,   I  do    not 


NATURE  AND   TREATMENT  OF  HEADACHES.  77 

know.  If  any  one  else  knows  these  things  I  have  yet  to 
learn  who  does. 

I  now  pass  to  the  consideration  of  that  class  of  cases 
in  which  the  exciting  causes  appear  to  be  the  particular 
subjects  for  consideration,  and  without  the  existence  of 
which,  in  some  abnormal  degree,  the  headaches  would  not 
occur. 

In  the  class  of  cases  just  described  the  exciting  causes  are 
comparatively  slight  ;  in  the  class  now  to  be  described  they 
are  all  important.  In  the  class  of  cases  now  to  be  described 
there  is  of  necessity  no  morbid  facility,  whether  hereditary 
or  acquired,  toward  irregular  vaso-motor  action.  But  there 
are  exciting  causes,  such  as  irritative  disorder  of  the  ali- 
mentary or  generative  systems,  excitations  from  which 
important  regions  finally  lead  to  irregularities  in  vaso- 
motor action  within  the  head.  Of  this  class  of  cases  the 
following  particulars  are  to  be  observed  :  In  the  first  place 
they  are  never,  except  by 'accident,  periodic.  In  the  second 
place  they  are  almost  never  unilateral  but  bilateral,  and  are, 
as  a  rule,  perhaps  general  rather  than  local.  In  the  third 
place,  as  a  rule,  they  are  not  very  acute.  In  the  fourth 
place  they  are  seldom  connected  with  nausea,  and  in  the 
fifth  place  they  nearly  always  follow  in  the  wake  of  over- 
exertion, errors  in  diet,  indigestion,  constipation,  loss  of 
sleep,  etc.,  in  an  otherwise  healthy  person.  If  they  arise 
from  digestive  disorder  they  are  usually  frontal ;  if  from  un- 
usual mental  exertion,  they  are  either  vertical  or  frontal ; 
but  if  from  disorder  of  the  generative  organs,  they  are  usu- 
ally perhaps  occipital  or  basilar.  This  class  of  headaches 
may  therefore  be  traced  usually  to  overwork,  undue  anxiety, 
loss  of  sleep  and  in  other  ways,  by  reason  of  which  con- 
ditions the  brain  or  certain  of  its  parts  become  and  remain 
hyperaemic.  Under  such  circumstances  persistence  in  men- 
tal labor  or  excitement  only  increases  the  congestion  which, 


78  y.   S.    JEWELL. 

it  is  presumed,  is  the  cause  of  the  headache  in  connection 
with  an  irritable  state  of  the  brain. 

Then  certain  disorders  of  the  digestive  system,  such  as 
overloading  the  stomach  with  indigestible  food,  gastric 
catarrh,  serious  constipation,  and,  as  results,  irritation  of  the 
alimentary  tract,  exhaustion  from  overwork  in  various 
ways,  including  losses  of  sleep,  and  finally  genito-urinary 
disorders,  more  particularly  in  women,  lead  to  the  headaches 
now  under  consideration.  The  mechanism  of  this  class  of 
headaches  appears -to  be  as  follows  :  There  is  first  of  all,  ex- 
cept when  a  result  of  over  brain  work,  a  temporary  irrita- 
tive or  over-sensitive  state  either  of  the  nervous  system  as 
a  whole,  or  of  some  parts  of  the  brain  in  particular.  In  the 
next  place,  within  these  irritable  zones  there  are  rather  vio- 
lent fluctuations  in  blood  supply  especially  tending  toward 
congestions.  The  temperature  of  the  head,  as  a  rule,  is  ele- 
vated in  this  class  of  cases.  These  circulatory  disturbances 
are  produced  by  means  of  irritation  or  excitations,  more 
particularly  in  certain  peripheral  tracts,  such  as  the  mucous 
membrane  of  the  stomach  or  the  membrane  just  below  it. 
Gastro-duodenal  catarrhs  are  especially  liable,  in  connection 
with  dyspepsias,  to  which  they  give  rise,  to  produce  vascu- 
lar disturbances  in  the  brain  and  about  the  head  just  re- 
ferred to.  Next  in  order  are  chronic  affections  of  the  lower 
intestine,  especially  of  either  extremity,  as  about  the  caecum 
or  the  sigmoid  flexure  ;  catarrhal  disorders  of  the  mucous 
membrane  of  these  portions  of  the  colon,  especially  if  ac- 
companied by  constipation  in  the  course  of  which  masses  of 
faecal  matter  accumulate  in  the  colon  to  irritate  by  their 
presence  the  diseased  membrane.  Then,  in  a  large  number  of 
cases  of  disease  of  the  neck  of  the  womb  which  is  very  sen- 
sitive, and  in  irritative  affections  of  the  ovaries,  headaches 
arise  of  the  kind  just  described,  particularly  at  the  time  of 
the  menstrual  period.   In  this  class,  the  headaches,  as  already 


NA  TURE  AND   TREA  TMENT  OF  HEADACHES.  79 

said,  do  not  depend  upon  hereditary  tendency  to  such  dis- 
orders, but  upon  the  strength  and  duration  of  the  exciting 
causes.  It  is  this  class  of  headaches  which  are  relieved  by 
emetics,  by  abstinence  from  food,  by  brisk  purgatives  of 
various  kinds,  by  the  passage  of  the  menstrual  period,  by 
cessation  from  work,  by  rest,  etc.  A  careful  examination 
of  the  history  of  a  case  belonging  to  this  class  of  headaches 
will  usually  lay  bare  the  morbid  condition  which  plays  the 
part  of  exciting  cause  and  upon  the  removal  of  which  the 
cure  of  the  headache  depends.  After  the  description  and 
explanations  just  given  of  the  great  group  of  headaches 
which  have  been  classed  as  vaso-motor,  I  will  call  your 
attention  to  their  treatment. 

(To  be  Continued.) 


MICROSCOPIC     STUDIES     ON     THE     CENTRAL 

NERVOUS    SYSTEM    OF    REPTILES   AND 

BATRACHIANS. 

By  JOHN  J.   MASON,   M.  D., 

NEWPORT,    R.    I. 

ARTICLE    III. 

DIAMETERS    OF    THE    NUCLEI    OF    THE    LARGE  NERVE  CELLS  IN  THE 

SPINAL    CORD    {co/jtinued),    ALSO    OF    THOSE    WHICH     GIVE 

ORIGIN     TO      THE     MOTOR     FIBRES     OF      THE 

CRANIAL    NERVES. 

SINCE  writing  article  II  of  this  series,  I  have  met  with 
nothing  which  could  fairly  be  regarded  as  an  objec- 
tion to  the  law  then  presented,  but  have,  on  the  contrary, 
noted  many  new  facts  which  tend  to  strengthen  it  and 
widen  its  application.  Nuclei  which,  by  means  of  the  pro- 
longations of  their  surrounding  cell  masses,  are  related  to 
muscles,  have  been  carefully  measured  throughout  the 
entire  nervous  system. 

Scattered  cells,  like  those  found  singly  or  in  pairs  near 
the  course  of  the  abducens  nerve,  with  those  which  I  have 
elsewhere  described  as  existing  in  the  meshes  of  the  raphe 
of  the  alligator,  and  certain  large  cells  in  lizards,  serpents, 
and  turtles  which  appear  to  be  connected  with  the  acoustic 
or  facial  nerves,  may  all  be  classed  as  of  doubtful  function. 
Although  the  diameters  of  their  nuclei  may  in  some  cases 
seem  to  furnish  exceptions  to  the  rule,  so  long  as  their 
anatomical  relations  remain  obscure  nothing  can  be  defi- 
nitely afifirmed  about  them  in  this  connection. 

80 


NERVOUS  SYSTEM  OF  REPTILES  AND  BATRACHIANS.  8  I 

I  would  suggest,  however,  to  those  who  may  feel  dis- 
posed to  regard  these  cells  as  connected  with  the  sense  of 
hearing,  that  such  a  view  involves  giving  to  this  apparatus, 
in  its  central  portion,  a  structure  almost  identical  with  one 
universally  admitted  to  be  motor,  like,  for  example,  that 
concerned  in  raising  the  lower  jaw  ;  whereas  in  the  central 
structures  for  vision  and  olfaction  the  cells  are  all  very 
small. 

Moreover,  these  large  cells,  found  in  the  vicinity  of  the 
acoustic  nerve  in  some  lizards,  turtles  and  serpents,  are  not 
found  at  all  in  the  frog,  while  in  the  alligator  their  posi- 
tion indicates  that  they  may  be  related  to  the  motor 
branch  of  the  fifth  pair  or  possibly  to  the  branch  which 
supplies  the  depressor  muscles  of  the  lower  jaw.  The  em- 
inentia  acoustica  in  the  latter  animal  swarms  with  uniformly 
small  cells  and  nuclei  which  are  very  probably  the  sole  cen- 
tres for  the  acoustic  nerve,  and  in  the  same  relative  plane 
the  same  numerous  groups  of  small  cells  can  be  seen  in 
frogs  and  some  lizards. 

During  the  past  summer,  through  the  kindness  of  Prof. 
S.  F.  Baird,  of  the  Smithsonian  Institution,  quite  a  num- 
ber of  valuable  specimens  have  been  placed  at  my  dis- 
posal, among  which  may  be  mentioned  Heloderma  Suspec- 
tum,  several  serpents  and  one  large  example  of  Chelydra 
Serpentina. 

Nuclei  of  the  cells  of  the  inferior  (anterior)  horns  of  the 
caudal,  lumbar,  dorsal,  cervical  and  upper  cervical  regions 
of  the  spinal  cord,  in  a  large  number  of  frogs  of  three 
species,  two  species  of  emys  and  two  of  land  turtles,  and 
in  several  alligators  and  lizards,  including  heloderma, 
have  been  measured.  Of  those  found  in  the  cervical  and 
lumbar  enlargements  enough  has  been  written  already  in 
the  two  preceding  papers.  The  preponderance  in  average 
size  is  here  in  striking  accord  with  that  of  the  power  of  the 


82  JOHN  J.  MASON. 

related  extremities,  and  has  since  been  repeatedly  con- 
firmed in  frogs,*  especially  in  longitudinal  sections. 

The  caudal  region  in  turtles  and  in  those  lizards  which 
have  few  and  delicate  caudal  muscles  furnishes  an  inter- 
esting fact  for  consideration.  In  turtles  the  cell  nuclei 
gradually  diminish  in  size  from  before  backward,  and 
finally  disappear  altogether  near  the  posterior  portion, 
where  the  horns  of  gray  matter  present  much  the  same 
appearance,  as  to  structure,  as  that  of  the  same  parts  in 
the  dorsal  region. 

While  in  the  alligator  some  of  the  largest  cell  nuclei  are 
met  with  in  this  part  of  the  cord,  in  those  saurians,  helo- 
derma  especially,  which  have  comparatively  little  power  in 
the  tail,  these  elements  are  reduced  gradually  in  size  in  the 
same  sense  as  are  those  in  the  turtle.  The  same  gradual 
transition  is  well  marked  in  the  caudal  region  of  Scincus 
Erythrocephalus. 

Stieda*  gives  measurements  of  nerve  cells  and  their 
nuclei  from  the  various  parts  of  the  spinal  cord  in  Testudo 
Graeca  and  Emys  Europaea,  agreeing  with  my  own  made 
later,  and  concludes  as  follows  : 

"  I  guard  myself  expressly  against  the  supposition  that 
the  great  differences  in  size  between  these  three  (large, 
medium-sized,  and  small)  classes  of  cells  are  evidences  of 
different  physiological  importance  in  these  elements.  I 
wish  rather  to  assert  that  what  is  found  in  the  spinal  cord 
of  the  turtle  can  and  must  be  used  to  support  the  contrary 
view.  The  fact  that  in  the  caudal  and  dorsal  regions  no 
large  cells  exist,  but  only  medium-sized  and  small  cells,  while 
inferior  (motor)  roots  are  given  out  from  these  same  regions, 

*  In  the  spinal  cord  of  a  bat  which  I  have  lately  examined,  the  nuclei  of  the 
cervical  region  were  found  to  be  far  more  abundant  than  those  of  the  lumbar 
region,  and  their  average  diameter  somewhat  greater.  The  muscles  of  the 
two  pair  of  extremities  bear  the  same  sort  of  relation  to  each  other. 

"  Ueber  den  bau  des  centralen  nerven  systems  der  amphibien  und  rep- 
tilian."    AxolotI  and  Schildkrote,  Leipzig,  1875,   p.  40. 


NERVOUS  SYSTEM  OF  REPTILES  AND  BATRACHIANS.     83 

must  have  great  weight  against  the  conclusion  that  only 
the  large  nerve  cells  are  connected  with  motor  fibres." 
Accepting  the  passage  as  it  stands  I  agree  with  him,  but  he 
has  not  fairly  stated  the  ordinary  view.  It  does  not  seem 
to  me  that  "  only  the  large  nerve  cells  are  connected  with 
motor  fibres,"  represents  fairly  the  prevailing  belief  of 
anatomists  and  physiologists.  That  all  the  large  nerve 
cells  are  thus  connected  is  more  accurately  what  is  thought 
to  be  the  fact.  Of  course,  no  one  has  ever  claimed  that 
the  cells  of  origin  of  the  oculomotorius,  for  example, 
were  large  cells  or  doubted  that  they  were  in  connection 
with  the  fibres  of  the  third  pair  of  cranial  nerves.  Nerve 
cells,  therefore,  may  be  small  and  still  be  connected  with 
motor  nerve  filaments.  In  the  dorsal  and  caudal  regions  of 
the  spinal  cord  of  turtles  the  motor  cells  are  small,  because 
the  muscles  which  they  innervate  are  small.  At  the  same 
time,  it  may  be  true  that  all  large  cells  connect  with  motor 
filaments.  To  me,  this  is  all  in  favor  of  ascribing  difference 
in  energy  to  different-sized  cells  or  rather  nuclei.  The 
nucleus  can  be  accurately  measured,  while  the  body  of  the 
cell  can  not  be,  and  as  the  former  probably  constitutes  the 
true  cell,  it  has  been  preferred-  as  an  object  of  study  in 
my  researches. 

MEASUREMENTS  OF  THE  DIAMETERS  OF  THE  NUCLEI  OF  NERVE 
CELLS  WHICH  ARE  RELATED  TO  THE  MOTOR  FIBRES  OF  THE  CRA- 
NIAL   NERVES. 

I.  In  four  species  of  turtle,  viz.:  (i)  Emys  Floridana, 
(2)  Emys  Terrapin,  (3)  Testudo  Polyphemus,  and  (4)  Chely- 
dra  Serpentina,  the  following  have  been  found  to  be  the 
comparative  dimensions  of  these  nuclei  : 

The  largest  nuclei  are  found  in  the  cells  of  the  spinal 
cord  and  those  of  the  nucleus  basilaris  of  Stieda.  Next  to 
these  in  size  are  those  of  the  centre  for  the  motor  root  of 
the  trigeminus,  supplying  with  its  fibres  the  elevator  mus- 


84  JOHN  y.  MASON. 

cles  of  the  lower  jaw  and  next  those  of  the  centres  of  the 
oculomotorius.     This  is  true  of  all  four  species. 

In  the  first  three  animals  weighing  about  four  pounds 
each,  the  nuclei  for  the  respective  centres  were  about  equal, 
while  differing  in  size  in  each  individual  as  stated  above. 
In  the  Chelydra  Serpentina  (snapping  turtle  weighing  24^ 
pounds)  all  the  motor  nuclei  were  much  larger  than  those 
of  the  smaller  specimens.  The  same  rule  holds  true  in 
frogs  and  alligators.  The  smaller  the  animal,  the  smaller 
the  cell  nuclei.  I  have  not  seen  any  mention  of  this  fact 
in  any  works  on  anatomy. 

2.  The  nervous  centres  of  the  alligator  are  especially 
well  fitted  for  sections,  and  I  have  obtained  three  series  of 
preparations,  many  hundred  in  all,  showing  the  nuclei  of 
the  cells  of  origin  of  all  the  motor  nerves.  In  this  animal, 
the  cell  nuclei  of  the  motor  root  of  the  trigeminus  are  found 
to  occupy,  as  to  size,  the  same  middle  rank  between  the 
nuclei  of  the  oculomotorius  and  those  of  the  motor  roots 
of  the  spinal  nerves,  that  they  do  in  the  turtle.  These  nu- 
clei are  remarkably  large  in  both  the  alligator  and  snapping 
turtle. 

3.  In  frogs  the  rule  is  even  more  strikingly  illustrated 
than  in  the  animals  just  mentioned.  Anatomists  have,  as 
yet,  made  no  centre  for  the  hypoglossus,  but  it  is  interest- 
ing to  note  that,  the  nuclei  of  the  cells  forming  the  "  nu- 
cleus centralis  "  of  Steida,  described  and  figured  also  by 
Reissner  (the  natural  centre  for  this  nerve),  have  a  diameter 
just  between  that  of  the  nuclei  related  to  the  oculomotorius 
and  those  related  to  the  motor  root  of  the  trigeminus. 

The  constant  variations  in  the  size  of  these  elements 
above  indicated  have  been  clearly  illustrated  by  photog- 
raphy. By  employing  exactly  the  same  degree  of  enlarge- 
ment— by  using  the  same  objective  and  having  the  same 
distance    always  between   the  focusing  screen   and   micro- 


NERVOUS  SYSTEM  OF  REPTILES  AND  BATRACHIANS.  85 

scope — for  all  the  nuclei  of  the  same  animal,  a  very  accurate 
representation  of  the  actual  condition  is  possible. 

These  photographs  can  now  be  examined  at  the  library 
of  the  Academy  of  Medicine,  the  New  York  Hospital  lib- 
rary, College  of  Physicians,  Philadelphia,  Surgeon-General's 
office  and  Smithsonian  Institute,  Washington,  and  at  some 
university  libraries.  The  same  subjects,  with  over  a  hun- 
dred others,  printed  by  the  Artotype  process  on  plate 
paper,  showing  the  structure  of  the  central  nervous  system 
of  all  the  North  American  reptiles,  will  soon  be  pub- 
lished. 

RECAPITULATION  OF  THE  FACTS  OBSERVED  IN  REGARD  TO 
THE  SIZE  OF  THE  NUCLEI  OF  THE  NERVE  CELLS  IN  THE 
SPINAL    CORD    AND    BRAIN    OF    REPTILES    AND    FROGS. 


I. 


-FROG. 


Diameters  in  divisions  of  Nachet's  micrometer  eye-piece  with 
objective  No.  5  : 


Spinal  cord,  brachial  enlargement 

crural 
Centre  of  motor  root  of  trigeminus. 
Possible  centre  of  hypoglossus 
Centre  of  oculomotorius 


II. EMYS    FLORIDANA. 

Spinal  cord,  cervical  enlargement 

"  lumbar  " 

Dorsal  region       .... 
Caudal     "         gradually  diminishing 
Centre  of  motor  root  of  the  trigeminus 
Cerebellum,  large  cells 
Centre  of  oculomotorius 
Cerebrum 
Optic  tubercles 

III. TESTUDO    POLYPHEMUS. 


7 
6 
4 
3 

6. 
6. 
2. 
6. 

5- 
4- 


5x8. 

xp. 

X6.5 
5x6. 

5  X4-5 


x6 
x7 

-4 
-  2 

x5 


3-5  X4 
3-5  X  5 
3-    ^3 


Same  as  eniys,  except  in  spinal  cord  where  the  conditions  are 
reversed  in  the  two  enlargements. 


86 


JOHN  J.  MASON. 


IV. ALLIGATOR    MISSISSIPIENSIS 

Si)inal  cord,  cervical  enlargement 

"  lumbar  " 

Centre  of  motor  cord  of  the  trigeminus 

"       motor  portion  of  the  vagus 

"        oculomotorius 
Large  cells  of  the  raphe 
Nuclei  of  eminentia  acoustica 
Sensitive  cells  of  the  vagus 
Large  cells  of  the  cerebellum     . 
Cerebrum  and  corpus  striatum    . 
Optic  tubercles 


6-5  X  7-5 
6-5  X  7-5 

6.  X  7. 
5-5x6. 
5-    X5. 

7.  x8. 

3-5  X  4-5 
3-5  X  4-5 
3-5  X4-5 
3-5  X  4-5 
2-5  X3. 


V. HELODERMA    SUSPECTUM. 

With  the  exception  of  the  caudal  region  of  the  spinal  cord, 
where  much  the  same  scarcity  and  successive  reduction  of  size  of 
the  nuclei  exist  as  in  the  turtle,  the  diameters  hold  the  same  rela- 
tion to  each  other  as  noted  in  the  alligator.  This  remark  also 
applies  to  the  nuclei  of  Scincus  Erythrocephalus. 

VI. ERYTHROCEPHALUS. 

The  nerve  cell  nuclei  of  small  specimens  are  notably  smaller 
than  the  corresponding  nuclei  of  larger  specimens  of  the  same 
order.  This  rule  only  applies  to  orders,  for  some  of  the  nuclei  of 
Rana  Pipiens,  from  the  spinal  cord,  measure  as  much  as  those  of 
the  24-pound  turtle.  The  nuclei  of  the  small  lizards  are,  as  a 
whole,  proportionally  larger  than  those  of  heloderma  or  the  alligator. 

The  proposed  law,  formulated  in  my  last  paper,  may  now 
read  as  follows  : 

TJie  nuclei  of  the  so-called  motor  cells  of  the  central  nervous 
system  have,  in  the  same  individual,  average  diameters,  which 
are  proportional  to  the  power  developed  in  the  related  mus- 
cles. 

The  writer,  in  conclusion,  while  admitting  the.  incom- 
pleteness of  his  work,  must  at  least  claim  to  have  demon- 
strated the  fact  that  a  hitherto  unobserved  relation  exists 
between  the  size  of  a  motor  nucleus  and  that  of  its  periph- 
eral organ,  the  muscle. 


A  HISTORICAL    CASE    OF    IMPULSIVE    MONO- 
MANIA. 

By  EDWARD  C.  SPITZ KA,  M.D. 

IN  reading  a  recent  sketch  of  Samuel  Johnson's  life,  I 
was  struck  by  the  marked  evidences  of  mental  aberra- 
tion exhibited  by  that  writer,  according  to  the  account  given 
by  his  biographer.*  It  has  been  the  fashion  among  Eng- 
lish alienists  to  study  historical  illustrations  of  insanity,  and 
it  would  be  remarkable  if  the  very  curious  case  of  Samuel 
Johnson  had  escaped  their  scrutiny.  However,  the  only 
reference  to  his  mental  state  which  occurs  to  me,  does  not 
deal  with  its  salient  points,  and  I  am  unacquainted  with 
any  article  which  mentions  Johnson  as  an  illustration  of  im- 
pulsive monomania  {Prhncere  Verruecktheit  in  Zwangs- 
vorstellungen).  At  some  risk  of  unconsciously  repeating 
what  may  have  been  already  said,  I  shall  briefly  comment 
upon  his  case. 

Samuel  Johnson  suffered  from  a  hereditary  taint  as  well 
as  from  severe  physical  disease.  It  is  known  that  his 
mother  took  him  to  London  to  be  touched  by  the  Queen 
for  the  "  King's  Evil,"  and  that  this  disease  (whatever  it 
was)  had  seriously  impaired  his  eyesight. 

His  father  was  tormented  by  hypochondriacal  tenden- 
cies, and  it  appears  that  Samuel  himself  exhibited  the  same 

*  Leslie  Stephen's  life  of  Johnson,  in  "  English  Men  of  Letters,"  published 
by  Harper  &  Bros. 

87 


88  EDWARD  C.   SPITZKA. 

symptom.  Among  the  signs  of  heredity,  I  regard  Samuel 
Johnson's  total  insensibility  to  music.  This  feature  has 
been  frequently  observed  as  a  transmitted  peculiarity  in 
families  afflicted  with  insanity.* 

The  evident  symptoms  of  impulsive  monomania  in  John- 
son were  the  following:  When  entering  the  doorway  with 
his  blind  companion,  Mrs.  Williams,  he  would  suddenly  de- 
sert her  in  order  to  whirl  and  twist  about  in  strange  gestic- 
ulations ;  this  performance  appeared  as  of  the  nature  of  a 
superstitious  ceremonial,  and  he  would  stop  in  a  street  or 
the  middle  of  a  room  to  go  through  it  correctly.  Once  he 
collected  a  laughing  mob  in  Twickenham  meadows  by  his 
antics.  On  this  occasion  his  hands  imitated  the  motions  of 
a  jockey  riding  at  full  speed,  his  feet  twisting  in  and  out  to 
make  heels  and  toes  touch  alternately.  He  presently  sat 
down  and  took  out  a  Grotius  "  De  Veritate  "  over  which  he 
"  see-sawed  "  so  violently  that  the  mob  ran  back  to  see 
what  was  the  matter. 

Once  in  such  a  fit  he  suddenly  twisted  off  the  shoe  of  a 
lady  who  sat  by  him.  Sometimes,  as  his  biographers  add, 
"he  seemed  to  be  obeying  some  hidden  impulse,"  which 
commanded  him  to  touch  every  post  in  a  street  or  tread  on 
the  centre  of  every  paving-stone,  and  he  would  return  and 
go  over  it  again  if  the  task  had  not  been  accurately  per- 
formed. 

The  only  alienist  who  refers  to  Johnson  seems  to  imply 
that  he  was  of  sound  mind.  In  his  article  on  "  Delusions  and 
Hallucinations,"  Rayf  says:  "  We  know  very  well  that  hal- 
lucinations have  been  exhibited  by  men  of  great  mental  en- 
dowments and  activity,  as  insulated  facts  havmg  little  or 
710  connectioji   with    the    ordinary  mental    movements.      Dr. 

*  Muhr  :  Archiv  fiir  Psychiatric,  vi. 

In  two  cases  of  transmitted  constitutional  insanity,  in  one  of  which,  lack  of 
the  musical  sense  was  noted,  in  the  other,  nothing  being  known  on  this  head, 
I  found  the  striae  meduUares  acustici  altogether  absent. 

f  Contributions  to  Mental  Pathology,  by  Isaac  Ray.      Boston,  1873. 


A  HISTORICAL  CASE  OF  IMPULSIVE  MONOMANIA.         89 

Johnson,  while  walking  in  the  street,  thought  he  heard  the 
voice  of  his  mother,  then  many  miles  away,  calling  to  him 
'  Sam,  Sam.'  "  Further  on,  our  author  states  that  "  In  most, 
if  not  all  of  these  cases,  there  was  undoubtedly  some  cere- 
bral defect," — but  the  interesting  facts  here  detailed 
must  have  been  unknown  to  him,  as  I  infer  from  the  itali- 
cized lines.  In  fact,  on  page  544,  the  same  author  says  : 
"  By  no  English  writer  have  the  delusions  of  pure  mono- 
mania been  more  truthfully  represented  than  by  Dr.  John- 
son in  '  Rasselas,' — an  achievement  wc  should  hardly  have 
expected  front  one  whose  own  mental  niovements  were  of  the 
most  regular  and  measured  character ^  (Italics  mine.) 

The  fact  referred  to  is  a  proof  of  the  great  family  rela- 
tionship existing  between  delusional  and  impulsive  mono- 
mania, and  the  ability  to  throw  himself  into  the  role  of  a 
delusional  monomaniac  is  not  to  be  wondered  at  in  John- 
son, who  had  imperative  conceptions  and  hallucinations 
himself. 

It  displays  a  good  insight  into  Johnson's  character  on 
the  part  of  his  biographer  when  the  latter  states,  of  John- 
son, "  if  he  had  gone  through  the  excitement  of  a  religious 
conversion,  he  would  probably  have  ended  his  days  in  a 
mad-house." 

It  was  said  by  those  who  knew  him  during  life,  and  this 
is  confirmed  by  such  writings  as  he  left  behind  him,  that 
although  a  man  of  deep  power  of  feeling  and  of  acute 
perception,  yet  that  his  views  were  very  narrow.  While 
one  may  question  whether  it  would  be  just  to  consider 
his  well-known  antipathy  to  everything  Scotch  as  a  symp- 
tom of  insanity,  yet  his  bigotry  on  the  question  of  the 
Stuart  dynasty  was,  to  say  the  least,  remarkable  in  a  man 
of  otherwise  high  intellectual  standing,  being  utterly  out 
of  harmony  with  his  time,  surroundings  and  interests,  not 
to  say  the  dictates  of  common  sense. 


90  EDWARD  C.   SPITZKA. 

Johnson  was  a  man  of  fitful  energy,  and  his  fits  of  indus- 
try alternated  with  long  periods  of  indolence. 

Many  impulsive  and  even  delusional  monomaniacs  pos- 
sess these  same  traits,  and  the  faculty  of  rude  repartee 
which  Johnson  had  is  not  by  any  means  rare  in  the  asylum 
corridor.  Like  Johnson,  there  are  patients  in  asylums  and 
out  of  them,  who  have  a  prodigious  memory,  have  accumu- 
lated vast  stores  of  miscellaneous  learning,  are  versatile, 
and  would  pass,  as  Johnson  did,  for  nothing  more  than  "  ec- 
centric." 

Had  Samuel  Johnson  lived  in  the  state  of  New  York  in 
the  present  time  and  proved  disagreeable  to  his  relatives, 
or  had  he  performed  his  antics  on  Broadway,  who  doubts 
that  he  would  have  been  committed  to  an  asylum  with  the 
evidences  of  impulsive  insanity  so  palpably  evident  as  they 
were  in  his  case  ?  Who  can  help  but  register  a  protest 
against  the  indiscriminate  committing  power  which  courts 
and  physicians  possess,  and  which  every  now  and  again  con- 
signs people  with  no  evidences  of  insanity  greater  than 
those  of  Johnson,  with  good  if  not  as  good  mental  endow- 
ments, useful  members  of  society  often,  to  the  living  tomb 
of  an  asylum,  and  to  the  tender  mercies  of  perhaps  an  ex- 
horse-car  conductor,  ex-night-watchman  or  other  politician. 

Another  valuable  lesson  to  be  drawn  from  the  case  of 
Samuel  Johnson  is  the  strong  proof  it  constitutes  of  the 
existence  of  partial  insanities.  His  moral  faculties  were  of 
the  highest  order,  his  perceptions  were  acute,  his  memory 
prodigious,  his  judgment  was  looked  up  to  by  his  cotempo- 
raries, — in  short,  his  only  evident  derangement  was  that 
manifested  in  his  morbid  impulses.  The  excessive  fear  of 
death,  I  attach  but  little  weight  to,  in  his  case. 


SURGERY  AMONG  THE  INSANE. 

By  ALLEN  W.   HAGENBACH,  M.D., 

ASST.    SUPT.,    COOK   CO.    HOSPITAL   FOR   INSANE. 

DURING  a  residence  of  five  years  in  the  Cook  Co. 
Hospital  for  Insane,  I  have  frequently  met  with 
interesting  surgical  cases,  a  few  of  which  are  here  reported 
as  examples  of  the  surgical  cases  usually  met  with  in  hos- 
pitals for  the  insane,  at  the  same  time  illustrating  some  of 
the  difficulties  encountered  in  their  treatment.  All  the  fol- 
lowing cases  not  otherwise  credited,  excepting  the  case  of 
perineal  abscess  and  mortification  of  the  scrotum,  have  oc- 
curred among  the  inmates  of  this  asylum.  The  excep- 
tional patient  was  an  inmate  of  the  Male  Hospital  Depart- 
ment of  the  Cook  Co.  Poor-house. 

Suicidal  tendencies,  as  is  well  known,  are  frequently  man- 
ifested by  the  insane,  and  the  most  difficult  and  painful 
modes  are  often  adopted  when  easier  and  more  direct 
means  to  terminate  life  are  usually  at  hand.  The  following 
case  while  illustrating  this  point  also  presents  various  inter- 
esting features  as  a  surgical  case. 

Suicide  by  cutting  through  chest  walls.  About  2  o'clock  a.m., 
Oct.  20,  1876,  I  was  called  by  the  night-watchman  to  see 
Mr.  C,  who,  he  informed  me,  was  bleeding  profusely.  On  enter- 
ing the  room  found  the  bedclothes  saturated  with  blood,  also 
considerable  blood  on  floor  and  walls.  The  patient  was  lying 
quietly  in  bed   muttering  incoherently.     On  the  left  side  of  his 

9t 


92  ALLEN  W.   HAGENBACH. 

chest  I  found  an  incised  wound  about  six  inches  in  length  di- 
rectly over  the  body  of  the  sixth  rib,  from  which  blood  was 
freely  escaping.  The  finger  used  in  exploring  the  wound  passed 
very  readily  to  the  surface  of  the  rib,  which  could  be  plainly  felt 
or  seen  by  separating  the  flaps,  but  as  the  blood  appeared  to 
come  from  the  bottom  of  the  wound,  passed  the  finger  along  the 
upper  border  of  the  rib  when  a  second  incision  was  found  fully 
two  inches  in  length,  extending  through  the  entire  chest  walls  and 
communicating  with  the  left  pleural  cavity.  The  patient  was 
greatly  exsanguinated  and  appeared  completely  exhausted. 
When  asked  his  reason  for  injuring  himself,  he  answered  that  he 
meant  to  expose  his  heart  to  view,  to  demonstrate  how  pure  it 
was.  Had  the  incision  extended  a  little  more  toward  the  median 
line  of  the  body,  he  might  have  penetrated  the  pericardial  sac 
and  really  exposed  his  heart  to  view.  The  instrument  with 
which  he  inflicted  the  wound  was  a  small  piece  of  glass  which  he 
obtained  by  breaking  a  window  pane. 

Cutting  through  the  entire  thickness  of  the  chest  walls  with  a 
small  piece  of  glass  must  have  necessitated  a  large  number  of  small 
incisions  which  only  the  fixed  determination  of  a  madman  could 
have  inflicted  upon  self.  The  treatment  consisted  in  stitching 
the  wound  after  all  hemorrhage  ceased,  and  applying  strips  of 
adhesive  plaster  to  exclude  the  air  from  the  pleural  cavity  and 
facilitate  union  by  first  intention.  l"he  wound  at  first  com- 
menced to  heal  kindly,  but  gangrene  of  the  toes  on  both  feet  fol- 
lowed from  apparently  insufficiency  of  the  blood  supply  to  parts 
so  distant  from  the  heart.  The  patient  died  on  the  twelfth  day 
after  the  injury. 

For  the  histories  of  the  two  following  cases,  I  am 
indebted  to  Dr.  Richard  Dewey,  Supt.,  State  Insane 
Hospital,  Kankakee.  The  first  case  was  under  his  care  while 
assistant  physician  of  the  asylum  at  Elgin.  The  second 
case  is  taken  from  his  notes,  and  happened  in  one  of  the 
eastern  hospitals  for  insane  : 

I.  A  female  patient,  victim  of  melancholia  and  hallucinations, 
who  had  made  an  effort  to  commit  suicide  by  drowning 
previous  to  her  admission  to  the  asylum,  believed  herself  the  ob- 
ject of  a  conspiracy  to  be  abducted  at  night  and  thrown  naked 
into  a  pit  to  perish.     Imagining  one  night  that  she  heard   her  ab- 


SURGERY  AMONG   THE  INSANE.  93 

ductors  approaching,  she  cut  several  incisions  in  her  abdominal 
walls  with  a  pair  of  rusty  scissors  she  had  in  some  unknown  man- 
ner obtained  possession  of  and  secreted  about  her  person.  The 
incisions  were  from  one  to  three  inches  in  depth,  and  from  one  to 
four  inches  in  length.  Fortunately,  the  adiposft  tissue  was  very 
thick,  so  that  the  incisions  escaped  the  peritoneal  lining.  The 
wounds  united  with  the  aid  of  a  few  sutures.  This  patient  was 
subject  to  frequent  frenzied  paroxysms  of  fear,  and  yet  conducted 
herself  with  dignity  and  conversed  so  intelligently  in  the  intervals, 
that  she  strongly  impressed  a  legal  gentleman,  with  whom  she  had 
an  interview,  that  she  was  unjustly  confined. 

2.  A  female  patient  with  hallucinations  very  similar  to  those  of 
the  previous  patient,  who  also  cut  in  her  abdominal  walls 
with  a  pair  of  scissors.  In  this  instance  the  wounds  were  more 
serious  in  character,  the  scissors  penetrating  the  peritoneal  cavity 
and  dividing  the  small  intestines  in  several  places.  The  patient 
died  from  the  injuries  sustained. 

Self-inflicted  injuries  are  by  no  means  uncommon  among 
the  insane.  At  the  present  writing  there  are  three  patients 
in  this  asylum  who  repeatedly  cut  themselves  about  the 
head,  face  and  chest,  with  pieces  of  glass,  scraps  of  tin,  or 
any  substance  suiificiently  hard  to  penetrate  the  integument. 
F.  B.,  a  valuable  female  patient  to  do  general  work  about 
the  asylum,  is  never  free  from  cuts  about  the  head  and  face. 
D.  S.  is  keeping  an  old  bullet  wound  in  the  leg  discharging 
by  filling  it  with  irritating  foreign  bodies  and  pounding  the 
leg.  J.  M.  scarifies  his  entire  chest  with  a  piece  of  glass. 
This  patient  also  pierces  his  ears  and  hands  with  pins,  fre- 
quently passing  needles  completely  through  the  hand. 

Another  class  of  more  serious  self-inflicted  injuries  is  oc- 
casionally met  with  in  asylum  practice.  The  following 
case  is  reported  as  an  example  : 

W.  C,  an  intelligent  traveling  agent,  was  admitted  to  the  asylum 
November,  1878,  suffering  with  general  paresis.  The  case  fol- 
lowed the  usual  course  run  by  similar  cases,  until  several  weeks 
prior  to  his  death,  when  he  commenced  to  break  out  his  teeth  by 
biting  some  solid  body  and  tearing  the   teeth  from  their  sockets. 


94  ALLEN  W.   HAGENBACH. 

In  this  manner  he  extracted  every  tooth  in  both  jaws  as  far  back 
as  the  first  or  second  molars.  Several  days  previous  to  his  death 
he  fractured  his  inferior  maxilla  in  two  places  in  the  same  man- 
ner that  he  extracted  the  teeth.  With  the  hsematoma  auris  un- 
usually well  marked  in  both  ears,  toothless,  with  a  double  fracture 
of  the  jaw,  and  with  ecchymoses  and  swellings  about  the  forehead, 
cheeks  and  prominent  points  of  the  face,  the  patient  presented  as 
repulsive  a  physiognomy  as  could  well  be  imagined. 

Three  patients  have  made  unsuccessful  efforts  to  commit 
suicide  by  cutting  their  throats.  In  two  instances  the  in- 
cisions extended  directly  across  the  anterior  surface  of  the 
throat,  both  cutting  into  the  trachea,  but  as  no  important 
arteries  were  divided,  they  made  rapid  and  complete  recov- 
eries. The  third  case  was  more  serious  in  character,  as  will 
be  seen  by  the  following  history : 

R.  C.  attempted  to  commit  suicide  by  cutting  his  throat  with  a 
sharpened  table  knife.  He  made  three  incisions,  extending  from 
below  the  left  ear,  terminating  in  a  common  incision  at  the  upper 
border  of  the  cricoid  cartilage,  and  extending  directly  across  the 
throat,  cutting  through  the  anterior  surface  of  the  trachea. 

The  hemorrhage  was  very  profuse,  the  patient  bleeding  to  syn- 
cope before  it  could  be  arrested.  He  made  a  very  slow  recovery, 
and  remained  in  about  the  same  mental  condition  until  October 
27,  1880,  when  he  made  a  successful  effort  to  commit  suicide  by 
hanging  himself.  He  was  found,  by  an  attendant  who  unlocked 
his  room,  suspended  from  an  iron  bedstead  stood  up  on  end,  with 
both  feet  resting  on  the  floor. 

The  following  history  of  a  patient  admitted  to  the  State 
Asylum  at  Kankakee  was  kindly  furnished  me  by  Dr.  H.  N. 
Moyer,  assistant  physician  : 

G.  G.,  admitted  February  16,  1880,  had  made  an  unsuccessful 
effort  to  commit  suicide  by  cutting  his  throat  eight  days  pre- 
vious to  his  admission.  The  incision  extended  along  the  upper 
border  of  the  thyroid  cartilage,  and  two-thirds  through  the  larynx. 
He  also  stabbed  himself  in  the  neck,  evidently  thrusting  the  point 


SURGERY  AMONG   THE  INSANE.  95 

of  knife  to  the  bodies  of  the  vertebrae,  causing  two  wounds  of  the 
oesophagus,  through  which  liquid  food  escaped.  An  attempt  had 
been  made  previous  to  his  admission  to  secure  apposition  of  edges 
of  wound  by  common  twine  sutures,  which  had  been  drawn 
through  the  edges  of  wound  by  the  struggles  of  the  patient. 

He  labored  under  that  form  of  acute  melancholia  in  which 
every  effort  at  interference  is  resisted  to  the  last  degree.  He  ab- 
stained from  all  food,  so  that  it  became  necessary  to  feed  him 
with  a  stomach  tube,  a  delicate  operation,  as  great  care  had  to  be 
exercised  to  prevent  further  injury  to  the  parts.  Fully  one-half 
of  the  hyoid  bone  necrosed  and  came  away  while  the  wound  was 
healing.  The  wound  healed  by  granulation.  The  chief  points  of 
interest  in  the  case  are  ;  The  difficulty  encountered  in  the  treat- 
ment, the  mechanical  feeding,  the  necrosis  of  hyoid  bone,  and 
the  complete  recovery. 

HOMICIDAL    TENDENXIES. 

Homicidal  tendencies  are  not  infrequently  manifested 
by  the  insane.  Aside  from  several  fractures  of  the  ex- 
tremities and  other  minor  injuries,  two  patients  at  least 
have  died  from  the  effect  of  injuries  received  at  the 
hands   of    fellow-patients.. 

One  sustained  a  fracture  of  the  skull  with  depression  of 
bone.  The  skull  was  trephined  and  the  depressed  bone  ele- 
vated, but  he  died  shortly  afterward,  probably  from  the 
effects  of  other  internal  injuries  he  sustained.* 

The  other  patient  did  not  sustain  any  fractures,  but  was 
so  severely  bruised  about  the  head,  face  and  body  by  his 
room-mate  that  he  died  on  the  fifth  day. 

M.  M.,  an  attendant,  quite  recently  received  a  severe  cut  about 
the  mouth  and  lips  with  a  triangular  piece  of  glass  in  the  hand  of 
an  epileptic  patient.  The  wound  extended  along  the  inner  sur- 
face of  the  cheek  from  opposite  the  second  molar  tooth  to  the 
median  line  of  the  face,  and  then  completely  dividing  the  lip,  to 
the  lower  border  of  the  inferior  maxillary  bone,  dividing  the  in- 
ferior coronary  and  inferior  labial  branches  of  the  facial  artery. 
The   hemorrhage   was  profuse,  bleeding  per  saltum   from  the  di- 

*  This  case  was  related  to  me  by  Dr.  G.  P.  Cunningham,  former  superin- 
tendent of  this  asylum. 


96  ALLEN  W.   HAGENBACH. 

vided  arteries  in  both  flaps  of  the  wound,  and  also  from  the  bot- 
tom of  the  wound  in  the  mouth.  The  inferior  labial  was  divided 
very  close  to  its  junction  with  the  facial,  and  could  not  be  ligated 
in  the  mouth.  The  hemorrhage  from  this  vessel  w£s  arrested  by 
passing  with  a  needle  a  ligature  through  the  cheek  and  under  the 
artery.     The  wound  healed  throughout  by  first  intention. 

To  illustrate  the  difficulties  sometimes  encountered  in 
surgical  practice  among  the  insane,  I  report  the  following 
case  of  Pott's  fracture  of  th-e  fibula : 

G.  P.,  while  quarreling  with  a  fellow-patient,  sustained  a  Pott's 
fracture  of  the  fibula.  A  Dupuytren's  splint  was  selected  in  dress- 
ing the  fracture.  On  making  the  usual  rounds  the  next  morning, 
found  the  patient  sitting  on  the  edge  of  his  bed,  with  the  splint  se- 
curely fastened  to  the  window  grating.  Thinking  that  he  would 
be  unable  to  remove  a  plaster  of  Paris  dressing  one  was  applied, 
but  here  we  were  mistaken,  and  the  next  morning  again  found  him 
sitting  on  the  edge  of  the  bed  and  the  plaster  dressing  also  securely 
fastened  to  the  window  grating.  Adhesive  plaster  dressings  were 
removed  as  fast  as  applied  ;  strait-jackets  and  other  modes  of 
restraint  were  useless,  as  he  would  twist  and  turn,  doing  more  in- 
jury to  the  leg  than  any  surgical  dressings  could  possibly  counter- 
balance. All  surgical  appliances  were  discontinued,  and  our  ef- 
forts directed  to  gain  as  good  a  position  of  foot  as  possible  by 
frequent  manual  manipulations.  The  result  was  in  every  respect 
satisfactory,  as  the  patient  was  able  to  bear  his  weight  on  the  foot 
at  the  end  of  four  weeks.  While  in  a  simple  fracture  of  the  fibula 
surgical  dressings  may  be  dispensed  with,*  what  would  be  the  re- 
sult in  a  case  of  compound  com.minuted  fracture  involving  both 
bones  of  the  leg  ? 

FOREIGN    BODIES. 

Foreign  bodies  in  the  larynx,  pharynx  and  oesophagus 
are  occasionally  met  with,  as  a  large  number  of  demented 
patients  swallow  their  food  almost  entirely  without  masti- 
cation. I  have  seen  but  two  cases  of  foreign  bodies  in  the 
pharynx,  and  none  in  the  larynx  or  oesophagus  requiring 
surgical  interference. 

*  A  case  presenting  great  difficulties  in  the  treatment  was  related  to  me  by 
Dr.  E.  A.  Kiibourne,  Superintendent,  State  Hospital  for  Insane,  Elgin,  111. 


SURGERY  AMONG   THE  INSANE.  97 

1.  Mrs.  C.  swallowed  a  sharp,  irregular  piece  of  bone  in  her  soup, 
which  was  arrested  in  the  pharynx  and  held  very  tightly  by  the 
spasmodic  contraction  of  the  constrictor  muscles,  preventing  its 
removal  without  injuring  the  surrounding  tissues.  During  a  se- 
vere paroxysm  of  vomiting  the  tissues  relaxed  and  the  bone 
was  removed  through  the  mouth,  but  not  without  considerable  in- 
jury to  the  mucous  lining  of  the  pharynx,  the  patient  expectorating 
sputa  streaked  with  blood  for  several  days. 

2.  C.  S.,  a  hemiplegic  patient,  managed  to  partially  swallow  an 
enormous  piece  of  meat,  which  lodged  in  the  lower  part  of 
the  pharynx  and  could  not  be  moved  up  or  down.  Respiration 
was  interfered  with,  by  pressure  against  the  larynx  and  pharynx, 
to  such  an  extent  that  the  patient  was  struggling  violently  for 
breath,  his  face  congested  and  the  veins  of  neck  greatly  distended. 
The  operation  of  tracheotomy  was  contemplated  to  gain  time, 
when,  during  a  convulsion  resembling  an  epileptic  fit,  the  foreign 
body  was  expelled  spontaneously,  and  all  the  alarming  symptoms 
at  once  disappeared. 

Of  foreign  bodies  introduced  into  the  other  openings  of 
the  body,  the  rectum,  urethra,  nose  and  auditory  canal,  I 
have  never  seen  any  examples  except  in  the  auditory 
canal.  Tampering  with  the  ears  by  patients  who  have  hal- 
lucinations of  hearing  is  quite  common,  and  how  some  of 
these  apparently  slight  injuries  lead  to  fatal  terminations 
will  be  seen  by  the  following  case  : 

L.  F.,  female,  aged  about  thirty-five  years,  suffering  from 
chronic  mania,  imagined  that  she  was  persecuted  by  "  spiritual 
enemies,"  who  were  constantly  using  the  most  insulting  language 
in  her  presence.  To  exclude  these  sounds  she  kept  her  ears  firmly 
plugged  with  cotton,  but  as  the  precaution  failed  to  remove  the 
dreadful  sounds,  she  filled  the  left  auditory  canal  with  some  lye 
she  managed  one  day  to  secrete  about  her  person.  The  contrac- 
tions of  the  tissues  which  accompanied  the  healing  process  resulted 
in  a  complete  closure  of  the  meatus  auditorius  externus.  She 
enjoyed  her  average  health  for  several  years,  and  died  very  sud- 
denly April  24,  1880.  A  post-mortem  examination  held  fifteen 
hours  after  death,  revealed  the  following  pathological  conditions  : 
The  cerebral  meninges,  especially  dura  mater,  greatly  thickened 
over  the  lower  surface  of  the  left  middle  cerebral  lobe  ;  consider- 


98  ALLEN   W.   HAGENBACH. 

able  blood  was  found  in  left  middle  cerebral  fossa,  which  had  es- 
caped from  the  left  superior  petrosal  sinus.  The  entire  petrous 
portion  of  bone  was  honey-combed  and  much  softer  than  natural, 
and  a  considerable  quantity  of  yellowish  matter,  resembling  pus, 
had  collected  on  the  anterior  surface  of  the  petrous  portion  of  the 
temporal  bone.  The  bone  was  so  soft  as  to  be  readily  cut  with  a 
cartilage  knife.  Upon  removing  a  shell  of  bone  the  entire  audi- 
tory canal  and  tympanum  were  found  distended  with  sebaceous 
matter  and  pus.  The  hemorrhage  was  regarded  as  the  immediate 
cause  of  death,  but  there  can  be  no  question  that  the  hemorrhage 
was  a  result  of  the  ulcerative  process  extending  through  the  cov- 
erings of  the  petrosal  sinus.  The  probable  pathological  history  of 
the  case  was  somewhat  as  follows  :  The  closure  of  the  auditory 
meatus  preventing  the  escape  of  sebaceous  matter  caused  a  grad- 
ual accumulation  to  take  place,  until  the  auditory  canal  Avas  en- 
tirely filled  ;  ulceration  through  the  membrana  tympani  followed, 
affording  temporary  relief  until  the  tympanum  also  was  distended, 
and  the  surrounding  bone  underwent  disintegration  and  absorp- 
tion as  a  result  of  the  pressure  caused  by  the  accumulated  matter. 
The  inflammation  extending  to  the  meninges  of  the  brain  caused 
the  hypertrophy  of  tliese  tissues,  while  the  rupture  of  the  diseased 
coats  of  the  superior  petrosal  sinus  (the  source  of  the  hemorrhage) 
was  the  immediate  cause  of  death.  A  timely  operation,  opening 
the  meatus  externus  and  removing  the  accumulated  sebaceous 
matter,  would  no  doubt  have  resulted  in  a  complete  cure. 

SUBOCCIPITAL    ABSCESS    CURED    BY    REST. 

O.  B.,  German,  aged  35,  was  admitted  April  22,  1S80.  Upon 
examination  found  him  anjemic  and  neurasthenic,  with  a  small 
erysipelatous  swelling  over  left  anterior  parietal  region,  following 
a  blow  on  the  head  with  a  policeman's  club.  The  erysipelas 
spread  very  rapidly,  soon  involving  the  entire  scalp.  The  pres- 
ence of  pus  was  detected  on  the  sixth  day,  when  several  incisions 
were  made  and  considerable  pus  discharged.  A  five-grain  solu- 
tion of  carbolic  acid  was  injected  once  daily.  The  entire  scalp 
appeared  as  if  completely  loosened  from  the  skull,  so  that  water 
injected  through  an  opening  in  the  left  temporal  region  escaped 
through  an  opening  in  right  temporal  region,  and  vice  versa. 
This  treatment  was  followed  without  any  apparent  improvement 
until  May  27th,  a  full  month,  when  a  roller  bandage  was  ap- 
plied, passing  firmly  over  the  occipital  and  frontal  portions  of  the 
occipito-frontalis  muscle,  preventing  all  movement  of  the  scalp. 


SURGER  Y  AMONG  THE  INSANE.  99 

The  discharge  at  once  diminished  in  quantity  and  ceased  alto- 
gether in  a  few  days,  the  abscess  healing  completely  in  two  weeks 
by  simply  putting  the  diseased  parts  at  rest.  * 

My  attention  was  recently  called  by  Dr.  Hoyt  to  a  very 
interesting  case  of  a  large  ulcer  on  forehead,  which  gradu- 
ally increased  in  size  under  the  use  of  various  lotions  and 
salves,  but  commenced  at  once  to  heal  after  he  applied  long 
strips  of  adhesive  plaster  and  kept  the  parts  at  rest. 

OBSTETRICS    UNDER    DIFFICULTIES. 

Confinements  in  asylums  are  very  infrequent,  and  gen- 
erally against  the  laws  governing  such  institutions,  but  what 
such  cases  lack  in  frequency  they  sometimes  make  up  for  in 
interest  and  the  difficulties  they  present  to  the  obstetrician. 
As  most  cases  of  puerperal  insanity  follow  delivery,  and  the 
class  of  insane  patients  that  become  pregnant  usually  suffer 
from  the  milder  types  of  insanity,  a  delivery  in  a  patient 
laboring  under  acute  mania  may  prove  of  interest. 

Mrs.  C.  was  admitted  to  this  asylum,  pregnant,  with  all  the 
symptoms  of  acute  mania  marked.  She  remained  in  about  the 
same  mental  condition  for  several  weeks,  when  labor  set  in. 
Unfortunately,  she  imagined  that  she  was  about  to  be  executed 
for  committing  some  imaginary  crime,  so  she  made  every  effort  in 
her  power  to  avoid  being  examined,  using  her  hands,  feet  and 
teeth  to  keep  every  one  at  a  safe  distance.  At  the  commence- 
ment of  each  pain  she  would  jump  out  of  bed  and  try  to  escape 
from  the  room.  During  the  first  stage  of  labor  she  was  allowed 
to  indulge  in  these  freaks,  but  when  the  second  stage  set  in  it  was 
deemed  necessary  to  have  her  at  least  remain  in  bed.  A  strait- 
jacket  was  applied,  but  even  then  she  was  almost  unmanageable, 
with  an  attendant  holding  her  head,  while  two  attempted  to  per- 
form tliat  duty  for  her  inferior  extremities. 

PERIXE.\L    ABSCESS    AND    GANGRENE    OF    SCROTUM. 

This  case  is  reported  as  affording  a  good  example  of  the 
rapidity  with  which  extensive  destruction  of  scrotal  tissue 
is  repaired. 

*  A  very  interesting  similar  case  is  reported  by  Mr.  Hilton,  page  79  of  his 
work  on  "  Rest  and  Pain." 


lOO  ALLEN  W.   HAGENBACH. 

T.  T.,  aged  42,  suffering  for  many  years  with  facial  neuralgia, 
presented  himself  at  the  out-department  of  the  Cook  County 
Poor-house  October  4,  1880,  complaining  of  severe  pain  in  the 
scrotum  and  testes. 

Upon  examination,  found  perineum  hard  and  swollen,  with  ery- 
sipelas involving  the  entire  scrotum.  He  was  transferred  to  the 
hospital  department,  and  hot  water  dressings  were  ordered  to  be 
applied  continuously. 

October  5th. — Scrotum  swollen  to  twice  its  normal  size,  and 
erysipelas  extending  over  lower  part  of  abdomen.  The  penis  is 
greatly  distended,  with  effusion  under  integument.  Hot-water 
dressings  continued,  and  the  following  preparation  prescribed  : 

Quinise  sulphatis,  4. 
Tinct.  ferri  chloridi,  8. 
Syr.  toiutani, 
Aquse  purse,  aa  30.  V\ 

Sig.     Teaspoonful  three  times  a  day. 
Opium  in  sufficient  quantities  to  relieve  pain. 

October  6th. — The  erysipelas  extending  higher  over  abdomen. 
Scrotum  enlarged  to  the  size  of  foetal  head.  The  swelling  on 
perineum  enlarging  and  very  painful.  No  fluctuation  can  be  de- 
tected. 

October  7th. — The  case  was  seen  to-day  by  Drs.  Wilde,  Cohen, 
Bessler  and  Thiely,  of  Chicago,  who  advised  a  continuation  of  the 
treatment  adopted,  and  expressed  an  unfavorable  prognosis,  as  all 
the  symptoms  present  pointed  to  extensive  destruction  of  scrotal 
tissue  and  death  from  exhaustion  or  septicaemia.  Opening  the 
perineal  abscess  as  soon  as  the  pus  approached  the  surface  was 
recommended. 

October  8th. — About  5  o'clock  this  a.  m.  the  abscess  opened 
spontaneously  near  the  centre  of  the  perineum,  discharging  a  large 
quantity  of  poorly -conditioned,  offensive  pus. 

October  loth. — Circulation  in  anterior  surface  of  scrotum  en- 
tirely arrested.  Urine  escaping  through  opening  in  perineum, 
an  elastic  catheter  was  passed  into  the  bladder  without  diffi- 
culty. 

October  14th. — Line  of  demarcation  commencing  to  form,  the 
mortification  involving  greater  part  of  anterior  surface  and  base 
of  scrotum.  Carbolized  linseed  poultices  were  now  applied  instead 
of  hot-water  dressings  ;  the  slough  at  once  commenced  to  separate, 


SURGERY  AMONG  THE  INSANE.  lOI 

and  was  completely  removed  by  the  19th,  when  nearly  half  of  the 
scrotal  tissue  was  gone,  both  testicles  being  plainly  exposed  to 
view,  the  left  protruding  partially  through  the  opening.  After 
pressing  the  testicle  upward,  applied  strips  of  adhesive  plaster, 
bringing  together  the  opposite  sides  of  the  wound,  and  affording 
support  to  the  testicles. 

October  24th. — Adhesive  straps  have  been  applied  daily  since 
the  19th  ;  opening  about  one-half  of  former  size.  Opening  in 
perineum  almost  closed.  Patient  can  retain  urine  for  several 
hours,  and  but  little  escapes  through  opening  in  perineum. 

October  30th. — Healing  very  rapidly,  the  opposite  sides  of  the 
wound  remaining  in  contact  without  strapping  ;  testicles  in  nor- 
mal position. 

November  15th. — Wound  healed,  and  patient  discharged  cured 
in  less  than  a  month  after  the  destruction  of  nearly  half  of  the 
scrotal  tissue. 


THE  TOWN  OF    GHEEL,  IN  BELGIUM,  AND  ITS 

INSANE; 

OR,    OCCUPATION    AND    REASONABLE    LIBERTY    FOR    LUNATICS.* 

By  W.  J.  MORTON,  M.D., 

NEW    YORK. 

"II  n'est  muraille  que  de  os."  The  inhabitants  themselves  are  the  best 
walls. — Rabelais. 

THE  Gheel  of  to-day  can  be  understood  only  by  know- 
ing the  Gheel  of  the  past.  In  its  essential  principle 
of  freedom  for  the  insane,  Gheel  has  never  changed.  What  it 
was  one  hundred  or  five  hundred  years  ago  it  is  now.  The 
kindly  nature,  the  inherited  instincts,  the  tact  and  the  prac- 
ticality of  the  inhabitants,  have  ever  been  the  only  walls 
which  have  encompassed  its  colony  of  insane,  numbering 
many  hundreds.  Lunatics  wander  at  will  through  the 
streets  and  mingle  in  the  daily  routine  of  the  home  life, 
enjoying  the  same  privileges  apparently  as  citizens  enjoy. 

And  this  has  been  the  case  for  centuries.  In  a  historical 
retrospect,  then,  we  shall  find  the  key-note  to  the  "  Gheel 
idea  "  carried  out  even  now  in  our  own  times. 

In  the  seventh  century,  so  the  legend  runs,  a  certain 
Dymphna,  daughter  of  an  Irish  king,  having  enraged  her 
father  by  adopting  the  Christian  faith,  fled  from  his  ven- 
geance to  the  then  far-away  land  of  Belgium.    There,  in  the 

*  Read  at  a  meeting  of  the  the  New  York  Neurological  Society,  January  4, 
1881. 


GHEEL  AND  ITS  INSANE.  IO3 

little  hamlet  of  Gheel,  she,  together  with  the  priest  Gere- 
bernus,  sought  and  found  refuge  with  a  band  of  Christian 
brothers  who  had  collected  in  this  remote  corner,  and  had 
erected  in  the  solitude  a  little  chapel  dedicated  to  St.  Mar- 
tin, an  English  missionary.  But  Dymphna's  father,  with  a 
band  of  retainers,  followed,  and,  as  the  quaint  language 
reads,  "  devoured  by  an  ungovernable  rage,"  beheaded  her. 
In  a  little  shrine  at  Gheel,  set  deep  into  a  wall  on  the  cor- 
ner of  the  main  street  in  the  town,  we  may  see,  carved  in 
wood  and  of  life  size,  a  group  of  figures  vividly  calling  this 
scene  to  mind.  The  daughter  on  her  knees  awaits  the 
stroke,  the  father  stands  wuth  upraised  sword,  while  just 
behind  and  waiting  to  receive  him,  the  devil,  with  veri- 
table hoof,  tail  and  horns,  and  painted  ebony  black,  is  ris- 
ing up  from  out  a  cleft  in  the  ground. 

Many  miraculous  incidents  attended  the  maiden's  death, 
and  hence  she  became  St.  Dymphna,  the  patroness  of  all 
who  prayed  to  be  delivered  from  insensate  acts  ;"  or,  if  we 
follow  another  line  of  tradition,  a  number  of  insane  who 
were  witnesses  of  the  young  Christian's  murder,  were  sud- 
denly and  miraculously  curqd  of  their  malady,  and  hence 
St.  Dymphna  was  considered  to  have  the  power  of  curing 
those  who  had  a  mental  disorder. 

Here,  springing  from  out  the  mists  of  the  seventh  cen- 
tury, is  all  we  shall  probably  ever  know  of  the  origin  of  this 
most  famous  colony  of  the  insane  in  the  world, — a  colony 
which  has  ever  shone  and  still  shines  a  beacon  light  to  all 
progress  toward  a  humane  treatment  of  mental  alienation. 

Be  the  facts  concerning  the  Irish  king's  daughter  as  they 

*  "  However  sad  may  be  one's  state,  the  name  of  St.  Dymphna  has  never 
been  invoked  in  vain  ;  but  since  she  courageously  resisted  and  vanquished  the 
insensate  love  and  fury  of  her  father,  she  has  been  established  by  God  as  a 
special  patroness  against  every  species  of  madness  ;  moreover,  the  miracles  per- 
formed at  Gheel  in  the  cure  of  the  insane  have  made  this  fact  sufficiently  well 
known."  Translated  from  Legende  der  Martelaren  ^■an  Gheel  SS.  Dimphna 
en  Gerebernus.  Antwerpen,  i860,  pp.66.  Exercises  of  devotion  at  present  in 
use  in  the  Church  of  St.  Dymphna. 


I04  W.   y.  MORTON. 

may,  certain  it  is,  from  existing  records,  that  in  the  eleventh 
and  twelfth  centuries  crowds  of  insane  were  conducted  by 
their  friends  to  the  shrine  of  St.  Dymphna,  where  they  re- 
mained days  and  months  awaiting  the  result  of  the  pious 
intercessions  made  in  their  behalf.  The  principal  curative 
measure  was  the  neuvaine  or  nine  days'  prayer,  during 
which  the  priests,  singly  and  in  procession,  solemnly  pro- 
ceeded to  exorcise  the  demon  which  was  supposed  to  pos- 
sess the  unfortunate  madfolk. 

In  1340  was  completed  a  beautiful  church  commemora- 
tive of  St.  Dymphna  and  the  incidents  of  her  death,  and 
erected  on  the  site  where  formerly  stood  the  little  chapel  of 
St.  Martin.  Here  Dymphna's  bones  and  many  relics  were 
guarded  in  state  and  conveniently  arranged  for  pilgrims  to 
pray  before,  while  votive  tablets  set  in  the  walls  bespoke  the 
numerous  miraculous  cures  effected.  Chapels,  shrines  and 
crosses  marked  other  historical  spots  in  the  town  ;  in  short, 
no  effort  seems  to  have  been  spared  to  foster  the  tradition 
which  brought  inhabitants  to  the  place,  money  to  the 
tradespeople,  and  both  fame  and  money  to  the  ecclesias- 
tics. Against  one  side  of  the  church,  and  directly  con- 
nected with  it,  was  built  a  two-storied  building,  divided  into 
strong  cells,  in  which  to  this  day  may  be  seen  the  iron  rings 
in  the  walls  and  the  chains  by  which  many  of  the  insane 
were  confined  during  the  continuance  of  the  nine  days'  re- 
ligious ceremony  alluded  to. 

When  at  last  these  cells  would  hold  no  more  it  became 
the  custom  to  quarter  the  natural  overflow  in  the  neighbors' 
houses,  or  when  the  cases  were  of  a  mild  nature  to  leave 
them  at  Gheel  for  further  prayers.  From  the  seventh  cen- 
tury, probably,  or  from  the  twelfth  century  with  certainty, 
counting  from  1340,  the  date  of  the  completion  of  the 
Church  of  St.  Dymphna,  up  to  1850,  the  insane  were  in  the 
charge  and  under  the  control  of  the  inhabitants  of  Gheel. 


GHEEL  AND  ITS  INSANE.  10$ 

Villager  and  priest  divided  their  care  and  cure  between 
them, — the  one  in  the  home  life,  the  other  at  the  altar, 
while  the  laws  and  regulations  for  their  treatment  and  pro- 
tection were  enacted  by  the  local  authorities. 

At  the  beginning  of  the  present  century  there  were  about 
400  insane  at  Gheel.  The  wave  of  reform  on  the  continent, 
started  by  Pinel  in  1792,  found  no  dungeons  or  restrictions 
for  harmless  insane  in  Gheel,  and  passed  over  it  without 
commotion.  Gheel  was  then  even,  certainly  in  its  treatment 
of  the  chronic  insane,  far  in  advance  of  the  best  results 
which  have  yet  followed  the  efforts  of  the  wise  and  humane 
Pinel  on  the  continent,  Conolly  in  England,  and  their  fol- 
lowers elsewhere.  Thus  Gheel  thrived,  isolated,  obscure, 
and  unconsciously  superior  ;  and  it  was  only  in  1850  that, 
in  common  with  all  the  institutions  for  the  insane  in  Bel- 
gium, Gheel  became  subject  to  central  governmental  con- 
trol. The  new  regulations  of  1850  provided  for  medical 
service.  It  is  a  notable  and  curious  fact  that  up  to  this 
comparatively  very  recent  date  the  insane  of  the  town  had 
never  been  under  any  organized  medical  care.  The  family 
life  and  the  neuvaine  for  the  restoration  of  reason  were  the 
predominant  principles  involved,  and  even  now  these  two 
elements  retain  much  of  their  former  importance. 

We  now  see  how  spontaneously  has  sprung  up  the  "  fam- 
ily system,"  that  curious  domestic  mixture  of  the  sane  and 
the  insane  that  has  made  Gheel  a  wonder  and  an  anomaly. 
And  no  less  natural  and  spontaneous  were  the  further  steps 
{a)  of  liberty  to  the  insane  person  of  wandering  about  the 
town  at  will  with  merely  that  general  supervision  of  parent 
to  child  ;  {b)  of  responsibility  of  each  family  for  the  one  or 
two  patients  in  their  charge  ;  {c)  of  participation  of  the  in- 
sane person,  as  far  as  his  mental  and  physical  strength 
allowed,  in  the  general  affairs  of  the  household  and  farm  ; 
and  finally,  {d)  of  the  growth  of  that  curious  sentiment  in 


I06  IV.   J.   MORTON. 

the  breasts  of  the  villagers  which  causes  them  to  regard  the 
care  of  the  insane  in  much  the  same  light  as  a  mother  re- 
gards the  care  of  a  child. 

The  Gheel  of  to-day,  then,  is  the  product  of  tradition, 
superstition,  religion,  and  long  custom,  into  which  have  been 
grafted  only  within  thirty  years  a  medical  service  and  cer- 
tain restrictions  as  to  the  non-reception  of  furious  and  dan- 
gerous patients.  Gheel  was  not  born  fully  equipped  for  its 
work  as  it  now  is — it  grew.  What  in  the  middle  ages  and 
earlier  was  a  sequence  to  religious  observances,  developed 
later  into  a  permanent  method  of  taking  care  of  the  insane. 
What  at  first  was  accidental  became  an  established  institu- 
tion, owing  little  in  its  main  elements  to  modern  additions. 

With  this  historical  preface  in  hand,  I  am  sure  that  my 
readers  will  accompany  me  in  a  visit  to  Gheel,  more  under- 
standingly,  and  with  more  brevity  of  description  on  my 
part,  than  would  otherwise  have  been  possible. 

It  was  a  long  pilgrimage  to  Gheel  in  the  old  time  to  in- 
voke the  aid  of  St.  Dymphna.  To-day  patient  or  visitor 
steps  into  the  train  at  Antwerp  and  reaches  Gheel  in  an 
hour. 

During  the  last  summer  I  visited  Gheel  twice.  Some 
years  ago  it  w^as  necessary  to  take  a  somewhat  tiresome 
journey  by  diligence,  but  a  railroad  now  passes  the  town. 
The  train,  as  on  all  Belgian  roads,  glides  across  the  country 
smoothly  and  noiselessly  as  compared  with  our  American 
lines.  The  first  part  of  the  way  is  over  a  fiat  and  fertile 
land,  along  which  are  scattered  at  irregular  intervals  little 
hamlets,  one  much  like  another,  with  its  low  one-storied 
houses,  thatched  and  covered  with  red  tiles.  Long  rows  of 
tall  and  slender  poplars  stretched  off  to  great  distances  and 
marked  the  position  of  narrow  lanes  or  equally  narrow  and 
paved  highways.  The  ground  is  cut  into  sections  by  varie- 
ties of  tillage,  but  no  fences  are  to  be  seen.      Every  scrap  of 


GHEEL  AND  ITS  INSANE.  lO/ 

land  is  cultivated.  Here  and  there  a  windmill  and  herds  of 
Dutch  cattle  completed  the  lowland  picture.  Peasants,  men 
and  women  alike,  were  in  the  fields  at  work  in  the  fresh 
morning  air.  But  the  aspect  of  the  country  cWanges  after 
the  first  half  of  the  way  is  travelled.  Stretches  of  land  and 
gravelly  knolls  replace  the  garden  lands.  Beech  and  pine 
and  oak  appear  instead  of  the  poplar.  One  wonders  how 
St.  Dymphna  found  her  way  into  this  uninviting  country. 

Upon  arriving  at  the  station  on  my  last  visit,  the  station- 
master  provided  a  brisk  little  Flamand  lad  to  act  as  guide, 
for  it  was  necessary  to  find  a  hotel,  as  well  also  as  the  dis- 
tinguished medical  director  of  the  colony,  Dr.  Peeters,  to 
whom  I  had  letters  of  introduction. 

In  some  way  I  had  formed  the  impression  that  Gheel  was 
a  rustic  village,  but  on  the  contrary,  I  found  a  large  town, 
with  long  and  paved  streets  and  well-built  and  solid  houses, 
in  many  instances  one  against  the  other,  as  in  cities,  or  built 
on  small  plots  of  ground  with  garden  in  front  and  rear. 
There  was  no  bustle,  neither  was  there  silence.  Things  ap- 
peared much  as  elsewhere  in  towns — here  and  there  a 
passer  by — here  or  there  a  wagon  or  two-wheeled  cart. 
Where,  then,  were  the  lunatics?  Nothing  at  first  sight  be- 
trayed their  presence.  I  put  this  question  to  my  guide, 
who  replied,  "  Oh,  we  shall  meet  them  everywhere."  We 
were  then  passing  the  large  church  of  St.  Amand.  "  There," 
he  said,  "  on  the  steps  beneath  the  shade  of  the  church,  is 
one,  tending  a  baby."  I  walked  up  to  a  healthy-looking 
young  woman,  who  was  carefully  holding  a  chubby  child, 
perhaps  eight  months  old.  "  I  am  the  Saint  Virgin,"  she 
said,  in  answer  to  my  inquiries.  "This  is  Julie's  child,  who 
lives  around  the  corner."  Julie,  it  seems,  was  the  nourri- 
ciere  or  guardian  with  whom  this  patient  was  placed. 

Later  I  found  that   it  was  not  at  all  uncommon  to  trust 
children  to  the  care  of  the  patients,  and  no  accident  has 


I08  W.   y.   MOKTOX. 

ever  happened.  Speaking  of  this  incident  to  Julie,  the 
mother  of  the  child,  she  said  :  "Ah,  but  I  wouldn't  let  this 
woman  (her  second  patient,  for  most  families  have  two) 
tend  the  children."  Long  acquaintance  with  the  insane, 
and  the  results  of  generations  of  inherited  devotion  to  their 
care,  make  clever  alienists  of  the  Gheelites,  it  seems. 

Still  on  our  way  to  the  hotel  we  met  a  very  polite  young 
gentleman  sauntering  along,  smoking  his  pipe  and  listening 
to  a  hand-organ.  "  Good  morning,"  I  ventured  ;  "  Good 
morning,"  he  replied  graciously.  "You  find  Gheel  very 
agreeable?"  I  continued.  "  Oh,  yes,"  he  said.  "  I  am  here 
on  a  visit  learning  the  Flamand  language  ;  I  am  a  gentleman 
of  leisure."  A  little  further  along  a  woman  stood  with  her 
face  to  the  wall  of  a  house,  talking  to  herself,  with  many 
gestures ;  people  passed  and  repassed  without  seeming  to 
be  aware  of  her  presence  or  her  acts. 

An  idiot  boy  came  hurrying  along  with  meat  in  a  butch- 
er's basket  on  his  arm.     It  seems  he  lived  with  a  butcher. 

It  was  quite  true,  as  my  little  guide  had  said,  we  could 
meet  the  insane  everywhere  ;  but  as  nobody  paid  any  spe- 
cial attention  to  them  it  required  some  little  care  to  pick 
them  out  from  the  sane.  However,  I  had  seen  enough  to 
satisfy  me  that  I  had  arrived  in  the  capital  city  of  the  in- 
sane, and  I  hastened  my  steps  involuntarily  to  begin  a 
nearer  examination  of  its  peculiarities.  From  the  little 
hotel  of  "  Het  Lamb  "  to  the  infirmary  where  resided  Dr. 
Peeters,  the  medical  director  of  the  colony,  the  way  was 
short.  Dr.  Peeters  has  aways  a  cordial  welcome  for  all  stu- 
dents of  the  Gheel  system.  On  the  register  in  his  office 
were  the  names  of  many  alienists  known  to  fame,  particu- 
larly from  England,  and  in  his  library  were  shelves  of  books 
upon  the  subject  of  Gheel  alone.  Under  his  guidance  I  at 
once  proceeded  to  examine  the  "  Gheel  system." 


GHEEL  AND  ITS  INSANE.  IO9 

GHEEL. 

Gheel  is  a  commune  in  Belgium,  situated  about  twenty- 
four  miles  to  the  northwest  of  Antwerp.  Its  inhabitants 
are  Flamands,  made  up  of  an  early  mixture  of  Germans  and 
Gauls.  It  has  no  special  industry,  but  the  population  is 
principally  occupied  in  agricultural  pursuits,  domestic  lace- 
making,  and  caring  for  the  insane.  Frugal  and  industrious, 
their  wants  are  few,  their  lives  calm.  While  there  are  few 
rich,  neither  are  there  many  poor.  Too  practical  to  be  far 
behind  the  times,  Gheel  is  at  the  same  time  too  isolated  to 
be  stirred  with  much  of  the  world's  bustle. 

The  inhabitants  are  almost  entirely  centered  in  the  large 
town  of  Gheel,  though  a  certain  number  are  scattered  in  the 
outlying  hamlets  situated  within  a  radius  perhaps  of  a 
mile.  Most  of  the  farm-hands  among  the  insane  live  at  these 
hamlets.  The  population  is  12,000,  and  there  are  abojut 
2,000  domiciles  of  which  nearly  1,000  receive  insane  pa- 
tients. 

The  insane  population  of  the  town  is  steadily  increasing. 
In  1868,  it  was  1,035;  i"  1869,  1,072;  in  1870,  1,095;  in 
1871,  1,127;  ^ri  1873,  1,230;  in  1874,  1,272;  in  1876,  1,383; 
and  iinally  in  this  year,  1880,  about  1,600.  Of  this  latter 
number  about  1,400  are  Belgian  ;  the  rest  are  Hollanders, 
Germans,  French  and  English.  Of  the  total,  about  two 
hundred  are  paying  patients  ;  the  rest  are  paupers. 

In  general  all  classes  of  insane  are  received  at  Gheel  ex- 
cepting such  as  require  continual  restraint,  or  those  who  are 
suicidal,  homicidal,  or  incendiary.  The  discretionary  power 
as  to  what  patient  may  be  rejected  as  an  unfit  subject  for 
residence  in  the  town  is  lodged  with  the  medical  inspector. 

We  have  already  traced  the  birth  of  the  "  Gheel  idea  " 
into  the  far  past,  and  commented  upon  its  religious  origin, 
and  we  have  noted  also  that  its  organized  medical  service 
was  of  very  recent  date — only  so  late  as  185 1. 


no  W.   y.  MORTON. 

This  new  medical  service  formed  but  a  small  part  of  a 
grand  alteration  in  the  internal  management  of  the  com- 
mune, as  regards  its  insane,  initiated  in  1850  upon  the 
recommendation  of  a  commission-  which  had  been  ap- 
pointed in  1841  to  examine  into  the  condition  of  all  the 
Belgian  establishments  for  the  insane.  The  royal  decree 
of  1850,  and  a  special  decree  regarding  Gheel  in  185 1,  placed 
Gheel  in  common  with  all  the  other  establishments  under 
central  government  control.  These  decrees  provided  not 
only  for  a  medical  service,  but  what  is  important  to  note, 
this  service  was  to  be  entirely  distinct  from  the  general  ad- 
ministration and  subordinate  to  it. 

ADMINISTRATION. 

The  administration  rests  in  the  hands  of  a  "  superior 
commission,"  composed  1st,  of  the  governor  of  the  prov- 
ince, or  his  delegate  ;  2d,  of  the  attorney-general  ;  3d,  of 
the  judge  of  the  canton  ;  4th,  of  a  physician  appointed  by 
the  government  ;  5th,  of  the  burgomaster  of  the  commune  ; 
and  6th,  of  five  members  nominated  annually  by  the  minis- 
ter of  justice. 

Added  to  this  commission  is  a  secretary,  at  a  salary  of 
550  francs  per  annum,  whose  functions  are  extensive  and 
important.  He  makes  the  reports,  conducts  the  correspon- 
dence, has  charge  of  all  that  concerns  the  receiving  of 
money  from  the  friends  of  patients  or  authorities,  and  the 
disbursing  of  these  funds  to  the  village  nourriciers,  has 
charge  of  the  books  and  is  steward  to  the  central  infirmary. 
He  is  of  course  a  resident  of  the  town.  Other  communes 
or  asylums  having  twenty-five  or  more  patients  at  Gheel 
may  be  represented  in  the  commission  by  a  delegate.  The 
medical  inspector  may  also  be  present,  having,  however, 
only  a  consulting  voice. 

*  Appointed  in  1841  by  the  Belgian  Government  to  examine  tlie  condition  of 
the  insane  in  Belgium.  The  report  of  M.  Ducpetiaux,  inspector-general  of 
prisons  and  charitable  institutions,  formed  the  basis  of  the  present  laws  in  force 
at  Gheel  regarding  the  insane. 


GHEEL  AND  ITS  INSANE.  I  I  I 

The  commission  meets  once  each  three  months  at  Gheel, 
and  makes  a  general  inspection  of  all  the  branches  and  all 
the  details  relating  to  the  care  of  the  insane,  making,  after 
each  visit  a  report  to  the  Minister  of  Justice  upon  the  con- 
dition of  the  town,  as  well  as  annually  a  more  complete 
report  in  which  it  points  out  necessary  ameliorations  and 
reforms.  It  also  decides  upon  the  list  of  nourriciers  author- 
ized to  receive  the  insane. 

The  real  working  portion  of  this  commission,  however,  is 
its  "  permanent  committee,"  composed  of  the  five  members 
and  citizens  already  referred  to,  and  presided  over  by  the 
burgomaster  or  mayor.  Its  meetings  are  held  once  a 
week.  Its  special  office  is  to  place  the  patients  in  their  vil- 
lage homes,  consulting  at  the  same  time  the  medical 
inspector  or  the  section  physicians.  It  furthermore  receives 
and  expends,  through  its  secretary,  the  money  for  the  sup- 
port of  the  insane,  watches  over  their  interests,  keeps  an 
eye  upon  the  nourriciers  and  the  hosts,  and  sees  that  the 
laws  and  regulations  are  carried  out. 

The  secretary  must  visit  daily  some  portion  or  another  of 
the  colony  and  make  a  monthly  report  to  the  committee. 

NOURRICIERS    AND    HOSTS. 

As  we  have  said  those  villagers  who  wish  to  receive  the 
insane  into  their  families  must  be  registered  on  the  list 
authorized  by  the  permanent  committee.  Those  who 
receive  paying  patients  are  termed  hosts  ;  those  who  receive 
paupers  are  termed  nourriciers  or  nurses.  Both  are  required 
to  furnish  evidence  of  good  moral  character,  of  attention  to 
their  duties,  healthy  and  abundant  food  and  sufficient  room 
for  the  patients  they  are  to  receive.  No  host  or  nourricier 
is  permitted  to  receive  more  than  two  patients.  I  found  in 
no  house  in  Gheel  more  than  this  number  under  a  single 
roof. 

The  nourricier  or  host  has  the  special  guardianship   and 


112  W.    y.  MORTON. 

direct  surveillance  of  the  insane  patient  placed  in  his  care, 
and  is  moreover  responsible  for  any  damage  which  his 
charge  may  commit.  If  his  patient  escapes,  the  expense 
of  his  capture  and  return  must  be  defrayed  by  him. 

A  multitude  of  minor  regulations  prescribe  the  amount 
and  character  of  food  supplied,  the  size  of  the  rooms  occu- 
pied, the  ventilation,  the  single  occupancy  of  a  room,  the 
covering  on  the  floor,  the  articles  of  bed  furniture,  and  the 
clothing. 

Lastly,  the  insane  thus  placed  with  a  host  or  nourricier 
may  be  employed  in  work  that  is  suitable  to  their  strength 
and  abilities,  or  in  occupations  which  serve  to  engage  their 
attention,  without  in  any  case,  however,  being  overworked  or 
wearied.  This  permission  may  be  withdrawn  at  any  moment 
if  the  privilege  it  accords  is  abused.  Care  is  taken  to  place 
patients  in  families  corresponding  to  their  former  condition 
in  life, — some  with  the  peasants  on  the  farms,  some  with 
mechanics,  others  with  the  small  shop  people  or  well-to-do 
residents.  With  rich  and  poor  alike  at  Gheel  it  is  an  honor 
and  a  duty  to  have  at  least  one  patient  in  charge. 

As  a  further  protection  to  the  interests  of  the  insane 
there  are  four  "section  guards;"  one  at  the  infirmary,  and 
the  other  three  in  charge,  respectively,  of  the  three  sections 
into  which  the  town  is  divided.  Their  duties  are  to  walk 
about  their  sections  continually,  enter  houses  unexpectedly, 
see  that  the  patient  is  not  overworked,  observe  his  mental 
condition,  and  make  a  daily  report  to  the  medical  inspector 
or  to  a  section  physician. 

MEDICAL    SERVICE. 

The  medical  service  of  Gheel  is  under  the  charge  of  a 
medical  inspector.  At  present  this  ofifice  is  held  by  the  very 
earnest  and  able  Dr.  Peeters,  who  is  efficiently  carrying  out 
the  methods  pursued  by  Dr.  Bulkens,  his  only  predecessor, 
now  deceased. 


GHEEL  AND  ITS  INSANE.  I  I  3 

Dr.  Peeters'  headquarters  are  at  the  infirmary,  and  owing 
to  the  careful  regulations  which  provide,  in  the  person  of 
the  secretary  of  the  superior  commission,  for  a  steward  or 
business  manager  who  shall  look  after  the  money  affairs, 
food,  bedding,  washing,  lighting,  fuel,  etc.,  he  is  able  to  give 
his  time  strictly  to  the  pursuit  of  medical  subjects. 

He  is  aided  by  three  physicians,  who  have  charge  of  three 
separate  sections  into  which,  for  convenience  of  attendance, 
the  town  is  divided.  These  physicians  reside  in  their 
sections  and  are  engaged  in  the  general  practice  of  medicine 
in  the  town.  Each  section  physician  visits  the  curable 
patients  in  his  district  at  least  once  a  week,  the  incurables 
once  a  month,  and  additionally  whenever  he  is  summoned 
by  those  having  the  patient  in  charge.  He  makes  a  monthly 
report  to  the  medical  inspector  who,  in  time,  makes  his 
report  to  the  superior  commission.  His  prescriptions  are 
filled  at  a  fixed  rate  by  pharmaceutists  living  in  the  same 
district. 

The  physician's  visit  is  entered  in  a  book  kept  by  the 
nourricier  or  host. 

I  examined  many  of  these  books  in  making  my  rounds  of 
the  town,  and  believe  that  the  medical  treatment  of  the 
insane  is  admirably  organized  and  carried  out. 

The  medical  inspector  himself  must  visit  patients  if  asked 
to  do  so,  and  must,  in  any  event,  have  visited  every  patient 
in  the  commune  at  least  twice  in  the  year. 

THE    INFIRMARY. 

The  infirmary,  erected  soon  after  the  decrees  of  1850,  is 
a  fine  building  which,  in  the  main  features  of  its  construc- 
tion, does  not  differ  from  the  usual  plan  of  closed  asylums, 
and  it  is  not,  therefore,  necessary  to  describe  it.  The  ob- 
ject for  which  it  was  built  and  for  which  it  is  now  used 
is,  however,  vastly  different  from  that  of  the  usual  asylum. 
It  is,  as  its  name   indicates,  an   infirmary  or  hospital.     It  is 


114  W.   y.  MORTON. 

not  the  centre  around  which  a  colony  is  located  ;  it  is  sim- 
ply an  adjunct.  Its  purpose  is  to  afford  the  usual  hospital 
treatment  to  patients  attacked  with  incidental  diseases,  to 
care  for  the  very  infirm,  and  to  take  a  brief  charge  of  cases 
that  suddenly  develop  a  condition  of  excitement  which  re- 
([uires,  for  short  periods,  continuous  and  special  watchful- 
ness and  restraint. 

The  patients'  stay  in  the  building  is  expected  to  be  tem- 
porary. 

The  general  management  of  the  infirmary  is  under  the 
control,  first,  of  the  permanent  committee,  whose  secretary 
is  at  the  same  time  the  steward  ;  and  second,  of  the  medical 
inspector.  Here,  then,  we  have  at  once  a  medical  ofificer 
and  a  lay  officer  or  business  manager,  who  together  perform 
the  duties  which  in  our  American  system  of  asylum  manage- 
ment are  vested  in  a  single  person,  viz.,  the  superintendent. 

On  the  occasion  of  my  last  visit  there  were  sixteen 
women  and  twenty-one  men  out  of  a  total  of  1603  in  the 
town,  at  the  infirmary.  There  was  no  restraint  employed 
with  these  patients,  beyond  the  fact  that  they  were  not  al- 
lowed to  leave  the  court  yard  and  the  building.  A  half 
dozen  "sisters"  from  a  special  order,  called  Norbertines, 
act  as  nurses. 

THE    INSANE    IN    THEIR    HOMES. 

Furnished  by  Dr.  Peeters  with  a  section  guard  who  spoke 
French  (most  of  the  villagers  speak  Flemish),  I  started  out 
to  spend  the  day  in  looking  about  the  town.  I  have  al- 
ready alluded  to  meeting  patients  about  the  streets  pursuing 
various  avocations  or  simply  strolling  about.  This  experi- 
ence became  too  common  finally  to  attract  much  attention. 
It  is  evident  from  what  I  have  previously  said  that  this 
liberty,  at  first  sight  apparently  almost  unbounded,  is  hedged 
round  by  carefully  considered  restrictions,  and  that  the  se- 
curity of  the  inhabitants,   apparently  imperilled,  is  equally 


GHEEL  AND  ITS  INSANE.  II  5 

secured  by  systematic  care  and  watchfulness.  Not  only  is 
each  patient  cared  for  by  his  own  particular  village  guar- 
dian, but  additionally  the  whole  community  cooperatively 
act  as  voluntary  guardians,  not  only  to  themselves  against 
improper  acts  of  the  insane,  but  also  to  the  insane  person 
himself  against  maltreatment  by  any  single  household.  In 
a  community  where  nothing  is  concealed,  abuses  are  not 
likely  to  thrive.  Public  opinion  and  open  dealing  are  the 
patients'  safeguards.  And  to  this  traditional  relation  be- 
tween villager  and  patient  we  must  add  the  surveillance 
guided  by  careful  legal  enactments  and  conducted  by  reg- 
ularly appointed  ofificers. 

In  the  face  of  such  facts,  a  superintendent  of  an  Amer- 
ican insane  asylum,*  who  is  among  the  very  few  American 
medical  visitors  to  Gheel  besides  myself  who  has  writ- 
ten anything  upon  the  subject,  thus  sums  up  his  views 
upon  this  point.  "A  few  of  the  manifest  defects  of 
the  system  are  the  absence  of  medical  care,"  *  *  *  * 
"and  the  almost  unlimited  opportunity  for  the  abuse  of 
patients,"  etc.,  etc.  Abuse  of  patients  is  simply  impossible 
at  Gheel,  while  from  a  therapeutic  point  of  view,  the  retreat 
to  the  infirmary,  the  medical  inspector  and  the  section  phy- 
sicians adequately  supply  all  the  treatment  necessary.  It 
must  be  remembered  that  since  the  duties  of  these  physi- 
cians are  simply  medical,  they  find,  as  I  have  already  re- 
marked, more  time  at  their  disposal  than  is  possible  in  our 
mixed  system  where  the  superintendent  is  also  business 
manager  and  steward. 

Moreover,  the  "  free  air,"  the  home  life,  the  household 
occupations  or  employment  on  the  farms,  are  more  than  an 
offset  for  the  rules,  discipline,  military  order  or  enforced  in- 
activity of  the  best-equipped  closed  asylum  in  the  world. 

*  In  a  pamphlet  entitled  "The  Insane  Colony  at  Gheel,"  by  A.M. Shew,  M.  D., 
Superintendent,  Hospital  for  the  Insane,  Middletown,  Conn.  Reprinted  from 
the  American  Jour,  of  Insanity,  ior  ]\i\y,  1879. 


Il6  fV.  y.  MORTON. 

If  the  question  between  the  Gheel  system  and  a  closed 
asylum  were  one  of  comparison  of  the  best  methods  of 
curing  insanity  by  early  treatment,  the  question  of  a  hos- 
pital treatment  would  be  an  important  one.  But  this  is  not 
the  case. 

It  is  simply  a  question  in  Dr.  Shew's  criticism  between 
the  curative  effects  of  the  ordinary  American  asylum,  used 
as  a  place  of  custody  or  simple  residence  for  the  most  part, 
as  compared  on  the  other  hand  with  Gheel.  I  have  no 
doubts  from  this  point  of  view  that  the  prospects  of  recov- 
ery for  the  patient  at  Gheel  are  vastly  superior  to  the  pros- 
pect in  the  closed  asylums  of  any  country. 

A  peculiar  classification  of  the  insane,  which  serves  as  a 
basis  upon  which  payment  is  made  to  the  nourricier  or 
guardian,  exists  at  Gheel. 

This  classification,  as  ludicrous  as  unscientific,  seems  to 
have  had  its  origin  in  the  simple  sense  of  the  people,  who 
measured  their  services  by  the  amount  of  trouble  occasioned 
them  in  keeping  their  charges  clean.  The  insane  are  di- 
vided into,  1st,  the  "dirty;  "  2d,  the  "half-dirty,"  and,  3d, 
the  "  clean."  * 

For  the  first  class  is  paid  about  19  cents  a  day  ;  for  the 
second,  about  18  cents  a  day,  and  for  the  third,  about  16 
cents  a  day. 

It  is  somewhat  curious  to  see  how  this  sum  is  distributed. 
It  is,  in  the  case  of  the  clean,  as  follows:  if  cents  for  medi- 
cal service,  -g-  of  a  cent  for  medicine,  about  1 1  cents  for  food, 
2  cents  for  clothes,  f  of  a  cent  for  the  bed,  -^  of  a  cent  for 
surveillance,  and  f  of  a  cent  for  administration.  Of  the  16 
cents,  the  nourricier  receives  about  12  cents;  for  the  "  half- 
dirty"  he  gets  14  cents;  for  the  "  dirty,"  15  cents. 

This  daily  rate  is  lower  than  that  existing  in  any  asylum 
or  other  institution  for  the  insane  in  Belgium.     It  is  paid, 

*  Gateux,  semi-gateux,  propres. 


GHEEL  AND  ITS  INSANE.  H? 

in  the  case  of  the  paupers,  by  their  respective  communes  or 
by  the  central  government. 

Selecting  one  of  the  large  main  streets  of  the  town,  my 
guide  and  I  entered  almost  every  house.  We  first  visited 
some  of  the  paying  patients.  In  a  fine,  large,  and  well-fur- 
nished two-storied  house  had  lived  an  Englishman  for  eight 
years.  He  paid  $600  a  year.  A  French  prince,  lately  ar- 
rived, paid  the  same.  In  a  neighboring  house  was  a  Dutch 
student,  with  his  classics  scattered  on  the  table ;  in  another, 
a  rich  Dutch  farmer.  They  were  cases  of  chronic  insanity, 
subject  to  exacerbations,  which  required  great  care. 

But  my  interests  were  rather  with  the  less  exceptional 
cases,  and  I  passed  on  to  the  ordinary  homes  of  the  village. 
These,  as  a  rule,  are  but  one  story  in  height,  and  roofed 
with  tiles.  They  presented  an  air  of  comfort  and  neatness; 
if  there  was  no  luxury,  neither  was  there  squalor;  they  were 
simply  and  usefully  furnished,  the  floors  clean,  the  cup- 
board full  of  polished  pewter  and  brass  and  a  modicum  of 
crockery ;  a  Dutch  clock  and  the  ever-present  crucifix  and 
highly-colored  prints  of  the  Virgin  and  child  were  the  only 
ornaments.  To  each  house  is  attached  a  garden.  I  care- 
fully inspected  in  every  house  the  rooms  in  which  the  pa- 
tients slept,  for  I  had  read  that  "  the  sleeping  accommoda- 
tions are  often  provided  in  garrets,  lofts,  and  out-of-the-way 
nooks  and  corners."*  In  every  instance  the  sleeping-room 
was  as  provided  by  law,  with  at  least  a  surface  of  6  metres 
square  and  provided  with  a  window.  It  was  clean,  and  con- 
tained a  good  bed. 

A  little  book  kept  by  each  nourricier  gave  the  record  of 
the  name,  age,  etc.,  of  the  patient,  the  garments  received 
from  the  infirmary,  the  number  of  visits  made  by  the  sec- 
tion physician  and  the  medical  inspector,  as  well  as  notes 
on  special  acts  of  boarders. 

*  Dr.  A.  M.  Shew.     Op.  cit.,  p.  5. 


Il8  W.    y.  MO  R  TO  AT. 

A  few  instances  of  households,  just  as  I  found  them,  will 
answer  for  samples  of  all  in  the  town.  There  are  two  pa- 
tients, it  will  be  remembered,  in  each. 

In  the  first  was  an  old  woman,  industriously  engaged  in 
peeling  potatoes.  She  had  lived  with  the  same  family  for 
40  years.  The  other  boarder  sat  at  the  front  door  knit- 
ting. 

In  a  second  house  a  strong  and  healthy-looking  woman 
sat  preparing  turnips  for  boiling,  while  her  companion  luna- 
tic was  engaged  in  general  housework. 

In  a  third  house  one  again  was  knitting  ;  the  other  could 
not  be  induced  to  work;  her  principal  occupation  was  to 
tear  things. 

In  a  fourth  house  was  a  middle-aged  woman  tending  the 
child  of  her  nourricier,  and  a  second  patient  knitting. 

In  a  fifth  house  one  was  polishing  the  stove,  and  was 
much  amused  at  being  caught  with  black  hands  ;  her  com- 
panion was  useless,  and  merely  sat,  refusing  to  take  part  in 
work. 

In  a  sixth  house  was  but  one  patient,  an  idiot  boy  of  per- 
haps 10  years  of  age.  The  fine,  fresh-looking,  and  elderly 
woman  who  took  care  of  him  was  as  fond  of  him  as  if  he 
had  been  her  own  child.  Though  he  had  epileptic  fits  and 
was  "dirty,"  she  had  his  crib  drawn  up  beside  her  own  bed, 
in  order  to  look  more  carefully  after  him  during  the 
night. 

In  a  seventh  house  were  two  idiots. 

In  an  eighth,  occupied  by  a  shoemaker,  were  two  more, 
who  seemed,  while  taking  part  in  the  work,  to  be  of  more 
trouble  than  assistance. 

In  a  ninth  was  a  case  of  chronic  mania  and  an  epileptic. 
The  woman  nourricier  lived  quite  alone  with  these  two. 
The  price  received  for  their  care,  $73  each,  was  her  only 
means  of  support. 


GHEEL  AND  ITS  INSANE.  1 1 9 

In  a  tenth  house  were  two  who  would  not  work  or  assist 
in  anything.     The  price  paid  for  each  was  $50. 

In  only  one  instance  did  I  find  a  patient  in  reslraint.  He 
was  a  strong  man  in  charge  of  a  woman  by  no  means  mas- 
culine, whose  husband  was  in  the  fields.  Finding  that  her 
charge  was  breaking  and  tearing  every  object  in  his  reach, 
she  had,  with  the  permission  of  the  section  phj'sician,  put 
him  in  a  camisole. 

A  couple  of  cases  from  Dr.  Peeters'  records*  will  illustrate 
very  vividly  the  nature  of  many  others  met  with  : 

A  patient  named  Virginia  A.,  number  6746  on  the  register, 
had  been  a  year  at  the  asylum  Sainte-Anne-les-Courtrai.  She 
entered  the  infirmary  at  Gheel  on  May  14,  18S0,  and  presented 
at  this  date. all  the  symptoms  of  intense  mania.  She  was  constantly 
in  movement,  ran  about  the  court-yard,  and  accosted  every  one. 
She  talked  unceasingly  and  with  ease,  but  what  she  said  was  in- 
coherent and  confused.  She  would  frequently  scream,  sing,  com- 
mit extravagant  acts,  tear  her  clothing,  or  pick  the  coverings  of 
her  bed.     She  did  not  sleep  at  all. 

On  May  19th  the  patient  was  placed  in  charge  of  a  peasant 
guardian  living  in  a  quiet  locality  some  distance  from  the  town. 
The  instructions  were  :  gentle  supervision,  protection  from  all 
causes  of  excitement,  occupation  in  household  affairs  and  out-of- 
doors.  At  the  end  of  three  weeks  one  would  scarcely  believe 
that  they  beheld  the  same  patient,  for  she  had  entirely  recovered. 
Fearing  a  return  of  an  excitement  which  had  so  suddenly  disap- 
peared, we  did  not  dare  sign  a  certificate  allowing  of  her  depart- 
ure until  the  27th  of  the  month.  But  the  cure  remained  perma- 
nent, and  the  patient  returned  to  her  own  home  on  October  2d. 

A  patient  named  Mary  V.,  number  6094  on  the  register,  suffer- 
ing from  delirious  melancholy.  Energetic  moral  and  other  treat- 
ment, and  the  devoted  attentions  of  the  "sisters  "  did  not  succeed 
in  modifying  her  condition.  She  spent  the  day  in  lamentation, 
saw  the  preparations  for  the  frightful  punishment  which  she 
believed  she  would  be  obliged  to  suffer,  and  slept  neither  day  nor 
night. 

*  Translated  from  lettres  Medicales  sur  Gheel,  etc.,  seconde  lettre.  p.  29,  by 
Dr.  J.  H.  Peeters,  Medecin  Inspecteur,  Sept.,  1880. 


I20  IV.   J.  MORTON. 

She  was  entrusted  to  an  intelligent  and  devoted  nourricier, 
who  lived  on  the  farms,  with  instructions  to  exercise  proper  super- 
vision and  kindness,  to  make  her  life  as  calm  as  possible,  to  pro- 
vide proper  occupation  for  her,  and  to  look  after  the  regularity  of 
the  excretions.  Mary  V.  was  scarcely  installed  in  her  new  home 
before  her  condition  modified  favorably.  Her  delirium  became 
somewhat  less  active.  She  mourned  less,  and  soon  took  part  in 
the  household  labor  with  the  wife  and  daughters  of  her  guardian. 
Her  appetite  became  excellent,  her  sleep  normal,  and  she  in- 
creased in  flesh.  This  improvement  developed  at  the  end  of 
four  months  into  a  permanent  cure.  Before  leaving,  the  pa- 
tient came  to  thank  us,  and  when  I  congratulated  her  on  her 
rapid  and  complete  cure,  she  replied  :  "  I  would  never,  I  believe, 
have  recovered  at  the  infirmary.  The  presence  of  the  other 
patients  fed  my  delirium  and  my  unrest.  As  soon  as  I  had  en- 
tered into  the  calm  and  happy  home  of  nourricier  G.  I  felt  my 
senses   grow  clearer   and  my  heart  encouraged." 

One  is  surprised  to  find  that  escapes  are  unfrequent;  they 
range  from  seven  to  twelve  annually;  the  patient  is  always 
quickly  caught  and  returned. 

Acts  of  violence  are  likewise,  compared  to  the  population, 
very  rare.  But  three  instances  of  the  latter  are  known  : 
one  a  homicide  in  1840;  the  second  and  third,  injuries  in- 
flicted by  farm  implements,  and  not  fatal  or  indeed  in  the 
last  instance  severe.  Three  suicides  have  occurred  since 
1875,  a  number  not  relatively  large. 

Offences  against  morality,  or  the  occurrence  of  preg- 
nancy, are  also  almost  unknown.  The  "  confusion  of  the 
sexes,"  so  often  urged  as  an  objection  to  the  Gheel  system, 
leads  to  no  unfortunate  results.  In  a  half  century  scarcely 
a  half  dozen  instances  of  pregnancy  among  patients  have 
occurred.* 

THE     HAMLETS, 

Leaving  the  town  by  any  of  its  principal  thoroughfares, 
one  is,  in  a  twenty  minutes'  walk,  out  in  the  open  country. 
Here  in  every  direction  are  scattered  the  farmers'  homes  in 

*  Lettres  Midicales  sur  Gheel,  etc.,  by  Dr.  J.  H.  Peeters,  Gheel,  1879. 


GHEEL  AND  ITS  INSANE.  121 

little  clusters  of  houses,  numbering  from  three  to  ten. 
These  houses  are  not  as  well  kept  as  the  houses  in  town, 
but  I  saw  no  evidences  of  discomfort.  That  "  the  hamlets 
were  low "  and  sometimes  "  dark "  was  sometimes  true, 
sometimes  not  ;  also  that  they  were  "  destitute  of  wooden 
floors,  and  covered  with  thatched  roofs;"  this  description 
would  apply  to  the  abodes  of  most  of  the  peasantry  on  the 
Continent,  but  that  they  were  "damp"  I  did  not  discover. 
Most  of  these  houses  were  divided  into  four  rooms  :  a  kit- 
chen, a  sitting-room,  and  two  chambers  ;  on  the  end  was  a 
continuation  occupied  by  the  cattle,  and  connecting  by  a 
door  into  the  kitchen.  This  seemed  to  me  the  most  un- 
pleasant feature  in  their  construction.  But  that  "  all  the 
peasanty  had  the  old  worn  look  that  is  produced  by  over- 
work and  underfeeding  ""  was  totally  contrary  to  what  I 
saw. 

I  have  never  seen  better  specimens  of  fine  physical  health 
than  among  these  peasant  people,  with  their  bright  glowing 
complexions  and  rounded  figures.  Certainly,  taken  as  a 
whole,  they  would  compare  favorably  with  the  generalty  of 
peasantry. 

There  were  many  idiots  scattered  among  the  farmers, 
many  dements,  and  cases  of  chronic  mania  and  epilepsy. 
In  case  a  patient  becomes  too  much  excited  and  un- 
manageable he  is  taken  to  the  infirmary.  The  average 
price  paid  here  is  about  $63  a  year.  Those  who  were  at 
work  seemed  to  work  willingly. 

One  saw  on  every  hand  evidences  of  at  least  complaisant 
labor  on  the  part  of  the  insane,  and  kindness  toward  them 
on  the  part  of  the  sane.  We  would  meet,  for  instance,  an 
insane  man  wheeling  a  barrow  of  potatoes  across  the  field, 
full  of  interest  in  his  task,  while  a  peasant  woman  who  was 
his   nourricier   followed   along  after  ;     or   again,   a   peasant 

*  Dr.  Shew,  op.  cit. 


122  W.   y.   MORTON. 

woman  coming  in  from  the  fields  with  a  barrow  full  of 
vegetables,  with  an  idiot  child  of  fifteen  mounted  on  top, 
whom  she  was  wheeling  because  the  child  was  weary  of 
walking. 

Everything  showed  care  and  kindness  on  the  part  of  the 
peasant  attendants.  To  look  after  their  charges  seemed  to 
be  a  settled  part  of  their  daily  lives.  There  was  nothing 
perfunctory  in  the  services  they  rendered  or  exacted. 

It  is  exceedingly  difificult  to  represent  in  statistic  form 
the  curative  value  of  the  Gheel  treatment,  for  the  reason 
that  the  proportion  of  incurables  admitted  to  Gheel  is 
larger  than  in  any  of  the  closed  asylums  with  whom  com- 
parisons must  be  instituted. 

For  instance,  in  1879,  of  313  patients  admitted  73  were 
received  from  other  Belgian  asylums,  of  whom  71  were  ab- 
solutely incurable.  Under  such  conditions  it  would  be  ob- 
viously unjust  to  reckon  the  percentage  of  cures  in  the 
usual  manner.  Reckoned  thus  for  the  years  1853  to  1870, 
the  proportion  of  cures  was  24  per  cent.* 

On  the  other  hand,  basing  his  figures  upon  an  enumera- 
tion of  those  cases  which  he  considered  from  the  first 
curable.  Dr.  Bulkens  estimated  the  proportion  of  cures  as 
from  79  to  89  per  cent. 

The  question  of  proportion  of  cures  as  between  the 
Gheel  system  and  the  closed  asylums  has  been  much  dis- 
cussed ;  and  there  is  nothing  satisfactory  to  be  derived 
from  the  discussion.  We  will  therefore  leave  the  subject 
here. 

I  have  said  enough  to  indicate  in  a  somewhat  minute 
manner  the  main  characteristics  of  Gheel.  They  are,  com- 
parative freedom,  occupation,  and  the  family  life.  We 
have  walked  about  a  town  where  the  insane  live  with  the 
sane  and   work  with   them   in    their   homes  and    on   their 

*  3,021  entries,  724  cures  or  ameliorations.      Dr.  Peeters. 


GHEEL  AND  ITS  INSANE.  123 

farms,  eat  with  them  at  their  tables,  act  sometimes  as 
nurses  to  their  children,  and  where  they  go  about  at  will. 
And  we  have  seen  no  excitement,  commotion  or  disorder. 

The  picture  is  unlike  anything  to  be  seen  in  America  or 
elsewhere  in  Europe,  and  therefore  valuable  for  its  con- 
trasts and  its  suggestions.  It  is  unusual  to  see  the  insane 
living  their  lives  in  natural  surroundings. 

Gheel  in  its  entirety  is  probably  an  ideal  which  can  never 
be  repeated  by  any  other  nation,  for  the  simple  reason  that 
there  is  but  one  village  of  Gheel,  removed  from  the  world's 
trafific  and  turmoil,  where  the  inhabitants,  by  reason  of  cen- 
turies of  inheritance,  have  learned  a  patience  sublime  in  its 
simplicity,  a  tact  in  management  born  only  of  affectionate 
regard  for  their  charges,  and  an  absence  of  timidity  impos- 
sible to  realize  until  witnessed.  There  are  services  and. 
solicitudes  which  money  cannot  buy,  and  these  we  find  at 
Gheel. 

But  though  the  "  Gheel  idea,"  i.  e.,  the  "  family  system," 
consisting  of  a  large  number  of  families  who  would  receive 
into  their  midst  a  thousand  or  more  insane,  may  not 
be  repeatable,  the  essence  of  this  idea,  /.  e.,  a  large  and 
reasonable  liberty,  healthful  and  sufficient  employment, 
and  accustomed  and  congenial  surroundings,  is  repeatable  ; 
but  not,  certainly,  in  any  of  our  great  asylum  buildings. 
Gheel  teaches  us  the  possibilities  that  exist  in  the  treat- 
ment of  the  insane.  It  shows  us  that  the  insane  will  work 
cheerfully  if  well  managed,  and  that  they  may  be  trusted, 
under  proper  precautions,  with  great  liberty  and  not  abuse 
it.  It  teaches  us,  moreover,  how  woefully  wide  our  ad- 
vanced civilization  is  from  the  mark  it  might  attain  to  in 
the  treatment  of  insanity. 


A   CASE    OF    PARALYSIS    AGITANS    CURED    BY 

CENTRAL      GALVANIZATION,      SODIUM 

BROMIDE  AND   HYOSCYAMUS. 

By  EDWARD  C.   MANN,   M.D., 

TARRYTOWX-ON-THE-HUDSON,    N.    Y. 

PHYSICIAN-IN-CHIEF,  SUNNYSIDE  MEDICAL  RETREAT  FOR  DISEASES  OF  THE  NER- 
VOUS SYSTEM,  INEBRIETY  AND  OPIUM  HABIT  ;    MEMBER,  NEW  YORK 
NEUROLOGICAL    SOCIETY  ;    NEW     YORK     MEDICO-LEGAL    SOCI- 
ETY ;    AM.   ASSN.   FOR  CURE  OF  INEBRIATES,    ETC. 

THE  following   interesting    case,  interesting  by   reason 
of    the    rarity    of    cures    obtained,  occurred    in    the 

person   of  a  Mrs.  E ,  aged  50,  resident   of  New  York 

City,  and  the  superintendent  of  one  of  our  charitable 
institutions.  The  disorder  had  come  on  gradually,  as  the 
result  of  domestic  unhappiness  and  grief,  and  had  finally 
culminated  in  a  condition  of  subacute  mania,  complicating 
the  case  very  much  and  very  seriously.  At  first  I  declined 
to  take  such  a  case,  and  gave  the  ladies  who  were  inter- 
ested in  the  patient  a  very  unfavorable  prognosis  concern- 
ing it.  I  was  prevailed  upon  to  say  that  I  would  treat 
her  for  one  month,  they  agreeing  to  remove  the  patient  at 
the  expiration  of  that  time  if  I  could  effect  no  improve- 
ment. At  the  time  of  admission  the  trembling  was  inces- 
sant and  involved  all  the  limbs.  There  were  delusions  of 
suspicion,  and  dread  and  fear  of  persecution, — in  other 
words,  marked  mental  disorder.  There  were  hallucinations 
of    sight    and    hearing.     There  would  be  exacerbations   of 

124 


CASE  OF  PARALYSIS  AGITANS.  12$ 

the  tremblings,  due  to  emotional  disturbance.  There  was 
marked  muscular  rigidity  and  contraction,  so  that  the  head 
was  thrown  forward  and  fixed,  and  the  trunk  was  also  bent 
forward.  Walking  seemed  very  difficult,  and  also  talking. 
The  muscular  force  and  the  cutaneous  sensibility  were  nor- 
mal, so  far  as  I  could  ascertain.  There  was  marked  trem- 
ulousness  of  the  tongue  when  protruded.  The  trembling 
at  first  attacked  one  hand  and  arm,  and  gradually  spread 
all  over  the  body.  I  considered  the  case  the  most  unfavor- 
able one  I  had  ever  received  for  treatment,  and  did  not 
hesitate  to  tell  one  or  two  of  my  professional  friends  that  I 
regarded  my  patient  as  hopelessly  incurable.  I  directed 
warm  baths  with  cold  effusion  to  the  head  at  night,  opened 
the  bowels  freely  with  a  mercurial  cathartic  followed  by 
salines,  and  then  put  my  patient  practically  on  a  milk  diet 
and  secluded  her  from  all  society  save  that  of  her  nurse, 
and  directed  the  latter  to  administer,  three  times  a  day, 
drachm  doses  of  sodium  bromide  and  tincture  of  hyoscya- 
mus.  Fortunately  I  obtained  a  very  good  article  of  hyo- 
scyamus,  and  I  soon  found  to  my  surprise  that  my  patient 
was  improving,  very  much.  Electricity  in  the  form  of 
central  galvanization  and  also  a  bi-temporal  current  were 
employed.  The  mental  excitement  soon  began  to  dis- 
appear, the  muscular  tremblings  gradually  subsided,  very 
much  in  proportion  as  the  mind  became  quiet,  and  at 
the  end  of  one  month  I  saw  that  my  patient  was 
rapidily  improving.  I  accordingly  allowed  her  to  take 
moderate  exercise  in  the  open  air  and  put  her  on  a  full 
diet.  The  rigidity  and  contraction  of  the  muscles  disap- 
peared gradually,  the  gait  becoming  assured,  the  head  com- 
ing up  erect  and  also  the  trunk.  The  speech  lost  its  trem- 
ulousness  and  the  face  assumed  a  much  more  bright  and 
intelligent  expression.  At  the  end  of  the  second  month 
all  mental  disturbance  had  passed  away,  the  mental   facul- 


126  EDWARD  C.   MANN. 

ties  remaining  normal.  I  now  discontinued  the  use  of 
the  sodium  and  hyoscyamus  and  also  the  central  galvaniza- 
tion, substituting  instead  the  induced  current  in  the  form 
of  general  faradization,  using  it  as  a  nervous  stimulant  and 
tonic.  I  considered  that  by  the  constant  current  I  had 
removed  the  nutritive  defect  in  the  central  nervous  system, 
improving  the  tone  and  nutrition  not  alone  of  the  brain 
and  cord,  but  also  of  all  the  deeper  tissues  of  the  body.  A 
tonic  containing  quinine,  phosphorus  and  strychnine  was 
now  ordered,  and  the  patient's  weight  increased  markedly 
during  the  third- month  of  her  stay  here.  At  the  expira- 
tion of  the  third  month,  she  was  discharged  perfectly  well, 
not  a  trace  of  trembling  being  visible  in  muscular  action, 
speech  or  gait.  The  mental  faculties  were  perfectly  re- 
stored. My  patient,  against  my  advice,  returned  to  her 
laborious  post  of  duty,  and  has  since  remained  perfectly 
well.  I  do  not  know  that  1  should,  in  another  case,  get 
such  a  favorable  result.     I  am  afraid  not. 

My  success  in  this  case,  however,  warrants  me  in  express- 
ing the  hope  that  such  cases  may  have  the  benefit  of  long 
continued  application  of  electricity,  and  my  preference 
for  the  future  would  be  hypodermic  injection  of  -^  grain 
of  the  crystallized  extract  of  hyoscyamine,  giving  drachm 
doses  of  the  bromide  of  sodium  in  half  a  tumbler  of 
water,  three  times  a  day,  between  meals.  Prof.  Charcot 
considers  it  probable  that  the  morbid  anatomy  of  many  of 
the  cases  that  go  on  to  a  fatal  termination,  consists  of  ob- 
literation of  the  central  canal  of  the  cord  by  increase  of  its 
epithelial  lining,  overgrowth  of  the  nuclei  which  surround 
the  ependyma,  and  marked  pigmentation  of  the  nerve  cells, 
principally  those  of  Clarke's  posterior  vesicular  columns. 
In  my  case,  if  the  paralysis  agitans  had  depended  upon  an 
atrophic  condition  of  the  spinal  cord,  pons  varolii,  crura  or 
medulla    oblongata,    or,  in    other  words,  had   depended  on 


CA  SE  OF  PA  RA  L  YSIS  A  GIT  A  NS.  1 2  7 

organic  changes,  I  do  not  think  a  cure  could  have  been  ob- 
tained. On  the  other  hand,  I  am  inclined  to  think  that,  if 
there  was  degeneration,  due  to  the  new  formation  of 
connective  tissue  compressing  the  cord  ai]d  nerve  struc- 
tures, the  constant  current  perhaps,  by  its  catalytic  effect 
could  have  had  the  power  to  remove  such  new  formation, 
freeing  the  compressed  nerve  structure.  My  case,  more- 
over, may  have  depended  on  congestion  of  the  nervous  sub- 
stance or  the  membranes  of  the  upper  part  of  the  me- 
dulla spinalis,  oblongata,  and  pons,  which  had  not  gone  on 
to  sclerotic  atrophy,  and  the  galvanic  current  unquestion- 
ably would  have-relieved  that  condition  permanently. 

I  not  only  had  to  combat  disease  of  the  motor  centres, 
but  also  of  the  intellectual  centres.  The  disease,  I  pre- 
sume, commenced  in  the  cervical  region  of  the  cord,  since 
the  arm  was  first  affected  and  soon  the  corresponding  one. 

I  considered  my  case,  however,  probably  to  have  been 
one  in  which  there  were  weakness  and  irritability  and  in- 
stability of  the  molecular  nerve  structure  of  the  nerve  cen- 
tres, owing,  perhaps,  to  mal-nutrition,  and  that  the  disease 
was  functional  in  character  rather  than  organic.  If  so, 
then  we  may  say  that  there  are  curable  functional  cases  of 
paralysis  agitans.  My  patient  had  not  a  rheumatic  diathe- 
sis or  any  other  morbid  diathesis  which  could  have  dis- 
posed her  to  her  disease.  The  case  was  to  me  exceed- 
ingly interesting,  and  I  therefore  ask  the  indulgence  of 
those  who  may  think  I  have  devoted  undue  space  to  a 
single  case. 


^etrleurs  aixd  glMt00vap^lticaX  poticies. 


I. — The  optic  nerve.  The  course  of  its  fibres  and 
their  central  termination  according  to  recent  publica- 
tions. 

A  correct  knowledge  of  the  topography  of  the  fibres  of  the 
optic  nerve  is  a  valuable  guide  in  both  diseases  of  the  eye  and 
of  the  brain.  The  prognosis  of  affections  of  the  nerve  varies  with 
the  nature  of  the  lesion,  which  the  oculist  can  sometimes  recog- 
nize only  by  means  of  proper  localization.  The  diagnosis,  on  the 
other  hand,  of  the  site  of  a  brain  lesion,  is  facilitated  often  by 
perimetric  observation  of  the  blindness  caused  by  it.  We  pro- 
pose to  review  in  this  article  the  various  statements  lately  pub- 
lished regarding  the  course  of  the  optic-nerve  fibres. 

An  attempt  has  been  made  by  Salzer  ( Wiener  Acad.  Sitz- 
ungsberichte,  1880,  Ixxxi,  3)  to  count  the  fibres  of  the  optic 
nerve.  By  counting  them  in  a  given  micrometric  space  and 
measuring  the  whole  area  of  the  optic  nerve  (minus  the  connec- 
tive-tissue septa)  with  a  planimeter,  438,000  was  obtained  as  the 
most  probable  figure.  By  a  similar  procedure,  the  number  of 
cones  in  the  retina  was  estimated  at  3  to  3.6  millions.  This  shows 
that  probably  about  7  to  8  cones  are  supplied,  on  an  average,  by 
one  nerve  fibre.  The  question,  which  of  the  bundles  of  fibres 
in  the  trunk  of  the  optic  nerve  supply  a  given  area  of  the  retina, 
can  not  be  solved  by  anatomical  research  alone.  But  by  com- 
paring the  cross- sections  of  a  partially  atrophied  nerve  at  the  post 
mortem,  with  the  impaired  field  of  vision  observed  during  life, 
an  answer  may  be  obtained. 

But  two  such  observations  are  as  yet  reported.  Wilbrand  and 
Binswanger  (according  to  Hirschberg's  Centr.  f.  Augenheilkd., 
July,  1879)  have  seen  an  instance  of  peripheral  constriction  of 
the  field  of   vision,  which  the  post  mortem  traced  to  a  neuritis 

128 


THE  OPTIC  NERVE.  1 29 

ending  in  atrophy.  The  central  bundles  of  the  optic  nerves, 
however,  were  intact  ;  only  a  peripheral  ring  underneath  the 
sheath  of  the  nerve  was  degenerated.  Hence,  in  this  case,  the 
periphery  of  the  retina  received  the  periplieral  fibres  of  the  optic 
nerve. 

Anotlier  instance  of  retro-bulbar  neuritis  is  reported  by  Samel- 
sohn,  in  the  Centralblait  f.  d.  Med.  Wiss.,  No.  23,  1880.  There 
existed  during  life  a  central  scotoma,  involving  only  the  macula. 
The  temporal  side  of  the  papilla  showed  an  atrophic  discoloration. 
The  fibres  supplying  the  defective  macula  could  be  recognized 
by  their  degeneration.  They  constituted  an  atrophied  bundle  in 
the  centre  of  the  optic-nerve  trunk  when  examined  at  the  optic 
foramen.  The  atrophy,  perfectly  symmetrical  in  both  nerves, 
had  not  extended  upward  beyond  the  optic  foramen.  But  in  its 
course  toward  the  eye,  the  atrophied  bundle  passed  toward  the 
temporal  side  of  the  trunk,  and  beyond  the  entrance  of  the  cen- 
tral vessels  it  was  found  in  the  form  of  a  wedge  with  its  apex  near 
the  centre  and  its  base  not  quite  reaching  to  the  temporal  pe- 
rii)hery.  Both  reports,  hence,  show  that  in  the  cross  section  of  the 
nerve  the  fibres  occupy  about  the  same  topographic  relation  as 
the  retinal  elements  which  they  supply.  Samelsohn  points  out, 
that  in  harmony  with  the  superior  dignity  of  the  centre  of  the 
retina,  the  fibres  innervating  the  macula  (atrophied  in  his  case) 
amounted  to  one-half  of  the  entire  nerve. 

The  most  interesting  part  of  the  optic  nerve  is  the  chiasm. 
Whether  this  formation  is  due  to  a  total  crossing  of  the  fibres  of 
one  optic  tract  to  the  nerve  of  the  other  side,  or  to  a  semi-decus- 
sation,  is  yet  a  question  considerably  agitated.  All  evidence, 
however,  points  to  the  latter  view.  In  fishes,  the  interlacing  of 
the  fibres  in  the  chiasm  is  either  absent,  or  so  simple  that  a  com- 
plete crossing  can  be  proven  beyond  doubt.  But  in  all  higher 
animals,  there  exists  such  an  intricate  interlacing  of  the  two 
nerves  that,  according  to  observers  like  Meynert  and  Gudden, 
microscopic  observations  cannot  decide  the  point.  Recently, 
however.  Stilling  again  reported  at  the  Ophth.  Congress  at  Milan, 
that  he  had  followed  the  fibres  with  the  naked  eye.  {^Centralbl.  f. 
Nervenheilkd.,  No.  22,  18S0.) 

After  hardening  of  the  human  chiasm  in  Miiller's  fluid  and  in 
alcohol,  it  was  macerated  in  pyroligneous  acid  and  then  teased. 
He  claims  to  trace  thus  both  the  decussated  fibres  and  a  bundle, 
equally  large,  of  direct  fibres.  The  latter  are  said  to  surround 
the  crossing  fibres.     He  claims,  likewise,  the  existence  of  an  an- 


I30  REVIEWS. 

terior  commissure  uniting  the  two  eyes.  This  formation  no  other 
modern  observer  has  recognized. 

Attempts  have  been  made  to  test  the  semi-decussation  experi- 
mentally. If  the  chiasm  is  divided  by  a  longitudinal  median 
incision,  complete  blindness  necessarily  indicates  a  total  crossing 
of  all  fibres.  Such  was  really  the  result  in  the  older  experiments 
of  Beauregard  and  of  Brown-Sequard.  The  former  used  pig- 
eons. The  latter  does  not  state  the  kind  of  animal  employed, 
but  they  were  probably  guinea-pigs  or  rabbits.  But  in  all  such 
researches  the  view  of  J.  Miiller  must  be  used  as  a  guiding  star. 
This  great  physiologist  predicted  that  the  completeness  of  the 
decussation  depends  inversely  upon  the  fusion  of  the  two  fields 
of  vision,  or,  in  other  words,  upon  the  angle  included  between 
the  two  orbits.  The  larger  the  common  field  of  vision  of  the 
two  eyes,  the  more  voluminous  must  we  expect  to  find  the  bun- 
dle of  optic-nerve  fibres,  which  does  not  decussate.  In  harmony 
with  this  view  are  the  results  of  Nicati  on  the  cat,  an  animal 
whose  eyes  have  at  least  a  partial  field  of  vision  in  common.  He 
perforated  the  base  of  the  skull  from  below,  and  bisected  the 
chiasm  longitudinally.  As  he  reported  to  the  Paris  Academy  of 
Science  (June  lo,  1878),  this  operation  does  not  render  the  ani- 
mals blind.  This  fact  alone  establishes  the  semi-decussation  in 
the  cat. 

The  attempts  have  been  more  numerous  to  trace  the  fibres 
through  the  chiasm  by  means  of  a  partial  atrophy.  Extirpation 
of  the  eyeball  in  a  new-born  animal  simply  prevents  the  further 
development  of  the  corresponding  nerve  fibres.  If  the  extirpa- 
tion is  performed  some  days  or  weeks  after  birth,  atrophy  of  the 
fibres  sets  in  in  the  course  of  several  months.  This  atrophy  oc- 
curs also  in  the  human  subject,  but  requires,  evidently,  several 
years  for  its  completion,  even  if  the  eye  is  lost  during  childhood. 
Atrophy  can  likewise  be  produced,  even  more  definitely,  when  the 
central  termination  of  the  nerve  is  destroyed  in  young  animals. 

Amongst  the  most  fervent  defenders  of  the  semi-decussation  is 
Gudden,  whose  articles  are  to  be  found  mainly  in  the  Archiv  f. 
Ophth.  (the  most  recent  being  xxv,  i,  p.  i,  and  xxv,  4,  p.  237). 
Pursuing  his  researches  during  many  years,  he  has  recently  found 
that  even  in  the  rabbits,  although  there  seenis  to  be  no  common 
field  of  vision,  there  exists  a  small  direct  bundle.  It  could  be 
demonstrated  by  destroying  the  central  end  of  one  optic  tract  or 
removing  both  tract  and  nerve  of  one  side  by  cutting  through  the 
chiasm.     In   the  course   of  six   months  the   corresponding  nerve 


THE  OPTIC  NERVE.  13 1 

had  atrophied  completely,  with  the  exception  of  a  slender  un- 
crossed fasciculus.  In  the  dog  the'bundle  of  direct  fibres  is  of 
larger  size,  though  smaller  than  the  decussating  fasciculus.  After 
the  production  of  atrophy  from  either  central  or  peripheral  lesion 
the  persistence  of  this  fasciculus  can  be  demonstrated  amidst  the 
other  degenerative  fibres.  It  can  likewise  be  learned  that  the 
atrophy  due  to  extirpation  of  the  eye  extends  into  both  optic 
tracts,  though  the  opposite  one  is  more  involved  on  account  of 
the  greater  number  of  crossed  fibres.  These  statements  are 
contradicted  by  Michel,  but  in  an  untrustworthy  manner  {Archiv 
f.  Ophth.  xxiii,  2,  p.  227).  Some  of  his  errors  are  due  to  a  mis- 
understanding of  the  commissures  included  in  the  chiasm.  Gud- 
den  describes  them  as  follows  :  The  commissure  known  under 
Meynert's  name  is  to  be  found  on  the  upper  (dorsal)  side  of  the 
chiasm,  thence  following  the  optic  tracts  toward  the  peduncle. 
In  the  rabbit  it  can  be  recognized  most  easily,  though  micro- 
scopically its  course  is  seen  to  be  the  same  in  man  and  the  dog. 
Behind  the  chiasm  it  moves  toward  the  upper  (dorsal)  and  me- 
dian border  of  the  tract,  and  can  here  be  usually  recognized, 
though  covered  with  a  thin  layer  of  gray  substance.  It  finally 
leaves  the  optic  tract  and  dips  down  between  the  bundles  of  the 
pes  pedunculi. 

According  to  Gudden  there  exists,  further  (in  man  and  mam- 
malia), a  strand  of  fibres  on  the  upper  (dorsal)  side  of  the  tractus 
opticus,  in  contact  with,  but  distinct  from,  Meynert's  commissure. 
The  direction  of  the  fibres  is  nearly  transverse  and  they  are  ul- 
timately lost  in  the  substance  of  the  tuber  cinereum.  Their 
morphological  significance  was  not  ascertained.  A  third  com- 
missure, called  by  Gudden  c.  inferior,  runs  toward  the  rear  from 
the  chiasm  along  the  upper  inner  border  of  the  tracts.  It  is  so 
closely  connected  with  the  optic  tract  that  it  cannot  be  recognized 
separately.  It  can  be  easily  demonstrated  by  enucleation  of  both 
eyes.  The  subsequent  atrophy  invades  all  fibres  except  the  com- 
missure. In  the  rabbit  it  can  be  recognized  in  a  cross  section  of 
the  normal  optic  tract  by  its  relatively  fine  fibres,  while  in  this 
animal  the  optic  tract  itself  consists  of  coarse  fibres. 

One  of  the  clearest  descriptions  of  the  human  chiasm  in  case 
of  atrophy  is  given  by  Kellerman  (Zehender's  Klin.,  Monatsbl.  f. 
Augenheilk.,  Ausserordentliches  Beilageheft,  xvii,  1879).  ^  patient 
who  had  lost  his  left  eye  by  an  accident  in  his  third  year  died  at  the 
age  of  40  with  phthisis.  The  left  eye  was  completely  shrunken, 
and  the  nerve  of  that   side  totally  atrophied.     The  right  eye  was 


132  REVIEWS. 

normal,  but  in  its  nerve  there  was  found  a  small  bundle,  showing 
a  descending  atrophy  which  had  not  quite  reached  the  eyeball. 
This  bundle  was  found  in  the  more  central  part  of  the  nerve,  be- 
low the  centre,  but  near  the  eye  it  gained  the  temporal  periphery. 
Its  significance  was  not  learned.  In  the  chiasm  it  could  be  seen 
that  about  two-thirds  of  each  nerve  crossed  into  the  tract  of  the 
other  side.  The  decussation  occurred  mainly  in  extensive  arcs. 
In  the  nerves  the  direct  bundles  are  situated  on  the  external  side, 
but  in  the  optic  tract  the  intermingling  was  so  complete  that 
Kellerman  could  not  trace  them  as  separate  fasciculi. 

In  another  case,  reported  by  Baumgarten  {Centralblatt  f.  d. 
Med.  Wiss.,  31,  1878),  the  topography  of  the  optic  tracts  was  dif- 
ferent. At  the  post  i?2orte??i,  seven  years  after  enucleation  of  the 
right  eye,  the  right  nerve  was  found  completely  atrophied.  De- 
generated fibres  were  found  in  both  tracts  to  the  extent  of  several 
millimetres  beyond  the  chiasm.  In  the  tract  of  the  same  side,  the 
atrophied  (direct)  fibres  existed  mainly  along  the  upper  part  of 
the  periphery,  less  so  in  the  upper  external  portion,  while  the 
crossed  degenerated  fibres  were  found  in  the  other  tract  in  the 
lower  inner  quadrant. 

In  the  same  number  of  the  Cetztralblait,  Gowers  reports,  likewise, 
a  case  of  ascending  atrophy  of  one  nerve  extending  into  both  op- 
tic tracts.  Two  further  cases  of  atrophy  of  one  nerve  extending 
into  both  tracts  were  reported  by  Schmidt-Rimpler  to  the  German 
Ophthalmological  Society  (1877).  In  his  last  articles,  Gudden 
likewise  details  three  instances  of  this  nature,  in  which  careful 
measurement  showed  the  involvement  of  both  tracts.  All  these 
cases  prove  that  the  crossed  bundle  in  man  is  more  voluminous 
than  the  direct  fasciculus.  At  the  last  International  Ophthalmo- 
logical Congress  at  Milan  {Centralbl.  f.  Augeiiheilk..,  Nov.,  1880), 
Purtscher  reported  six  more  cases  of  one-sided  atrophy  of  the 
optic  nerve,  confirming,  in  all  details,  Gudden's  views  as  regards 
the  semi-decussation  and  the  existence  of  an  inferior  commissure. 
In  two  cases  of  bilateral  atrophy  of  optic  nerves,  Purtscher  found 
intact  only  the  inferior  commissure  of  Gudden,  and  a  few  narrow 
strands  of  normal  fibres  in  the  midst  of  the  degenerated  tracts. 
These  strands  represent,  probably,  another  commissure. 

The  semi-decussation  of  the  optic  nerves  is  also  proven  by  a 
number  of  cases  in  which  the  hemianopsia  existing  during  life 
was  explained  by  the  lesion  found  at  \\\t  post  mortem.*    The  most 

*  The  term  hemianopsia,  introduced  by  Hirschberg,  is  preferable  to  the  for- 
mer word,  hemianopia,  since  it  signifies,  in  an  unmistakable  way,  blindness 
toward  one  side, — loss  of  one-half  of  the  field  of  vision. 


THE  OPTIC  NERVE.  133 

instructive  cases  in  which  the  lesion  was  found  involving  the  visi- 
ble part  of  one  optic  tract  are  the  following  : 

Hughlings-Jackson  {^Lancet,  May,  1875).  Left-sided  hemian- 
opsia, hemiplegia  and  hemianaesthesia,  caused  by  softening  of  the 
posterior  half  of  the  right  thalamus.     No  other  brain  lesion. 

Hirschberg  {Virchow's  Archiv,  Bd.  65,  p.  116).  Right-sided 
hemianopsia,  caused  by  gliosarcoma  in  the  left  frontal  lobe  of  the 
cerebrum,  the  left  optic  tract  being  thinner  than  the  right. 

Pooley  (Knapp's  Archives  of  Ophth.  and  Ot.,  v,  2,  p.  148). 
Right-sided  hemianopsia,  due  to  a  tumor  in  the  left  posterior  lobe 
of  the  brain,  and  softening  of  the  surrounding  region,  especially 
the  left  thalamus  opticus. 

Gowers  {Cetitralblatt  f.  d.  Med.  Wiss.,  31,  1878).  Left-sided 
hemianopsia.  A  small  tumor  in  the  inner  and  lower  part  of  the 
right  temporo-sphenoidal  lobe,  involving  the  optic  tract,  and  ex- 
tending into  the  crus  cerebri.  Degeneration  of  the  right  optic 
tract.     The  left  tract  and  both  optic  nerves  were  normal. 

L  Dreschfeld  {Centralblatt  f.  Aj/genheilk.,  February,  1880).  Left 
hemianopsia,  produced  by  a  tuberculous  tumor,  extending  along  the 
outer  lower  side  of  the  right  thalamus  opticus,  and  crowding  that 
structure  out  of  place  and  compressing  the  right  optic  tract.  In 
another  instance  reported  by  the  same  author,  a  carcinomatous 
tumor,  pressing  on  the  right  side  of  the  chiasm  and  surrounding 
the  right  optic  nerve,  had  produced  temporal  (left)  hemianopsia 
of  the  left  eye,  but  complete  blindness  of  the  right  eye.  On 
account  of  the  position  of  the  tumor,  the  case  is,  hence,  not  ab- 
solutely convincing.  Similar  doubts  are  permissible  in  the  fol- 
lowing instances  : 

Hjort  {Klin.  Monatsbl  f.  Augenheilk.,  v,  1867,  p.  166).  Left- 
sided  hemianopsia  of  the  left  eye,  but  complete  amaurosis  of  the 
right  eye.  T\\q  post  mortem  showed  tubercles  in  the  pia  mater,  also 
a  few  at  the  convexity  of  the  cerebrum.  A  tuberculous  tumor  of 
the  size  of  a  hazel-nut  was  found  in  the  right  half  of  the  chiasm. 

Mohr  {Arch.  f.  Ophth.,  xxv,  i,  p.  57).  Left-sided  hemianopsia 
of  the  right  eye,  but  amblyopia  of  the  left  eye.  The  autopsy 
showed  two  cysts  on  the  median  side  of  the  left  optic  thalamus, 
and  a  tumor  of  the  size  of  a  walnut  pressing  on  the  chiasm  and 
left  optic  nerve.  The  real  importance  of  the  case  is  to  be  sought 
in  the  complete  degeneration  of  the  left  optic  tract,  proving  that 
the  intact  temporal  half  of  the  right  retina  received  its  fibres  from 
the  optic  tract  of  the  right  side. 

Even   if  the  evidence  of  some  of  the  last  cases  is  considered 


1 34  RE  VIE  WS. 

doubtful,  the  first  instances  quoted  decide  absolutely  that  the 
human  chiasm  represents  a  semi-decussation,  and  that  each  optic 
tract  supplies  the  temporal  half  (/.  <?.,  the  smaller  portion)  of  the 
retina  of  the  same  side  and  the  nasal  half  of  the  opposite  r-otina. 
In  most  of  the  cases  the  line  separating  the  sensitive  half  of  the 
retina  from  the  blind  area  passed  vertically  through  the  point  of 
direct  vision.  Hence  each  macula  receives  fibres  from  both  optic 
tracts,  which  fibres  remain  on  the  corresponding  side. 

In  cases  of  homonymous  hemianopsia,  the  lesion  must,  hence, 
be  referred  to  the  optic  tract  of  the  side  of  the  blind  half  of  the 
retinae.  It  may  be  situated  anywhere  in  the  rear  of  the  middle  of 
the  chiasm,  either  in  the  exposed  portion  of  the  tract  or  in  its 
concealed  course,  between  its  origin — the  cerebral  cortex — and 
its  emergence  at  the  base  of  the  brain.  The  exact  location  can 
be  diagnosed  only  by  interpretation  of  other  accompanying  brain 
symptoms  which,  in  the  above  cases,  we  omitted  as  irrelevant. 
Further  instances  of  hemianopsia,  due  to  cortical  lesions,  will  be 
referred  to  for  demonstration  of  the  origin  of  the  optic  tracts. 

With  the  exception  of  Stilling,  no  recent  author  has  attempted 
to  trace  the  roots  of  the  optic  nerve.  Stilling  read  the  following 
resume  of  his  reseaches  at  the  meeting  of  the  German  Ophthal- 
mological  Society  in  1879  : 

"  The  optic  tract,  as  it  approaches  the  optic  thalamus,  divides 
into  two  branches,  which  pass  separately  to  the  external  and  in- 
ternal geniculate  bodies.  At  the  place  where  these  branches  sep- 
arate a  third  branch  can  be  detected,  which  joins  the  anterior 
brachium  conjunctivum,  and  reaches  with  it  the  corpora  quadri- 
gemina.  At  this  place  the  fibres  subdivide.  A  part  of  them 
passes  over  the  superior  (anterior)  corpus  quadrigeminum,  and 
forms  a  commissure  with  the  fibres  of  the  other  side;  while  another 
part  spreads  along  the  surface  of  this  body  and  thence  pursues  a 
backward  direction.  The  greater  portion,  however,  enters  di- 
rectly the  gray  substance.  The  two  corpora  geniculata,  hitherto 
called  the  points  of  origin  of  the  optic  nerve,  are  in  reality  but  its 
ganglia.  The  fibres  only  surround  and  include  the  geniculate 
bodies,  and  thence  pass,  at  least  to  a  large  extent,  to  the  surface 
of  the  optic  thalamus,  where  they  form  a  layer  of  fibres.  This 
arrangement  had,  indeed,  been  recognized  by  Reil  many  years 
ago.  Some  of  the  fibres  pass  around  the  external  geniculate  body, 
and  terminate  in  the  thalamus  opticus.  A  third  strand  perforates 
the  external  corpus  geniculatum  to  reach  the  thalamus.  The  me- 
dullary streaks  of  the  geniculate  body  are,  indeed,  but  the  plates 


THE  OPTIC  NERVE.  135 

of  nerve  fibres  from  the  optic  tract,  between  which  ganglionic 
cells  are  deposited. 

A  deep  horizontal  section  through  the  optic  tract  and  foot  of 
the  peduncle  shows  a  fourth  branch  of  the  optic  tract  entering 
between  the  fasciculi  of  the  pes  pedunculi.  In  some  cases  the 
fibres  of  this  root  radiate  gradually  into  the  substance  of  the  pe- 
duncle. In  other  more  demonstrative  instances  the  root  forms  a 
distinct  strand,  separating  itself  from  the  rest  of  the  optic  tract 
and  dividing  into  numerous  fasciculi,  which  dip  in  between  the 
bundles  of  the  pes  pedunculi.  This  root  reaches  and  terminates 
in  an  almond-shaped  gray  nucleus  situated  below  the  substantia 
nigra,  underneath  the  "  red  "  nucleus  of  the  tegmentum  pedunculi. 
This  body  had  been  described  by  Luys  as  the  "  bandelette  acces- 
sorie  de  I'olive  siiperieure."  Forel  has  termed  it  the  nucleus  of 
Luys.  It  seems  almost,  from  this  description,  that  the  root  de- 
scribed by  Stilling  is  not  at  all  an  integral  part  of  the  optic  nerve, 
but  really  the  commissure  of  Mcynert. 

Stilling  further  describes  a  conical  root  arising  from  the  tuber 
cinereum.  Again,  it  must  be  doubted  whether  this  is  really  a  part 
of  the  nerve  or  the  strand  described  by  Gudden.  Stilling  refers 
to  Gudden's  former  observations.  In  his  recent  article  the  latter 
showed,  however,  that  this  strand  (perhaps  a  commissure)  does 
not  atrophy  when  the  rest  of  the  nerve  degenerates  in  consequence 
of  enucleation  of  the  eyes.  Finally,  Stilling  claims  that  another 
origin  of  the  nerve  is  to  be  found  in  the  substantia  perforata  an- 
tica.  lie  details  thus  seven  different  points  of  origin,  viz.  :  the 
branch  from  the  optic  thalamus  through  the  external  geniculate 
body  ;  the  branch  from  the  internal  geniculate  body  ;  the  super- 
ficial branch  in  the  corpora  quadrigemina  ;  the  nucleus  in  the  pes 
pedunculi  (?)  ;  the  tuber  cinereum  (?)  ;  the  substantia  perforata 
antica,  and  the  surface  of  the  thalamus  opticus. 

At  the  meeting  of  the  International  Ophthalmological  Congress 
at  Milan  (1880),  Stilling  demonstrated  also  the  existence  of  a 
"  spinal  "  root  of  the  optic  nerve  {^Centralblatt  f.  Nervenheilk., 
Nov.,  1880,  p.  474).  This  root  proceeds  from  the  external  genic- 
ulate body  in  a  half  spiral  turn,  and  enters  in  a  radiating  manner 
the  pes  pedunculi.  The  author  traced  it  in  the  macerated  speci- 
men through  the  pons  into  the  medulla  oblongata.  He  points  out 
how  the  existence  of  this  root  can  explain  the  mysterious  connec- 
tion between  diseases  of  the  optic  nerve  and  affections  of  the 
medulla.* 

*  The  last  number  of  Hirschberg's  Centralbl.  f.  Augenheilk.  (December) 


I  36  RE  VIE  WS. 

In.  a  previous  article  {Centralblatt  f.  Avgenheilk.,  Feb.,  1879) 
Stilling  had  shown  the  importance  of  the  occipital  lobe  as  a  visual 
centre.  In  large  cross  sections  it  can  be  seen  that  numerous  fascic- 
uli pass  from  the  optic  thalamus  into  the  medullary  substance  of 
the  occipital  lobe  (previously  described  by  Gratiolet). 

Pathological  observations  have  as  yet  contributed  nothing  to 
our  knowledge  of  the  topography  of  the  optic  roots  in  the  interior 
of  the  brain.  In  the  few  instances  which  have  been  reported,  the 
lesions  were  too  extensive  to  allow  of  any  conclusion.  But  evi- 
dence is  gradually  accumulating  as  regards  the  location  of  the 
visual  centre  in  the  cortex.  Cases  of  atrophy  of  certain  convolu- 
tions, following  loss  of  one  eye,  are  by  far  the  most  conclusive. 

Huguenin  has  reported  the  following  observations  in  the  Corre- 
spOTidenzblatt  f.  ScJnveizer  Aerzte,  Nov.  15,  1878.  A  man,  who  had 
lost  the  left  eye  in  his  third  year,  died  of  pneumonia  at  the  age  of 
56.  Left  optic  nerve  thin  and  atrophied  ;  the  right  one  normal. 
Left  optic  tract  about  one-half  the  size  of  the  right  tract,  which  is 
of  normal  size.  Left  pulvinar  smaller  than  the  right  one  ;  the 
corpora  quadrigemina  also  much  smaller  on  the  left  than  on  the 
right  side.  A  similar  difference  in  the  size  of  the  two  external 
geniculate  bodies,  with  absence  of  the  superficial  fibres  derived 
from  the  optic  tract  on  the  left  side.  The  two  internal  geniculate 
bodies  alike  in  size.  A  noticeable  atrophy  in  the  cortex  of  both 
occipital  lobes  around  the  occipital  fissure,  where  it  passes  from 
the  median  surface  over  on  the  convexity  of  the  cerebrum.  The 
atrophy  is  more  marked  on  the  right  (opposite)  side.  The  convo- 
lutions are  thinned,  and  the  sulci  widened.  The  atrophy  extends 
down  also  on  the  median  side  of  the  hemispheres,  but  not  as  far 
as  the  sulcus  hippocampi. 

The  second  autopsy  was  made  on  a  woman  of  42  years,  dead  of 
typhus,  who  had  had  small-pox  during  youth,  and  was  nearly 
blind  in  both  eyes.  Both  optic  nerves  equally  and  considerably 
thinner  than  normally,  likewise  the  two  tracts.  The  two  pulvinaria 
also  seem  reduced  in  size.  The  corpora  quadrigemina  are  flat- 
contains  a  further  report  by  Stilling.  He  describes  a  second  spinal  root,  con- 
sisting of  a  large  number  of  bundles,  which  leave  the  optic  tract  to  reach  the 
inner  surface  of  the  internal  geniculate  body,  whence  they  pass,  in  a  half-spiral 
turn,  underneath  the  bracchiuin  conjunctivum  posticum  and  join  the  lemniscus. 
Between  the  bundles  of  the  latter  they  can  be  traced  to  the  inferior  olivary 
body.  Other  bundles,  which  at  first  pursue  the  same  course,  terminate  in  the 
nucleus  of  the  motor  oculi  nerve.  The  latter  discovery  is  an  important  con- 
firmation of  a  physiological  desideratum,  whereby  the  path  of  reflexes  passing 
from  the  optic  nerve  to  the  motor  nerve  of  the  iris  is  defined.  Stilling  has 
finally  traced  other  bundles  into  the  crus  cerebelli  ad  corpus  quadrigeminum 
and  thence  into  the  cerebellum. 


THE  OPTIC  NERVE.  137 

tened,  and  the  external  geniculate  bodies  small  and  gray,  on  ac- 
count of  atrophy  of  the  superficial  fibres.  In  the  cortex  of  the 
occipital  lobes  the  atrophy,  equal. on  both  sides,  invaded  the  same 
region  as  in  the  first  case. 

A  similar  instance  is  reported  by  Burkhardt  in  the  report  of  tlie 
institution  Waldau  for  1879  (according  to  the  Centralblatt  f.  Ner- 
venheilk'd,  1880,  Sept.,  p.  361).  A  man  of  22  years  had  lost  the 
right  eye  during  youth,  probably  by  injury.  The  left  eye  had  a 
small  central  capsular  cataract  with  fair  sight,  but  there  existed 
nystagmus.  At  \.h.Q  post  i7wrtetn  (death  by  purpura  hemorrhagica) 
the  convolutions  were  found  well  developed,  but  the  gyrus  angu- 
laris  of  the  left  side  was  smaller  and  less  distinct  than  the  corre- 
sponding part  of  the  right  hemisphere.  A  similar  distance  was 
observed  in  the  precuneus  of  the  two  sides,  the  right  one  being 
the  smaller. 

The  last  case  is  evidently  of  less  significance.  It  cannot  be  said 
what  influence  the  imperfection  of  the  left  eye  exerted,  and  the 
cortical  region,  moreover,  is  not  the  one  toward  which  most  clini- 
cal evidence  points,  though  in  agreement  with  Ferrier's  experi- 
ments. But  the  first  of  Huguenin's  examples  demonstrates  conclu- 
sively both  the  cortical  centre  and  the  semi-decussation.  In- 
stances of  hemianopsia  due  to  cortical  lesion  are  more  numerous  in 
literature,  but  rarely,  however,  was  the  lesion  so  distinct  and  small 
as  to  equal  in  demonstrative  value  the  cases  of  ascending  atrophy. 

Omitting  various  complicated  cases  with  multiple  lesions  in  dif- 
ferent parts  related  to  the  optic  tract,  the  following  resume  is  a 
complete  list  of  all  records  which  could  be  found  : 

Wernicke  (quoted  by  Foerster  in  Hand.  b.  d.  ges.  Augeriheilk' d, 
vii,  p.  118).  Right-sided  hemianopsia,  of  sudden  origin,  with 
peripheral  constriction  of  the  remaining  field  of  vision.  Death  in 
twenty  months.  A  foyer  of  softening  in  the  convexity  of  the  left 
hemisphere,  in  a  part  of  the  occipital  lobe  corresponding  to  the 
operculum  of  the  monkey.  The  spot  extended  backward  two 
centimetres  from  an  ideal  continuation  of  the  sulcus  parieto-occip- 
italis.  Above  it  reached  the  sulcus  interparietalis  ;  it  extended 
forward  up  to  the  turn  of  the  first  temporal  convolution  around 
the  fossa  sylvii,  and  downward  to  the  sulcus  between  the  first  and 
second  temporal  convolutions.  In  the  white  substance  it  ex- 
tended to  the  middle  of  the  gyrus  postcentralis. 

Baumgarten  {Cenfralbl.  f.  d.  Med.  IViss.,  1878,  No.  21).  Sud- 
den left-sided  hemianopsia,  with  sharp  line  of  demarcation  through 
the  point  of  direct  vision.     Sight  and  color-sense  of  the  intact  ret- 


138  REVIEWS. 

inal  half  were  normal.  Death,  after  several  months,  from  kidney- 
disease.  Apoplectic  cyst  of  the  size  of  a  walnut  in  the  right  oc- 
cipital lobe,  comprising  the  three  gyri  occipitales.  It  did  not 
quite  extend  down  to  the  cavity  of  the  right  posterior  ventricular 
horn.  A  second  pea-sized  spot  of  red  softening  in  the  roof  of  the 
left  anterior  horn,  and  a  smaller  apoplectic  cyst  in  the  centre  of 
the  right  optic  thalamus.  Optic  tracts,  nerves  and  chiasm  nor- 
mal. 

] a?,iro\v\iz  {Centrall^lait /.  Aiigenheilk'd,  1877,  p.  254.)  Right- 
sided  hemianopsia  due  to  a  gelatinous  sarcoma  in  the  occipital 
convolutions  and  precuneus,  with  softening  in  the  circumference 
not  attaining  the  optic  thalamus.  Optic  nerves,  tracts  and  chiasm 
normal. 

Hosch  {Schweiz.  Correspondenzbl.,  Sept.  15,  1878,  p.  554).  Left- 
sided  hemianopsia  after  apoplexy.  Death  after  three  years. 
Atheromatous  condition  of  the  cerebral  arteries,  multiple  miliary 
aneurisms  on  the  convexity  of  the  brain.  In  the  left  parietal  lobe 
a  small  exudation  at  the  convexity  and  a  small  brown  cicatrix  in 
the  white  substance.  Recent  apoplexy  on  the  left  side  of  the 
third  ventricle  evidently  the  cause  of  death.  All  the  other  lesions 
were  on  the  right  side,  in  the  region  of  the  visual  centre,  viz.  : 
large  cavity  due  to  the  the  destruction  of  the  greater  part  of  the 
right  occipital  lobe  ;  in  the  region  of  the  corpus  striatum  a  large 
pigmented  cicatrix  extending  into  the  right  thalamus.  Atrophy 
of  the  inner  bundles  of  both  optic  nerves  in  front  of  the  chiasm. 
The  multiplicity  of  the  lesions  deprives  the  case  of  much  of  its 
value. 

Nothnagel  {Topische  Diagnostik,  1879,  p.  389).  Right-sided 
hemianopsia,  apparently  with  gradual  diminution  of  sight,  which 
was  difficult  to  determine  on  account  of  the  mental  state.  Death 
after  some  months.  Lesions  on  the  right  side  of  the  brain  con- 
sist in  softening  of  the  middle  third  of  the  anterior  and  posterior 
central  convolutions,  extending  down  to  the  centrum  semi-ovale, 
likewise  of  a  portion  of  the  superior  parietal  lobe  and  circumfer- 
ence, and  of  the  third  occipital  convolution.  On  the  left  side 
were  found  two  patches  of  softening  in  the  temporal  and  parietal 
lobes  and  total  destruction  of  the  occipital  lobe.  Again  no  defi- 
nite conclusion  can  be  arrived  at  on  account  of  the  multiplicity 
of  the  lesions. 

If  we  compare  these  pathological  observations  with  experimen- 
tal results  on  animals,  a  certain  agreement  is  evident.  Ferrier 
in  his  earlier  observations  claimed  that  destruction  of  the  gyrus 


THE  OP  TIC  NER  VE.  I  39 

angularis  caused  merely  blindness  of  the  opposite  eye  in  all  ani- 
mals examined,  including  monkeys.  He  has  now  modified  these 
statements.  At  the  meeting  of  the  British  Association  in  Cam- 
bridge (1880)  he  reported  the  results  of  limited  extirpations  of 
cortical  centres  undertaken  with  Dr.  Yeo.  By  means  of  antisep- 
tic dressings  the  monkeys  recovered  quickly,  and  could  be  kept 
alive  permanently  (preliminary  account  by  Pierson  in  the  Central- 
Matt  f.  Nerven/ieilk'd,  Oct.  i,  1880,  p.  393).  He  claims  that  the 
occipital  lobes  can  be  removed  completely  without  blindness  if 
the  lesion  dees  not  extend  beyond  the  parieto-occipital  sulcus. 
Extirpation  of  the  angular  gyrus  of  one  side  causes  a  complete 
blindness  of  the  eye  of  the  other  side,  which  disappears  in  some 
hours.  The  restitution  of  sight  does  not  depend  on  the  integrity 
of  the  cortex  of  the  other  side,  since  subsequent  destruction  of 
the  other  angular  gyrus  causes  either  no  blindness  at  all  or  but 
a  transient  trouble.  Simultaneous  destruction,  however,  of  both 
angular  gyri  gave  rise  to  a  complete  blindness,  lasting  three  days, 
with  imperfect  recovery  of  the  sight.  Hemianopsia  can  be 
caused  by  destruction  of  the  angular  gyrus  and  occipital  lobe  of 
one  hemisphere,  the  retinal  halves  of  the  same  side  being  the 
parts  involved,  but  even  this  lesion  is  but  transient  in  its  effects 
in  the  monkey.  Ferrier  states  even  that  full  sight  will  ultimately 
be  regained  if  both  occipital  lobes  and  the  gyrus  angularis  of  one 
side  be  destroyed,  as  long  as  only  one  gyrus  angularis  remains  in- 
tact. Destruction,  however,  of  these  parts  in  both  hemispheres 
leads  to  irreparable  blindness  without  impairment  of  other  senses. 

An  interpretation  of  these  results  seems  as  yet  scarcely  possible. 
They  are,  moreover,  at  variance  with  the  experiments  of  Munk, 
although  Ferrier  has,  in  his  last  statement,  allowed  (with  Munk) 
some  importance  to  the  occipital  lobes  as  visual  centres.  Ferrier's 
claims  regarding  the  role  of  the  gyrus  angularis  have  received 
some  support  by  observations  made  by  Fiirstner  and  reported  at 
the  meeting  of  southwest  German  neurologists  at  Heidelberg  in 
1879  {Centra/blatt  f.   JVerven/ieilkd'd,  June  i,  1879). 

On  extirpating  the  left  eye  of  some  new-born  pnppies,  he 
found,  after  the  lapse  of  seventeen  weeks,  atrophy  of  a  spot  in 
the  second  longitudinal  convolution  of  the  right  hemisphere,  cor- 
responding to  the  angular  gyrus  of  the  monkey.  However,  it 
must  be  remembered  that  the  recognition  of  partial  atrophy  in 
the  cortex  without  microscopic  change  is  a  matter  of  individual 
judgment.  Caution,  moreover,  is  not  out  of  place,  when  we  re- 
member that  the  semi-decussation  in  the  dog  is  definitely  proven. 


I40  REVIEWS. 

Munk's  experiments  on  monkeys  have  not  been  very  numerous, 
but  they  are  stated  in  a  very  definite  way.  He  denies  all  impor- 
tance of  the  gyrus  angularis  for  visual  purposes.  A  suggestion  he 
makes  may  indeed  serve  to  explain  P'errier's  contrary  results. 
According  to  Wernicke,  the  corona  radiata,  uniting  the  ganglia  of 
the  optic  nerves  to  the  occipital  lobes,  passes  underneath  and 
close  to  the  gyrus  angularis.  Hence  any  deep  extirpation  would 
involve  these  fibres.  Evidently  not  all  the  uniting  fibres  take  this 
course,  since  destruction  of  both  angular  gyri  does  not  produce 
permanent  blindness.  Munk  claims  that  only  the  occipital  lobes, 
but  these  in  their  entire  extent,  represent  the  visual  centre.  Each 
hemisphere  controls  both  retinae  in  the  monkey  in  such  a  manner 
that  the  external  half  of  the  occipital  lobe  represents  the  temporal 
half  of  the  retina  of  the  same  side,  while  the  median  part  of  the 
occipital  lobe  receives  the  fibres  coming  from  the  internal  half  of 
the  other  retina  (Verhandl.  d.  Berlin,  phys.  Ges.  in  Archiv  f. 
Anat.  6^  Phys.,  1878,  i  and  ii,  p.  i68,  and  1880,  iv  and  v,  p.  149). 
In  monkeys,  therefore,  destruction  of  one  occipital  lobe  causes 
permanent  hemianopsia. 

The  experiments  of  Munk  on  dogs  are  more  complete  {Arch. 
f.  Anat.  and  Phys.,  1878,  pp.  162,  547  and  599  ;   1879,  p.  581). 

The  most  marked  visual  disturbance  was  found  on  extirpating 
a  relatively  small  spot  near  the  upper  posterior  apex  of  the  occip- 
ital lobe.  While  the  eye  of  the  same  side  appeared  normal,  the 
animal  had  lost  the  use  of  the  other  eye  almost  completely.  It 
could  still  see  with  the  eye  opposite  the  site  of  the  lesion,  but 
failed  to  interpret  the  visual  impressions.  The  sight  of  that  eye 
improved  gradually,  but  never  became  normal.  Munk  called  this 
trouble  "psychic  blindness,"  but  admits,  in  his  last  memoirs,  that 
it  can  be  explained  by  the  assumption  that  this  cortical  spot  cor- 
responds to  the  retinal  macula,  or  at  least  the  spot  of  direct  vision. 
The  animal,  hence,  retains  only  the  use  of  the  peripheral  and  less 
sensitive  part  of  that  retina.  Munk  denies,  however,  that  the 
simple  supposition  of  blindness  in  the  centre  of  the  retina  will 
account  for  the  phenomena  ;  he  still  insists  on  psychic  blindness 
under  these  circumstances,  due  to  loss  of  visual  remembrances. 
Further  experiments  showed  him  that  in  the  dog  also  each  hemi- 
sphere represents  parts  of  both  retinae.  The  direct  fibres,  how- 
ever, supply  the  extreme  temporal  portion  of  the  retina  of  the 
same  side,  the  extent  and  sensibility  of  which  are  so  slight  that  its 
integrity  is  easily  overlooked  when  the  rest  of  that  retina  is  blind. 
These  fibres  terminate  in  the  extreme  external  part  of  the  occip- 


THE  OPTIC  NERVE.  I41 

ital  lobe  of  the  same  side.  The  greacer  internal  part  of  the  cor- 
tical centre  sends  its  fibres  to  the  retina  of  the  other  side,  with 
the  exception  of  its  temporal  periphery.  The  topographical  rep- 
resentation of  the  retina  in  the  visual  centre  is  such  that  the  upper 
periphery  of  the  retina  is  represented  by  the  anterior  border  of 
the  occipital  lobe,  the  lower  retinal  area  by  the  posterior  part,  and 
each  lateral  retinal  border  by  the  cortical  margin  of  the  corre- 
sponding side.  In  the  dog,  hence,  the  retinal  spot  of  sharpest 
vision  receives  its  fibres  from  the  cortex  of  the  other  side  ;  the 
hemianopsia,  therefore,  caused  by  one-sided  destruction,  is  diffi- 
cult to  detect.  Munk  claims  that  the  effect  of  all  extensive  le- 
sions of  the  cortical  centre  is  permanent,  though  difficult  to  detect 
after  a  time  on  account  of  the  adaptation  of  the  animal  by  the 
movements  of  its  eyes. 

Lastly,  the  results  of  Luciani  and  Tamburini  must  be  men- 
tioned, which  are  again  at  variance  with  the  above  statements 
(Riv.  sperim.  di  frenatria,  1879,  ^  ^^d  2,  quoted  in  Ceiitralbl.  f. 
Nervenheilkd.,  October,  1879).  As  regards  the  monkey,  they  have 
found  that  the  entire  occipital  lobe  is  concerned  in  vision,  and 
not  merely  the  angular  gyrus. 

They  admit  the  semi-decussation  in  the  monkey,  having  seen 
hemianopsia  produced  by  one-sided  destruction.  In  the  dog  the 
visual  centre  is  located  by  them  in  second  (upper)  longitudinal 
convolution  from  the  front  to  the  rear.  Destruction  of  this  region 
on  one  side  causes,  as  they  observed,  nearly  complete  blindness  of 
the  other  eye,  and  slight  amaurosis  of  the  same  side.  They  claim 
that  these  results  are  not  permanent,  but  compensation  is  effected 
by  vicarious  activity  of  the  unmutilated  remnants  of  the  centres, 
especially  the  one  of  the  other  side.  Finally,  they  refer  to  an  ex- 
periment upon  a  monkey,  in  which  removal  of  both  angular  gyri 
and  both  occipital  lobes  permitted  a  moderate  recovery  of  siglit. 
Of  the  various  experimental  results,  those  obtained  by  Munk  are 
brought  forth  in  the  most  trustworthy  manner  ;  and  whetlier  or 
not  we  accept  Munk's  explanation,  they  agree  best  with  patho- 
logical observations  on  man.  [h.  graplf..] 

II.— On  the  use  of  the  cold  pack  followed  by  mas- 
sage in  the  treatment  of  anaemia.  By  ^fAKv  Pi  inam 
Jacobi,  M.D.,  and  Victoria  A.  White,  M.D.  New  York  :  G. 
P.  Putnam's  Sons,   1880. 

This  work  is  a  practical  contribution  to  scientific  tlieraixnitics. 
It  consists  of  three  articles  originally  contributed  to  the  Arciuiti 


142  RE  VIE  WS. 

of  Medicine  during  the  past  year,  but  now  republished  in  book- 
form.  The  first  of  these,  by  Mrs.  Putnam  Jacobi,  reports  eleven 
cases  of  anemia,  more  or  less  complicated  in  most  with  nervous 
symptoms,  in  which  she  had  been  led  to  utilize  the  cold  pack  by 
the  belief  that  it  would  increase  or  accelerate  tissue  metamor- 
phosis and  thus  indirectly  increase  assimilation  and  nutrition. 
Together  with  the  pack,  massage  was  employed  with  rest,  as 
advised  by  Weir  Mitchell.  For  medical  treatment  iron  was  in 
most  cases  given  in  small  and  frequent  doses,  and  other  remedies 
pro  re  nata.  The  urine  was  carefully  measured  and  analyzed 
during  the  treatment,  and  the  results  of  several  of  the  cases  are 
given  in  tabulated  form. 

In  the  second  and  third  articles,  which  alone  seem  to  show  the 
joint  authorship  indicated  in  the  title,  these  cases  are  analyzed 
and  discussed.  The  results  of  the  cold  pack  and  massage  treat- 
ment were,  increase  in  amount  of  urine  during  and  after  the  pack, 
actual  increase  but  relative  decrease  of  urea  excreted,  and  gener- 
ally a  slight  increase  also  of  extractive  and  inorganic  salts.  Later 
there  was  a  decrease  of  excretion  both  of  water  and  of  urea,  so 
that  the  actual  amount  for  the  day  was  not  decreased.  In  some 
instances,  where  there  was  an  actual  increase  in  the  excretion  of 
urea  for  the  twenty-four  hours,  if  this  condition  persisted,  symp- 
toms of  malaise  or  exhaustion  appeared.  It  seems,  therefore,  that 
the  compensatory  decrease  was  a  normal  and  necessary  result. 
On  a  few  occasions,  massage  was  given  without  any  preceding 
pack  and  a  somewhat  less  marked  increase  of  water  and  urea  in 
the  urine  was  observed  than  when  both  were  given. 

In  order  to  test  the  effect  of  the  pack  alone,  it  was  given  to 
three  healthy  women  and  the  same  results  obtained  as  in  the  other 
cases. 

The  beneficial  results  of  this  treatment  were,  increase  of  ap- 
petite, relief  of  insomnia,  enrichment  of  the  blood  as  shown  by 
reestablishment  of  menstruation  in  three  cases  of  prolonged 
amenorrhoea,  and  disappearance  of  intense  dyspeptic  symptoms. 
In  one  case  there  was  a  rapid  involution  of  a  subinvoluted  uterus, 
but  as  ergot  was  given  at  the  same  time,  it  cannot  be  said  that  the 
hydro-therapy  and  massage  produced  this  result.  In  two  neuras- 
thenic cases,  in  which  nervous  headache  was  a  prominent  symp- 
tom, the  appetite  and  the  general  condition  were  not  at  all  im- 
proved, but  rather  the  reverse,  by  the  treatment. 

The  remainder  of  the  book  is  given  to  a  discussion  of  the  path- 
ological conditions  of  anaemia  and  the  physiological  modes  of  ac- 


ON  THE   USE  OF    THE  COLD  PACK.  1 43 

tion  of  the  cold  pack  with  or  without  massage.  We  cannot  here 
follow  in  detail  this  very  elaborate  discussion,  but  will  merely 
give  the  substance  of  the  results  arrived  at  by  the  authors.  They 
recognize  in  anaemia  a  morbid  condition  often  congenital  or  early 
acquired,  characterized  by  an  inability  on  the  part  of  the  tissues 
to  condense  oxygen  and  store  albumen  in  sufficient  quantity. 
Hence  the  reserve  material  for  the  elaboration  of  force  is  lacking 
and  this  elaboration  fails  ;  there  is  a  general  functional  debility. 
They  criticise  Dr.  Weir  Mitchell's  brochure  on  massage,  as  having 
overlooked  the  fact  that  anaemic  muscles  are  in  a  state  of  chronic 
fatigue  in  which  tliey  cannot  receive  benefit  from  being  stimulated 
to  fresh  contraction  alone.  That  is,  when  waste  exceeds  repair, 
no  good  can  come  from  sim.ply  increasing  waste  ;  a  bottom  prin- 
ciple in  the  treatment  of  all  these  asthenic  conditions  on  which 
we  do  think  Dr.  Mitchell  has  not  always  laid  sufficient  stress. 
Therefore,  the  criticism  may  be,  to  some  extent,  a  just  one,  and 
there  has  been  started  by  his  little  work  a  furor  for  massage  that 
may  have  been  carried  to  an  irrational  extreme  in  some  cases. 
When  massage  alone  does  not  succeed  in  increasing  the  blood 
supply  of  the  muscles,  its  effects,  as  here  stated,  are  likely  to  pro- 
duce only  further  exhaustion. 

The  following  is  the  summary  of  the  effects  of  the  cold  pack  in 
anaemia  as  stated  by  the  authors  : 

"  The  cold  pack  meets  the  following  indications  for  the  treat- 
ment of  anaemia  thus  understood  : 

1.  "  In  the  first  moments  of  application  it  produces  the  same 
stimulation  of  the  peripheric  nerves  as  may  be  caused  by  any  ap- 
plication of  cold — shower-baths,  douche,  plunge-bath,  etc. 

2.  '■  It  impresses  upon  the  mass  of  circulating  blood  a  pro- 
found movement  of  oscillation  first  from  without  inward,  then  the 
reverse.     The  effect  is  different  in  the  two  periods. 

"  During  the  inward  movement  of  the  blood,  the  tension  of  the 
abdominal  blood-vessels,  which  has  at  first  been  lowered  through 
the  agency  of  the  depressor  nerve,  at  first  relaxed,  becomes  raised 
by  the  increased  volume  of  blood  driven  to  them  and  circulating 
through  the  abdominal  viscera,  not  with  increased  rapidity  but 
with  increased  force.     As  a  consequence  there  is  : 

a.  "  Increased  metamorphosis  of  albuminoid  substances  in  the 
liver  and  spleen,  resulting  finally  in  greater  production  of  urea. 
When  iron  is  absorbed  with  the  albumen,  there  seems  to  be 
initiated  in  these  same  glands  more  abundant  regeneration  of  red 
corpuscles. 


144  REVIEWS. 

b.  "Increased  consumption  of  stored  or  latent  oxygen  in  the 
series  of  oxidations  culminating  in  urea.  Hence,  during  the 
period  following  the  pack,  probably  increased  absorption  of  oxy- 
gen, coinciding  with  diminished  oxidations.  These  latter  are  in- 
dicated by  diminished  production  of  urea  (of  carbonic  acid 
also  ?). 

c.  "  Possibly  increased  movement  of  assimilation  of  now  de- 
composed albumen  (and  other  food),  coinciding  with  the  move- 
ment of  increased  decomposition  affecting  that  portion  of 
circulating  albumen  which  has  originated  the  urea,  both  move- 
ments immediately  dependent  on  an  increased  force  of  elementary 
intervascular  circulation. 

d.  "  Probable  assimilation  of  the  non-nitrogenous  portion  of 
the  decomposed  albumen. 

e.  "  Increased  elimination  of  water  from  the  kidneys  and, 
hence,  aspiration  of  excess  of  water  from  anaemic  tissues. 

f.  "  During  this  elementary  outstreaming  of  water,  facilitated 
washing  away  of  acid   fatigue-products  from  nerves  and  muscles. 

"  This  latter  (calculated)  effect,  to  be  attributed  partly  to  the 
second  half  of  the  movement  of  oscillation  of  the  blood  mass. 
During  this  secondary  movement  from  within  outward,  we  have  : 

A.  "  Diminution  of  passive  hyperaemia  in  the  alimentary  mu- 
cous membrane. 

B.  "  Increased  nutritive  absorption,  partly  in  consequence  of 
allayed  hyperaemia,  partly  as  the  direct  expression  of  a  movement 
of  fluids  outward  from  the  alimentary  canal. 

C.  "Afflux  of  blood  to  muscles,  enabling  them  to  increase 
their  store  of  contractile  material,  and  thus  become  more  capable 
of  exercise. 

D.  "  In  this  afflux,  and  on  account  of  thermic  irritation  of  the 
peripheric  nerves,  increased  production  of  heat.  From  the  coin- 
cident immobility  of  the  body  and  the  arrest  of  radiation,  a  cer- 
tain proportion  of  this  increment  saved.  (The  increment  of  urea 
is  probably  derived  in  part  from  increased  chemical  changes  of 
circulating  albumen  in  the  muscles  during  the  production  of 
heat.) 

E.  "  In  the  production  of  heat  in  response  to  a  physiological 
stimulus,  the  nervous  system,  through  the  portion  involved  in  the 
reflex  mechanism,  is  especially  stimulated,  and  the  stimulus  is  im- 
mediately followed  by  special  provisions  for  repose. 

F.  "  During  the  afflux  of  blood  to  the  periphery,  blood  is  drawn 
from   the   nerve   centres,  which   are  thus   placed  in   a  condition 


ON  THE   USE  OF   THE  COLD  PACK.  1 45 

analogous  to  sleep — a  condition  favorable  to  repose  and  nutritive 
assimilation. 

"  The  establishment  of  an  equilibrium  of  temperature  is  fol- 
lowed by  a  cessation  of  chemical  activity  in  the  muscles,  and 
necessarily  by  sedation  of  the  nerves.  These  effects  are  of  espe- 
cial symptomatic  importance  in  irritable  anaemias, 

3.  "  During  the  pack  the  radial  pulse  is  slackened,  and  its 
tension  lowered.  We  may  infer  increased  facilities  for  nutrition 
in  tissue  elements  hitherto  irritated  rather  than  nourished  by  a 
blood  stream  imperfect  in  quantity  and  too  rapid  in  duration. 

"  Massage  intensifies  and  prolongs  some  of  the  effects  of  the 
pack  when  this  has  been  previously  administered. 

"  Given  alone  it  is  much  less  effectual  than  the  pack,  because 
its  influence  is  less  complete,  and  especially  because  it  is  less  cer- 
tain to  determine  blood  to  anaemic  muscles. 

"  In  cases  of  '  neurasthenia  '  or  of  hysteria,  the  cold  pack  is 
only  beneficial  in  proportion  to  the  coexisting  anaemia.  If  this 
is  not  marked  in  proportion  to  the  neurotic  element,  the  pack  may 
be  useless  or  even  injurious. 

"  The  cold  pack  is  decidedly  dangerous,  if  administered  too 
near  to  periods  of  abdominal  hyperaemia,  whether  physiological, 
as  digestion  and  menstruation,  or  pathological,  as  in  lurking  peri- 
tonitis." 

We  need  add  nothing  to  this  summary  except  to  say  that  it  is 
well  supported  by  the  argument  in  the  preceding  text  and  that  the 
treatment  appears  every  way  exceedingly  rational.  That  experi- 
ence has  confirmed  its  value  is  shown  by  the  cases  here  narrated. 
The  work  is  a  real  contribution  to  medical  literature. 

III. — The  brain  as  an  organ  of  the  mind.  By  H.  Charl- 
ton Bastian,  M.A.,  M.D.,  F.R.S.,  etc.  New  York  :  D.  Appleton 
&  Co.,  1880. 

This  book  has  been  widely  advertised  in  newspapers  and 
medical  journals,  and  we  have  met  with  many  physicians  who 
are  disposed  to  regard  it  as  a  stupendous  achievement  in 
neurological  literature.  Students  who  have  kept  pace  with 
the  advances  in  microscopical  research,  who  have  carefully  read 
the  short  but  multitudinous  monographs,  polemical,  dogmatic, 
and  strictly  scientific,  which,  month  after  month,  appear  in  the 
better  class  of  physiological  and  medical  periodicals,  cannot 
avoid  a  feeling  of  surprise  that  an  attempt  to  condense  such 
matters  into  the  form  in  which  Dr.  Bastian  presents  it  to  us, 
should  have  attracted   so  much  general  attention. 


146  RE  VIE  WS. 

It  is  an  evidence  of  the  interest  taken  in  these  subjects  by  those 
who  are  obliged  to  derive  their  information  at  second-hand  from 
compilers,  and  who  must,  from  this  fact,  be  necessarily  behind  the 
times. 

Dr.  Bastian  has  himself  done  some  honest  original  work,  and 
has,  therefore,  a  respectable  position  as  an  investigator.  This 
popular  work  will  not,  we  think,  enhance  his  reputation,  however 
complete  and  instructive  it  may  be  to  the  general  public  ;  it  is  too 
unsatisfactory  to  the  student  or  specialist  in  this  department. 

The  world  has  but  few  really  original  investigators,  but  many 
popularizers.  There  are  few  who  have  the  ability  or  the  desire  to 
pin  themselves  to  facts  as  they  have  been  toilsomely  discovered  in 
laboratory  or  field,  and  make  legitimate  deductions  therefrom  ; 
while  the  imagination  runs  riot  in  print  everywhere.  We  are  not  in- 
clined to  disparage  the  use  of  the  imagination  in  scientific  research, 
but  it  must  be  kept  within  bounds.  We  are  led  to  think  that  no 
more  imaginative  explorer  ever  existed  than  Faraday,  for  he  said 
that  for  every  theory  the  scientific  man  ventured  to  publish,  thou- 
sands had  been  crushed  before  they  were  formulated  into  words. 
While  Meynert,  we  fancy,  was  of  that  kind  of  whom  Bacon  spoke 
when  he  said  there  were  "  men  who  could  not  reason  beyond  a 
fact"  (for  we  find  him  carefully  essaying  a  few  ventures  outside 
his  "  Brains  of  Mammals,"  and  generally  getting  beyond  his 
depth),  Bastian  has  not  reasoned  even  up  to  the  facts.  He  has 
not  let  his  imagination  carry  him  a  step  beyond,  nor  even  as  far  as 
recent  investigations  permit  advances  to  be  made.  He  is  some 
years  behind  the  times  in  having  published  what  purports  to  be  an 
expose  of  neurological  science.  We  have  the  book  as  an  evidence 
that  in  something  like  a  hundred  years  from  now  the  medical  and 
general  public  will  have  some  appreciation  of  what  is  being  ac- 
complished in  the  way  of  psychological,  physiological,  and  anatom- 
ical research.  Particularizing,  the  first  chapter  treats  of  the  uses 
and  origin  of  a  nervous  system,  wherein  he  quotes  his  own  "Begin- 
nings of  Life  "  and  writings  of  Spencer,  the  former  being  based 
upon  the  latter  largely.  The  second  chapter  is  on  the  structure 
of  a  nervous  system,  copied  from  elementary  and  ancient  works 
on  anatomy.  The  remainder  of  the  book  consists  in  most  part  of 
a  literal  quotation  of  Gegenbaur's  "  Elements  of  Comparative 
Anatomy,"  interspersed  with  occasional  passages  from  Huxley's 
"Vertebrate  and  Invertebrate  Anatomy,"  with  a  dissertation  upon 
"  Phrenology,  Old  and  New,"  derived  from  a  reading  of  Ferrier 
on  "  Localization  of  Function,"  concluding  with  a  glance  at  men- 


THE  BRAIN  AS  AN  ORGAN  OF  THE  MIND.  147 

tal  processes,  wherein  Sir  Wm.  Thompson,  Ziemssen's  Cyclopaedia 
(Kussmaul),  and  Ferrier's  later  work  on  "  Localization  of  Cerebral 
Disease  "  are  made  to  do  good  service. 

The  work  concludes  with  an  appendix,  which  is  wholly  devoted 
to  a  discussion  of  views  concerning  the  existence  and  nature  of  a 
muscular  sense,  views  which  may  appear  novel  to  Bastian,  but 
which  read  tiresomely  to  those  who  have  indulged  in  their  peru- 
sal ad  nauseam. 

To  sum  up  : 

Bastian's  work  is  useful  in  being  a  serious  though  unavailing 
attempt  to  bring  psychological  and  physiological  knowledge  of  a 
few  years  back  into  accord.  It  is  also  useful  to  genuinely  scien- 
tific men  as  an  evidence  of  the  money  that  can  be  made  by  step- 
ping aside  from  vigorous  methods  of  investigation  to  indulge  the 
natural  curiosity  of  those  who  earnestly  desire  to  know  what  is 
going  on  in  those  fields  without  the  necessity  of  acquiring  the 
ability  to  weigh  logically  the  value  of  the  details  encountered.  At 
the  same  time,  it  warns  the  scientific  man  that  were  he  to  under- 
take some  such  work  as  this  he  would  be  liable  to  fall  behind  as 
signally  as  Bastian  has.  [s.  v.  c] 


SHORTER  NOTICES. 


I.  A  Treatise  on  the  Practice  of  Medicine  for  the 
Use  of  Students  and  Practitioners.  By  Roberts  Bartholow, 
M.A.,  M.D.,  LL.D.  New  York  :  •  D.  Appleton  &  Co.,  1880. 
Chicago  :   Jansen,  McClurg  &  Co. 

II.  Atlas  of  Skin  Diseases.  By  Louis  A.  Duhring,  M.D. 
Part  VII.  Philadelphia:  J.  B.  Lippincott  &  Co.,  1880.  Chi- 
cago :  Jansen  McClurg  &  Co. 

III.  A  Practical  Treatise  on  Surgical  Diagnosis.  By 
A.  L.  Ramsey,  A.M.,  M.D.  New  York  :  Wm.  Wood  &  Co., 
1880.     Chicago  :  W.  T.  Keener. 

IV.  A  Treatise  on  Diphtheria.  By  A.  Jacobi.  New  York  : 
Wm.  Wood  &  Co.,  1880.     Chicago  :  W.  T.  Keener. 

V.  Diagnosis  and  Treatment  of  Ear  Diseases.  By  Albert 
H.  Buck,  M.D.  New  York  :  Wm.  Wood  &  Co.,  1880.  Chi- 
cago :  W.  T.  Keener. 

VI.  Treatise  on  Therapeutics.  Translated  by  D.  F.  Lin- 
coln, M.D.,  from  the  French  of  A.  Trousseau  and  H.  Pidoux. 
Ninth  Edition,  Revised  and  Enlarged  with  the  assistance  of  Con- 


148  REVIEWS. 

stantin   Paul.      Vol.   III.      New  York  :  Wm.  Wood  &  Co.,  1880. 
Chicago  :  W.  T.  Keener. 

VII.  Cutaneous  and  Venereal  Memoranda.  By  Henry 
G.  Piffard,  A.M.,  M.D.,  and  George  Henry  Fox,  A.M.,  M.D. 
Second  Edition.  New  York  :  Wm.  Wood  &  Co.,  1880.  Chi- 
cago :  W,  T.  Keener. 

VIII.  Ophthalmic  and  Otic  Memoranda.  By  D.  B.  St. 
John  Roosa,  M.D.,  and  Edward  T.  Ely,  M.D.  Revised  Edition. 
New  York  :  Wm.  Wood  &  Co.,  1880.     Chicago  :  W.  T.  Keener. 

IX.  The  Medical  Record  Visiting  List  ;  or,  Physician's 
Diary,  for  1881.  New  York:  Wm.  Wood  &  Co.  Chicago  :  W. 
T.  Keener. 

I.  This  is  somewhat  different  from  most  works  on  the  practice 
of  medicine,  in  that  it  enters  at  once  on  the  special  part  of  its 
subject  without  any  preliminaries  on  general  principles  of  pathol- 
ogy, symptomatology,  etc.  This  is,  in  some  respects,  a  disadvan- 
tage, if  the  work  is  intended  as  a  student's  manual,  for  it  is  not 
always  the  case  that  the  medical  student  will  possess  special  works 
on  pathology,  or,  if  he  does,  will  always  associate  their  contents 
properly  with  their  practical  applications  in  special  diseases.  It 
is  no  disadvantage,  however,  to  the  practitioner  who  wishes  to  ob- 
tain the  views  of  so  able  a  therapeutist  as  Prof.  Bartholow,  on  the 
nature  and  treatment  of  the  several  diseases,  and  while  it  ought 
not  to  be  alone  depended  on  by  the  student,  its  clear  and  positive 
statements  and  condensed  style  will  undoubtedly  make  it  as  popu- 
lar as  the  treatise  on  therapeutics  to  which  it  is  intended  to  be  a 
companion  volume. 

Dr.  Bartholow,  as  he  himself  say's  in  the  introduction  to  the 
present  volume,  is  by  no  means  in  sympathy  with  what  he  calls 
"  the  therapeutic  nihilism  of  the  day,"  and  this  is  made  evident 
throughout.  Some  of  the  doses  recommended  seem  almost  heroic, 
as,  for  example,  half  a  drachm  to  a  drachm  of  bromide  of  potas- 
sium, frequently  repeated,  in  that  form  of  migraine  "  dependent  on 
contraction  of  the  arterioles."  Duquesnel's  aconitia  is  mentioned 
as  employed  in  solution,  internally,  in  doses  of  from  one-hun- 
dredth to  one-twentieth,  or  even  one-tenth  of  a  grain,  and  the 
qualification  "  very  cautiously  "  seems  to  be  scarcely  enough  with 
these  minimum  and  maximum  doses. 

We  notice  also  that  Dr.  Bartholow  does  not  appear  to  recognize 
the  popular  modern  affection  known  as  "  neurasthenia  "  or  nervous 
exhaustion.  Indefinite  as  it  may  appear  to  be,  this  name  implies, 
to  our  mind,  a  condition  that  is  not  included  under  any  other 
head,  and  the  importance  of  which  is  not  easily  overrated. 


SHORTER  NOTICES.  149 

We  might  notice  other  points  in  which  the  work  apparently 
calls  for  criticism,  had  we  the  space  to  give.  But  these  do  not 
materially  detract  from  its  general  merits  ;  it  is  in  most  respects 
an  admirable  work  of  its  class,  and  one  which,  we  doubt  not,  will 
meet  with  the  same  general  approval  that  has  greeted  the  author's 
volume  on  materia  medica  and  therapeutics. 

II.  The  seventh  part  of  Duhring's  atlas  of  skin  diseases  contains 
the  plates  and  text  on  eczema  (pustulosum),  impetigo  contagiosa, 
syphiloderma  (papulosum),  and  lupus  vulgaris.  In  all  respects  it 
seems  to  be  fully  up  to  its  predecessors  in  merit,  and  the  good 
words  we  have  been  obliged  to  give  for  these  illustrations  have 
become  almost  monotonous.  We  are  unable,  however,  to  change 
the  tone  ;  the  series  is  as  fine,  in  its  way,  as  anything  we  have 
ever  seen. 

III.  The  demand  for  a  second  edition  of  a  work  almost  within 
a  year  from  its  first  publication,  is  itself  sufficient  evidence  of  a 
certain  sort  of  merit  in  a  book,  or  at  least  that  it  meets  a  felt  want. 
This  volume  certainly  does  fill  a  place  in  medical  literature,  and 
its  value  is  unquestionable.  As  far  as  we  can  see,  it  is  accurate, 
and,  with  the  additions  made  in  this  second  edition,  much  more 
nearly  complete.  It  is  a  work  well  worthy  a  place  in  every  prac- 
tising physician's  or  surgeon's  library. 

IV.  Dr.  Jacobi's  reputation  will  go  far  to  insure  any  work  of  his 
careful  attention,  and  the  present  volume  will  in  no  way  detract 
from  it.  It  is  a  thoroughly  scientific  and  also  practical  treatise 
on  diphtheria,  its  history,  etiology,  pathology,  symptoms  and 
treatment,  and  one  that  will  be,  we  believe,  the  standard  mono- 
graph on  its  subject  for  a  considerable  time  to  come.  Dr.  Jacobi 
does  not  uphold  the  bacteria  theory  of  the  disorder,  and  quotes 
with  high  approval  the  recent  researches  of  Wood  and  Formad  on 
the  subject,  in  an  appendix  to  his  preface,  their  paper  not  having 
appeared  in  time  to  be  noticed  in  the  text.  As  regards  the  ques- 
tion of  the  identity  of  croup  and  diphtheria,  he  considers  it  as 
yet  one  that  lacks  evidence  enough  for  any  positive  decision  either 
way.  The  work  is  throughout  scientifically  conservative,  and  ad- 
vocates no  theories  that  do  not  rest  on  adequate  bases. 

About  one-third  of  the  book  is  devoted  to  the  treatment  of 
diphtheria,  and  here  the  reader  will  find  discussed  nearly  every- 
thing that  has  ever  been  recommended  or  used  in  the  disease,  with 
the  most  judicious  remarks  on  each  by  the  author.  Notwithstand- 
ing the  space  allowed,  there  is  a  very  great  condensation  and  con- 
ciseness of  statements. 


I  50  RE  VIE  WS. 

Dr.  Jacobi's  style  is  clear  and  very  readable,  though  he  occa- 
sionally introduces  a  Germanism.  The  make-up  and  typography 
of  the  work  are  excellent.  It  is  one  to  be  recommended  to  every 
practitioner. 

V.  This,  it  would  appear  to  one  who  is  not  a  specialist  in  the 
department  of  aural  surgery,  is  likely  to  be  a  useful  work.  It  is 
intended,  as  the  author  says  in  his  preface,  to  show  the  usual  types 
of  ear  disorders  as  met  with  in  hospital  and  private  practice.  So 
far  as  we  can  judge,  it  is  quite  comprehensive  in  its  scope,  and  we 
have  been  able  to  find  in  its  pages  mention  of  at  least  one  minor 
aural  disorder  that  we  have  looked  for  in  vain  in  one  or  two  more 
pretentious  works  on  otology.  Appearing,  as  it  does,  in  a  cheap 
series  of  medical  publications,  it  seems  to  us  well  worth  its  cost. 

VI.  We  have  already  noticed  the  two  previous  volumes  of 
Trousseau  and  Pidoux's  therapeutics  in  our  last  number.  The 
present  one  completes  the  work  which,  as  a  whole,  is,  in  the  form 
it  now  appears  in  Dr.  Lincoln's  translation,  a  useful  addition  to 
the  medical  literature  of  our  language. 

VII  and  VIII.  These  two  little  volumes  are  intended  as  con- 
venient aids  for  cramming  and  reference.  They  are  too  brief  for 
text-books,  and  are  liable  to  the  objection  to  short  compendiums 
generally,  that  they  encourage  superficial  study  and  prevent  stu- 
dents from  obtaining  the  large  works  from  which  alone  an  approxi- 
mately thorough  knowledge  of  their  subjects  can  be  obtained. 
The  special  disorders  of  which  they  treat  are  not  so  limited  or  so 
infrequent  that  the  average  physician  requires  no  more  informa- 
tion concerning  them  than  these  volumes  afford.  Nevertheless, 
they  can  be  of  service  as  works  of  ready  reference  ;  their  authors 
are  men  of  reputation  in  their  several  departments  of  medicine, 
and  their  names  are  a  guarantee  of  accuracy  and  give  the  volumes 
a  certain  authority.  They  are  handsomely  gotten  up,  and  very 
convenient  in  size  for  pocket  reference  books,  and  are  worth 
their  price  to  those  who  can  properly  utilize  them. 

IX.  This  is  one  of  the  neatest  in  appearance  of  the  visiting 
lists  of  the  year.  It  contains,  besides  the  usual  calendar  and  dose 
list,  formulae  for  hypodermic  injection,  lists  of  poisons  and  their 
antidotes,  directions  for  emergencies,  memoranda  of  urine  analysis, 
cautions,  tables  for  calculating  duration  of  pregnancies,  antiseptic 
and  disinfectant  directions,  etc.  It  also  contains  a  catheter  gauge, 
that  may  be  useful  for  other  purposes,  such  as  estimating  the  size 
of  the  pupil,  etc.  The  ruling  is  also  very  conveniently  arranged 
for  the  physician's  wants. 


%(lxtoxml  ^zpAxtmtnt 


"\X  TE  have  received  the  minutes  of  the  business  meeting  of  the 
Council  of  the  National  Association  for  the  Protection  of 
the  Insane  and  the  Prevention  of  Insanity,  held  at  New  York, 
November  nth,  of  the  past  year.  In  addition  to  regular  rou- 
tine business,  the  following  resolutions  were  formulated  and 
adopted  : 

1.  ''  Resolved  :  That  Mary  Putnam- Jacobi,  M,  D.,  Margaret  A. 
Cleaves,  M.D.,  E.  C.  Seguin,  M.D.,  J.  C.  Shaw,  M.D.,  be  a  com- 
mittee to  take  such  steps  as  shall  be  best  calculated  to  induce 
medical  colleges,  medical  journals,  and  asylum  authorities  to  do 
all  in  their  power  to  diffuse  a  better  knowledge  of  psychiatry 
amongst  the  profession,  and  to  specially  educate  physicians  who 
may  desire  a  thorough  knowledge  of  the  subject. 

2.  "  Resolved :  That  a  committee  of  five,  the  chairman  of 
which  shall  be  president  of  our  association,  be  appointed  by  the 
president  to  obtain  facts  and  statistics  relating  to  the  methods  and 
use  of  restraint  and  the  use  of  labor  in  the  asylums  of  this  coun- 
try, 

3.  "  Resolved  :  That  a  committee  of  five  be  appointed  to  assist 
in  the  investigation  the  New  York  Senate  Committee  (appointed 
last  winter  by  the  New  York  Senate  to  investigate  the  condition 
of  the  insane,  and  management  of  the  state  lunatic  hospitals,  and 
county  insane  asylums  of  the  state,  and  to  report  to  the  next 
legislature)  is  now  making,  in  such  a  manner  as  shall  be  deemed 
advisable." 

151 


152  EDITORIAL  DEPARTMENT. 

The  first  of  these  committees,  as  appointed,  consists  of  the 
chairman,  Dr.  Wilbur,  Judge  Andrews  of  Ohio,  Dr.  Reynolds 
of  Iowa,  Dr.  Corbus  of  Illinois,  and  Hon.  F.  B.  Sanborn  of  Mas- 
sachusetts. The  second  is  made  up  of  Drs.  E.  C.  Seguin,  M. 
Putnam-Jacobi,  G.  M.  Beard,  H.  B.  Wilbur,  and  Miss  A.  A.  Che- 
vallier. 

It  will  be  seen  by  this  programme  that  this  new  association  in- 
tends to  make  itselt  felt  as  a  motor  for  reform.  That  reform  is 
needed  in  some  places  is  sufficiently  evident  from  the  revelations 
before  the  above-mentioned  Senate  Committee  and  elsewhere, 
and  it  appears  useless  to  expect  it  from  the  Association  of  Asylum 
Superintendents,  the  only  heretofore  constituted  body  dealing  es- 
pecially with  the  questions  of  insanity.  From  the  composition  of 
these  committees  we  look  for  good  work  to  be  reported  at  the 
meeting  next  June. 

Scarcely  an  asylum  has  been  the  subject  of  investigation  in 
which  some  abuse  has  not  been  unearthed,  or  some  phase  of  asy- 
lum management  shown  to  be  inadequate  or  faulty.  Let  the 
good  work  go  on  in  a  proper  spirit.  Let  the  modes  of  treatment, 
the  amount  and  kind  of  medical  service  be  carefully  inquired 
into.  Let  it  be  ascertained  how  much  care  is  taken  to  find  out 
the  real  condition  of  a  patient  on  entering  an  asylum,  and  how 
often  they  are  seen.  What  are  the  appliances  for  treatment  ? 
What  are  the  principles  of  classification  ?  What  pains  is  taken 
to  watch  nurses  or  attendants,  to  check  the  disposition  toward 
cruel  treatment  to  which  the  less  scrupulous  attendants  are 
tempted  ?  Inquire  into  the  financial  management  down  to  the 
minutest  details  once  for  all.  Let  all  these  things  be  done,  not 
for  the  purpose  of  harrassing  the  medical  officers  of  asylums,  or 
in  a  spirit  of  fault-finding,  but  to  find  out  where  are  the  defects  of 
asylum  management  in  our  own  country,  and  how  they  may  be 
removed.  It  is  simply  useless  for  asylum  superintendents  any  lon- 
ger to  expect  those  who  may  have  friends  or  relatives  in  these  in- 
stitutions, or  even  the  general  public,  to  remain  quiet  with  the  an- 
nual expose  of  the  bad  results  of  our  present  system  in  this  or  that 
asylum. 


EDITORIAL  DEPARTMENT.  153 

We  have  received  from  Dr.  J.  J.  Mason  of  New  York  City, 
on  two  different  occasions,  sets  of  micro-photographs  of  thin 
sections  of  the  spinal  cord  at  different  levels,  and  under  various 
powers.  They  are  by  Dr.  Mason  himself,  and  are  from  his  own 
preparations.  They  are  without  exception  the  clearest  and  best 
photographs  of  nerve  tissue  we  have  ever  seen.  Taken  altogether 
they  are  so  exceptionally  good  as  to  be  subjects  for  admiration. 
They  are  among  the  fruits  of  a  prolonged  study  of  the  spinal  cord 
in  lower  vertebrates,  upon  which  the  author  has  been  long  en- 
gaged. Fortunately  Dr.  Mason  has  the  leisure,  taste  and  means 
to  enable  him  to  pursue  the  scientific  side  of  a  study  of  the  ner- 
vous system,  and  we  shall  look  forward  with  pleasant  anticipation 
to  the  final  results  of  his  unselfish  labor,  pursued  for  the  love  of 
science. 

THE    "HAMMOND   PRIZE"   OF   THE   AMERICAN 
NEUROLOGICAL   ASSOCIATION. 

The  American  Neurological  Association  offers  a  prize  of  five 
hundred  dollars,  to  be  known  as  the  "  William  A.  Hammond 
Prize,"  and  to  be  awarded  at  the  meeting  in  June,  1882,  to  the 
author  of  the  best  essay  on  the  Functions  of  the  Thalamus  Op- 
ticus in  Man. 

The  conditions  under  which  this  prize  is  to  be  awarded  are  as 
follows  : 

1.  The  prize  is  open  to  competitors  of  all  nationalities. 

2.  The  essays  are  to  be  based  upon  original  observations  and 
experiments  on  man  and  the  lower  animals. 

3.  The  competing  essays  must  be  written  in  the  English,  French, 
or  German  language  ;  if  in  the  last,  the  manuscript  is  to  be  in  the 
Italian  handwriting. 

4.  Essays  are  to  be  sent  (postage  prepaid)  to  the  Secretary  of 
the  Prize  Committee,  Dr.  E.  C.  Seguin,  41  West  20th  Street,  New 
York  City,  on  or  before  February  i,  1882  ;  each  essay  to  be 
marked  by  a  distinctive  device  or  motto,  and  accompanied  by  a 
sealed  envelope  bearing  the  same  device  or  motto  and  contain- 
ing the  author's  visiting  card. 

5.  The  successful  essay  will  be  the  property  of  the  association, 
which  will  assume  the  care  of  its  publication. 


154  EDITORIAL  DEPARTMENT. 

6.  Any  intimation  tending  to  reveal  the  authorship  of  any  of 
the  essays  submitted,  whether  directly  or  indirectly  conveyed  to 
the  committee,  or  to  any  member  thereof,  shall  exclude  the  essay 
from  competition. 

7.  The  award  of  the  prize  will  be  announced  by  the  undersigned 
committee,  and  will  be  publicly  declared  by  the  president  of  the 
association  at  the  meeting  in  June,  1882. 

8.  The  amount  of  the  prize  will  be  given  to  the  successful  com- 
petitor in  gold  coin  of  the  United  States,  or,  if  he  prefer  it,  in  the 
shape  of  a  gold  medal  bearing  a  suitable  device  and  inscription. 

(Signed)  F.  T.  Miles,  M.D.,  Baltimore. 

J.  S.  Jewell,  M.  D.,  Chicago. 
E.  C.  Seguin,  M.  D.,  New  York. 


Two  years  ago  we  noticed  and  expressed  our  approval  of  a 
proposition  to  amend  the  Illinois  law  in  relation  to  the  commit- 
ment of  lunatics.  That  measure,  as  is  well  known,  failed  to  pass 
the  legislature  on  account,  we  suppose,  of  the  public  sentiment  of 
jealousy  for  the  rights  of  the  individual  ;  and  the  jury  trial  of  the 
insane,  with  all  its  disadvantages,  is  still  the  only  legal  method  of 
commitment. 

It  is  probable  that  a  new  attempt  to  change  the  law  by  the  same 
or  similar  provisions  as  those  then  introduced  will  be  made  this 
winter.  It  is  probable  that  it  will,  to  some  extent,  meet  with  the 
same  opposition  ;  but  the  chance  of  its  success  is,  we  think,  much 
better  now  than  then.  To  insure  it,  however,  some  recognition 
should  be  given  to  a  popular  sentiment  which,  no  matter  how  mis- 
directed it  may  be  occasionally,  is  founded  on  correct  principles. 
Our  present  law  does  not  provide  against  unjust  commitment  so 
well,  in  fact,  as  the  law  proposed  as  a  substitute  for  it  two  years 
ago,  and  neither  of  them  contained  the  necessary  provisions  for 
the  protection  of  the  insane  once  committed.  The  only  real 
guard  against  abuses  in  our  asylums,  in  our  present  law,  so  far  as 
we  are  aware,  is  the  provision  for  their  inspection  by  the  State 
Board  of  Charities.  How  adequate  this  provision  is  can  best  be 
understood  from   the  following  facts.     The  State  Board  of  Chari- 


EDITORIAL  DEPARTMENT.  155 

ties  consists  of  several  professional  gentlemen,  one  of  them  a  phy- 
sician, who  serve  without  salary,  and  are  obliged  to  borrow  the 
time  for  their  official  duties  from  their  daily  bread-winning  occu- 
pations. Their  secretary,  on  whom  really  most  of  the  actual  labor 
of  the  Board  devolves,  is  not  a  medical  man,  but  a  clergyman,  and 
though  an  able  statistician  and  expert  in  administrative  matters,  can 
hardly  be  expected  to  possess  the  intimate  knowledge  of  diseases 
of  the  brain  and  mind  that  is  needed  to  properly  inspect  an  insane 
hospital  and  be  independent,  in  all  matters  requiring  medical 
knowledge,  of  the  resident  officials  whose  critic  he  is  to  be,  and  if 
he  does  possess  this  knowledge,  his  duties  are  so  numerous  in  other 
directions  that  it  would  be  impossible  for  him  to  properly  attend 
to  the  duties  of  inspection.  In  fact,  the  State  Board  of  Charities 
may  do  all  that  can  reasonably  be  asked  of  it,  and  yet  let  this  par- 
ticular duty  entirely  alone. 

The  remedy  for  this  condition  of  affairs  is  simply  the  appoint- 
ment of  a  competent  and  otherwise  well-qualified  medical  man  as 
state  commissioner  or  visitor  in  lunacy,  who  shall,  acting,  it  may 
may  be,  as  regards  the  immediate  management  of  the  asylums,  in 
chiefly  an  advisory  capacity,  visit  each  and  every  institution  in  the 
state  unannounced  and  at  unexpected  times,  as  often  as  four 
times  a  year,  and  make  the  most  thorough  examination  of  every 
detail  relating  to  the  immediate  care  of  the  insane,  investigate  all 
cases  of  suicide,  homicide,  or  accidental  death  ;  hear  complaints, 
have  private  interviews  with  patients  if  desired  by  them,  inspect 
the  diet,  visit  all  portions  of  the  wards  at  all  hours,  and  with  and 
without  the  company  of  the  resident  officers,  and,  in  short,  fulfil 
the  functions,  with  perhaps  less  direct  authority,  of  the  English 
commissioners  in  lunacy,  under  whom  so  beneficial  a  change  has 
been  effected  in  the  management  of  the  insane  in  Great  Britain. 
This  officer  should  receive  a  salary  commensurate  with  his  duties, 
and  travelling  expenses.  Asylum  authorities  should  be  obliged  to 
afford  him  every  facility,  but  he  should  be  absolutely  independent 
of  them  in  all  respects,  not  owing  them  the  slightest  favor,  and 
they  should  have  nothing  to  do  with  his  appointment.  He  should 
make  a  report,  annually,  to  the  governor,  or  biennially  to  the  leg- 


156  EDITORIAL  DEPARTMENT. 

islature,  which  should  be  published.  His  office  should  be  held 
during  good  behavior,  subject  to  removal  by  the  governor,  or 
better,  by  the  Supreme  Court.  All  correspondence  with  him  by 
the  patients  should  be  inviolate,  and  all  letters  withheld  by  the 
superintendents  should  be  submitted  to  him. 

These  are  a  portion  of  the  duties  that  would  devolve  upon  such 
an  official,  and  it  is  easy  to  see  that  their  proper  fulfilment  would 
be  amply  sufficient  to  occupy  all  his  time,  and  that  it  is  saying 
nothing  to  the  discredit  of  the  Board  of  Charities  when  we  say 
that  it  cannot  be  expected  of  them.  If  all  the  insane  in  county 
alms-houses  are  to  be  visited  as  they  should  be,  there  is  more  than 
enough  for  two  such  officials  in  the  state  of  Illinois  to  do. 

In  stating  the  necessity  of  such  an  appointment  for  the  proper 
protection  of  the  insane,  we  do  not  intend  to  imply  any  charges 
against  the  present  management  of  our  state  hospitals.  For  all 
we  can  say,  they  are  as  well  managed  as  the  average  of  similar  in- 
stitutions in  this  country,  and  some  of  them  probably  better.  But, 
under  the  present  system  of  non-oversight,  this  is,  like  a  benevo- 
lent despotism,  at  best  only  a  happy  accident.  Nothing,  however, 
is  so  absolutely  perfect  that  improvement  is  not  desirable,  and  this 
desirable  end  will  be  best  obtained  by  constant  oversight  and 
judicious  criticism.  Moreover,  such  an  official  would  be  a  protec- 
tion not  only  to  the  insane  wards  of  the  state,  but  also  to  the 
asylum  authorities  who,  however  well  they  may  strive  to  do  their 
duty,  are  constantly  liable  to  suffer  from  misapprehension  and 
suspicion  on  the  part  of  the  public.  If  they  should  fail  to  do  their 
duty,  the  value  of  such  an  honest  inspection  is  obvious. 

There  is  one  other  point  worthy  to  be  noted.  Any  such  change 
in  the  present  law  as  is  contemplated  is  likely  to  open  the  way  to 
the  establishment  of  a  certain  number  of  private  asylums.  These 
establishments  have  their  uses  ;  in  fact,  we  believe  that  the  present 
lack  of  a  certain  class  of  them  is  a  serious  disadvantage  at  the 
present  time.  But  of  all  kinds  of  business,  this  keeping  of  a  pri- 
vate asylum  is  one  that  most  needs  proper  governmental  supervi- 
sion, and  this  can  be  best  given  by  the  method  we  have  indicated. 
In  connection  with  the   State  Board  of  Charities,  of  which  he 


EDITORIAL  DEPARTMENT.  1S7 

should  perhaps  be  an  ex-officio  member,  the  commissioner  in 
lunacy  should  examine  the  character  and  qualifications  of  all  per- 
sons desiring  to  open  such  asylums,  examine  the  buildings  and 
their  situation,  and  grant  or  refuse  licenses  .accordingly.  They 
should  also  have  the  power  to  revoke  such  licenses,  once  issued, 
for  sufficient  reasons,  and  no  one  should,  under  severe  penalty, 
open  such  establishment  or  attempt  to  otherwise  take  the  care  of 
the  insane,  for  profit,  away  from  their  own  homes,  without  such 
license.  Only  in  some  such  way  as  this  can  security  against 
abuses  be  obtained. 


^tviscopt. 


a. — ANATOMY   AND    PHYSIOLOGY   OF   THE   NERVOUS 
SYSTEM. 

The  Innervation  of  the  Heart.  An  exhaustive  article  on 
the  ganglia  in  the  frog's  heart  is  to  be  found  in  Pfliiger's  Archiv 
(Bd.  xxiii,  H.  7  and  8),  by  M.  Lovvit.  He  details,  in  the  first  place, 
the  researches  of  others,  instigated  by  Stannius'  well-known  ex- 
periments. No  agreement  has  yet  been  arrived  at  in  explaining 
the  effect  of  ligatures  applied  according  to  Stannius'  direction. 
This  uncertainty  Lovvit  traces  to  the  peculiar  insertion  of  the 
veins  into  the  right  auricle.  The  figure  described  by  the  junction 
of  the  venous  sinus  with  the  heart  is  not  situated  in  one  plane,  and 
cannot,  hence,  be  accurately  grasped  by  a  ligature.  The  author, 
therefore,  resorted  to  section  with  very  sharp  scissors  with  the  fol- 
lowing results  : 

He  found,  in  the  first  place,  an  inhibitory  apparatus  in  the 
venous  sinus.  Division  of  the  sinus  itself  or  irritation  with  a 
needle  causes  a  temporary  slacking  of  the  heart's  action.  This 
effect  is  prevented  by  atropin.  It  is,  hence,  due  to  the  irritation 
of  some  inhibitory  organ,  as  Liiwit  thinks — of  the  vagus  fibres 
themselves.  Below  the  sinus  no  inhibitory  organ  could  be  traced. 
Separation  of  the  sinus  from  the  heart,  by  cutting  accurately  along 
the  line  of  junction,  permits  the  pulsations  of  both  parts  to  con- 
tinue, until  the  heart  dies.  As  a  rule,  however,  the  auricles  and 
ventricle  beat  somewhat  slower  than  the  detached  sinus. 

The  contrary  effect  produced  by  Stannius'  ligature — the 
stoppage  of  the  auricle  plus  ventricle — is  due  to  the  fact  that 
the  ligature  necessarily  grasps  more  or  less  of  the  inter-auricu- 
lar septum.     If  the  upper  portion  of  the   septum  be  cut  off  from 

158 


A NA  TOM  Y  AND  PH  YSIOL OGY.  159 

the  heart,  previously  detached  from  its  venous  sinus,  the  auricles 
(and  ventricle)  will  either  beat  slower  or  stop  altogether,  accord- 
ing to  the  size  of  the  piece  removed.  By  cutting  transversely 
through  tlie  auricles,  the  lower  part  of  them  with  the  attached 
ventricle  will  remain  at  rest  definitely,  unless  artificially  irritated. 
But  by  cutting  through  the  auriculo-ventricular  junction,  i.  <?., 
through  the  ganglia  existing  in  the  flaps  forming  the  auriculo- 
ventricular  valves,  the  ventricle  will  again  commence  pulsating, 
but  only  for  a  short  time.  When  once  at  rest,  fresh  pulsations 
can  be  started  by  any  stimulus.  But  if  the  ventricular  apex, 
which  contains  no  ganglia,  is  isolated,  every  stimulus  evokes 
merely  a  single  contraction.  Extirpation  of  the  valve-flaps  con- 
taining the  ganglia  excludes  the  ventricle  from  further  contractions. 
They  can  be  extirpated  by  opening  the  lower  part  of  the  ven- 
tricle, without  otherwise  disturbing  the  action  of  the  heart. 

Lowit's  views  and  explanations  may  be  thus  reproduced.  The 
systole  commences  always  in  the  venous  sinus,  as  inspection 
shows.  The  sinus  ganglion  is,  in  all  probability,  the  organ  starting 
the  impulse.  The  ganglia  in  the  interauricular  septum  suffice  for 
the  maintenance  of  the  auricular  pulsations,  but  since  the  de- 
tached auricle  beats  slower,  it  is  to  be  assumed  that  they  are  less 
irritable  than  the  ganglia  of  the  sinus  in  which  the  impulse  is 
started.  There  is  no  doubt  a  summation  of  nerve  energy  as  the 
impulse  reaches  the  interauricular  ganglia.  The  ganglia  at  the 
base  of  the  ventricle  cannot  start  pulsations  anatomically  ;  they 
must  be  stimulated  from  above.  They  evidently  serve  to  trans- 
mit the  nerve  impulse  to  the  ventricular  musculature,  as  is  shown 
by  the  result  of  their  extirpation.  Moreover,  it  has  been  shown 
(Engelmann,  Bernstein)  that  the  contraction-wave  is  delayed  in 
its  passage  from  auricle  to  ventricle. 


The  Cheyne- Stokes  Phenomenon. — By  some  casual  observa- 
tions Luchsinger  learned  that  the  above  modification  of  the  res- 
piratory movements  could  be  induced  in  the  frog  by  asphyxia. 
Further  researches  which  he  has  published  together  with  Dr. 
Sokolow  in  Pfiuger's  Arch.  (vol.  xxiii,  H.  5  and  6,  p.  283),  have 
yielded  some  results  of  high  interest  as  regards  the  irritability  of 
nerve  centres.  The  animal's  brain  was  asphyxiated  by  ligature 
of  the  two  aortas.  The  loss  of  irritability  follows  in  from  one  to 
eiglit  hours,  the  quicker  the  higher  the  temperature  of  the  animal. 

The  function  of  the  brain  is  annihilated  first  only  ;  subsequently 


l6o  PERISCOPE. 

the  cord  loses  its  reflex  excitability.  The  recovery  after  removal 
of  the  ligature  occurs  in  the  reverse  order.  Before  the  reflex  ex- 
citability is  wholly  lost  the  Cheyne-Stokes  mode  of  breathing 
can  be  observed  ;  likewise  on  removal  of  the  ligature  it  reap- 
pears immediately  after  the  return  of  spinal  reflexes.  On  watch- 
ing the  inspiratory  movements  of  the  larynx,  it  can  be  seen  that  a 
few  inspirations  occur  in  quick  succession,  followed  by  a  long 
pause.  During  the  course  of  asphyxia  the  number  of  inspira- 
tions in  such  di group  diminishes  while  the  pauses  intervening  be- 
tween the  groups  lengthen  in  duration  until  the  respiration  ulti- 
mately stops.  The  reverse  order  is  witnessed  during  recovery. 
The  Cheyne-Stokes  phenomenon  does  not  depend  on  rhythmic 
changes  in  the  width  of  the  vessels  as  Filehne  has  supposed. 
This  is  indeed  proven  by  its  very  occurrence  while  the  cranial 
vessels  are  shut  off.  Moreover,  the  manometer  failed  to  reveal 
any  corresponding  changes  in  the  blood  pressure  of  the  frog. 
The  phenomenon  is,  of  course,  independent  of  the  cerebrum, 
and  occurs  just  as  well  after  its  extirpation.  It  can  occur  also 
after  destruction  of  the  cord  below  the  medulla  and  after  section 
of  the  vagi. 

The  cause  of  the  Cheyne-Stokes  mode  of  breathing,  Luch- 
singer  refers  to  a  diminished  excitability  of  the  respiratory  cen- 
tres, while  acted  upon  by  an  intense  stimulus.  According  to 
this  view  it  seems  easy  to  explain  how  the  gradual  increase  of 
the  stimulus — the  venosity  of  the  blood — during  the  narcosis  of 
mammals,  which  reduces  the  excitability  of  the  medulla,  can  pro- 
duce the  phenomenon,  as,  indeed,  it  does  occur  during  the  nar- 
cosis of  morphia,  ether,  chloral  and  alcohol.  In  frogs,  however, 
the  mere  narcosis  is  not  sufficient,  although  the  anaesthesia  re- 
duces the  irritability  of  the  nerve  centres,  and  in  consequence 
thereof  the  energy  of  the  respiratory  movements  ;  the  breathing 
through  the  skin  of  the  frog  prevents  a  sufficient  venosity  of  the 
blood.  But  on  substituting  another  stimulus,  the  action  of 
picrotoxin  or  strychnia,  the  Cheyne-Stokes  phenomenon  can  be 
produced  in  the  narcotized  frog. 

A  phenomenon  similar  to  the  Cheyne-Stokes  breathing  has 
been  observed  by  Luciani,  Rossbach  and  others  in  the  frog's 
heart  when  filled  with  serum.  It  is  the  appearance  of  beats  in  a 
group  with  long  pauses  between  successive  groups.  By  analysis 
of  the  conditions  the  authors  refer  this  periodicity  likewise  to  di- 
minished irritability  and  increased  stimulus. 

The  details  of  Luchsinger's  plausible,  and,  it  seems  to  us,  well- 


A NA  TOM  Y  A ND  PH  YSIOLOG  Y.  1 6 1 

founded  explanation,  are  the  following  :  By  deprivation  of  ar- 
terial blood  the  nerve  centres  lose  gradually  their  excitability, 
since  the  accumulated  store  of  complex  molecules,  whose  decom- 
position furnishes  the  force,  is  gradually  exhausted.  These  and 
the  following  statements  apply,  according  to  Luchsinger,  equally 
to  all  irritable  tissues.  The  stimulus,  for  instance,  the  accumu- 
lation of  waste  products,  must  hence  increase  before  it  can  evoke 
a  response.  Every  discharge,  however,  of  a  nerve  centre  leaves  it 
for  a  short  time  in  a  more  irritable  condition,  as  can  be  proven 
by  numerous  physiological  instances.  Hence,  the  first  discharge 
of  energy  is  followed  by  a  group  of  discharges  until  the  fatigue 
becomes  too  great.  The  next  series  of  discharges  can  only  occur, 
hence,  by  the  time  the  stimulus  has  increased  to  a  sufficient  extent. 


Innervation  of  the  Uterus. — Experiments  on  the  above 
topic  have  been  performed  by  Dr.  G.  Reni  {Pflugers  Archiv,  vol. 
xxiii.,  H.  I  and  2,  p.  68)  by  means  of  the  method  of  nerve  sec- 
tion, a  plan  hitherto  but  little  employed  in  connection  with  the 
uterus.  Instead  of  watching  the  uncertain  results  of  experimental 
irritation,  the  author  observed  whether  the  processes  of  conception, 
gestation  and  delivery,  were  interfered  with  by  division  of  the  sym- 
pathetic or  the  sacral  nerves.  As  a  result,  he  found  that  the  func- 
tions of  the  uterus  are  not  sensibly  disturbed  by  cutting  off  its 
entire  nerve  supply.  Extirpation  even  of  the  ganglia  in  the  plexus 
surrounding  the  cervix,  the  gaizglion  cervicale,  did  not  interfere 
with  the  uterine  functions. 


The  Idio-Muscular  Contraction  is  the  subject  of  a  post- 
humous paper  by  Lautenbach  in  the  Philadelphia  Medical  Times 
(Sept.  25,  1880).  He  claims  with  Schiff  that  this  form  of  con- 
traction is  the  only  positive  evidence  of  independent  muscular 
irritability,  and  tliat  it  is  not,  according  to  some  German  views, 
merely  the  remnant  of  a  general  muscular  contraction.  His 
experiments  were  made  with  saponin  which,  when  dropped  upon 
muscle  in  a  solution  of  one  per  cent.,  produced  a  localized  idio- 
muscular  contraction  merely.  If  the  solution  is  carefully  injected 
into  the  vessels,  the  muscle  is  often  thrown  into  a  state  in 
which  no  stimulus  whatever  can  evoke  a  general  contraction, 
while  tapping  readily  produces  a  limited  idio-muscular  ridge.  He 
considers  the  effect  of  saponin  upon  muscles  as  identical  with 
rigor  mortis,  and  the  latter  but  the  last  idio-muscular  contraction 


1 62  PERISCOPE. 

of  a  muscle.  He  adds  that  the  myosin  can  be  removed  from 
muscles  by  means  of  a  five-per-cent.  solution  of  chloride  of 
ammonium  injected  into  the  vessels,  without  altering  the  micro- 
scopical appearance.  But  after  this  procedure,  neither  general 
nor  idio-muscular  contractions  are  possible. 


Action  of  Pressure  on  the  Motor  and  the  Sensory 
Nerves. — Luederitz,  Zeitschr.  f.  Klin.  Med..,  Bd.  iii  (abstr.  in 
St.  Petersb.  fued.  IVochensc/iri/t,  No.  42,  18S0),  has  applied  com- 
pression to  the  sciatic  in  rabbits  by  a  ligature  for  varying  periods 
of  time,  and  found  that,  even  after  complete  suppression  of  all 
conduction,  the  nerve  returned  to  its  normal  functions  on  loosen- 
ing the  cord.  This  occurred  four  to  six  times  in  succession,  by 
alternately  tightening  and  loosening  the  ligature.  He  found, 
further,  that  with  gradual  increase  of  pressure  the  suppression  of 
function  occurred  earlier  in  the  motor  nerves  than  in  the  sensory 
ones,  so  much  so,  indeed,  that  when  the  motor  conduction  was 
completely  destroyed,  that  for  sensation  remained  still  intact.  In 
some  cases  there  was  an  apparent  retardation  of  the  sensory  con- 
duction at  the  i)oint  of  compression. 

These  facts  agree  well  with  those  of  clinical  observation.  Vul- 
pian  remarks  regarding  spinal  paralysis  :  "  If  there  is  conservation 
of  sensibility  with  abolition  of  voluntary  motility,  we  may  say 
almost  with  certainty  that  we  have  to  deal  with  compression." 
Baerwinkel  and  Duchenne  remark  in  regard  to  peripheral  paraly- 
sis, that  the  presence  of  sensibility,  even  if  weakened,  is  a  very 
favorable  circumstance  as  regards  prognosis. 


The  Vaso-Dilator  Nerves. — At  the  session  of  the  Societiede 
Biologie,  July  17,  1880  (rep.  in  Gaz.  Des  Hopitatix,  No.  86),  ISI. 
Laffont,  continuing  his  investigations  on  the  vaso-dilator  fibres 
contained  in  the  different  peripheral  branches  of  the  trigeminus 
nerve,  announced  that,  as  he  had  shown  to  the  society  on  the 
1 7th  of  January,  he  had  succeeded  in  dividing  simultaneously  with- 
in the  cranium  the  facial  and  the  accessory  nerve  of  Wrisberg, 
the  trigeminus  between  the  gasserian  ganglion  and  the  pons 
Varolii,  and  one  month  later  the  excitation  of  the  peripheral 
ends  of  the  buccal,  lingual  and  superior  maxillary  nerves  of  the 
same  sides  produced  as  strong  a  congestion  of  the  mucous  mem- 
brane on  the  side  operated  upon  as  on  the  other. 


A NA  TOM  Y  A ND  PH  YSIOL OGY.  1 6 3 

The  post-7norte7n  examination  showed  that  the  intracranial 
division  of  the  trigeminus  had  been  successful. 

Thus  it  appears  that  the  vasd-dilator  nerves  in  the  various  pe- 
ripheral divisions  of  the  fifth  nerve  do  not  arise  in 'the  roots  of 
this  nerve,  nor  do  they  arise  with  the  facial,  as  has  been  shown 
independently  by  MM.  Laffont  and  Vulpian  ;  they  can  therefore 
only  come,  as  M.  Laffont  justly  thought,  from  the  glosso-pharyn- 
geal,  by  way  of  Jacobson's  nerve.  The  very  elegant  experiment 
of  M.  Vulpian,  faradization  of  the  tympanic  caisson  causing  rube- 
faction  of  the  buccal  mucous  membranes  of  the  same  side,  sup- 
jjorts  this  theory. 

M.  Laffont,  wishing  to  test  the  origin  of  the  glosso-pharyngeal, 
applied  the  excitation  through  the  foramen  lacerum  posterior  and 
obtained  the  same  results. 

In  order  to  definitely  test  the  matter,  it  is  needful  to  perform 
the  complete  extirpation  of  the  glosso-pharyngeal  in  such  a  way 
as  to  interrupt  the  communications  between  Jacobson's  nerve  and 
the  other  branches.  Unfortunately,  this  is  impracticable  in  adult 
animals,  and  M.  Laffont  employed  very  young  puppies  and  kittens. 
Wishing  also  to  study  this  point  in  a  comparative  physiological  way, 
he  studied  the  mechanism  of  the  erection  in  the  comb  and  wattles 
of  the  cock.  He  observed  that  excitation  with  a  weak  faradic 
current  of  the  peripheral  end  of  the  ophthalmic  nerve,  which  in- 
nervates the  comb  (by  the  intermediation  of  nerves  analogous  to 
the  suborbital  branches  of  mammals),  caused  rubefaction  and 
turgescence  of  the  comb  on  the  side  of  the  operation.  Excitation, 
also,  of  the  peripheral  end  of  the  inferior  maxillary  nerve,  which 
innervates  the  jugular  wattle  (through  fibres  analogous  to  the 
mental  branches  of  mammals),  caused  turgescence  and  erection  of 
the  corresponding  wattle.  The  same  nerve  fibres,  therefore,  have 
the  same  functions  in  these  two  classes  of  animals,  birds  and 
mammals. 

Is  the  origin  of  the  dilator  fibres  the  same  ?  Do  they  arise  in 
birds,  as  in  dogs,  from  the  glosso-pharyngeal  ?  To  ascertain 
whether  this  is  the  case  M.  Laffont  exposed  the  glosso-pharyn- 
geal nerve  in  a  cock,  at  its  exit  from  the  occipital,  where  it  is  easily 
isolated  from  the  superior  cervical  ganglion  with  which  it  is  in- 
timately connected. 

The  excitation  of  this  nerve  caused  immediate  erection  of  the 
comb  and  the  corresponding  wattle. 

This  last  experiment,  according  to  M.  Laffont,  ought  to  explain 
the   observation  of   Legros   in    1866,  that   the   extirpation   of  the 


164  PERISCOPE. 

superior  cervical  ganglion  in  a  young  cock  hindered  the  growth 
of  these  erectile  appendages.  This  fact,  that  extirpation  of  a 
sympathetic  ganglion  arrested  the  nutrition  of  an  organ,  was  in 
flagrant  opposition  with  CI.  Bernard's  discoveries  in  regard  to  the 
functions  of  the  sympathetic.  M.  Legros,  therefore,  thought  to 
explain  it  by  attributing  a  different  vitality  to  erectile  from  that 
of  other  tissues.  But  anatomical  examination  shows  that,  even  in 
the  adult,  the  small  superior  cervical  ganglion  is  very  closely  joined 
to  the  glosso-pharyngeal  nerve,  and  cannot  be  removed  without 
damage  to  this  nerve.  It  is,  therefore,  altogether  improbable  that 
in  the  young  animal  this  ganglion  can  be  removed  without  de- 
stroying the  nerve  also.  Under  these  circumstances,  Legros 
practically  only  performed  on  birds  the  same  experiment  as  M. 
Laffont  made  on  mammals  ;  he  destroyed  the  vaso-dilator  nerves, 
and  thus  abolished  the  principal  function  of  the  erectile  tissues. 

It  also  happened  that  Nuchon,  experimenting,  at  nearly  the 
same  time  as  Legros,  on  the  adult  animal,  in  whom  the  ganglion 
is  more  distinct  and  can  with  care  be  separated  without  too  seri- 
ous damage  to  the  nerve,  obtained  results  contradicting  those  of 
the  latter  observer. 


The  Vaso-Dilators  of  the  Bucco-Labial  Region. — At  the 
session  of  the  Soc.  de  Biologic,  October  24th  (rep.  in  Gaz.  des 
Hopitaux,  1880,  No.  126),  M.  Laffont  recalled  that  he  had  re- 
ported to  the  society  the  fact  that  the  vaso-dilator  fibres  contained 
in  the  trigeminus  did  not  arise  from  the  nucleus  of  origin  of  that 
nerve,  but  were  merely  acquired  fibres,  the  origin  of  which  is  still 
unknown. 

Nevertheless,  in  a  note  to  the  Acad,  des  Sciences,  August  i6th, 
MM.  Dastre  and  Morat  had  accused  MM.  Jolyet  and  Laffont, 
of  considering  the  fifth  nerve  as  a  typical  vaso-dilator.  In  the 
same  note,  these  physiologists  claim  to  have  discovered  the  origin 
of  the  vaso-dilators  of  the  buccal  region  in  the  thoracic  sympa- 
thetic. With  this  view,  they  are  content  to  examine  the  effects 
produced  by  excitation  of  the  cervical  sympathetic  ;  but,  as  CI. 
Bernard  has  said,  it  does  not  suffice  to  merely  irritate  a  nerve  to 
attribute  to  it  a  certain  function  ;  it  is  needful,  also,  to  divide  it 
and  see  whether  in  these  new  conditions  its  function  persists  in 
its  integrity.  This  has  been  done  by  M.  Laffont  ;  he  extirpated 
the  superior  cervical  ganglion  in  a  dog  and  resected  the  cervical 
vagosympathetic  on  the  same   side.     Twenty  days   later,  he  ob- 


A NA  TOM  Y  AND  PH  YSIOLOG  V.  1 6$ 

tained  the  same  effects  of  vaso-dilatation  in  the  bucco-labial  re- 
gion on  the  same  side  and  that  of  the  resected  sympathetic,  by 
exciting  the  two  superior  maxillary  nerves. 

The  origin  of  the  vaso-dilator  nerves  of  this  region  is  not,  there- 
fore, in  the  cervical  sympathetic,  as  announced  by  MM.  Dastre 
and  Morat.  There  is,  then,  only  a  reflex  action  that  has  also  been 
studied  by  M.  Laffont. 

He  exposed  the  circle  of  Vieussens  in  a  dog,  the  afferent 
branch  of  the  inferior  cervical  ganglion,  that  of  the  superior  cer- 
vical ganglion,  and  the  occipito-atloidean  space.  Then  he  found 
that  excitation  of  the  circle  of  Vieussens  and  of  the  cervical 
sympathetic,  caused  bilateral  redness  of  the  bucco-labial  region, 
only  predominating  on  the  side  of  the  excitation  when  the  cur- 
rent was  strong. 

Opening  the  occipito-atloid  space,  he  hooked  on  through  the 
posterior  foramen  lacerum,  without  injuring  the  medulla,  to  the 
glosso-pharyngeal,  spinal,  pneumogastric,  and  hypoglossal  nerves, 
rupturing  them  in  withdrawing  the  hook.  Then  exciting  again 
the  circle  of  Vieussens,  he  met  with  no  more  vaso-dilator  effects, 
while  the  oculo-pupillary  ones  persisted,  thus  proving  that  the  re- 
flex arch  being  interrupted,  the  reflex  failed  to  occur  ;  but  if,  in 
these  new  conditions,  the  excitation  is  applied  to  the  peripheral 
portion  of  the  divided  nerves,  placing  one  electrode  at  the  fora- 
men lacerum  and  the  other  to  the  periphery,  we  obtain  vaso- 
motor effects  limited  to  the  side  excited. 

Conclusions. — The  results  announced  by  MM.  Dastre  and 
Morat,  correct  as  far  as  they  go,  have  received  from  these  observ- 
ers an  erroneous  interpretation  ;  they  have  not  discovered  the 
vaso-dilators  or  their  origin,  but  only  a  new  reflex  action  on  these 
vaso-dilator  nerves. 

At  the  same  session  M.  Mathias  Duval  presented,  in  the  names 
of  MM.  Dastre  and  Morat,  a  note  on  the  same  subject.  In  the 
course  of  their  experiments  they  had  observed  the  effects  of  ab- 
lation of  the  superior  cervical  ganglion  and  section  of  its  vari- 
ous branches,  especially  the  principal  intercarotidean  filaments. 
These  effects  they  had  noted  at  various  periods  of  lime  after 
the  operation  ;  four  days,  eight  days  and  three  weeks.  Some 
survived  two  months. 

Among  the  more  interesting  phenomena  one  was  especially 
noted.  They  tore  away  in  a  dog  the  superior  cervical  ganglion, 
leaving  the  vagus.  The  animal  recovered  very  quickly,  and  ate 
and  acted  naturally,  even  the  evening  after  the  operation.     Eight 


1 66 


PERISCOPE. 


days  later  it  was  slightly  curarized,  and  the  vago-sympathetic  was 
divided  on  the  side  of  the  former  operation.  The  cephalic  por- 
tion being  irritated,  the  usual  effects  were  not  observed  ;  the 
buccal  vaso-dilatation,  as  was  expected,  did  not  occur.  The  re- 
markable fact,  however,  was  that  of  a  very  beautiful  reddening  of 
the  opposite  side.  If  the  ganglion  was  extirpated  on  the  right 
side,  the  dilatation  occurred  on  the  left.  To  show  the  route  by 
which  this  effect  was  produced,  it  was  sufficient  to  cut  the  vago- 
sympathetic of  the  left  side  also,  and  then  renew  the  excitation, 
and  the  vaso-motor  flush  occurred  on  neither  side.  This,  MM. 
Dastre  and  Morat  claim  as  a  new  proof,  that  the  dilatation  is  due 
to  the  sympathetic,  since,  they  say,  this  being  cut,  the  vaso-motor 
phenomena  cease  on  the  side  operated  upon,  and  the  crossed  or 
reflex  action  on  the  other  side  also  ceases  when  the  sympathetic 
is  cut  on  that  side  also. 

It  still  remains  to  be  explained  why  the  phenomenon,  lacking  in 
the  uninjured  animal,  appears  after  ablation  of  the  ganglion.  In 
any  case,  this  zigzag  reflex  is  very  significant  in  point  of  view  of 
our  knowledge  of  the  reflex  routes  in  the  medulla  and  cord. 
MM.  Dastre  and  Morat  offer  the  fact  with  the  immediate  conclu- 
sion it  justifies,  reserving  its  complete  interpretation  and  its  con- 
sequences. 


The  Terminal  Distribution  of  the  Nerves  in  the  Uter- 
ine Mucous  Membrane. — Prof.  Schroder,  of  Berlin,  furnished 
Dr.  Patenko  with  the  freshly  excised  uteri  of  five  women,  and  the 
latter  has  utilized  this  material  for  studying  the  nervous  termina- 
tion in  the  mucous  membrane.  Dr.  Patenko  states  that  in  all 
these  cases  the  operation  was  undertaken  for  primary  causes, 
but  the  malignant  disease  never  extended  above  the  os  inter- 
num ;  and  the  microscopical  and  minute  appearance  of  the  uter- 
ine mucous  membrane  was  always  perfectly  normal.  He  em- 
ployed chloride  of  gold  and  osmic  acid  in  solutions  having  a 
strength  of  o  oi  per  cent,  to  0.5  per  cent.  Portions  of  the  speci- 
mens were  subsequently  placed  in  96  per  cent,  alcohol,  and  used 
for  thin  sections.  Other  preparations  were  made  by  tearing 
small  bits  of  tissue  in  the  solutions  mentioned.  He  makes  a  pro- 
visional statement  of  the  results  of  his  examinations.  By  suita- 
ble manipulations  he  succeeded  in  isolating  some  of  the  uterine 
glands,  and  a  beautiful  reticulum  of  delicate  non-medullated 
nerve  fibres  was  seen  in  connection   with  the    membrana  propria. 


A NA  TOM  Y  AND  PH  YSIOL OGY.  1 6/ 

This  network  was  situated  above  the  external  surface  of  the 
glands,  and  minute  filaments  were  seen  to  proceed  from  it  into 
the  interior  of  the  glands.  These  extremely  delicate  fibres  were 
found  between  the  endothelial  cells  of  the  membrana  propria,  or 
in  the  glandular  epithelial  cells.  Their  ultimate  termination 
in  the  latter  was  not  positively  ascertained.  The  nodular  points 
of  the  surface  reticulum  frequently  showe'd  small  nerve  cells. 
The  author  believes  that  this  network  takes  its  origin  from  the 
nerve  fibres  which  course  in  the  muscular  substance  of  the 
uterus,  and,  accompanied  by  some  intermuscular  connective 
tissue,  proceed  to  the  boundary  line  of  the  mucous  membrane. 
{Centr.  f.  Gyndk.,  Sept.  nth.  JV.  Y.  Med.  Record,  Nov.  27, 
tSSo.) 


The  Determination  of  the  Position  of  Objects  in  Space. 
— At  the  session  of  the  Boston  Society  of  Medical  Sciences,  Oct. 
21,  1879  (reported  in  Boston  Med.  and  Surg.  Journal,  Nov.  nth), 
Dr.  H.  P.  Bowditch  spoke  briefly  of  some  experiments  which  he 
had  made  bearing  on  the  question  as  to  the  relative  degree  of  assist- 
ance which  we  get  from  our  sense  of  touch  and  muscular  sense,  and 
from  our  sense  of  sight,  in  the  determination  of  the  position  of  objects 
in  space. 

It  would  seem,  at  first  glance,  as  if  the  delicacy  of  the  visual 
sense  were  much  greater  that  that  of  the  tactile  sense  ;  yet,  as  a 
matter  of  fact,  we  constantly  use  the  latter  in  connection  with  the 
so-called  muscular  sensibility  to  correct  the  former;  thus  in  detect- 
ing the  flaws  in  a  piece  of  nice  joiner's  work. 

Dr.  Bowditch's  own  ex])eriments .  were  to  study  the  point 
whether  the  use  of  the  sight  or  of  the  muscular  sense  best  fixes 
the  exact  position  of  an  object  in  the  memory.  To  this  end  he 
had  brought  a  small  glass  bead  into  different  positions  on  the 
table,  at  times  with  the  eyes  open,  but  without  placing  it  with  the 
hand  ;  at  times  with  the  eyes  closed,  while  the  finger  was  used  to 
place  the  bead,  and  had  then  tried  under  which  of  these  two  con- 
ditions he  was  best  able  to  locate  the  bead  subsequently  with  the 
end  of  a  knitting-needle,  the  eyes  of  course  being  closed.  The 
results  were  as  follows  : 

Location  by  touch  :  minimal  error,  8  mm.  ;  maximal  error, 
38  mm.  ;  average,  19  mm. 

Location  by  sight :  minimal  error,  S  mm.  ;  maximal  error, 
2^1  mm.  ;  average,  11.4  mm. 


1 68  PERISCOPE. 

Dr,  Bowditch  observed  that  he  was  well  aware  that  it  was  not 
•exact  to  speak  of  the  sense  of  sight  in  these  experiments,  since  in 
reality  the  tests  principally  concerned  the  ocular  muscles. 

Another  method,  not  yet  tested,  would  be  to  try  comparative 
estimates  of  size  of  objects  by  the  use  of  sight  and  of  touch. 

In  the  discussion  that  followed,  Dr.  Blake  suggested  that  the 
best  form  of  object  for  this  purpose  would  be  a  raised  circle,  round 
which  the  finger  should  be  carried,  since  with  small  objects  more 
could  be  felt  than  would  be  exposed  to  sight  from  any  one  point 
of  view. 

Dr.  Hay  spoke  of  various  conditions  which  modify  the  judgment 
of  the  eye,  as  whether  a  line  is  horizontal  or  perpendicular,  etc. 

Dr.  James  said  that  these  observations  of  Dr.  Bowditch  brought 
to  mind  the  experiment  of  Helmbolz,  who  found  that  his  ability 
to  reconverge  his  eyes  upon  an  object  (finger)  held  up  before  him 
was  increased  if  before  opening  his  eyes  he  touched  the  object 
with  his  finger. 

Dr.  BoUes  spoke  of  the  degree  to  which  education  (which  may 
be  excessively  rapid)  comes  into  these  problems  as  a  complicating 
factor  ;  as  for  example  in  the  case  of  type-setters. 

The  delicacy  of  muscular  sense,  as  compared  with  sight,  is 
shown  in  the  ease  with  which  we  move  a  slide  under  the  micro- 
scope through  the  minutest  distances. 

Dr.  Wadsworth  thought  it  would  be  hardly  fair  to  compare  the 
efficiency  of  sight  with  that  of  touch  in  estimating  the  size  of  ob- 
jects, since  our  very  notion  of  size  and  distance  requires  the  use 
of  both  senses,  one  to  supplement  the  other.  Certainly  by  sight 
alone  we  could  acquire  no  idea  of  distance. 

Dr.  Bowditch  admitted  this  as  regards  sight,  but  said  that  with 
touch  alone  (including  muscular  sense)  it  is  manifestly  possible  to 
acquire  quite  accurate  notions  of  distance,  as  in  the  case  of  the 
blind.  Dr.  Bowditch  further  suggested  that  behind  education 
there  might  be  anatomical  and  physiological  reasons  for  the 
greater  accuracy  of  different  sets  of  muscles  ;  as,  for  instance,  the 
varying  richness  of  their  nerve  sup])ly. 

Dr.  Dwight  thought  that  the  importance  of  this  point  could  be 
overrated.  The  abducens  oculi,  for  example,  receives  a  larger 
supply  of  nerve  fibres  than  any  of  the  other  ocular  muscles,  yet 
its  functional  power  is  not  greater  than  theirs. 


Among  others,  the  following  have  been  recently  published  on 
the  anatomy  and  physiology  of  the  nervous  system  : 


ANATOMY  AND  PHYSIOLOGY.  169 

Ragosin  and  Mendelssohn,  Graphic  Investigation  as  to  the 
Movements  of  the  Brain  in  the  Living  Man.  St.  Petersb.  Med. 
IVochenschr.,  Sept.  25th.  Debove  and  Gombault,  On  the  Sen- 
sory Decussation  in  the  Medulla.  Arch,  de  Neurolgie,  I,  July, 
1880.  Ott,  The  Dilatation  of  the  Pupil  as  an  Index  of  the 
Path  of  the  Sensory  Impulses  in  the  Spinal  Cord.  Jour,  of 
Phys.,  II,  V  and  vi,  July,  1880.  Gray,  The  Physiological  Anat- 
omy of  the  Cord  and  the  Motor  Tract  of  the  Cerebrum.  Ann, 
Anat.  and  Surg.  Soc.  of  Brooklyn,  Oct.  Westphal,  On  Para- 
doxical Muscle  Contraction.  Centralbl.  f.  Nervenheilk.,  Oct. 
Bufalini,  On  the  Preparation  of  the  Cylinder  Axis  of  the  Nerve 
Fibre.  La  Sperimeniale.,  Nov.  Spitzka,  A  Remarkable  Peculi- 
arity of  the  Anthropoid  Brain.     Science,  July  17th. 


-PATHOLOGY     OF    THE     NERVOUS     SYSTEM     AND     MIND, 
AND    PATHOLOGICAL  ANATOMY. 


Neuritis. — Lcyden,  Charite  Annalen,  Bd.  v.  (abstr.  in  St. 
Petersb.  Med.  Woc/ienschy.,  No.  44),  after  the  report  of  a  case  of 
multiple  neuritis  ending  fatally  in  ten  months,  gives  the  following 
general  data  as  to  the  pathological  anatomy  and  symptomatology 
of  the  disorder  : 

I. — Pathological  Anato7?iy  of  Neuritis. 

1.  Simple  acute  neuritis  or  perineuritis,  characterized  by  swell- 
ing, hyperaemia  and  hemorrhage  of  the  sheath.  This  form  is  at 
the  bottom  of  many  neuralgias,  and  marks  itself  by  its  changeabil- 
ity and  tendency  to  extend  itself.  In  it  there  is  no  nuclear  pro- 
liferation or  degeneration  of  the  nerve  substance. 

2.  Chronic  perineuritis,  consisting  in  thickening  of  the  sheath 
without  disease  of  the  nerve,  may  exist  without  showing  itself  by 
any  symptoms,  but  may  also  cause,  occasionally,  severe  pain.  To 
this  form  belong  the  chronic  neuritis  nodosa  and  the  eccentric 
neuroma  formations. 

3.  Degenerative  neuritis  (parenchymatous  neuritis  of  Joffroy) 
leading  to  atrophy  of  the  nerve  with  thickening  of  the  nerve 
sheath,  myositic  muscular  atrophy,  and  pigmentation  of  the 
muscles. 

This  form  may  occur  primarily,  as  {a)  traumatic  (Erb)  ;  {b) 
rheumatic  ;   (^)  saturnine  (lead  paralysis)  ;   (^)  degenerative  neu- 


1 70  PERISCOPE. 

ritis  in  acute  diseases  ;  (<?)  acute  multiple  neuritis  ;  (/)  diffuse 
neuritis  found  by  Eichhorst  in  acute  ascending  paralysis,  and  by 
Dejerine  in  diphtheritic  paralysis. 

As  secondary  degenerative  neuritis  are  to  be  reckoned  (a)  the 
descending  neuritis  with  myositis  connected  with  acute  softening 
of  the  spinal  cord  ;  [J))  the  degenerative  neuritis  of  chronic  mye- 
litis ;  ((t)  the  acute  ascending  neuritis,  a  form  not  esteemed  as 
fully  established  by  Leyden,  but  one  accepted  by  those  authors 
who  consider  progressive  muscular  atrophy  as  a  peripheral  myosi- 
tis advancing  upward  toward  the  cord. 

II. — Symptomatology  of  JVeuritis. 

1.  Sensory  symptoms.  Hyperaesthesia  and  tenderness,  spon- 
taneous tearing  pains  as  well  as  pain  on  pressure  or  movement  ; 
the  later  occurring  contractures  are,  at  least  in  part,  results  of  the 
increased  sensibility.  With  these  appear  moderate  anaesthesia,  in- 
distinctness of  tact  sense. 

2.  Motor  symptoms.  Paralytic  motor  disturbances,  with  later 
muscular  atrophy,  and,  where  this  does  not  recover,  degeneration 
reaction. 

3.  (Edematous  swelling  at  the  locality  of  the  neuritis — a  rather 
rare  but  very  valuable  symptom,  perhaps  connected  with  sanguine- 
ous infiltration. 

4.  Trophic  symptoms.  Fragility  of  the  nails  ;  excessive  growth 
of  hair.  (Articular  and  cartilage  affections  were  lacking  in  Ley- 
den's  cases.) 

The  extent  of  the  symptoms  corresponds  to  the  nerve  tracts 
involved. 

Leyden  expresses  himself  with  much  reserve  in  regard  to  the 
diagnostic  significance  of  the  degeneration  reaction  ;  he  seems  in- 
clined, in  those  cases  in  which  it  appears  in  connection  with 
poliomyelitis,  to  explain  it  by  the  secondary  descending  degenera- 
tive neuritis  which  accompanies  this  disease,  and  believes,  indeed, 
that  many  cases  described  as  poliomyelitis  really  belong  to  the 
class  of  multiple  neuritis. 

The  tendency  of  neuritis  to  extend  itself  is  especially  marked 
with  the  neuralgic  acute  forms  ;  it  is  less  so  with  the  degenerative 
forms.  The  former,  which  practically  consists  only  in  hyper- 
aemia  and  swelling  of  the  connective-tissue  envelopes  of  the 
nerve,  more  readily  attacks  the  cord,  but  is  there  limited  to  the 
envelopes.  The  degenerative  form  is  more  apt  to  pass  downward 
to  the  periphery,  where  it  leads  to  muscular  atrophy  through  my- 
ositis (inflammatory  proliferation  of  nuclei  with  pigmentation). 


PATHOLOGY.  _  I/I 

Paralysis  of  all  the  Ocular  Nerves. — Dr.  H.  Bresgen, 
of  Kreuznach,  reports  in  the  Deutsche  Med.  Wochenschr.  the  fol- 
lowing case  :  On  September  2,  1875,  he  saw,  for  the  first  time, 
a  well-formed  and  nourished  and  previously  sound  female,  aged 
25,  who  had  been  seeing  double  for  a  few  days.  The  trouble  was 
evidently  due  to  paralysis  of  the  right  abducens.  In  the  follow- 
ing spring,  bilateral  ptosis  appeared,  with  slow  but  steadily  ad- 
vancing paralysis  of  all  the  muscles  of  the  left  eye,  so  that  all 
movements  were  impeded.  In  the  meanwhile  the  vision  was  un- 
impaired ;  also  the  pupillary  reaction  and  the  accommodation. 
The  ophthalmoscope  revealed  nothing  abnormal.  The  eyelids 
could  be  only  partially  closed.  The  patient's  condition  continued 
to  grow  worse  till,  in  the  beginning  of  1879,  both  eyes  were  com- 
pletely paralyzed,  the  ptosis  more  marked,  and  the  eyelids  could 
not  be  brought  together.  Speech  was  also  much  altered,  though 
the  lips  and  tongue  were  freely  movable  and  nothing  abnormal 
was  observed  in  the  palate  ;  the  voice  was  strongly  nasal  and  the 
labials  B  and  P  could  not  be  pronounced.  Together  with  these 
symptoms  appeared  difficulty  in  swallowing,  and  noticeable  emaci- 
ation. The  movements  of  the  iris  and  the  accommodation  re- 
mained perfect.  By  the  commencement  of  the  year  1880,  the 
symptoms  of  bulbar  paralysis  had  so  advanced,  together  with 
general  emaciation,  that  the  patient  could  no  longer  be  under- 
stood ;  the  upper  branch  of  the  facial  was  also  paralyzed,  but  the 
pupillary  and  accommodation  movements  were  still  perfect.  Death 
occurred  early  in  February. 

Though  a  post  fuortem  was  not  performed  the  clinical  history 
indicated  a  combined  paralysis  of  the  two  oculo-motor,  trochlear, 
and  abducens  nerves,  together  with  the  upper  branches  of  the 
facial,  occurring  before  the  dysphagia  and  alalia  revealed  the  gen- 
eral bulbar  paralysis.  It  indicates,  also,  very  clearly,  a  lesion  of 
some  kind  in  the  floor  of  the  fourth  ventricle  and  the  aqueductus 
Sylvii,  involving  the  angle  of  the  facial  root,  the  trochlear  nucleus, 
and  the  fibres  of  origin  of  the  motor  oculi,  except  its  most  anterior 
fasciles.  Hence  the  normal  pupillary  reaction  and  accommodation,- 
which  are  incompatible  with  total  paralysis  of  the  third  nerve,  Graefe 
to  the  contrary  notwithstanding,  as  has  been  shown  by  Volkers  and 
Hensen,  whose  conclusions  Dr.  Bresgen  quotes. 


The  relation  of  the  Nerves  to  Aneurysm. — Lewaschow, 
St.  Petersb.  Med.   Wochetischr.,  August  14th,  publishes  the  account 


172  PERISCOPE. 

of  some  researches,  undertaken  by  himself  in  Botkin's  laboratory, 
for  the  purpose  of  ascertaining  the  effects  of  the  nerves  on  the  nu- 
trition of  the  blood-vessels,  and  their  relations  to  the  production 
of  aneurysm.  The  subjects  of  his  experiments  were  dogs  and 
cats,  and  he  chose  the  nerves  of  the  posterior  extremity  for  his 
operations.  After  exposing  the  main  sciatic  of  the  limb,  he  irri- 
tated it  with  dilute  acid,  taking  all  precautions  to  avoid  disturbing 
its  surrounding  tissues.  Then  the  wound  was  closed  and  left 
alone  for  four  to  six  days,  then  the  operation  was  repeated,  and  so 
on,  till  the  death  of  the  animal.  Immediately  after  the  operation, 
the  temperature  of  the  limb  operated  upon  rose,  and,  as  a  rule, 
continued  higher  than  that  of  the  other  corresponding  limb.  Sen- 
sibility was  not  much  disturbed  in  successful  cases  ;  the  bodily 
temperature  was  only  slightly  increased.  Death  occurred  rapidly 
in  a  few  cases  from  gangrene  of  the  operated  limb  ;  others  sur- 
vived several  weeks,  dying  of  dysentery  or  putrid  infection,  and 
some,  as  much  as  two  months,  and  these  last  are  the  ones  from 
which  he  draws  his  conclusions. 

Part  of  the  animals  exhibited  no  other  consequences  of  the  op- 
eration than  those  mentioned  above.  Others,  however,  after  a 
longer  or  shorter  period,  developed  convulsive  phenomena,  very 
closely  resembling  epilepsy,  occurring  at  first  but  seldom,  but  in- 
creasing in  frequency  as  time  passed,  so  that  some  died  in  almost 
continuous  convulsions. 

The  section  showed  in  the  above  animals  results  approximately 
alike,  and  the  more  pronounced,  as  a  rule,  the  longer  the  time 
since  the  irritation  of  the  nerve  had  been  begun.  The  thigh  of 
the  operated  side  was  more  or  less  atrophied,  the  lower  leg  and 
foot  hypertrophied,  and  inflammatory  swellings,  etc.,  on  the  skin, 
elsewhere  than  where  the  nerve  was  exposed.  The  nerve  itself 
was  noticeably  thickened,  reddened  and  grown  to  the  adjacent 
tissues.  The  arteries  exhibited,  especially  at  the  junctions  of  the 
smaller  branches  with  the  main  stem,  moderate-sized  swellings, 
yellowish-white  in  color,  sometimes  also  dirty-red  in  comparison 
with  the  other  portion  of  the  inner  wall  of  the  vessel. 

The  microscopic  appearances  of  the  vessels  of  both  the  limb 
operated  on  and  the  corresponding  sound  one  were  compared. 
Besides  those  appearances  already  described  as  observable  mi- 
croscopically, there  were  found  marked  changes  in  parts  apparent- 
ly healthy  on  naked-eye  observation.  These  consisted  chiefly  of 
a  noticeable  infiltration  of  the  adventitia,  and  partly  also  of  the 
media  of  the  vessels,  with  round  and  elongated  cells.     These  alter- 


PATHOLOGY.  173 

ations  toward  the  periphery  resembled  more  a  gradual  increase  of 
the  cell  elements  ;  toward  the  centre  they  took  more  the  character 
of  an  infiltration. 

Lewaschow  also  experimented  by  extirpating  the  lower  cervi- 
cal and  upper  thoracic  ganglia,  in  order  to  ascertain  whether  it 
would  cause  any  alteration  of  nutrition  in  the  large  vessels  of  the 
thorax.  Though  the  experiments  were  not  altogether  satisfactory 
on  account  of  the  animals  dying  too  soon,  there  were  found  quite 
pronounced  inflammatory  alterations  in  the  aorta,  especial  at  the 
points  where  the  branches  were  given  off.  Still,  the  general  phe- 
nomena of  pleuritis  and  pyaemia  which  accompanied  these  alter- 
ations, made  it  difficult  to  speak  positively  as  to  their  cause.  He 
is  still  continuing  the  investigations  on  these  points. 


Locomotor  Ataxy. — Dr.  George  Fischer,  Deutsch  Arch.  f. 
Klin.  M^dicifte,  Bd.  xxvi,  p.  83  (abstr.  in  Deutsche  Med.  Wo- 
chenschr.,  No.  38,  1880.) 

I.  The  author  calls  attention  to  a  peculiar  connection  between 
the  patellar  reflex  and  conduction  of  painful  impressions  in  loco- 
motor ataxia.  Out  of  nineteen  cases  examined,  there  was  retarda- 
tion in  fifteen,  and  normal  conduction  in  four,  in  the  lower  ex- 
tremities, and  in  these  last  he  still  found  the  tendon  reflex,  and 
normal  condition  of  the  bladder,  both  of  which  were  lacking  in 
the  others.  One  case,  which  formed  the  transition  between  the 
others,  exhibited  a  peculiar  condition  ;  on  one  side  there  was  im- 
paired tendon  reflex  and  pain-conduction,  and  on  the  other,  the 
normal  conditions.  On  physiological  grounds,  he  thinks  that  in 
these  cases,  with  the  normal  tendon  reflex  and  conduction,  the 
morbid  process  is  confined  to  the  posterior  columns  without  im- 
plication of  the  gray  substance. 

II.  A  symptom  first  described  by  Leyden  and  more  recently 
mentioned  by  Remak,  is  the  separation  in  time  of  the  perceptions 
of  tact  and  pain  in  simple  prick  with  needle.  It  indicates  a 
simple  diminution  of  the  cross  section  of  the  gray  substance  with 
still  functioning  posterior  columns.  Among  the  fifteen  cases  with 
retarded  pain-conduction,  Fischer  found  this  double  sensation  in 
eight.  The  examination  for  this  phenomenon  revealed  a  curious 
anomaly  in  the  cutaneous  reflexes.  The  normal  reflex  acts,  as  is 
well  known,  according  to  Pflueger's  law  along  the  motor  nerves 
from  that  point  of  the  cord  where  the  sensory  nerves  excited  join 
it.     With  stronger  excitations   it  reaches  still  higher  spinal  cen- 


174  PERISCOPE. 

tres,  and  motor  nerves  are  involved  which  arise  from  points  in  the 
cord  much  higher  khan  the  junction  of  the  irritated  sensory 
nerves.  Witli  very  strong  excitations,  through  the  medium  of 
cerebral  sensibility,  a  centrally-started  reflex  may  take  place, 
closely  resembling  voluntary  movement.  The  author  observed 
various  compli-cations  of  reflexes  and  retardations  in  tabes  : 

1.  Two  cases  of  retarded  pain-conduction  without  double 
sensation  and  without  any  reflex  ;  the  first  had  pronounced  hy- 
peralgesia, and  the  second,  muscular  paresis.  The  lack  of  reflex 
activity  was,  in  the  first  case,  based  ujjon  disease  of  the  central 
portion  of  the  reflex  arch  ;  in  the  second,  on  disorder  of  its  pe- 
ripheral portion. 

2.  Three  cases  of  retarded  pain-conduction  without  double 
sensation  showed  reflexes  combined  with  conscious  voluntary  re- 
action. The  spinal  reflex  act  is  the  product  of  a  cerebral  trans- 
mission process. 

3.  One  case  of  retarded  pain-sense  without  Remak's  symp- 
tom gave  a  reflex  synchronous  with  the  prick.  The  sensory  exci- 
tation thus  reached  the  normal  spinal  reflex  centre. 

4.  Two  cases  of  retarded  pain-sensation  with  Remak's  double 
sensation  symptom  gave  reflexes  synchronous  with  the  conscious- 
ness of  pain.  The  primary  reflex  arch  in  these  cases  was  out  of 
order,  and  the  reflex  must  be  considered  as  having  a  cerebral 
origin. 

5.  In  one  case  with  retarded  pain-sense  and  double  sensation 
the  reflex  occurred  at  the  same  time  as  the  prick  and  the  corre- 
sponding tact  'sensation.  This  corresponds  with  normal  reflexes 
as  in  3. 

6.  In  some  cases  with  retarded  pain-sense  and  Remak's  double 
sensation  the  reflex  occurred  both  at  the  point  of  contact  and 
tact  sensation,  and  at  that  of  pain.  In  these  cases  the  first  is  the 
spinal  reflex,  and  the  second  is  cerebral. 

Of  course,  these  varieties  do  not  include  all  cases  ;  there  is  every 
variety  of  transition  between  them. 

III.  In  some  patients  the  author  discovered  a  remarkable  con- 
dition of  the  sense  of  locality.  With  simple  contact  of  one  point 
of  the  aesthesiometer,  they  felt  the  sensation  of  two,  and  with 
both,  that  of  four  or  five  points  (poly^esthesia).  The  explanation 
of  this  is  not  clear.  There  is  possibly  an  abnormal  irritability  of 
the  gray  substance,  so  that  a  wave  of  irritation  entering  a  gan- 
glion cell  of  the  posterior  horn  extends  itself,  not  merely  in  a  cen- 
tral direction,  but  laterally  through  the  fine  nervous  network,  and 


PATHOLOGY.  175 

is  diffused  into  neighboring  ganglions,  which  are  connected  with 
other  centripetal  routes  from  the  periphery.  This  would  produce 
to  consciousness  the  impression  of  contact  at  each  of  these  points 
connected  with  these  ganglion  cells.  In.  this  manner,  the  author 
explains  the  case  of  two  patients  who,  when  brisk  contact-impres- 
sions were  produced  on  one  leg,  always  felt  it  also  in  the 
other. 

MM.  Debove  and  Boudet,  of  Paris,  Archives  de  Neurologie,  i, 
p.  42,  experimenting  with  a  new  apparatus,  the  myophone,  in- 
vented by  one  of  themselves,  which  gives  the  sound  of  the  mus- 
cles in  contraction  and  at  rest,  found  a  decided  inequality  in  the 
tonicity  of  different  groups  of  muscles  in  ataxics,  which  had  begun 
to  display  the  symptom  of  incoordination.  It  was  not  noticeable 
in  those  cases  characterized  only  by  the  frequent  pains  of  the  in- 
cipient stages  of  the  disease.  They  explain  the  incoordination  of 
this  disease  by  this  lesion  of  tonicity,  which  in  turn  is  accounted 
for  by  the  disease  of  the  posterior  roots,  as  the  section  of  these, 
experimentally,  in  animals,  produces  locomotor  troubles  referable 
to  loss  of  muscular  tonicity.  They  cannot,  in  those  cases,  be  as- 
similated to  those  of  ataxics,  because  in  the  latter  we  have  only 
inequality  of  tonicity,  not  complete  loss  of  tonus  ;  but  the  prin- 
ciple is  the  same  in  both.  MM.  Debove  and  Boudet  notice  briefly 
the  theories  of  the  incoordination  in  tabes  :  that  of  Tschiriew 
who  attributed  it  to  loss  or  diminution  of  muscular  tonus  ;  that  of 
Pierret,  who  considered  it  to  be  caused  by  limited  muscular 
paralysis  ;  that  of  many  authors,  who  have  considered  it  due  to 
loss  of  general  sensibility  ;  and  after  an  analysis  of  the  facts  of 
the  movements  of  ataxics,  conclude  that  "  the  incoordination  of 
tabetics  is  due  to  an  unequal  tonicity  of  their  muscles,  the  effects 
of  which  are  diminished  by  the  maximum  contraction  of  these 
muscles." 

They  do  not  refer  to  the  idea  largely  held,  and  which  seems  to 
us  rational,  that  the  loss  of  the  muscular  sense  has  much  to  do 
with  the  incoordination.  We  are  still  inclined  to  attribute  it,  in 
part  at  least,  to  this  deficiency. 


Functional  Isch.-emia  of  the  Brain. — Prof.  Ball,  of  Paris, 
read  a  paper,  at  the  last  meeting  of  the  British  Medical  Associa- 
tion, on  this  subject,  which  is  given  in  full  in  the  British  Medical 
yournal  of  October  30th.  In  it  he  relates  and  discusses  three 
interesting  cases,  which  may  be  summed  up  as  follows  :  The  first 


I  'J^i  PERISCOPE. 

was  a  young  man  of  good  character,  married,  temperate,  who, 
after  giving  way  to  a  fit  of  passion,  was  suddenly  struck  deaf  and 
dumb,  with  hemiangesthesia  and  sh'ght  motor  paralysis  on  the  left 
side.  Speech  was  recovered  in  eighteen  hours,  but  the  other 
symptoms  continued  twenty-two  days,  suddenly  disappearing  after 
a  few  galvanic  applications  applied  to  the  posterior  part  of  the  left 
forearm.  The  patient's  health  was  previously  good,  but  the  year 
before  he  had  been  suddenly  struck  blind  on  the  left  side,  and 
only  recovered  his  vision  after  the  lapse  of  a  month.  The  intel- 
lectual faculties  were  always  intact. 

The  second  case  was  that  of  a  cab-driver,  set.  -^^^ii  strong,  healthy, 
and  of  sober  habits.  He  was  married  and  of  an  easy,  cheerful 
disposition.  In  Deceml)er,  1879,  he  had  an  attack  of  acute 
rheumatism,  and  immediately  after  his  recovery  resumed  his  work, 
being  at  tlie  time  exposed  to  intense  cold.  On  February  24th  he 
had  a  severe  attack  of  vertigo,  and  the  next  day  came  home  in  a 
peculiar  condition,  which  still  continued  on  his  admission  to  the 
hospital,  March  ist.  He  was  in  a  sort  of  mental  stupor,  could  not 
answer  the  simplest  questions,  but  repeated  them  automatically  ; 
nor  could  he  attend  on  himself  in  the  simplest  matters.  He  was 
completely  hemianoesthetic  and  paretic  on  the  right  side.  He 
gradually  improved,  however,  without  any  specified  treatment  ex- 
cept an  abortive  attempt  to  use  mercury  and  iodine,  which  had  to 
be  discontinued  on  account  of  the  unpleasant  effects  of  the  latter, 
and  on  April  30th  he  was  discharged,  suffering  only  from  a  de- 
fect of  memory.  The  motor  power  was  recovered  earlier  than 
the  sensory.  There  was  afterward  noticed  a  tendency  to  the 
recurrence  of  some  of  the  symptons  for  a  short  time  in  the  even- 
ing. 

The  third  case  was  somewhat  like  the  first.  A  man,  aged  45, 
suddenly  became  aphasic  in  a  fit  of  anger.  The  difificulty  seemed 
to  be  due  to  a  spasm  of  the  tongue  during  the  attempt  to  speak  ; 
there  was  no  paralysis,  and  all  other  functions  were  normal.  Re- 
covery took  place  suddenly  without  treatment. 

The  explanation  of  all  three  cases  given,  is  that  there  was  a 
local  vaso-motor  ischcemia  of  those  parts  of  the  brain  that  have  to 
do  with  the  functions  observed  to  be  disturbed  in  each  case.  In 
none  of  the  cases  was  there  any  heart  disease  discovered.  It 
would  have  been  easy  to  increase  the  number  of  facts,  but  it  was 
thought  important  to  exclude  all  possibility  of  the  charge  of 
hysteria,  and  therefore  the  cases  selected  to  report  were  only 
those  of  strong,  healthy  laboring  men,  against  whom  this  charge 


PATHOLOGY.  1/7 

could  not  be  raised.     Prof.  Ball  deduces  from  these  facts  the  fol- 
lowing conclusions  : 

1.  Spasmodic  contraction  of  the  brain-vessels  may  be  pro- 
duced by  moral  impressions,  fear,  anger,  or  grief,  and  also  by  the 
prolonged  action  of  severe  cold. 

2.  Ail  the  symptoms  of  organic  injury  of  the  brain  may  be 
created  by  functional  ischaemia. 

3.  Mental  disturbances  of  a  peculiar  kind,  and  especially  low- 
ering of  intellectual  power,  as  apart  from  positive  insanity,  may  be 
the  result  of  this  process. 

4.  Spasmodic  contraction  of  the  brain-vessels,  when  once  in- 
duced, may  persist  for  a  considerable  length  of  time  without  pro- 
ducing structural  changes  in  the  nervous  centres. 

5.  This  morbid  condition  may,  in  certain  cases,  suddenly  dis- 
appear, while  it  is  not  unreasonable  to  suppose  that  the  converse 
may  be  equally  true,  and  that  the  symptoms  may  culminate  in 
rapid  or  even  sudden  death. 


Fatigue  as  a  Causk  of  Epilepsy. — Dr.  B.  Saloman,  of  Cob- 
lenz,  Deutsch.  Med.  Wochenschr.,  Nos.  34  and  35,  as  a  frequent 
cause  of  the  epileptic  attacks  sometimes  observed  in  persons 
otherwise  sound  and  without  any  hereditary  or  other  predisposi- 
tion to  nervous  disorder,  suggests  mental  or  physical  overstrain, 
especially  the  latter.  He  claims  the  functions  of  the  nervous 
centres  may  be  interfered  with  by  muscular  over-exertion  in  sev- 
eral ways,  viz.  :  i,  by  the  blood  circulating  in  them  containing  an 
excess  of  carbonic  acid,  and  a  deficient  quantity  of  oxygen  ;  2,  by 
the  brain  being  inadequately  supplied  with  oxygenated  blood  on 
account  of  the  heart  being  unable  to  overcome  sufficiently  the  in- 
creased resistance  caused  by  the  general  muscular  contraction  ; 
and  3,  by  the  heightened  reflex  irritability  of  the  brain  due  to  the 
continuous  irritation  of  the  sensory  nerves  passing  through  the 
contracted  muscles. 

Muscular  activity  consumes  oxygen  and  causes  formation  of 
carbonic  acid,  which  is  ordinarily  gotten  rid  of  by  increased 
action  of  the  lungs.  But  when,  as  in  marching  soldiers,  the  chest 
is  embarrassed  by  a  heavy  pack,  and  the  abdomen  compressed  by 
the  sword  belt,  this  cannot  be  always  effected  even  with  increased 
frequency  of  respiration.  The  circulation  of  the  brain  is  also  in- 
terfered with  in  other  ways,  by  the  pressure  of  the  cravat  or 
stock,   and   these,   together  with  the   altered  and  abnormal   con- 


1 78  PERISCOPE. 

ditions  and  mode  of  life,  will  serve  to  account  for  such  cases  when 
they  occur  in  soldiers  in  active  service  or  engaged  in  vigorous 
practice  drill  and  manoeuvres  in  time  of  peace.  But  they  occur 
also  frequently  in  civil  life  under  analogous  conditions,  and  Dr. 
Saloman  gives  brief  accounts  of  a  number  of  cases.  They  gener- 
ally occur  in  youthful  and  physically  not  very  robust  individuals, 
who  have  been  for  one  cause  or  another  subjected  temporarily  to 
excessive  fatigue. 

The  prognosis  of  these  cases  is  relatively  favorable  ;  the  epilepsy 
does  not  have  very  much  tendency  to  become  chronic,  if  the 
conditions  are  not  unfavorable. 


Neurasthenia. — Dr.  C.  H.  Hughes,  in  the  Alienist  and  Neur- 
ologist for  October,  publishes  an  article  on  neurasthenia,  mainly 
consisting  of  e.xcerpts  from  a  report  by  Dr.  Van  Deusen  of  the 
Michigan  Asylum  in  Kalamazoo,  published  first  in  1868.  In  that 
paper,  Dr.  Van  Deusen  described  and  discussed  quite  fairly  the 
symptoms  of  a  large  number  of  neurasthenic  cases,  and,  fully 
recognizing  the  condition,  named  it  neurasthenia.  To  him,  there- 
fore, as  much  as  to  Dr.  Beard,  belongs  the  honor  of  identifying 
and  designating  the  disease. 

It  should  be  also  generally  known,  however,  that  the  condition 
has  been  recognized  and  its  symptoms  noted  for  more  than  a  cen- 
tury by  various  writers,  among  whom  we  may  mention  Whytt, 
Swann.  Frank,  Stilling,  etc.,  not  to  mention  a  host  of  more  recent 
authors,  and  the  terni  "neurasthenia  "  itself  is  alluded  to  by  Dr. 
Beard  in  one  of  his  earlier  papers  on  the  subject  as  an  "  old  and 
almost  forgotten  term." 


Paralysis  of  the  Bladder. — At  the  session  of  the  Verein  fiir 
Natur  und  Heilkunde,  Dresden,  February  21,  1880  (rep.  in 
Deutsche  Med.  Wochenschr.,  October  23d),  Dr.  Erdmann  read  a 
paper  on  paralysis  of  the  bladder  of  which  the  following  abstract 
is  given. 

After  the  speaker  had  given,  at  the  beginning  of  his  lecture,  the 
innervation  relations  of  the  bladder  both  from  an  anatomical  and 
a  physiological  standpoint,  and  had  especially  described  the  act 
o^  urination  (according  to  Goltz's  researches)  as  a  reflex  mechan- 
ism, and  the  importance  of  the  lumbar  spinal  reflex  centre  for  this 
function,  he  turned  to  the  neuroses  of  the  bladder,  so  far  as  these 


PATHOLOGY.  .  1/9 

are  not  connected  with  anatomo-pathological  alterations  that 
bring  them  into  the  province  of  surgery.  Amongst  them  are  to 
be  distinguished  neuroses  of  motility  and  neuroses  of  sensibility. 
They  include  : 

1.  Vesical  hypercesthesia.  This  is  observed  especially  among 
those  given  to  sexual  exercises  and  to  onanism  in  particular.  A 
moderate  distention  of  the  bladder  produces  a  strong  impulse 
to  urination,  and,  if  this  is  not  met,  a  severe  pain  in  the  penis. 
Vesical  hyperaesthesia  is  also  a  consequence  of  a  morbidly  altered 
condition  of  the  urine,  sometimes  when  this  alteration  is  scarcely 
perceptible,  as,  for  example,  after  drinking  too  fresh  beer. 

2.  Vesical  aricBsthesia.  There  are  individuals  who,  without  ex- 
periencing any  desire  to  urinate,  allow  the  bladder  to  become 
largely  distended,  and  who,  nevertheless,  cannot  be  considered  as 
diseased.  When  this  condition  is  long  continued,  however,  it 
leads  to  paralysis  of  the  detrusor  muscles  and  retention  of  urine. 

The  nocturnal  enuresis  of  children  also,  perhaps,  belongs  in  this 
category,  if  we  are  to  consider  it  as  due  to  an  imperfect  anaesthe- 
sia of  the  sensory  nerves  of  the  bladder.  The  sensation  produced 
by  fulness  of  the  organ  is  felt,  but  not  strongly  enough  to  awaken 
the  child  from  normal  sleep.  Urination  then  occurs  as  an  invol- 
untary reflex.  The  author  recommends  against  this  very  unpleas- 
ant infirmity  a  tonic  and  electric  treatment,  and  attributes  much 
value  to  psychic  and  moral  agencies  without  physical  correction. 

Among  the  neuroses  of  motility  belongs  vesical  cramp.  Under 
this  designation  we  ought  to  include  only  those  abnormal  irrita- 
tive conditions  of  the  motor  nerves  of  the  bladder  that  are  inde- 
pendent of  visible  structural  disease  of  the  vesical  walls.  Thus, 
foreign  bodies,  especially  calculi,  in  consequence  of  the  irritation 
they  produce  on  the  lining  of  the  bladder,  cause  violent  contrac- 
tions of  the  muscular  walls. 

The  most  frequent  causes  of  this  spasm,  however,  are  either 
psychic  irritations,  such  as  fright  or  shock,  or  reflex  irritations 
caused  by  irritative  conditions  of  neighboring  organs  such  as  the 
uterus,  the  rectum,  etc.,  or  they  may  be  due  to  hysteria.  They 
may  involve  the  detrusor  muscles  or  the  sphincter  of  the  bladder, 
producing,  as  the  case  may  be,  enuresis  spastica,  dysuria  spastica, 
or  ischuria  spastica. 

Turning  now  to  paralysis  of  the  bladder,  the  author  showed 
how  it  might  involve  either  the  detrusors  or  the  vesical  sphincter, 
or  both  antagonists  together  in  some  cases.  He  stated  also,  that 
the  contraction  of  the  expelling  muscles  is  not  under  the  control 


l8o  PERI  SCOP  R. 

of  the  will,  but  is  excited  by  the  reflex  irritation  of  the  contained 
urine,  while  that  of  the  spincter  is  governed  by  volition.  Dis- 
turbances of  the  innervation  of  the  bladder  may  be  caused  : 

1.  By  functional  or  structural  disorder  of  the  brain,  as  well  as 
by  severe  febrile  conditions  in  which  the  cerebral  functions  are 
depressed.  In  these  cases  paralysis  of  the  sphincter  is  most  fre- 
quently observed,  since  the  will  is  suppressed  or  weakened,  while 
the  reflex  expulsory  impulse  is  still  active. 

2.  By  spinal  lesions. 

3.  Through  alteration  of  the  peripheral  extensions  of  the  motor 
and  sensory  nerves  of  the  bladder  themselves,  through  which  they 
lose  their  irritability.  To  this  group  belong  the  so-called  myo- 
pathic paralyses  of  the  bladder.  They  are  produced  by  fine 
texture  changes  of  the  muscular  fibres  and  their  contained  nerve- 
terminations.  Frequently,  perhaps,  the  cause  of  this  disease  is 
only  excessive  dilatation  of  the  bladder  arising  from  some  mechani- 
cal obstruction  to  urination,  or  from  a  false  feeling  of  modesty.  A 
vesical  catarrh  also,  which  itself  is  the  consequence  of  numerous 
other  disorders,  such  as  those  of  the  urethra,  may  be  the  cause  of 
the  muscular  structure  of  the  bladder  becoming  diseased  and  lead 
to  its  paralysis.  After  noticing  briefly  the  symptoms,  the  author 
of  the  paper  passed  to  the  treatment  of  these  conditions  : 

Internal  medication  with  narcotics,  such  as  opiates,  belladonna, 
etc.,  is  often  very  useful  in  disordered  conditions  of  the  bladder, 
but  in  paralysis  of  the  viscus  a  cure  is  never  thus  produced. 
Medicines  are  only  useful  as  prophylactics  to  ward  off  cystitis. 
Among  them  he  mentioned  Vichy  and  Wildunger  waters,  chlorate 
of  potash,  benzoi-salicylic  acid,  etc.  In  retention  the  catheter 
must  be  faithfully  employed  to  keep  the  urine  drawn  off,  and 
attention  should  be  given  to  its  cleanliness.  Sitz  baths  and  recipi- 
ents are  urgently  required  if  incontinence  exists.  A  good  urine 
receiver  for  night  use  is  a  desideratum.  In  general,  the  author 
promised  best  results  from  the  use  of  electricity,  especially  in 
cases  of  atony  and  weakness  following  excessive  distention  of  the 
bladder  or  vesical  catarrh.  He  recommends  the  most  direct  pos- 
sible faradic  excitation  of  the  vesical  walls,  so  as  to  arouse  its  sen- 
sory nerves  and  produce  reflex  contractions.  Faradic  irritation 
causes  energetic  contractions  if  a  sound-shaped  electrode  is  used, 
isolated  by  rubber  to  its  point,  in  the  previously  emptied  bladder, 
and  the  other  electrode  is  introduced  into  the  rectum.  Usually,  it 
is  sufficient  to  place  one  on  the  symphysis  and  the  other  on  the 
sacral  region. 


PATHOLOGY. 


i8i 


Galvanic  applications  should  be  made  only  externally,  since 
they  may  cause  electrolytic  and  caustic  effects  on  the  lining 
mucous  membrane.  Dr.  Erdmann  recommends  the  application 
of  the  anode  to  the  occiput  and  the  third  lumbar  vertebra  (the 
reflex  centre)  and  the  cathode  to  the  symphysis  or  perineum. 
Fifteen  to  twenty  elements  for  from  two  to  four  minutes,  and  sep- 
arate strong  induction  shocks. 


Hysteria  Major. — Dr.  Wm.  J.  Morton  in  a  communication 
to  the  N.  Y.  Medical  Record,  Oct.  2,  describes  a  typical  case  of 
hystero-epilepsy  in  one  of  Charcot's  wards,  who  was  only  kept 
from  recurring  attacks  by  continuous  mechanical  pressure  over  the 
left  ovary,  and  ends  his  letter  as  follows  : 

"And  what  is  the  practical  bearing  of  this  study,  conducted 
now  for  several  years  with  so  much  care  by  Prof.  Charcot  ?  The 
practical  value  of  this  work  lies  in  having  taken  up  the  hitherto 
confused  story  of  hystero-epilepsy,  and  in  having  brought  order 
out  of  chaos  ;  in  having  marshalled  into  line  under  a  simple  law, 
whose  immutability  is  at  once  recognizable,  the  diverse  phenomena 
of  the  disease  ;  in  having  shown,  in  short,  that  in  accordance  with 
this  law,  all  the  symptoms  of  hystero-epilepsy  could  be  marshalled 
into  groups,  and  that  each  group  was  related  to  another  in  an 
invariable  order  of  succession  and  development.  It  is  this  analy- 
sis which  established  that  what  was  at  first  glance  so  evidently 
epileptic  was  epileptic  only  in  outer  form,  just  as  is  the  case  in 
certain  other  diseases  of  the  nervous  system  where  convulsions  are 
epileptoid  without  being  epileptic. 

"  The  term  hystero-epilepsy,  then,  is  a  misnomer  ;  there  is  no 
epilepsy  present.  The  disease  is  really,  as  we  have  already  inti- 
mated, hysteria  major,  while  the  hysteria  of  every-day  practice 
must  be  called  hysteria  minor, — the  one  the  fully  developed  dis- 
ease, the  other  rudimentary.  Knowing  the  completed  pattern  of 
a  hysteria-major,  it  is  easy  to  fit  into  their  proper  places  the  frag- 
mentary and  detached  phases  of  a  hysteria  minor.  Here,  then,  in 
this  nomenclature,  this  division  of  hysteria  into  major  and  minor, 
lies  a  great  advance.  Not  only  has  hystero-epilepsy  become  an 
intelligible  disease,  but  in  becoming  hysteria  major  it  has  thrown 
a  brilliant  light  upon  ordinary  hysteria,  and  rendered  its  manifold 
phases  clearer  to  the  practising  physician." 


The  Symmetrical  Neuralgias  of  Diabetes. — At  the  session 
of  the  Paris  Academy  of  Medicine,  Sept.  10   (rep.  in  Le  Progres 


1 82  PERISCOPE. 

Medical),  M.  J.  Worms  read  a  paper  on  the  symmetrical  neural- 
gias in  diabetes.  He  thought  that  in  a  subject  so  obscure  as  that 
of  diabetes^  no  new  facts  should  be  neglected.  He  therefore 
presented  the  points  suggested  by  two  cases  of  neuralgia  in  the 
sciatic  and  inferior  dental  nerves  of  both  sides,  which  he  had 
come  across  in  diabetic  subjects.  These  had  not  been  previously 
described  as  symptoms  of  this  disease. 

He  drew  the  following  conclusions  from  these  cases  : 

1.  There  is  a  special  form  of  neuralgia  connected  with  dia- 
betes, characterized  by  appearing  in  the  two  symmetrical  divisions 
of  the  same  pair  of  nerves. 

2.  Up  to  the  present  time  this  has  been  observed  in  the  sciatic 
and  dental  nerves. 

3.  Diabetic  neuralgia  appears  to  be  much  more  painful  than 
other  neuralgias. 

4.  It  does  not  yield  to  the  ordinary  treatment  (quinine,  mor- 
phine, bromides,  etc).  It  is  aggravated  or  lessened  with  the  in- 
crease or  decrease  of  the  intensity  of  the  glycemia. 

He  ranks  these  neuralgias  with  those  dyscrasic  forms  observed 
in  gouty,  chlorotic,  and  saturnine  subjects.  He  leaves  as  unde- 
cided and  requiring  new  investigations,  the  question  whether  al- 
terations of  the  nerves  or  neurilemma,  due  to  the  glycemia, 
exist. 


The  Occurrence  of  Hysteria  in  Children  {Jahrbch.  /. 
Kind/ilkde.,  xv,  B.,  i  H). — Dr.  Hermann  Schmidt  (Bremen)  opens 
this  number  of  the  Jahrbuch  with  such  an  interesting  and  thor- 
ough article  on  this  subject  that  it  deserves  a  rather  longer  ab- 
stract than  usual. 

The  old  authors  v/ho  considered  hysteria  a  disease  essentially 
connected  with  the  generative  functions  of  the  uterus,  could  not 
conceive  of  its  existence  in  children  or  in  men.  Galen  and  Are- 
tseus  mentioned  certain  hysterical  symptoms  as  occurring  in  men, 
but  they  still  held  to  the  opinion  of  Hippocrates  that  true  hys- 
teria came  only  from  the  uterus.  Charles  Lepois  (1618)  took  his 
stand  upon  a  new  opinion.  He  says  that  neither  the  utevus,  the 
stomach,  nor  any  internal  organ  is  to  be  blamed  for  hysteria  ;  it 
is  the  head  only  which  is  its  generator,  and  this,  too,  not  sympa- 
thetically, but  idiopathically.  The  important  sentence  for  us 
is  :  "  Enim  vera  experienticz  fide  mitltcz  puellulcs  vivunt  hysterias 
tentaice   symptojuatibus  aut    duodeciinum^    decimujn    quifitum    nedum 


PATHOLOGY.  ■  1 83 

decimum  octavum  cetatis  annum."  A  half  century  later  (1667) 
appeared  Willis'  important  work  :  "  Pathologice  cerebri  et  7ier- 
vosi  generis."  He  considered  hysteria  a  convulsive  disease 
caused  by  a  mixture  of  heterogeneous  elements  with  the 
"  spirit  of  life."  For  us  it  is  important  that  he,  too, 
like  Lepois,  declared  that  hysteria  might  occur  before  pu- 
berty. His  work  was  answered  and  opposed  by  Hygmore 
(London,  1670),  who  looked  for  the  convulsions  in  a  change 
in  the  blood.  From  then  on  for  some  years  the  great 
question  was  :  "  Are  hysteria  and  hypochondriasis  identical  ? 
Is  hysteria  a  neurosis  and  dependent  on  the  central  nervous 
system  ?  "  At  the  commencement  of  this  century  the  discussion 
gained  new  interest  in  France  on  account  of  prizes  offered  by 
the  Academy  of  Medicine.  Georget  (1824),  Landouzy  (1846) 
and  others  reported  cases  of  hysteria  in  children.  In  1859  ap- 
peared Briquet's  great  work.  He  considered  hysteria  a  nervous 
disease  of  the  brain,  and  just  as  apt  to  occur  in  children  as  in 
adults.  Scanzoni,  in  the  same  year,  admitted  the  existence  of 
hysteria  in  children,  but  considered  it  due  to  masturbation.  Al- 
thaus,  Amann,  Bouchut,  all  admit  the  existence  of  hysteria  in 
children,  though  the  latter  weakens  his  position  by  giving  to  the 
same  group  of  symptoms,  in  adults  one  name,  in  children 
another.  Skey  (London,  1867)  reports  hysteric  men,  says  noth- 
ing of  children.  Passing  over  others,  we  notice  Dr.  Jacobi's 
work  {A7ner.  your.  Obstet.,  1876).  The  first  part  of  this,  on 
masturbation,  Dr.  Schmidt  considers  excellent,  but  the  second 
part,  hysteria,  he  thinks  is  confusing,  because  J.  includes  under 
the  head  hysteria  almost  any  nervous  or  neuralgic  symptom.  He 
does  not  find  one  genuine  case  of  hysteria  in  the  whole  article. 
Many  others  are  then  mentioned.  While  gynecologues  and  neu- 
ropathologues  seem  now  to  be  agreed  as  to  the  existence  of  hys- 
teria in  children,  it  is  remarkable  that  works  on  pediatrics  seem 
to  have  little  or  nothing  to  say  on  the  subject.  The  author  gives 
a  long  list  of  all  the  works,  monographs,  and  articles  on  the  sub- 
ject which  he  has  been  able  to  collect,  with  the  number  and  kind 
of  cases  reported  in  each,  and  the  history  in  full  in  nine  of  the 
most  interesting  cases.  Assuming  the  point  proved  that  hysteria 
may  occur  in  early  childhood,  it  remains  only  to  consider  its 
characteristics  when  so  occurring. 

Etiology. — Practically,  the  causes  are  predisposing  and  exciting. 
Hysteria,  considered  as  a  general  psychoneurosis,  must  have  some 
general   ground.     As   the  predisposition  is  greater  or   less,  it   will 


184  PERISCOPE. 

occur  earlier  or  later — or  the  greater  the  predisposition  the  smaller 
need  the  exciting  cause  be.  The  principal  predisposing  causes 
are  what  we  call  a  "nervous  constitution," — nervous  temperament, 
whilst  the  most  important  excitant  is  disturbance  of  the  sexual 
organs.  The  predisposition  is  decidedly  hereditary.  It  comes 
not  only  from  parents,  but  from  grandparents  ;  not  only  from  hys- 
teria in  the  ancestors,  but  from  epilepsy,  neuralgias,  various  ner- 
vous diseases,  drunkenness,  etc.  The  predisposition  also  depends 
on  the  bodily  and  mental  "bringing  up,"  and  education.  School 
customs  and  the  habits  of  large  "pensions"  (boarding-schools) 
have  much  to  do  with  it.  Neglect  of  bodily  care,  causing  anaemia 
and  chlorosis,  may  also  be  mentioned.  Although  disturbances  of 
the  sexual  organs  belong  to  the  exciting  causes,  they  may  also  be 
counted  among  the  predisposing,  and  Jacobi,  Scanzoni,  Linder, 
and  others,  have  given  interesting  details  of  the  extent  to  which 
mischief  of  this  sort  may  be  carried  by  even  small  children.  Pass- 
ing to  the  exciting  causes,  we  notice  first,  pathological  changes  in 
the  sexual  organs.  Anomalies  of  menstruation,  of  course,  must  be 
omitted.  Pain  of  the  ovaries  has  been  mentioned,  but  it  was  hard 
to  say  whether  it  was  cause  or  symptom.  Malpositions  of  the 
uterus  seem  to  have  no  effect  till  menstruation  begins.  Most  gen- 
eral diseases  seem  to  have  little  or  no  causal  action.  More  im- 
portant, by  far,  as  excitants  are  psychical  disturbances,  bad  treat- 
ment by  parents  or  friends,  fright  or  fear.  The  overstraining  of 
the  mind  at  school  is  noted  frequently,  and  finally,  as  a  very  fre- 
quent cause,  the  seeing  of  others  in  hysterical  attacks. 

Diagnosis. — This  is  not  easy.  The  patients  cannot  and  will  not 
help  us.  An  exact  family  and  personal  history  must  be  obtained, 
the  early  life  of  the  child  inquired  about,  whether  it  had  convul- 
sions during  dentition,  its  mode  of  life,  etc.  The  commencement 
of  treatment,  or  even  the  behavior  of  the  child  under  explorative 
examination  (laryngoscopy,  etc.)  often  furnishes  diagnostic  signs. 
The  imposing  presence  of  the  doctor  is  often  sufficient,  while 
many  have  had  their  questions  answered  by  the  use  of  hot  iron, 
etc.  It  is  hard  to  differentiate  hysteria  from  simulation.  The 
questions  here  are  :  Is  the  child  predisposed  to  hysteria  ?  Has  it 
any  good  reason  for  simulation  ?  Are  the  symptoms  presented 
such  as  could  be  simulated  ? 

Prognosis. — We  may  say,  a  priori,  that  the  symptoms  will  in- 
crease at  the  time  of  puberty.  The  general  prognosis  is  not  good. 
The  severest  forms  seen  in  adults  are  those  which  began  in  child- 
hood, and  even  in  cases  apparently  cured  relapses  are  apt  to  occur. 


PATHOLOGY.  1 8$ 

Treatment  is  not  different  from  that  used  for  adults.  The 
symptoms  sometimes  disappear  under  purely  psychical  measures, 
but  usually  there  is  need  of  tonics,  with  good  diet,  fresh  air,  and 
before  all,  when  possible,  the  removal  of  the  exciting  as  well  as 
the  predisposing  cause. 

Summing  up,  the  author  says  : 

1.  Completely  developed  hysteria  occurs  both  in  boys  and  girls 
many  years  before  puberty. 

2.  It  is,  however,  rare  at  that  age. 

3.  The  ground  for  it  is  either  anaemia  or  chlorosis,  or,  on  the 
other  hand,  a  hereditary  "nervousness." 

4.  In  light  cases,  psychical  treatment  is  sufficient  ;  but  the 
general  constitution  must  always  be  built  up.  (^w.  jfour.  Obstet., 
October,  1880.) 


Cases  of  Alcoholic  Insanity  in  Private  Practice. — 
At  the  last  meeting  of  the  British  Medical  Association  Dr. 
H.  Sutherland  (London)  read  a  paper  on  this  subject  :  Two 
hundred  cases  had  been  carefully  considered  ;  one  hundred  male 
and  one  hundred  female,  private  patients.  Out  of  one  hundred 
male  cases,  twenty-six,  and  out  of  one  hundred  female  cases,  six, 
were  alleged  to  have  been  caused  by  intemperance. 

These  percentages,  twenty-six  for  males  and  six  for  females, 
correspond  pretty  accurately  with  the  percentages  given  in  the 
Report  of  the  Commissioners  in  Lunacy  for  1879,  where  the  per- 
centages were  21.3  for  males  and  7.9  for  females.  But,  on  closer 
investigation.  Dr.  Sutherland  found  that  eight  of  his  twenty-six 
male  cases  and  two  of  the  six  female  cases,  were  cases  in  which 
alcoholic  excess  was  only  a  premonitory  symptom  ;  in  other 
words,  he  believed  that  one-third  of  the  cases  for  both  sexes,  usu- 
ally said  to  be  caused  by  intemperance,  were  in  reality  cases  in 
which  alcoholic  excess  was  only  a  premonitory  symptom.  The 
distinctions  between  cases  of  insanity  caused  by  intemperance  and 
cases  in  which  alcoholic  excess  was  only  a  premonitory  symptom 
were  stated  to  be  as  follows  :  When  intemperance  was  a  cause, 
the  previous  habits  of  the  patient  were  those  of  a  drunkard  : 
when  it  was  a  symptom,  the  previous  habits  had  been,  compara- 
tively speaking,  those  of  sobriety.  When  intemperance  was  a 
cause,  frequently  no  other  influence  could  be  detected  which  had 
produced  the  insanity,  or  the  proofs  of  intemperance  were  so 
marked  as  to  obscure  all  other  etiological  points  in  the  previous 


1 86  PERISCOPE. 

history.  When  intemperance  was  a  symptom  only,  some  other 
distinct  influence  was  found  to  have  existed,  which  was  more 
likely  to  produce  mental  symptoms  than  alcohol  itself — for 
instance,  a  blow  on  the  head.  When  alcohol  was  a  cause,  habits 
of  intemperance  had  preceded  the  appearance  of  the  mental 
symptoms,  which  had  only  been  developed  gradually. 

When  the  intemperance  was  a  symptom,  the  mental  aberration 
had  preceded  the  abuse  of  alcoholic  stimulants,  and  the  mental 
symptoms  were  developed  more  suddenly.  When  alcohol  was  a 
cause,  the  mental  symptoms  were  most  frequently  those  of  homi- 
cidal mania  or  suicidal  melancholia,  with  acts  of  eccentricity. 
When  intemperance  was  a  symptom,  the  mental  phenomena  were 
those  of  melancholia  of  a  subdued  form  or  of  delirium  tremens. 
The  writer  had  observed  a  transient  attack  of  epilepsy  on  the 
admission  of  two  cases  where  intemperance  was  only  a  symptom 
of  insanity.  This  he  had  only  seen  in  cases  caused  by  intemper- 
ance, in  the  last  stages  of  the  disorder,  and  the  epilepsy  was  then 
permanent  and  incurable.  When  intemperance  was  a  cause,  the 
delusions  were  of  a  disagreeable  character,  and  were  either  those 
of  suspicion  or  of  grandeur.  When  intemperance  was  a  symptom, 
the  delusions  were  either  of  a  quiet  order,  referring  to  persons 
other  than  the  patient,  or  they  partook  of  the  peculiar  nature  of 
those  accompanying  delirium  tremens.  Acute  cases  of  alcoholic 
insanity  recovered  ;  but,  if  the  intemperance  had  been  a  cause, 
the  patient  invariably  took  to  drinking  again  as  soon  as  he  was  at 
liberty,  and  died  an  early  death,  frequently  from  cirrhosis  of  the 
liver.  On  the  other  hand,  when  the  intemperance  was  merely  a 
symptom,  the  patient  frequently  remained  sober  after  his  discharge 
from  the  asylum,  and  was  able  to  return  to  his  duties  of  social 
life.  Chronic  cases  of  alcoholic  insanity  did  not  recover  ;  but,  if 
the  intemperance  had  been  a  cause,  there  was  constant  craving 
for  drink,  whether  the  patient  remained  in  an  asylum  or  was  dis- 
charged. Such  patients  drifted  rapidly  into  the  abyss  of  chronic 
dementia.  If,  on  the  contrary,  the  intemperance  had  been  merely 
a  symptom,  the  patient  was  always  contented  with  a  moderate 
supply  of  stimulants  ;  his  delusions  and  his  mental  condition 
remained  stationary,  but  he  did  not  become  afflicted  by  dementia, 
even  when  advanced  age  came  upon  him. 

Cases  were  read  illustrating  these  points  of  distinction. 


Headache    in    School    Children. — A    recent    writer,    Dr. 
Treichler,   states  that  about  one-third   of    the  pupils  in   school 


PATHOLOGY.  1 87 

suffer  more  or  less  from  headache.  It  leads  to  poorness  of  blood, 
and  loss  of  cheerfulness  and  mental  Energy.  Its  chief  cause  is, 
probably,  overwork,  and  especially  nocturnal  study.  The  ana- 
tomical changes  which  accompany  the  more  advanced  stages  of 
this  habitual  headache  are,  in  the  author's  opinion  :  i.  Trophic 
changes  in  the  ganglion  cells  of  the  brain  cortex,  caused  by  anae- 
mia. An  anaemic  brain  is  much  more  easily  exhausted  by  mental 
exertion  than  a  normal  one.  2.  Passive  dilatation  of  the  cere- 
bral blood-vessels  and  consequent  stasis  ;  the  perivascular  spa- 
ces round  the  capillaries  become  narrowed  ;  the  removal  of 
waste  products  is  thus  hindered,  and  in  this  way,  again,  trophic 
disturbance  is  caused.  Recent  views,  which  regard  progressive 
paralysis  as  commencing  by  vaso-motor  trophic  changes  in  the 
brain  cortex,  paretic  dilatation  of  the  vessels  of  the  pia  mater,  and 
degeneration  of  the  cortex  through  lymph-stasis,  increase  the  sig- 
nificance and  importance  of  the  conditions  believed  by  the  author 
to  be  brought  about  by  prolonged  habitual  headache  in  young 
people. 


The  following  are  some  of  the  recently,  published  articles  on 
the  pathology  of  the  nervous  system  and  mind  : 

GiBNEY,  Cervical  Pacliymeningitis  ;  the  Detailed  Histories 
of  Three  Cases  Occurring  in  Children,  N.  Y.  Med.  Record., 
Sept.  25. — Wright,  Cerebral  Trance,  Cin.  Lancet  and  Clinic, 
Sept.  II. — Collins,  Asthma  as  a  Reflex  Phenomenon,  Rocky 
Mt.  Med.  Review,  Sept.  —  Hutchinson,  A  Report  of  Three 
Typical  Cases  of  Neurasthenia,  N.  Y.  Med.  Record,  Oct.  9. 
— Crothers,  Clinical  Studies  of  Inebriety  ;  Permanence  of 
Curability,  Aled.  and  Surg.  Rep.,  Oct.  2. — Mason,  Lead- 
Poisoning  in  Frogs,  N.  Y.  Med.  'your.,  Oct, — Fernandez, 
Paralysis  of  the  Fourth  and  Sixth  Pairs  of  Nerves  from 
Cerebral  Traumatism,  Riv.  Med.  Quirurg  de  Habana,  Sept. — 
Gombault,  Contribution  to  the  Anatomical  Study  of  Subacute 
and  Chronic  Parenchymatous  Neuritis,  Arch,  de  Neurologic,  July, 
1880. — Magnan,  On  the  Coexistence  of  Deliriums  of  Different 
Nature,  Ii>id.  Bourneville,  Contribution  to  the  Study  of  Idiocy, 
/bid. — BuCKNELL,  Puerperal  Convulsions,  Si.  Louis  Med.  and 
Surg,  your.,  Oct.  20. — Beard,  Inebriety  and  Allied  Nervous 
Diseases  in  America,  Gaillard's  Med.  Jour.,  Oct. — Lepine,  On  a 
Case  of  Paralysis  of  Motion  and  Sensibility  in  the  Four  Fingers, 
with  Absolute  Integrity  of  the  Thumb.     Contribution  to  Cerebral 


155  PERISCOPE. 

Localizations,  Reviie  Mensuelle,  Oct.  lo. — Arango,  Considera- 
tions on  Spiritualism,  Cronica  Med.  Quirurg  de  la  Habana,  Octo- 
ber.— Wight,  How  shall  we  Interpret  the  Deviation  of  the  Head 
of  the  Incurable  Epileptic  ?  Med.  and  Surg.  Reporter,  Nov.  20. — 
Lander-Brunton,  Indigestion  as  a  Cause  of  Nervous  Depression, 
Practitioner,  Nov. — BoswoRTH,  Bilateral  Paralysis  of  the  Abductor 
Muscles  of  the  Larynx,  N.  Y.  Med.  Jour.,  Nov.,  1880. — Everts, 
Diagnosis  of  Insanity,  Am^  Pract.,  Nov. — Petrone,  Contribution 
on  the  Subacute  Arthropathia  Connected  with  Brain  Lesions,  La 
Sperimentale,  Nov. — Wood,  Contribution  to  our  Knowledge  of 
Nervous  Syphilis,  Atn.  J^our.  Med.  Sci.,  Oct. — Gray,  Diagnostic 
Significance  of  a  Dilated  and  Mobile  Pupil  in  Epilepsy,  Ibid. — 
CoRNWELL,  A  Case  of  Basedow's  Disease  Terminating  in  Total 
Loss  of  Sight  from  Inflammation  of  the  Cornea,  Ibid. — Kiernan, 
Insanity,  Gaillard's  Med.  Jour.,  Nov. — Alvisi,  The  Speech  in 
Insanity,  Rivista  Clinica  di  Bologna,  Oct. 


C. — THERAPEUTICS   OF    THE    NERVOUS    SYSTEM   AND    MIND, 


Influence  of  Bromides  on  the  Cerebral  Temperature. — 
Prof.  Edward  Maragliano  rQ\)or\.s,  Rivista  Clitiica.  di  Bologna,  Oct., 
the  results  of  a  series  of  ten  experiments  on  the  effect  of  bromide 
of  potash  on  the  cerebral  (cranial)  temperature,  from  which  he 
draws  the  following  conclusions  : 

1.  Bromide  of  potassium  in  single  doses  of  three  to  five 
grammes  gives  rise  to  an  increase  of  cerebral  temperature. 

2.  This  increase  averages  about  one  degree  Centigrade. 

3.  It  commences  to  appear  a  few  minutes  after  the  taking  of 
the  drug,  reaches  its  maximum  at  the  end  of  one  hour  and  a  half 
to  two  hours  and  a  half,  and  decreases  at  the  end  of  another  two 
or  three  hours. 

4.  Contemporaneously  with  this  rise  of  cerebral  temperature, 
occurs  a  very  slight  increase  (two-  or  three-tenths  of  a  degree)  in 
the  axilla. 

These  observations  contradict  the  previously  reported  action  of 
bromides,  but  tliey  seem  to  have  been  carefully  made  and  are  de- 
serving of  attention,  if  for  no  other  reason  than  that  of  the  repu- 
tation and  authority  of  their  reporter. 


THERA  PE  U  TICS.  1 89 

^STHESiOGENic  VIBRATIONS. — M.  Romain  A'igouroux  recalls, 
in  Le  F /ogres  Medical,  Sept.  5th,  some  experiments  performed 
by  him,  in  which  the  hypothesis  of  Schiff,  that  molecular  vibra- 
tions, transmitted  by  contiguity,  produced  a  concussion  or  shock 
to  the  nerves,  and  that  rhe  aesthesiogenic  effects  of  various  metals 
applied  to  the  skin  were  due  to  such  vibrations,  differing  in  rhythm 
and  amplitude  according  to  the  substance  employed,  was  sug- 
gested and  anticipated.  His  first  experiments  were  made  in  1878, 
in  which  he  employed  a  tuning-fork  ii  t  3,  introducing  the  hand 
of  the  patient  into  the  sounding-box  of  the  instrument.  These 
experiments  were  noticed  at  the  time  in  the  Progres  Medical  of 
that  year,  page  747,  and  the  conclusion  was  deduced  "that  the 
vibrations  of  a  tuning-fork  have  precisely  the  same  physiological 
action  as  metals,  magnets,  and  electricity." 

Now,  reviewing  the  subject  and  establishing  his  own  priority  in 
the  experimental  investigation,  M.  Vigouroux  concludes  that  this 
theory  of  vibrations  affords  a  means  of  comparison,  but  not  an 
explanation  of  the  phenomena  of  metallotherapy.  He  still  holds 
to  this  opinion  even  after  reading  the  memoirs  of  Schiff  and  Mag- 
giorani. 

Nerve-Stretching  in  Ataxia. — Two  cases  are  now  on  record, 
one  by  Langenbuch,  the  other  by  Esmarch,  in  which  nerve- 
stretching  was  resorted  to  as  a  remedy  against  the  intense  pains  of 
locomotor  ataxia.  In  both,  the  success  was  complete,  not  merely 
as  far  as  the  pain  was  concerned,  but  as  a  matter  of  great  aston- 
ishment, the  well-developed  disease  itself — locomotor  ataxia — was 
cured. 

Encouraged  by  these  unexpected  observations.  Dr.  Erlenmeyer 
attempted  nerve-stretching  in  a  case  of  tabes  of  two  years'  stand- 
ing. {Centralblatt  f.  N'ervetiheilk'de,  Nov.,  1880.)  The  patient,  a 
man  of  39  years  of  age,  had  the  disease  in  a  well-developed  form, 
especially  the  atactic  symptoms,  though  but  little  pain  at  the  time. 
He  had  previously  had  a  hard  chancre,  but  no  secondary  symp- 
toms. Specific  treatment  had  been  employed  without  result.  At 
two  successive  operations  the  sciatic  nerves  were  exposed  and 
violently  stretched,  and  the  wounds  dressed  antiseptically.  Never- 
thelesS;  the  wound  of  the  left  thigh  was  infected  by  the  faeces  ; 
erysipelas  set  in,  and  it  required  over  four  weeks  before  the  wound 
was  healed.  The  success  of  the  operation  was  almost  wholly  neg- 
ative. The  only  improvement  gained  was  an  increase  in  the 
strength   of  the  legs.     But  none  of    the  atactic  symptoms   were 


190  PERISCOPE. 

lessened.     Dr.   Erlenmeyer  believes  that   the  failure  is  probably 
due  to  insufficient  stretching  of  the  nerves. 


Absinthism. — M.  Lancereaux,  in  a  recent  communication  to 
the  Paris  Academy  of  Medicine,  Sept.  7th  (reported  in  La  France 
Medicale),  in  which  he  states  the  conclusion  derived  from  his  in- 
vestigations that  in  the  syndrome  of  acute  absinthism  we  do  not 
have  the  genuine  epileptic  attack,  but  rather  the  convulsive  phe- 
nomena of  hysteria,  and  that  this  resemblance  between  hysteria 
and  absinthism  exists  not  only  for  the  acute  form  of  the  latter,  but 
also  for  its  chronic  form. 

M.  Dujardin-Beaumetz  referred  to  his  own  experiments  on  pigs 
(see  last  number  of  this  Journal),  to  some  of  whicli  he  had  also 
administered  absinthe.  In  these  latter  he  had  developed  symp- 
toms of  excitement,  but  nothing  like  epilepsy. 


DuBOisiA  IN  Exophthalmic  Goitre. — M.  Dujardin-Beaumetz 
has  substituted  dubuisia  in  hypodermic  injection  for  atropia,  in 
the  treatment  of  exophthalmic  goitre.  In  thetwo  cases  in  which 
he  has  employed  it  he  obtained  a  great  decrease  in  the  palpitations 
and  the  vascular  pulse.  He  noticed,  moreover,  a  ready  cumula- 
tive action  of  the  drug,  although  he  used  quite  small  doses,  from  a 
quarter  to  a  half  a  milligram,  or  more.  A  few  days  sufficed  to  de- 
velop indubitable  signs  of  intoxication  analogous  to  that  pro- 
duced by  belladonna.  The  solution  employed  was  as  follows  : 
neutral  sulphate  of  duboisia,  .01  ;  distilled  cherry  laurel  water,  20. 
Each  charge  of  the  syringe,  containing  one  cubic  centimetre,  con- 
tained half  a  milligram  of  the  duboisia  salt. 


Direct  Cauterization  of  a  Nerve  for  Neuralgia.—  Dr. 
Augustus  Brown  reports  to  the  British  Med.  Journal,  Nov.  6th,  a 
case  of  very  severe  neuralgia  of  many  years'  standing,  relieved  at 
once  by  a  rather  novel  operation.  The  pain  was  paroxysmal  and 
was  located  in  the  mental  nerve  on  the  right  side  just  at  the  point 
of  its  exit  from  the  foramen  ;  from  there  it  extended  backward  to 
the  front  of  the  ear  ;  then  upward  to  the  vertex,  forward  to  the  fron- 
tal nerve,  down  the  right  side  of  the  face  and  neck  to  the  arm, 
and  backward  to  the  scapula.  The  gum  above  the  painful  point 
was  congested  and  harder  than  on  the  opposite  side  ;  the  tongue 
was  white  and  tremulous.     All  the  teeth   were   gone  (the  patient 


THERAPEUTICS.  IQI 

was  a  lady,  aged  56),  and  a  portion  of  the  alveolus  had  been  ex- 
tracted on  the  idea  that  the  pain  was  due  to  pressure  from  a 
buried  dental  snag,  but  this  proved  not  to  be  the  case. 

Dr.  Brown  made  an  incision  along  the  lower  border  of  the 
jaw  and  dissected  upward  till  he  reached  the  mental  foramen. 
Then  he  ran  a  red-hot  steel  wire  a  quarter  of  an  inch  or  more 
into  the  foramen  and  completely  destroyed  the  nerve  for  that  dis- 
tance. Considerable  hemorrhage  followed  the  operation,  but  the 
wound  healed  kindly  and  the  patient  was  completely  restored  to 
health  and  perfect  freedom  from  pain.  The  doctor  never  wit- 
nessed a  more  satisfactory  result  from  an  operation,  and  he  thinks 
that  in  the  actual  cautery  of  nerves  is  a  remedial  measure  on 
which,  in  many  cases,  we  can  depend  when  others  fail,  and  one 
that,  in  many  instances,  may  supersede  nerve-stretching,  as  well  as 
possibly  be  of  great  benefit  in  tetanus. 


Treatment  of  Asthma. — Dr.  R.  B.  Faulkner  of  Alleghany, 
Pa.,  claims,  N.  Y.  Med.  Record,  Sept.  25,  to  have  succeeded,  in 
cases  of  spasmodic  asthma  that  were  resistant  to  other  treatment, 
by  the  use  of  local  counterirritation  over  the  course  of  the  pneu- 
mogastrics  in  the  neck,  with  tincture  of  iodine,  even  to  producing 
a  blister.  He  also  gives  iodide  of  potash  internally.  This  treat- 
ment not  only  appears  to  afford  quick  relief  from  the  paroxysms, 
but  to  prevent  their  return.  All  the  cases  on  which  he  has  tried 
this  treatment  since  the  idea  occurred  to  him,  three  in  number, 
have  had  the  same  relief. 


Urechites  Subrecta. — Dr.  Isaac  Ott,  Therapeutic  Gazette,  Oct. 
iSth,  publishes  his  investigation  on  the  physiological  action  of 
Urechites  subrecta,  a  Jamaica  plant  passing  under  the  local 
name  of  nightshade,  which  had  been  already  chemically  described 
by  J,  J.  Bowrey,  Government  chemist  of  Jamaica.  The  latter 
found  it  to  contain  three  active  substances  in  its  poisonous  leaves, 
which  he  named  urecliitoxin,  amorphous  urechitoxin  and  urechi- 
tin,  all  glucosides.  The  last-named  one  includes  all  the  poisonous 
principle,  the  urechitoxin  being  a  chemically-changed  urechitin. 

Dr.  Ott's  experiments  were  performed  on  cats,  frogs  and  rab- 
bits. Its  general  effects  had  been  already  described  by  Bowrey, 
including  vomiting,  incoordination,  weakness,  sweating,  convulsive 
movements,  salivation,  etc.,  and  therefore  most  of  his  own  ex- 
periments were  mostly  directed  to  find  its  action  on  the   various 


192  PERISCOPE. 

vital  organs  respectively.  Dr.  Ott  found  that  it  does  not  special- 
ly affect  the  motor  nerves,  nor  completely  destroy  sensibility, 
though  that  is  much  impaired.  This  impairment,  is  due  to  its 
effects  on  the  spinal  cord  ;  the  convulsions  are  probably  cerebral, 
as  they  were  not  observed  after  section  of  the  medulla  in  frogs. 
As  regards  its  action  on  the  circulation  he  found  that  it  decreased 
the  frequency  of  the  cardiac  pulse,  and  increased  and  then  de- 
creased the  arterial  tension.  This  depression  of  the  pulse  is  not 
due  to  irritation  of  cerebral  inhibitory  centres,  as  it  appeared 
after  the  vagi  had  been  divided.  Nor  is  it  due  to  the  peripheral 
inhibitory  apparatus,  as  this  was  paralyzed  with  atropia  without 
changing  the  effect.  As  the  drug  reduces  the  irritability  of  striped 
muscular  fibre  it  is  probable  that  its  action  was  exerted  on  the 
cardiac  muscle  itself.     It  was  found  not  to  paralyze  the  vagus. 

The  increase  of  blood  pressure  is  produced  by  an  action  on 
the  peripheral  vaso-motor  system  and  not  by  one  on  the  prime 
vaso-motor  centre.  As  it  produces  a  cramped  condition  of  the 
intestinal  tube,  it  is  possible  that  this  may  have  to  do  with  the  in- 
crease of  arterial  tension.  Further  experiments,  however,  are 
needed  to  decide  the  question.  The  following  parallel  of  the 
actions  of  urechitin  and  aconite  is  offered,  the  statements  in  re- 
gard to  the  action  of  the  latter  drug  being  mainly  on  the  au- 
thority of  Dr.  J.  M.  Murray. 

Urechitin.  Aconite. 

Contains  no  nitrogen.  Contains  nitrogen. 

Powerful  toxicant.  Powerful  toxicant. 

Kills  mainly  through  cardiac  arrest.  Kills  mainly  through  respiratory  ap- 

paratus. 

Does  not  paralyze  motor  nerves.  Does  not  paralyze  motor  nerves. 

Does  not  paralyze  sensory  nerves,  but        First    paralyzes    sensory    nerves,    and 
does  the  spinal  sensory  ganglia.  then    nerve     trunks,      and     finally 

the  spinal  sensory  ganglia. 

Reduces   pulse  by   an  action  on   the       Reduces  pulse  by  an  action  on  the  in- 
heart,    probably    on     its    muscular  tracardiac  ganglia, 

structure. 

Increases   arterial  tension,    and    then  Increases  and  then   decreases  arterial 

reduces    it  ;  the  rise  is    due  either  tension  by  an  action  on  the    cardiac 

to  peripheral  vaso-motor  system,  or  ganglia, 
to  cramp  of  the  intestinal  canal. 

Does  not  paralyze  the  pneumogastrics.       Small  doses  paralyze  the  pneumogas- 

trics. 

Causes  no  delirium  cordis.  Causes  delirium  cordis. 

Is  a  salivator.  Is  a  salivator. 

Increases  the  secretion  of  the  skin.  Increases  the  secretion  of  the  skin. 


THERA  PE  U  TICS.  1 9  3 

It  will  be  seen  from  the  above  that  while  its  action  is  some- 
what different  from  that  of  aconite,  the  results  are  very  similar. 
Dr.  Ott  advises,  therefore,  its  trial  in  diseases  where  aconite  is 
found  useful.  On  account  of  its  dangerous  special  properties,  he 
advises  the  use  of  digitalis  in  case  of  poisoning,  The  paper  con- 
cludes with  an  account  of  an  experiment  on  a  man  weighing  215 
pounds,  who  took  five  drops  of  the  fluid  extract  followed  at  in- 
tervals of  forty  and  thirty  minutes  respectively  by  additional 
doses  of  five  and  twenty  drops.  This  produced,  as  in  the  lower 
animals,  decreased  pulse,  salivation,  perspiration,  vomiting  and  di- 
arrhoea. 

AcoNiTiA. — The  following  are  the  conclusions  of  a  paper  by 
Dr.  Sidney  Ringer  on  the  antagonisms  of  aconitia  on  the  frog's 
heart,  in  the  Journal  of  Physiology,  ii,  5  and  6  : 

1.  Aconitia  slows  and  weakens  the  heart  and  incoordinates  the 
ventricular  contraction,  this  incoordination  occurring  before  the 
heart's  contractions  are  greatly  weakened. 

2.  Sometimes  the  contractions,  though  greatly  slowed  and 
very  incoordinate,  continue  fairly  strong  till  the   heart  stops. 

3.  Aconitia  acts  on  the  ventricle  far  more  powerfully  than  the 
auricles. 

4.  Aconitia  has  a  more  powerful  action  on  the  cerebro-spinal 
centres  than  on  the  nervous  structure  of  the  heart,  for  after  com- 
plete paralysis  the  heart  often  continues  to  contract  well  for  a 
considerable  time. 

5.  The  general  depression  from  a  poisonous  dose  of  aconitia 
is  partly  and  perhaps  chiefly  due  to  the  direct  action  of  the  drug 
on  the  nervous  centres,  rather  than  to  the  weakening  of  the  cir- 
culation consequent  on  the  failure  of  the  heart. 

6.  Atropia  antagonizes  the  action  of  aconitia  on  the  heart. 
It  restores  the  contractions  in  a  heart  arrested  by  aconitia,  and 
strengthens,  accelerates,  and  coordinates  the  heart  simply  weak- 
ened, slowed,  and  incoordinated  by  aconitia. 

7.  Aconitia  does  not  antagonize  the  action  of  muscarin,  nor 
can  muscarin  antagonize  the  action  of  aconitia  on  the  heart. 

8.  Atropia  antagonizes  the  combined  effects  of  aconitia  and 
muscarin. 

9.  Pilocarpine  does  not  antagonize  the  action  of  aconitia  on 
the  heart. 

10.  Atropia  antagonizes  the  combined  effects  of  aconitia  and 
pilocarpine. 


194  PERISCOPE. 

II.  I  have  suggested  that  the  antagonisms  are  due  to  chemi- 
cal displacement.  Atropia  antagonizes  muscarin,  pilocarpine  and 
aconitia  because  it  has  a  stronger  affinity  for  the  muscular  and 
nervous  structures  of  the  heart  than  these  substances,  and  dis- 
places them,  replacing  their  effect  by  its  own. 


The  Therapeutic  Use  of  Magnets. — Dr.  W.  A.  Hammond 
reports,  in  the  November  number  of  the  Neiu  York  Medical 
Journal^  his  experience  with  the  therapeutic  use  of  magnets.  He 
describes  two  cases  of  hemiplegia  and  two  of  chorea  in  which 
the  application  of  strong  horseshoe  magnets  produced,  apparently, 
astonishing  results.  In  the  two  choreic  cases  a  few  minutes'  ap- 
plication cured  the  disease,  and  there  was  no  relapse.  In  one  of 
the  hemiplegics  there  was  a  recovery  of  both  sensation  and  mo- 
tion of  the  paralyzed  side  on  the  day  of  the  application,  and 
speech  (the  patient  was  aphasic)  returned  before  the  next  morn- 
ing. Some  twenty  days  later,  however,  a  second  attack  proved 
fatal.  In  the  other  case  there  followed  the  use  of  the  magnet  a 
complete  and  lasting  return  of  sensibility,  but  no  improvement  in 
other  respects.  In  seven  other  cases  of  chorea  the  magnets  had 
no  effect. 

Dr.  Hammond,  commenting  on  these  cases  of  hemiplegia,  as 
well  as  those  reported  by  Debove  and  Boudet,  suggests  that  what- 
ever organic  lesion  existed  was  mainly,  at  least,  situated  in  the 
thalamus.  It  would  be  asking  too  much,  he  thinks,  to  claim  any 
specific  influence  of  the  magnets,  and  the  frequent  transitory  char- 
acter of  the  symptoms  in  thalamic  lesions  affords  one  of  the  best 
means  of  explanation.  It  may  be  that  a  strong  mental  influence 
was  the  cause  of  the  relief.  He  offers  the  cases  simply  as  facts  of 
interest,  pointing  out  a  line  worthy  of  further  research. 


The  following  are  the  titles  of  a  few  of  the  recently-published 
articles  on  the  therapeutics  of  the  nervous  system  and  mind  : 

Rockwell,  On  the  Value  of  the  Galvanic  Current  in  Ex- 
ophthalmic Goitre,  N.  Y.  Med.  Rec,  Sept.  ii. — Newland, 
On  the  Rational  Treatment  of  Epilepsy,  St.  Louis  Med.  and 
Surg,  ^our.,  Oct.  5. — Segur,  Prophylaxis  of  Puerperal  Con- 
vulsions, Prac.  Med.  Sac.  Co.  Kings,  Oct.,  1880. — Garrett- 
SON,  Excision  of  the  Inferior  Dental  Nerve  by  means  of  the  Den- 
tal  Engine,   for  the  Relief  of  Obstinate   Neuralgia,  N.   Y.  Med. 


THERAPEUTICS.  195 

Record,  Oct.  23. — Mann,  Dipsomania  and  the  Opium  Habit,  and 
their  Treatment,  Southern  Clinic,  Oct. — Rutter,  Lunatic  Asy- 
lums, Cincinnati  Lancet  and  Clinic,  Oct.  30. — Landesberg,  Case 
of  Neuralgia  of  the  First  Branch  of  the  Fifth  Pair,  of  Six  Years' 
Duration,  Cured  by  Duquesnel's  Aconitia,  Med.  and  Surg.  Re- 
porter, Nov.  6. — Allen,  Asylum  Supervision,  Jour,  of  Psych. 
Med.,  vol.  vi,  part  2. — Graff,  Headache  and  the  Remedies  Pro- 
posed, Physician  and  Surgeon,  Dec. 


196  BOOKS  RECEIVED. 

BOOKS,  ETC,  RECEIVED. 


Real-Encyclopadie  der  Gesammten  Heilkunde.  Medicinisch- 
chirurgisches  Handworterbuch  fiir  praktische  Arzte.  Herausge- 
geben  von  Dr.  Albert  Eulenburg.  Mit  zahlreichen  Illustrationen 
in  Holzschnitt.  IV  Band  (Heft  31-40).  Wien  und  Leipzig, 
1880. 

Handbuch  der  Allgemeinen  Therapie.  Herausgegeben  von  Dr. 
H.  V.  Ziemssen.  Zweiter  Band,  Erster  Theil  :  Klimatotherapie 
von  Dr.  H.  Weber.  Balneotherapie,  von  Prof.  O.  Leichtenstern. 
Leipzig,  1880. 

Compendium  der  Psychiatric  fiir  praktische  Arzte  und  Studir- 
ende.     Von  Dr.  J.  Weiss.     Wien,  1880. 

Handbuch  der  Speciellen  Pathologie  und  Therapie.  Heraus- 
gegeben von  Dr.  H.  v.  Ziemssen.  Achter  Band  :  Krankheiten 
des  Chylopoetische  Apparates.  II.  Erste  Halfte,  Zweite  Ab- 
theilung  :  Gall  und  Pfortader.  Von  Prof.  O.  Schiippel.  Leipzig, 
1880. 

Dictionnaire  Encyclopedique  des  Sciences  Medicales.  Direc- 
teur  A.  Dechambre.  Deuxieme  Serie,  L-P.  Tome  Quatorzieme. 
Oci-Olc.  Troisieme  Serie,  Q-Z.  Tome  Huitieme,  Sen-Sep. 
Tome  Neuvieme,  Sep-Ser.     Paris,  1880. 

Sulla  Genesi  della  Allucinazioni.  Pel  Prof.  Augusta  Tamburini. 
Reggio  nell  'Emilia,  1880. 

Die  Provinzial  Irren-,  Blinden-,  und  Taubstummen-Austalten 
der  Rheinprovinz,  in  ihrer  Entstehung,  Entwickelung  und  Verfas- 
sung,  dargestellt  auf  Grund  eines  Beischlusses  des  26.  Rheinischen 
Provinzial-Landtages,  von  3.  Mai,  1879.  Mit  48  in  den  Text  ge- 
druckten  Holzschnitten.     Diisseldorf,  1880. 

Contribute  alio  Studio  delle  Malattie  Accidentali  dei  Pazzi.   Dei 
Dottori  Seppilli,  Guiseppe  e  Riva,  Gaetano.     Della  Clinico  Psy 
chiatrica    della    R    Universita   di    Modena.       Diretta   del    Prof. 
Tamburini.     Milano,  1879. 

Minor  Surgical  Gynecology  ;  a  Manual  of  Uterine  Diagnosis 
and  the  lesser  Technicalities  of  Gynecological  Practice,  by 
Paul  F.  Munde,  M.  D.,  with  three  hundred  illustrations.  New- 
York  :  William  Wood  and  Company,  1880.  Wood's  Library  of 
Standard  Medical  Authors,  No.  12. 

Ein  Fall  von  Tumor  in  der  vorderen  Centralwindung  des 
Grosshirns.  Mitgetheilt  von  Dr.  W.  Erb,  Professor  in  Leipzig. 
(Separatabdruck.  Deutsches  Arc hiv  fiir  Klinische  Medicin,  1880.) 

The  Practicability  and  Value  of  Non-Restraint  in  Treating  the 
Insane,  by  J.  C  Shaw,  M.D.  Read  before  the  Conference  of 
Charities  at  Cleveland,  Ohio,  July  i,  1880. 


BOOKS  RECEIVED.  I97 

Electricity  in  Medicine  and  Surgery,  with  cases  to  illustrate,  by 
John  J.  Caldwell,  M.D.,  Baltimore,  Md. 

Report  of  ten  cases  of  Gastric  Ulcer  ;  one  case.  Malignant  Ulcer 
of  the  Stomach,  and  two  cases,  Perforating  Ulcer  of  the  Jeiunum  ; 
with  extracts  from  a  lecture  by  Dr.  Murchison,  of  London,  on  the 
subject.  By  A.  Van  Derveer,  M.D.  Reprinted  from  the  Medical 
Annals,  August,  1880. 

The  Treatment  of  the  Genito-Urinary  Organs  ;  the  Use  of  Elec- 
tricity, Danicana,  etc.,  etc.  By  J.  J.  Caldwell,  M.D.,  Baltimore, 
Md.  Reprint  from  the  St.  Louis  Medical  and  Surgical  Journal, 
June,  1878. 

Diet  for  the  Sick.  By  J.  W.  Holland,  M.D.  Morton's  Pocket 
Series,  No.  i. 

Report  of  the  Board  of  Health  of  the  State  of  Louisiana  for  the 
year  1880.     New  Orleans  :  J.  S.  Rivers,  1880. 

Acts  of  the  Legislature  of  Louisiana  Establishing  and  Regulat- 
ing Quarantine,  also  Rules  and  Regulations  of  the  Board  of 
Health  and  Health  Ordinances  of  the  city  of  New  Orleans.  By 
Joseph  Jones,  M.  D.     New  Orleans  :  J.  S.  Rivers,   1880. 

Report  of  the  Pennsylvania  Hospital  for  the  Insane  for  the  year 
1879.  By  'T,  S.  Kirkbride,  M.D.,  Physician-in-Chief  and  Superin- 
tendent.    Philadelphia,  1880. 

Report  of  the  Board  of  Trustees  of  the  Eastern  Michigan 
Asylum  at  Pontiac,  for  the  biennial  period  ending  Sept.  30, 
1880. 

Second  Biennial  Report  of  the  Trustees,  Superintendent,  Treas- 
urer, and  Architect,  of  the  Illinois  Eastern  Hospital  for  the  Insane, 
at  Kankakee,  October  i,  1880. 


iq8  periodicals  received. 

the  following  foreign  periodicals  have   been 
received  since  our  last  issue. 


Allgemeine  Zeitschrift  fuer  Psychiatric  und  Psychisch.     Gerichtl. 

Medicin. 
Annales  Medico-Psychologiques. 
Archives  de  Neurologic. 

Archives  de  Physiologic  Normalc  et  Pathologique. 
Archiv  fuer  Anatomic  und  Physiologic. 

Archiv  fuer  die  Gesammtc  Physiologic  dcr  Mcnschcn  und  Thicre. 
Archiv  fuer  Path.  Anatomic,  Physiologic,  und  fuer  Klin.  Medicin. 
Archiv  f.  Psychiatric  u.  Ncrvenkrankheiten. 
Archivio  Italiano  per  le  Malatie  Ncrvosc. 
Brain. 

British  Medical  Journal. 
Bulletin  Generalc  dc  Therapeutique. 
Ccntralblatt  f.  d.  Med.  Wissenschaftcn. 
Ccntralblatt  f.  d.  Ncrvenhcilk.,  Psychiatric,  etc. 
Cronica  Med.  Quirurg.  dc  la  Habana. 
Deutsche  Mcdicinische  Wochcnschrift. 
Deutsches  Archiv  f.  Geschichte  dcr  Medicin. 
Dublin  Journal  of  Medical  Science. 
Edinburgh  Medical  Journal. 
Gazetta  dcgli  Ospitali. 
Gazetta  del  Frenocomio  di  Reggio. 
Gazetta  Medica  di  Roma. 
Gazette  dcs  Hopitaux. 
Gazette  Medicale  dc  Strasbourg.. 
Hospitals-Tidcndc. 
Hygeia. 

Jahrbiichcr  fur  Psychiatric. 
Journal  de  Medecinc  dc  Bordeaux. 
Journal  de  Medecinc  et  dc  Chirurgie  Pratiques. 
Journal  of  Mental  Science. 
Journal  of  Physiology. 
La  France  Medicale. 
Le  Progres  Medical. 
Lo  Sperimcntalc. 
L'Union  Medicale. 
Mind. 

Nordiskt  Medicinskt  Arkiv. 
Norsk  Magazin  for  Lagcnsvidcnskabcns. 
Practitioner. 

Revue  MensucUc  de  Medecinc  et  dc  Chirurgie. 
Rivista  Clinica  di  Bologna. 

Rivista  Spcrimentale  di  Frcniatria  e  di  Medicina  Legale. 
Schmidt's   Jahrbucher  dcr   In-   und    Auslandischcn   Gesammten 

Medicin. 


PERIODICALS  RECEIVED.  1 99 


St.  Petersburger  Med.  Wochenschrift. 
Upsala  Lakarefornings  Forehandlinger. 


THE    FOLLOWING   DOMESTIC   EXCHANGES   HAVE   BEEN 
RECEIVED  : 

Alienist  and  Neurologist. 

American  Journal  of  Insanity. 

American  Journal  of  Medical  Sciences. 

American  Journal  of  Obstetrics. 

American  Journal  of  Pharmacy. 

American  Medical  Journal. 

American  Practitioner. 

Annals  of  the  Anatomical  and  Surgical  Society. 

Archives  of  Comp.  Med.  and  Surgery. 

Archives  of  Dermatology. 

Archives  of  Medicine. 

Atlanta  Medical  and  Surgical  Journal. 

Boston  Medical  and  Surgical  Journal. 

Buffalo  Medical  Journal. 

Bulletin  National  Board  of  Health. 

Canada  Medical  and  Surgical  Journal. 

Canada  Medical  Record. 

Canadian  Journal  of  Medical  Sciences. 

Chicago  Medical  Journal  and  Examiner. 

Chicago  Medical  Review. 

Chicago  Medical  Times. 

Cincinnati  Lancet  and  Clinic. 

Clinical  News. 

College  and  Clinical  Record. 

Country  Practitioner. 

Detroit  Lancet. 

Dial. 

Gaillard's  Medical  Journal. 

Independent  Practitioner. 

Index  Medicus. 

Indiana  Medical  Reporter. 

Maryland  Medical  Journal. 

Medical  and  Surgical  Reporter. 

Medical  Annals. 

Medical  Brief. 

Medical  Herald. 

Medical  News  and  Abstract. 

Medical  Record. 

Michigan  Medical  News. 

Monthly  Review. 

Nashville  Journal  of  Medicine. 

Neurological  Contributions. 


200  PERIODICALS  RECEIVED. 

New  Orleans  Medical  and  Surgical  Journal. 

New  Remedies. 

New  York  Medical  Journal. 

Pacific  Medical  and  Surgical  Journal. 

Philadelphia  Medical  Times. 

Physician  and  Bulletin  of  the  Medico-Legal  Society. 

Physician  and  Surgeon. 

Proceedings  of  the  Medical  Society  of  the  County  of  Kings. 

Quarterly  Epitome  of  Braithwaite's  Retrospect. 

Quarterly  Journal  of  Inebriety. 

Rocky  Mountain  Medical  Review. 

Sanitarian. 

Science. 

Southern  Clinic. 

Southern  Practitioner. 

Specialist  and  Intelligencer. 

St.  Joseph  Medical  and  Surgical  Reporter. 

St.  Louis  Clinical  Record. 

St.  Louis  Courier  of  Medicine. 

St.  Louis  Medical  and  Surgical  Journal. 

Therapeutic  Gazette. 

Toledo  Medical  and  Surgical  Journal. 

Veterinary  Gazette. 

Virginia  Medical  Monthly. 

Walsh's  Retrospect. 


Vol.  VIII.  APRIL,    1881.  No.  2. 

THE 

Journal 

OF 

Nervous  and  Mental  Disease 


©rigmal  Jirticlts. 


A  CASE  OF    RAPID  AND  WIDESPREAD  MUSCU- 
LAR WASTING  WITHOUT  DISEASE 
OF  THE  SPINAL  CORD. 

By  J.  J.  PUTNAM,  M.  D., 

BOSTON. 

THE  patient  whose  history  is  the  subject  of  this  paper 
entered  the  Massachusetts  General  Hospital  in 
May,  1879,  undei*  the  care  of  Dr.  S.  L.  Abbot,  who  very 
kindly  allowed  me  to  see  and  investigate  the  case,  and  sub- 
sequently to  examine  the  spinal  cord,  and  now  permits  me 
to  make  full  use  of  his  clinical  notes.  My  thanks  are  due 
both  to  him  and  to  his  then  clinical  assistant,  Dr.  W.  P. 
Gannett. 

The  essential  features  of  the  patient's  last  illness  were  as 
follows  :  It  was  an  acute  febrile  attack,  ending  fatally  in 
about  one  month,  and  characterized  by  severe  pain,  diminu- 
tion of  sensibility,  rapid  muscular  wasting,  and  diminution 
of  electrical  irritability  in  all  four  extremities,  mainly  con- 
fined to  the  parts  below  the  elbows  and  the  knees,  also  by 
alteration  of  the  mental  condition,  and  delirium. 

After  death,  spots  of  softening  were  found  in  the  great 
ganglia  of  the  brain  and  in  the  centrum   semiovale.     The 

201 


202  J.   J.   PUTNAM. 

spinal  cord  was  essentially  healthy.  The  peripheral  nerves 
were  not  examined,  but  the  inference  is  drawn  that  the  case 
was  one  of  disseminated  neuritis. 

The  following  are  the  details  of  the  case : 

Margaret  C,  married,  50  years  old,  was  admitted  to  the  Massa- 
chusetts General  Hospital  May  22,  1879,  and  gave  the  following 
history  : 

She  had  always  been,  well,  as  she  thought,  until  three  weeks  be- 
fore entrance.  At  that  time  she  became  chilly  and  feverish,  and 
supposed  herself  to  have  taken  cold.  She  was  attacked  at  the 
same  time  with  severe  pain,  which  began  in  the  toes  of  both  feet, 
but  extended  over  the  entire  body.  The  use  of  the  legs  became 
progressively  impaired,  and  the  hands  also  grew  so  weak  that  in 
the  course  of  two  weeks  she  became  unable  to  hold  anything  in 
her  grasp.  She  had  been  obliged  to  keep  her  bed  from  the  first  of 
the  attack,  and  her  sleep  had  been  much  disturbed  by  pain.  No 
nourishment  could  be  retained  except  milk. 

On  examination  there  was  found  to  be  no  swelling  of  the  joints  ; 
a  good  deal  of  general  tenderness  on  pressure,  not  sharoly  local- 
ized ;  motion  at  the  wrist  and  ankle  and  phalangeal  joints  was 
found  to  be  greatly  impaired,  and  the  cutaneous  sensibility  of  the 
skin  over  the  feet  and  ankle  joints  diminished.  Auscultation  of 
the  heart  revealed  nothing  abnormal.  No  reflex  movement  could 
be  excited  by  tickling  the  soles  of  the  feet.  The  temperature 
was  100.1°  (F.)  ;  pulse,  no  ;  respiration,  30.  Milk  was  ordered 
in  small  quantities,  and  salicyl.  soda,  grs.  x,  every  hour,  p.  r.  n. 

The  subsequent  history  of  the  case  is  as  follows : 

May  23d. — Much  pain  during  night.  Was  given  Dover's  pow- 
der, grs.  X.     The  catamenia  appeared  during  the  night. 

May  24th. — Was  somewhat  delirious  and  quite  restless  through 
the  night,  and  is  still  slightly  so.  Complains  of  pain  and  burning 
in  the  feet,  but  they  are  not  swollen  or  tender. 

May  25th. — Delirious  during  night  ;  nearly  free  from  pain  and 
delirium  this  morning.    Tongue  dry  in  centre,  furred  on  both  sides. 

May  26th  to  31st. — No  marked  change. 

The  report  of  the  examination  of  the  urine  (Prof.  E.  S, 
Wood)  is  as  follows  : 

Urine. — Acid;  yellow;  sp.  grav.  1017  ;  urophain  slightly  di- 
minished ;  indican  and  urea  normal  ;  uric  acid  in  excess. 


A  CASE  OF  MUSCULAR   WASTING.  203 

Earthy  phosphates  normal.  Alkaline  phosphates  slightly  in- 
creased. A  slight  trace  of  albumen.  Considerable  sediment 
containing  numerous  hyaline  and  granular  casts,  considerable  uric 
acid,  excess  of  mucus,  a  little  blood,  clumps  of  pus,  much  bladder 
and  vaginal  epithelium.  Some  of  the  casts  have  highly  refracting 
granules  on  them. 

May  31st  to  June  2d. — Complains  of  no  pain  except  in  feet. 
No  tenderness  or  other  abnormal  sign  about  vertebral  column.  A 
subcutaneous  injection  of  pilocarpine  (gr.  Yi)  yesterday  caused  a 
profuse  sweat. 

Her  present  condition  is  as  follows: 

All  movements  of  the  arms  at  the  shoulder  and  elbow,  and  of 
the  legs  at  the  thigh  and  knee,  are  possible,  though  but  slowly 
and  feebly  performed.  There  is  no  voluntary  or  reflex  move- 
ment of  the  fingers  and  hands,  nor  of  the  feet  and  toes.  The 
movements  of  the  head  are  apparently  free. 

There  is  well-marked  loss  of  sensibility  of  the  skin  of  all  four" 
extremities,  especially  of  the  arms  below  the  elbows,  and  of  the 
legs  below  the  knees,  the  intensity  of  the  anaesthesia  increasing 
the  nearer  the  feet  are  approached. 

Within  these  areas  neither  contact  of  the  finger  nor  moderately 
strong  applications  of  electricity  excite  any  sensation.  Applied 
to  other  parts  of  the  arms  or  legs,  such  currents  cause  manifesta- 
tions of  pain. 

The  arms  are  usually,  though  not  invariably,  somewhat  flexed, 
and  the  biceps  rigid. 

Under  these  circumstances  the  biceps  can  be  excited  to  con- 
traction by  sudden,  passive  stretching. 

The  results  of  the  electrical  examination  at  this  date 
were  as  follows : 

Left  arm ;  faradic  current;  the  reaction  of  the  ulnar  and 
musculo-spiral  nerves,  and  of  the  muscles  supplied  by  them,  is 
preserved  but  greatly  diminished.  The  biceps  and  triceps  react 
better,  though  hardly  as  well  as  normal. 

The  reaction  of  the  median  nerve,  and  of  all  the  muscles  sup- 
plied by  it,  as  well  as  that  of  the  interosseous  muscles,  is  entirely 
wanting. 

Galvanic  currerit.  The  typical  degenerative  reaction  is  no- 
where present.     Strong  currents,  however,  elicit  feeble  contractions 


204  J-   J-  PUTNAM. 

from  most  or  all  of  the  muscles,  if  applied  directly  ;  not,  however, 
through  the  medium  of  their  nerves,  except  in  the  case  of  the 
median.  However  excited,  the  contractions  are  quick  and  short 
in  character. 

The  condition  of  the  right  arm  is  essentially  the  same  with  that 
of  the  left. 

Left  (and  right)  leg  j  faradic  current.  The  reaction  of  the 
quadriceps  ext.  cruris  group  and  of  the  hamstring  muscles  is 
preserved,  though  only  the  feeblest  contractions  can  be  excited. 

When  applied  to  the  peroneal  nerve  even  the  strongest  currents 
fail  to  excite  any  contraction  in  the  corresponding  muscles. 

A  strong  galvanic  current,  on  the  other  hand,  applied  to  the 
same  nerve,  excites  marked  though  feeble  contractions  in  all  the 
muscles  supplied  by  it.  These  contractions  appear  and  disappear 
more  slowly  than  normal. 

Strong  galvanic  currents  applied  directly  also  excite  contractions 
in  these  same  muscles.  These  contractions  likewise  are  slower 
than  normal,  and  if  repeatedly  excited  their  intensity  becomes 
rapidly  less  (reaction  of  exhaustibility). 

The  muscles  of  the  back  and  of  the  neck  react  apparently  well. 

All  the  muscles  of  the  body,  but  especially  those  which  have 
lost  their  faradic  reaction,  are  extremely  feeble.  The  interosseous 
muscles,  as  well  as  the  long  flexors  of  the  fingers,  are  noticeably 
atrophied. 

All  the  reflexes  (except  that  of  the  biceps  above  alluded  to), 
including  also  the  reflex  of  the  abdominal  muscles,  and  the  con- 
junctival reflex,  are  wanting.  The  corners  of  the  mouth  are  drawn 
down,  giving  the  face  a  haggard  expression  ;  but  this  may  be 
partly  due  to  the  fact  that  the  patient  is  drowsy  and  but  semi- 
conscious. 

The  fundus  of  the  right  eye,  examined  with  the  ophthalmoscope, 
shows  no  abnormal  appearance. 

Passive  movements  of  the  arms  and  legs  cause  decided  ex- 
pressions of  pain. 

The  patient  lies  groaning  without  interruption,  though  she  can 
be  aroused  by  the  sound  of  her  name,  etc.,  when  her  face  often 
breaks  into  a  senseless  smile. 

The  pupils  are  equal  and  about  normal  in  size  ;  they  respond 
slightly,  though  promptly  enough  to  light. 

June  4th.  Condition  the  same.  Patient  lies  in  a  stupefied  con- 
dition, but  can  be  aroused  without  much  difficulty,  and  says  she 
has  no  pain. 


A  CASE  OF  MUSCULAR   WASTING. 


205 


June  6th.  Since  the  last  report  the  patient  has  failed  very  rap- 
idly. Cannot  now  be  aroused.  Swallows  a  little  brandy  and 
water  with  much  choking.  Passes  urine  involuntarily,  as  she  has 
for  several  days. 

The  patient  sank  rapidly  during  the  following  night,  and  died 
quietly  at  4.15  a.m.  of  the  7th,  the  temperature  having  risen 
through  the  past  two  days,  reaching  107°  an»hour  before  death. 

The  temp,  (axillary)  chart  of  the  greater  part  of  the  sickness 
was  as  follows  : 


Temp 

•  (F.). 

Pulse. 

Resp. 

Date. 

A.M. 

P.M. 

A.M.            P.M. 

A.M.             P.M. 

May  22d 

100.4° 

no 

—          30 

"     23d 

100° 

99' 

no           100 

21           24 

"     24th     . 

98.7° 

98.7° 

no           102 

20           25 

"     25th 

98.6" 

99° 

100           108 

20           25 

"     26th     . 

98° 

104" 

106           104 

20          30 

"     30th 

ICO° 

102° 

no           140 

17           30 

"     31st     . 

100' 

102° 

108           120 

30           34 

June     2d 

101° 

102.4° 

no           128 

28           32 

Noon. 

Midnight. 

Noon.       Midnight. 

Noon.       Midnight. 

"      6th     . 

105.2'' 

3    A.M 

106.4° 

no           140 

34           39 

"       7th         . 

107' 

] 

)eath  at  4.15  a.m. 

The  treatment  employed  (salicylic  acid  at  first,  subse- 
quently brom.  pot.  and  other  palliatives,  moderate  alco- 
holic stimulation,  milk)  had  the  effect  of  keeping  excite- 
ment, pain  and  fever  down  to  a  moderate  point,  and  in 
view  of  the  acute  softening  in  the  brain,  discovered  post 
mortem,  it  is  im.probable  that  death  was  directly  hastened 
by  any  of  these  conditions. 

At  the  autopsy,  which  was  made  by  Dr.  R.  H.  Fitz,  the 
organs  of  the  chest  and  abdomen  were  found  to  present  no 
abnormal  appearance.  The  kidneys  were  not  further  exam- 
ined, but  the  condition  of  the  urine,  together  with  the  fact 
that  the  arteries  throughout  the  spinal  cord  were  subse- 
quently found  notably  thickened,  suggest  that,  nevertheless, 
some   degree  of   disease  may  have  been   present   in  them. 


2o6 


J.   y.  PUTNAM. 


Examination  of  the  brain  revealed  the  presence  of  a  num- 
ber of  spots  of  softening,  of  yellowish  color,  varying  in  size 
from  that  of  a  marble  to  that  of  a  pea.  The  largest  of 
these  spots  lay  in  the  upper  portion  of  the  white  substance 
of  the  left  parietal  lobe,  and  the  tissue  round  it  was  red- 
dened. 

In  the  right  optic  thalmus  and  left  corpus  striatum  were 
similar  spots  of  rather  smaller  size,  and  the  posterior  third 
of  the  outer  division  of  the  nucleus  lenticularis  on  both 
sides  showed  evident  microscopic,  though  but  slight  macro- 
scopic signs  of  a  somewhat  ill-defined  process  of  the  same 
kind,  in  the  presence  of  numerous  granular  corpuscles  such 
as  the  larger  spots  also  contained. 

The  internal  capsule  was  but  little  if  at  all  involved,  and 
that  in  its  posterior  part. 

The  spinal  cord  was  not  removed  until  the  following 
morning,  and,  owing  no  doubt  to  that  cause,  the  subse- 
quent processes  of  hardening  (by  Miiller's  fluid)  and  color- 
ing were  not  so  satisfactory  as  could  have  been  wished,  and 
there  was  difificulty  in  making  as  thin  sections  as  were  de- 
sired. Still,  with  the  aid  of  Rutherford's  freezing  micro- 
tome and  the  methods  of  hardening  in  mucilage,  specimens 
were  obtained  which  permitted  of  careful  microscopic  study. 

Before  hardening,  cuts  were  made  into  the  cord  at  short 
intervals,  but  no  departure  from  the  normal  appearances 
could  be  discovered.  The  membranes  seemed  everywhere 
healthy.  After  the  specimen  had  lain  for  a  day  in  Miiller's 
fluid,  the  surface  of  several  of  the  cuts,  both  in  the  cervical 
and  lumbar  enlargement,  was  scraped,  and  fine  specimens 
of  ganglion  cells  obtained.  Of  these  almost  all  contained 
more,  sometimes  much  more,  pigment  than  is  usually  met 
with,  but  they  presented  no  appearance  that  was  distinctly 
pathological.  Neither  was  any  abnormal  condition  of  the 
nerve  fibres  to  be  made  out. 


A   CASE  OF  MUSCULAR   WASTING.  20/ 

On  examination  of  the  hardened  cord  one  pathological 
change  was  everywhere  visible,  namely,  thickening  of  the 
walls  of  the  arteries,  and  there  was  also,  in  the  cervical  re- 
gion, a  very  slight  increase  in  the  connective  tissue  of  one 
of  the  lateral  columns,  giving  rise  to  a  slightly  heightened 
blush  in  the  carmine-stained  sections.  This  change  did  not 
extend  through  the  whole  length  even  of  the  cervical  cord, 
most  of  the  sections  showing  no  trace  of  it.  As  it  was 
thought  to  be  of  but  little  significance  no  attempt  was 
made  to  define  its  limits. 

The  ganglion  cells  of  the  anterior  cornua  were  normal 
both  in  number  and  outline.  They  contained,  as  stated, 
more  pigment  than  usual,  failed  to  take  up  the  carmine 
readily,  and  in  a  few  of  them  small  vacuoles  were  found. 

No  great  importance  could  be  attached  to  the  loss  of  re- 
action to  the  carmine  in  the  absence  of  other  signs  of  dis- 
ease, since  this  may  well  have  been  due  to  the  same  putre- 
factive changes  that  prevented  hardening,  the  more  so  that 
the  other  cellular  elements  of  the  cord  were  in  the  same  con- 
dition in  this  respect. 

The  formation  of  the  small  vacuoles  may  have  been  due 
to  disease,  but  it  also  may  have  been  due  to  putrefactive 
changes,  and  at  any  rate  the  number  of  the  cells  affected  in 
this  way  was  too  small  to  account  for  the  widespread  mus- 
cular atrophy. 

Of  the  condition  of  \}s\^  peripheral  nerves  and  of  the  mus- 
cles I  am,  unfortunately,  unable  to  speak.  A  portion  of 
the  peroneal  nerve  and  of  one  of  the  diseased  muscles  was 
reserved  for  examination,  but  was  accidentally  thrown  away. 
To  the  naked  eye  the  nerve  seemed  to  have  undergone  no 
change  whatever,  either  in  size,  consistency  or  color. 

The  symptom  which  presents  the  most  interest  in  this 
unusual  case,  and  for  which  we  might  have  expected  the 
most  readily  to   find   an   explanation  through  the  post-mor- 


208  y.   y.  PUTNAM. 

tern  examination,  is  the  rapid  muscular  atrophy,  associated, 
as  it  was,  with  great  diminution  or  entire  loss  of  electrical 
reaction  of  the  affected  nerves  and  muscles.  Only  so  far 
as  the  pathological  changes  that  were  actually  discovered 
may  be  taken  as  a  guide,  the  lesion  which  brought  about 
this  result  must  have  had  its  seat  either  in  the  muscles 
themselves  or  in  the  peripheral  nerves,  and,  as  a  matter  of 
fact,  the  clinical  picture  was  closely  like  those  presented  by 
most  of  the  cases  quoted  and  reported  by  Leyden  in  his 
recent  admirable  paper,*  or  others  given  in  the  thesis  of 
Dr.  J.  Gros,f  and,  indeed,  in  the  case  given  at  greatest 
length  by  Leyden  (p.  40),  and  in  one  or  two  of  those 
quoted  from  others,  just  such  slight  changes  in  the 
spinal  cord  were  found  (formation  of  small  vacuoles,  in- 
crease of  pigmentation)  as  in  this  case,  and  good  reasons 
are  offered  for  thinking  that  they  were  secondary  and  of 
little  moment. 

The  diagnosis  by  exclusion  speaks  likewise  with  great 
positiveness  either  for  disseminated  neuritis  or  for  a  myositis 
with  secondary  involvement  of  the  mixed  nerves.  The 
idea  could  not  be  entertained  that  the  lesions  in  the  cere- 
bral ganglia  might  account  for  the  pain  and  the  rapid  atro- 
phy ;  the  cord  was  essentially  healthy  ;  there  remains  only 
the  nerves  and  the  muscles  themselves  to  consider.  That 
all  the  symptoms,  even  including  the  pain,  might  be  due  to 
an  acute  myositis  is  not  to  be  denied  on  a  priori  grounds  ; 
but  we  are,  perhaps,  bound  to  exhaust,  first,  the  better  ac- 
cepted hypothesis,  which  favors  the  neurotic  origin  of  such 
cases  as  this.  It  remains,  at  the  same  time,  to  be  said  that 
since,  in  all  the  cases  quoted,  the  muscles  as  well  as  their 
nerves  were  found  diseased,  it  is  somewhat  a  begging  of  the 
question  to  say  that  the  nerves  were  certainly  primarily  at 
fault. 

*  Ueber  Poliomyelitis  und  Neuritis.    Zeitschr.  Jiir  Kliri.  Med.,  Bd.  i,  Hf.  3. 
f  Contrib.  a  I'liistoire  des  nevrites.      Paris,  1879. 


A  CASE  OF  MUSCULAR   WASTING.  209 

At  any  rate,  if  the  disease  begins  in  the  nerves  it  does  so 
usually  at  their  peripheral  extremities.  Thus,  in  this  case, 
as  in  very  many  of  those  which  have  been  reported,  the 
severest  symptoms  affected  not  all  the  muscles  or  sur- 
faces of  skin  supplied  by  one  great  nerve  trunk,  but  the 
parts  furthest  removed  from  the  central  organs,  irrespective 
of  the  source  of  the  nerve  supply, — the  legs  below  the  knee, 
the  arms  below  the  elbow,  and  of  these  the  feet  and  the 
hands  more  than  the  forearms  and  the  legs. 

As  regards  the  changes  of  sensibility,  this  rule  was  in  our 
case  most  striking,  and  the  same  is  true  of  some  of  the  cases 
reported  by  others.    Thus,  in  one  quoted  by  Gros*  we  read  : 

"  24  fevr.  Depuis  quelques  jours,  le  malade  se  plaint  de 
douleurs  tres  vives,  exclusivements  localisees  aux  deux 
pieds,"     *     *     *     etc. 

"  5  mars.  Toujours  des  memes  douleurs  aux  membres 
inferieurs.  Diminution  de  la  sensibilite.  Tous  ces  symp- 
tomes  restent  Hmites  aux  pieds  et  aux  regions  mall^olaires. 
Depuis  deux  jours,  il  accuse  des  douleurs  de  la  meme  nature 
dans  la  paume  de  la  main  du  cote  gauche."     *     *     * 

In  another  place  (p." 51):  "  Elle  (la  sensibilite)  est  abolie 
completement  dans  les  pieds,  dans  la  region  externe  des 
jambes,  c'est-a-dire  dans  le  domaine  du  nerf  saphene  externe 
et  dans  les  brariches  terminales  des  atitres  nerfs!' 

It  is  not,  however,  always  the  case  that  the  peripheral 
distribution  of  several  nerves  is  simultaneously  and  exclu- 
sively involved,  so  much  so  that  Gros  lays  it  down  as  one  of 
the  diagnostic  marks  of  the  affection  that  the  symptoms, 
both  sensitive  and  motor,  predominate  in  the  distributioh 
of  one  or  more  nerves. 

I  hope  soon  to  bring  further  evidence  in  favor  of  the 
opinion  which  I  expressed  some  years  ago,  that  whether  we 
are   dealing   with  diseases   of    muscles,   nerves    or    (motor) 

*  Loc.  cit.,  p.  61. 


2IO  J.   J.  PUTNAM. 

nerve  nuclei,  the  types  of  disease  are  apt  to  be  the  same, 
showing  a  greater  vulnerability  on  the  part  of  certain  mus- 
cles, their  corresponding  nerve  fibres  and  their  corresponding 
nerve  nuclei,  than  is  shown  by  their  fellows.  It  is  my  belief 
that  this  may  hold  good  of  the  sensitive  tracts  as  well, 
and  that  this  general  law  will  render  clear  the  recurrence  of 
certain  types  of  diseases  involving  alterations  of  sensibility 
and  muscular  nutrition  better  than  any  simply  topographi- 
cal explanation. 

The  admission  of  disseminated  neuritis  into  our  nosolo- 
gies opens  a  wide  field  for  study,  the  limits  of  which  are 
well  defined  in  the  monographs  to  which  I  have  referred. 
The  differential  diagnosis  has  to  take  account,  not  only  of  the 
so-called  ascending  spinal  paralysis  of  Landry,  of  poliomye- 
litis, perhaps  progressive  muscular  atrophy  (Leyden)  and 
lead  paralysis  of  rapid  onset  (of  which  I  have  recently  seen 
a  striking  illustration),  but  even  of  meningitis,  as  is  pointed 
out  by  Gros  (p.  53). 

It  is  possible  that  the  following  case  will  prove  to  be  an 
illustration  of  this  fact : 

A  patient  died  last  summer  at  the  Massachusetts  General 
Hospital,  under  the  care  of  Dr.  B.  S.  Shaw,  who  kindly  al- 
lowed me  to  examine  the  case  and  the  specimens,  who, 
throughout  her  sickness,  showed  marked  symptoms  of  acute 
meningitis,  viz.,  extreme  pain  in  the  neck,  the  back  and  the 
limbs,  greatly  increased  on  even  the  slightest  movement, 
fever  and  muscular  paralysis,  which  improved  after  a  time 
with  marked  wasting,  especially  in  certain  groups  of  muscles. 
At  the  autopsy  no  sign  of  meningitis  was  present. 

The  cord  has  not  yet  been  examined  microscopically,  but 
seemed  to  contain  minute  scattered  foci  of  inflammation. 

The  pain,  which  was  the  marked  feature  of  the  whole 
case,  could  hardly  be  explained  by  the  trifling  disseminated 
myelitis,  if  this  proves  to  be  present,  while  the  latter  could 
well  have  been  secondary  to  an  acute  neuritis. 


CONTRIBUTIONS    TO    THE  PHYSIOLOGY    OF 

THE  SPINAL  CORD  AND  ADJACENT 

PARTS. 

By  Geo.   B.  WOOD  FIELD,  M.D., 

EASTON,  PENN. 

THE  nervous  system  has  lately,  through  the  researches 
of  Fritsch,  Hitzig  and  Ferrier,  been  the  subject  of 
much  observation  and  experiment.  The  path  of  the  con- 
ductors of  sensation  and  motion  in  the  spinal  cord  has  been 
and  is  still  an  object  about  which  much  discussion  exists. 
Alexander  Walker,  in  1809,  first  started  the  idea  that  the 
posterior  columns  contained  the  motor  conductors,  whilst 
the  anterior  columns  contained  the  sensory.  It  was  held  by 
Galen,  Flourens,  Nasse,  Longet,*  Kurschner,  Volkmann 
and  Chauveau  that  the  conductors  of  voluntary  movement 
and  sensibility  did  not  decussate.  Brown-Sequard  and 
Budge  believed  the  conductors  of  voluntary  movement  did 
not  decussate,  but  that  the  conductors  of  sensory  impres- 
sions did  in  part. 

Lately,  Brown-Sequard  explains  this  sensory  decussation 
in  another  way.  Van  Kempenf  held  that  the  transmission 
of  voluntary  movement  in  animals  is  direct  in  each  half  of 
the  spinal  cord,  and  that  it  is  partly  crossed  in  the  cervical 

*  Nerven  System,  Leipzig,  1849. 

f  Experiences    Physiologiques   sur   la  Transmission    de  la  Sensibilite,  et  du 
Mouvement  dans  Moelle  Epinere,  Bruxelles,  1859. 


2  12  GEO.   B.    WOOD  FI^LD. 

region;  that  the  transmission  of  sensibiHty  in  the  spinal 
cord  is  partly  crossed  throughout  the  whole  extent  of  the 
cord. 

Fodera,  Cooper,  Kolliker  and  Eigenbrodt"  arrived  at  the 
conclusion  that  the  conductors  of  motion  and  sensation 
partly  decussate.  The  opposite  views  were  thought  to  re- 
sult from  the  different  animals  experimented  upon,  but  Von 
Bezold-f  proved  this  to  be  an  error.  Schiff:}:  arrived  at  the 
conclusion  that  the  antero-lateral  columns  conduct  motion 
and  not  sensation,  and  that  the  gray  matter  conducts  painful 
sensations,  whilst  the  posterior  columns  conduct  tactile  im- 
pressions. Ludwig  '■  and  his  pupils,  Miescher,  Nawrocki 
and  Dittmar,  held  that  in  the  rabbit  all  the  sensory  and 
efferent  vaso-motor  fibres  are  contained  in  the  lateral 
columns. 

Woroschiloff  §  was  able,  by  means  of  a  specially  devised 
instrument,  to  divide  the  spinal  cord  in  different  extents 
with  the  least  possible  injury  to  the  undivided  parts.  He 
proved  that  in  the  lumbar  segment  of  the  cord  of  the 
rabbit  all  the  sensory  and  motor  fibres  run  in  the  lateral 
columns.  Ott  and  Smith^  have,  by  means  of  Woroschiloff's 
instrument,  shown  that  in  the  cervical  segment  of  the  spinal 
cord  the  sensory,  vaso-motor,  motor,  cilio-spinal  and  respira- 
tory nerves  run  in  the  lateral  columns  ;  that  the  posterior 
columns  are  concerned  in  coordination,  and  that  the  motor 
and  sensory  fibres  in  the  cervical  segment  partly  decussate. 
Ott  has  shown,  by  the  pupil  and  bleeding  tests,  that  tactile 
fibres  not  only  run  in  the  posterior  columns,  but  also  in  the 
lateral    columns ;  that    inhibitory   fibres    run   in    the   lateral 

*Uber  die  Leitungegesetze  im  Riickenmarke,  Giessen,  1848. 
f  Untersuchungen    aus    dem    Phybiologischeii    Laboratorium    im    Wurzburg, 
und  Uber  die  gekreuzten  Wirkungen  des   Riickenmarkes,  Leipzig,  iS6g, 
X  Lehrbuch  die  phy.siologie  des  Menschen,  Jahr,  1859. 
I  Ludwig's  Arbeilen.  §  Ludwig's  Arbeiten. 

^:Am.  Med.  Jotirnal,  October,  1879. 


PHYSIOLOGY  OF  THE  SPINAL  CORD.  213 

columns  and  decussate,  and  that  sweat  fibres  also  run  in  the 
lateral  columns. 

Recently,  Schiff  has  returned  to  the  subject  of  the  spinal 
cord,  holding  that  the  Leipzig  School  and  its  followers  have 
been  misled  by  traumatisms  ;  that  the  anterolateral  columns 
are  unable  to  transmit  any  sensory  impulses,  whilst  sensa- 
tions of  pain  are  conveyed  by  the  gray  matter.  He  used 
dogs,  and  permitted  them  to  live  for  a  long  time,  and  after 
death  made  sections  of  the  cord,  which  he  examined  with  a 
polarizing  apparatus. 

N.  Weiss  {Ce?itralb!att,  1880,  No.  29)  has  arrived  at  com- 
pletely opposite  conclusions  to  those  put  forth  by  Schiff. 
He  also  used  dogs,  and  made  sections  at  the  junction  of 
the  lumbar  and  dorsal  segment  of  the  spinal  cord.  In  a 
young  dog  the  cord  was  cut  so  that  only  the  left  lateral 
and  left  anterior  columns  were  intact,  the  whole  of  the  gray 
matter,  right  half  of  the  cord,  and  left  posterior  column 
being  divided.  It  was  found  that  the  dog  had  sensibility 
in,  and  could  move,  both  posterior  extremities.  The  con- 
clusion necessarily  followed  that  one  lateral  column  con- 
tains sensory  and  motor  fibres  for  both  halves  of  the  body. 
If  the  lateral  columns  are  divided  on  both  sides,  then  the 
sensibility  and  motility  is  lost  behind  the  section  in  a  com- 
plete manner,  so  that  there  is  no  reason  to  regard  the  gray 
matter  as  conducting,  for  any  distance,  either  motion  or 
sensation.  He  holds  that  the  anterior  columns  do  not  con- 
duct either  sensibility  or  motion,  and  confirms  completely 
the  experiments  of  Woroschiloff  and  those  of  Ott,  that  the 
lateral  columns  only  contain  motor  and  sensory  fibres,  Ott 
believing  with  Schiff  that  the  posterior  columns  contain 
tactile  fibres.  Further,  the  polarizing  tests  are,  to  my 
mind,  by  no  means  so  conclusive  as  those  made  by  micro- 
scopic   section.     Prof.    F.   Schultze*  has  made    some  very 

*  PJlugers  Archiv,  Bd.  22. 


2  14  GEO.  B.    WOOD  FIELD. 

pertinent  experiments  with  the  polarizer,  which  cause  con- 
siderable doubt  to  exist  as  to  the  value  of  this  method  of 
investigation.  I  cannot  see  what  traumatisms  have  done 
where  I  have  divided  everything  except  one  lateral  column, 
and  the  animal,  a  few  hours  afterward,  had  sensibility  and 
voluntary  movement.  There  is  no  need  of  allowing  the 
animal  to  live  in  order  to  show  that  the  lateral  columns 
conduct  motion  and  sensation.  That  the  traumatisms 
might  not  affect  other  results,  I  made  experiments  on 
animals  who  lived  for  a  considerable  time. 

Method. — Kittens  were  selected,  etherized,  and  the  cord 
bared  at  the  junction  of  the  dorsal  and  lumbra  vetebrae ;  the 
skin  was  divided  vertically  in  the  median  line,  the  tissues 
on  each  side  of  the  spinous  processes  of  the  vertebrae  being 
held  away  by  weighted  hooks.  The  spinous  process  was 
denuded  by  a  sharp  scraper,  and  snipped  off  with  a  pair  of 
bone  forceps.  After  this,  the  transverse  processes  were 
carefully  denuded  of  their  soft  tissues,  and  the  vertebrae 
broken  down  with  a  bone  forceps  and  knife,  the  bones  of 
the  kitten  being  quite  soft.  The  spinal  dura  mater 
was  now  exposed,  and  divided  by  a  forceps  and  small 
knife.  The  columns  of  the  cord  were  then  divided  by  a 
Cooper  bistoury.  Any  hemorrhage  following  was  checked 
with  absorbent  cotton.  The  wound  was  closed  with 
thread  sutures,  and  the  animal  allowed  to  recover  and 
live  as  long  as  possible.  After  its  death,  the  cord  was 
carefully  removed,  immersed  for  a  short  time  in  alcohol, 
and  then  in  a  weak  solution  of  bichromate  of  ammonium. 
After  hardening,  sections  were  made,  rendered  transparent 
by  oil  of  cloves,  and  mounted  in  Canada  balsam. 

To  estimate  sensibility,  I  used  the  following  test : 
When  the  animal  was  pinched  and  attempted  to  bite,  it 
was  inferred  that  it  had  yet  sensations  of  pain.  Reflex 
movements   were-  carefully    distinguished    from   voluntary 


PHYSIOLOGY  OF  THE  SPINAL  CORD.  21  5 

movements.  To  localize  the  path  of  the  sweat  fibres  in 
the  lateral  columns,  I  etherized  the  cat,  performed  trache- 
otomy, and  laid  bare  the  cord,  not  in  the  lumbar  region, 
but  in  the  dorsal  above  the  origin  of  the  sweat-fibres  run- 
ning in  the  abdominal  sympathetic.  The  cord  was  then 
partially  divided  by  means  of  Woroschiloff's  instrument. 
After  waiting  about  five  hours,  I  divided  the  medulla 
oblongata,  kept  up  artificial  respiration,  and  irritated  the 
lower  end  of  the  cut  medulla  with  a  Du  Bois  apparatus. 
The  appearance  or  absence  of  sweat  on  the  pulps  of  the 
posterior  extremities  was  then  noted.  After  death  the 
cords  were  carefully  removed  and  treated  with  reagents, 
in  the  same  manner  as  has  been  described.  In  the  cat,  the 
sensory  fibres  are  stated  not  to  decussate,  but  the  ap- 
pended experiments  prove  that  they  do  in  part. 

When  I  cut  everything  except  one  right  lateral  column, 
then  sensation  and  voluntary  motion  were  intact. 

Kitten  Experiment  i,  May  9,  1880. 

Everything  cut  except  one  right  lateral  column,  which  remained 
intact. 

May  nth. — Has  no  motion  in  posterior  extremities,  but  has 
sensibility. 

May  1 2th. — Has  voluntary  motion  in  right  posterior  extremity, 
but  none  in  left.  Has  sensibility  in  posterior  extremities.  No 
anal  rhythm. 

May  15th. — Begins  to  use  hind  legs  in  walking  (right  one  most). 
Has  sensibility  in  posterior  extremities. 

May  1 8th. — Can  support  herself  while  standing  on  hind  ex- 
tremities as  well  as  fore,  also  uses  them  in  walking,  although  she 
cannot  coordinate  properly. 

May  2 2d. — Can  run  as  fast,  and  plays  as  lively,  as  any  of  the 
uninjured  cats,  but  cannot  coordinate  as  perfectly,  one  posterior 
extremity  sometimes  getting  twisted  on  the  other. 

May  26th. — Wound  nicely  healed  up.     Runs  around. 

June  4th. — Sensibility  and  voluntary  motion,  with  loss  of  co- 
ordination. 

June  8th. — Died. 


2l6  GEO.  B.    WOOD  FIELD. 

Kitten  Experiment  2,  May  20,  1880. 

Everything  cut  except  one  lateral  column. 

May  2ist. — Sensibility  and  motion  on  right  side  behind  the 
section.     Seems  to  have  a  good  deal  of  pain.     (Cries.) 

May  2 2d. — Tetanic  convulsions  in  morning  ;  in  afternoon  re- 
mained quiet  in  bo.x,  seeming  perfectly  well  and  without  pain. 

May  24th. — Can  support  herself  on  hind  legs  ;  has  a  little 
motion  in  right  hind  leg,  but  more  in  left.  When  she  walks  she 
pulls  or  rather  drags  her  posterior  limbs  after  her. 

May  27th. — No  sensibility  or  motion  in  posterior  extremities  ; 
drags  them  after  her. 

May  30th. — Died. 

Kitten  Experime7it  3,  May  30,  1880. 

Everything  cut  except  one  lateral  column. 

May  31st. — Has  sensibility,  but  no  voluntary  power  in  posterior 
extremities. 

June  I  St. — No  sensibility  or  voluntary  power  in  posterior 
extremities. 

June  7th. — Died. 

When  I  cut  the  lateral  and  posterior  columns,  leaving 
the  anterior  and  gray  matter  intact,  then  no  sensibility 
existed,  but  voluntary  movement  ensued. 

Kitten  Experiment  4,  May  ti,  1880. 

Everything  cut  except  anterior  columns  and  gray  matter. 

May  1 2th. — No  sensibility  or  voluntary  motion  in  hind  ex- 
tremities. 

May  15th. — No  sensibility  or  voluntary  motion  in  posterior 
extremities. 

May  17th. — Has  slight  voluntary  motion  in  posterior  extremities, 
but  cannot  use  them  as  a  support. 

May  i8th. — Still  has  voluntary  motion  in  posterior  extremities, 
which  she  ?noves  in  walking  or  running,  but  cannot  support  her- 
self on  them.     Has  no  sensibility  in  posterior  extremities. 

May  22d. — No  sensibility  or  motion  in  posterior  extremities. 

May  28th. — Died. 

Kitten  Experiment  5,  May  20th. 

Everything  cut  except  anterior  columns  and  adjacent  gray  mat- 
ter. 


PHYSIOLOGY  OF  THE  SPINAL  CORD.  21/ 

May  2ist. — No  sensibility  or  motion  of  posterior  extremities. 
May  2  2d. — Same  as  May  21st. 
May  26th. — Same  as  above. 
May  29th. — Died. 

Kitten  Experiment  6,  May  20th. 

Everything  cut  except  anterior  columns  and  adjacent  gray  mat- 
ter. 

May  2 1  St. — No  sensibility  or  motion  in  posterior  extremities. 

May  2 2d. — Same  as  above. 

May  26th. — Slight  voluntary  power  over  right  hind  foot.  No 
sensibility. 

Evening. — Died. 

Kitten  Experiment  7,  June  2d. 

Everything  cut  except  anterior  columns  and  adjacent  gray  mat- 
ter. 

June  3d. — No  sensibility  or  voluntary  motion  of  posterior  ex- 
tremities. 

June  4th. — No  sensibility,  but  has  slight  voluntary  movement 
in  posterior  extremities. 

June  7th. — Died. 

When  I  divided  the  gray  matter  and  posterior  columns 
then  sensibility  and  motion  were  intact. 

Kitten  Experiment  8,  May  ^oth. 

Gray  matter  and  posterior  columns  divided. 

May  31st. — Has  sensibility  in  both  posterior  extremities,  and 
slight  voluntary  power  in  right  posterior  extremity. 

June  I  St. — Same  as  above. 

June  4th. — No  sensibility  or  voluntary  power  in  posterior  ex- 
tremities. 

June  7th. — Died. 

Kitten  Experiment  9,  J^une  2d. 

Gray  matter  cut. 

June  3d. — Sensibility  in  posterior  extremities,  and  slight  volun- 
tary movement  on  the  right,  side  posteriorly. 
June  4th. — In  a  collapsed  state. 
Evening. — Died. 


2l8  GEO.  B.    WOOD  FIELD. 

These  experiments  prove  that  motor  and  sensory  fibres 
run  in  the  lateral  columns,  that  the  gray  matter  does  not 
conduct  the  sensations  of  pain,  and  that  the  sensory  fibres 
in  part  decussate.  In  these  experiments,  after  section  of 
everything  except  the  anterior  columns  and  the  gray  mat- 
ter, there  was  in  a  few  cases  slight  voluntary  motion.  I  do 
not  believe  the  broken-down  gray  matter  had  any  part  in 
the  conduction  of  voluntary  movement.  The  two  narrow 
bands  adjacent  to  the  anterior  commissure  of  the  cord  are 
the  transmitters  of  voluntary  movement.  It  is  evident  that 
trauma  has  prevented  this  phenomenon  from  taking  place  in 
the  late  experiments  upon  this  subject.  The  section  of  the 
inhibitory  fibres  in  both  lateral  columns  would  explain  the 
usual  absence  of  voluntary  movements  by  the  anterior  col- 
umns in  sonie  experiments.  The  inhibitory  fibres  being 
irritated  depress  the  action  of  the  spinal  ganglia  beneath,  so 
that  they  do  not  respond  to  the  voluntary  impulses  coming 
from  above.  These  observations  are  also  in  accord  with 
evidence  derived  from  pathology,  as  in  "  descending  degen- 
eration," after  an  old  hemiplegia,  there,  the  fibres  are  degen- 
erated in  the  crossed  and  direct  pyramidal  tracts.  The  ob- 
servations of  Flechsig  on  embryos  also  substantiate  these 
observations,  comparative  anatomy,  pathology  and  phys- 
iology being  in  complete  agreement  upon  this  question. 
According  to  the  researches  of  Dr.  Ott  and  myself,  the  fol- 
lowing table  explains  the  conclusions  upon  the  physiology 
of  the  spinal  cord  : 

Posterior  columns  conduct  in  part  tactile  impressions  and  coordi- 
nation impulses. 

Lateral  columns  conduct  vaso-motor  impulses,  voluntary  motion, 
sensations  of  pain  and  partly  tactile  sensibility  ; 
the  inner  half  of  the  middle  third  of  the  lateral 
columns  contain  mainly  the  inhibitory  and 
sudorific  nerves,  the  sudorific  nerves  running 
mainly  anterior  to  the  inhibitory. 


PHYSIOLOGY  OF  THE  SPINAL  CORD.  2ig 

Anterior  columns  conduct  voluntary  motion  in  part. 
Gray  matter  does  not  directly  conduct  any  of  the  above-named 
impressions. 

That  the  tactile  fibres  cannot  be  demonstrated  in  the 
posterior  columns  except  after  bleeding,  does  not  prove  that 
they  are  pathological  phenomena.  I  believe  the  relations 
of  the  phenomena  are  explained  as  follows  :  When  all  the 
spinal  cord  is  divided  except  the  posterior  columns,  all  the 
inhibitory  fibres  have  been  irritated  which  inhibit  the  trans- 
mission of  sensations  below  the  section,  whilst  the  irrita- 
tion of  the  sensory  nerves  by  the  section  calls  into  activity 
the  monarchical  inhibitory  centres  in  the  crura  and  thalami, 
which  restrain  the  passage  of  sensations  above  the  section. 
Now  bleeding  produces  a  state  of  hyperaesthesia,  either  by 
paralysis  of  the  inhibitory  ganglia  or  by  an  excitation  of 
the  spinal  sensory  ganglia.  That  inhibition  is  overcome  in 
the  central  nervous  system  in  some  manner  is  shown  by 
the  rhythm  of  the  sphincters  after  bleeding.  In  experi- 
ments on  the  functions  of  the  posterior  columns,  the  bleed- 
ing in  some  way  antagonizes  the  inhibitions,  and  tactile 
impressions  are  readily  conducted  to  the  brain,  and  the 
animal  moves  when  touched. 

THE    PATH    OF    THE    SWEAT-FIBRES. 

It  has  already  been  shown  by  Dr.  Ott*  that  these  fibres 
run  in  the  lateral  columns.  My  object  has  been  to  deter- 
mine more  accurately  in  what  part  of  the  lateral  columns 
they  run.  The  sections  of  the  cord  were  made  with  Woros- 
chiloff's  instrument.  I  divided  both  lateral  columns,  and 
then,  after  waiting  some  hours,  I  irritated  the  medulla,  but 
no  sweat  appeared  upon  the  posterior  extremities.  The 
animals  used  were  cats,  and  artificial  respiration  was  kept 
up  during  the  irritation  of  the  medulla.     When  I  divided 

*  yournal  of  Physiology,  vol.  ii,  No.  2. 


220 


GEO.  B.    WOOD  FIELD. 


the  cord  as  in  fig.  i,  then  sweat  appeared  upon  the  right 
posterior  extremity,  but  not  upon  the  left.  When  the  cord 
was  divided  as  in   fig.  4,   everthing  being  cut   except  the 


Fig.  I. 


Fig.  2. 


Fig.  3. 


left  anterior  column  and  the  anterior  third  of  the  left 
lateral  column,  then,  upon  medullary  irritation,  no  sweat 
appeared  upon  the  posterior  extremities.  If  the  cord  was 
divided  as  in  fig  3,  then  no  sweat  appeared  upon  the 
posterior  extremities  after  irritation  of  medulla.  These 
experiments  show  that  the  sweat-fibres  run  mainly  in  the 
inner  half  of  the  lateral  columns.  If  the  cord  is  divided  as 
m  fig.  2,  then  sweating  appeared.  If  the  cord  was  divided 
as  in  fig.  5,  then  sweating  appeared  more  on  the  right  side 
than  upon  the  left.  It  is  evident  that  the  cut,  in  this 
experiment,  on  the  left  side  of  the  cord  struck  the  main 
body   of  the  sweat-fibres.     The  above  experiments  prove 


Fig.  4. 


Fig.  5. 


Fig.  6. 


fhat  the  sweat-fibres  run  mainly  in  the  inner  half  of  the 
middle  third  of  the  lateral  columns.  When  the  spinal  cord 
was  divided  as  in  fig.  6,  and  the  medulla  irritated,  sweat- 


PHYSIOLOGY  OF  THE  SPINAL  CORD.  221 

ing  ensued  in  both  posterior  extremities,  more  so  on  the 
right  side  than  upon  the  left,  the  lateral  columns  of  the 
right  side  being  not  so  deeply  divided.  In  this  experiment 
the  rhythm  of  the  sphincters  was  present,  showing  that  the 
sweat-fibres  mainly  run  anterior  to  the  inhibitory. 

ACTION  OF  DRUGS  ON  THE  SWEAT  CENTRES. 

The  effect  of  drugs  on  the  sweat  centres  is  a  subject 
which  is  yet  to  be  worked  out  in  the  main.  A  few  drugs 
have  been  worked  out  by  Luchsinger,  Nawrocki,  Ott  and 
myself.  Ott  has  shown  that  after  a  sweat-fibre  in  the  sciatic 
has  degenerated  and  its  irritation  by  faradic  current  pro- 
duces no  effect,  the  use  of  muscarin  still  called  out  sweat 
in  that  foot.  The  following  drugs,  bromide  of  ethyl, 
piscidia  erythrina,  aconitia  and  lobelia,  have  been  investi- 
gated. My  method  of  procedure  was  as  follows  :  Cats  were 
selected,  the  sciatic  divided,  and  the  drug  given  either  sub- 
cutaneously  or  by  the  jugular;  then  the  posterior  extremi- 
ties were  watched  as  to  their  sweat  secretion.  Artificial 
respiration  was  kept  up  lest  an  excess  of  carbonic  anhydride 
would  stimulate  the  sweat  centres  and  confuse  the  result. 
I  shall  give  here  only  a  few  of  the  many  experiments  made 
with  different  drugs. 

Bromide  of  Ethyl. 

This  new  anaesthetic  causes  sweating,  and  it  was  desired 
to  determine  if  it  was  due  to  a  central  or  peripheral  stimu- 
lation. 

Experiment,  kitten. — Left  sciatic  was  divided,  then  it  was 
ethylized,  and  it  was  found  that  no  sweating  appeared  in  the 
left  posterior  extremity,  while  sweating,  to  a  considerable 
degree,  did  take  place  in  all  the  others.  Artificial  respira- 
tion was  kept  up  to  eliminate  an  excess  of  carbonic  anhy- 
dride.    This    experiment    proves   that    bromide    of    ethyl 


222  GEO.  B.    WOOD  FIELD. 

mainly  excites  sweat  by  a  stimulant  action  on  the  sweat 
centres  located  in  the  spinal  cord. 

Fiscidia  Erythrina. 

This  new  narcotic  was  tested  as  follows  : 

Experiment,  kitten. — Left  sciatic  divided,  subcutaneous 
injection  of  half  teaspoonful  fluid  extract  piscidia  erythrina. 
All  the  extremities  sweat  except  the  one  whose  sciatic  is 
divided. 

This  shows  that  piscidia  erythrina  acts  partly  by  a  central 

stimulation. 

Aconitia. 

Experiment,  kitten. — Left  posterior  extremity  has  its 
sciatic  divided. 

1.40  P.M. — Subcutaneous  injection  ^  grain  aconitia  in 
water. 

1.55  P.M. — Subcutaneous  injection  ^  grain  aconitia  in 
water. 

2.09  P.M. — Cries  and  bites. 

2.15  P.M. — Subcutaneous  injection  j^  grain  aconitia  in 
water. 

2.20  P.M. — Profuse  salivation. 

2.28  P.M. — Sweating  in  all  extremities  except  the  one 
whose  sciatic  is  divided. 

2.40  P.M. — Tracheotomy  performed,  and  artificial  respira- 
tion was  resorted  to,  proving  that  aconitia  acts  by  an 
excitant  action  of  the  sweat  centres. 

2.48  P.M. — Atropia  solution  administered  subcutaneously 
caused  the  feet  to  become  dry. 

Lobelina. 

Experiment,  kitten,  at  12  M. — One  sciatic  divided,  and 
one  drop  of  the  acetate  of  lobelina  (in  water)  injected  into 
the  central  end  of  the  carotid,  toward  the  brain.  Sweating 
occurred  in  all  the  extremities  except  the  one  in  which  the 
sciatic  was  divided. 


PHYSIOLOGY  OF  THE  SPINAL  CORD.  22^ 

12.22  P.M. — Another  injection  of  acetate  of  lobelina  given 
subcutaneously. 

12.28  P.M. — Sweating  ensued  in  all  the  extremities. 

This  experiment  proves  that  lobelina  can  excite  sweating 
by  a  peripheral  action. 

The  following  experiment  was  then  performed : 

Experiment,  kitten. — Left  sciatic  divided  and  left  to  de- 
generate. One  week  after  section  of  this  nerve  the  periph- 
eral end  was  irritated  by  the  induction  current  of  a  Du  Bois 
apparatus,  which  produced  no  sweating  in  the  attached 
foot. 

1.20  P.M. — Fluid  extract  lobelina  given  subcutaneously. 
Profuse  sweating  occurred  in  all  extremities  except  the  one 
whose  sciatic  had  been  divided. 

1.25  P.M. — Second  injection  fluid  extract  lobelina  with 
same  result. 

2.20  P.M. — Third  injection  fluid  extract  lobelina. 

2.30  P.M. — Sweats  in  all  extremities. 

This  experiment  proves  that  lobelina  can  excite  sweating 
in  a  foot  whose  sciatic  has  degenerated.  Ott  has  already 
proved  that  muscarin  acts  in  a  similar  manner. 

Veratrum    Viride. 

Expt.,  kitten. — Left  sciatic  divided,  tracheotomy  per- 
formed and  artificial  respiration  kept  up ;  one  fluid  drachm 
of  fid.  ext.  veratrum  viride  was  then  administered  subcuta- 
neously. Sweating  ensued  in  all  the  extremities  except  the 
one  with  sciatic  cut.  This  experiment  proves  that  veratrum 
viride  mainly  excites  sweating  by  a  central  action. 

PONTAL    CONVULSIONS. — THEIR   INHIBITION. 

It  has  already  been  shown  by  Nothnagel  that  injections 
of  chromic  acid  into  the  medulla  and  pons  excited  convul- 
sions of  an  epileptiform  character.     In  a  cat,  I   injected  a 


224  GEO.  B.    WOOD  FIELD. 

few  drops  of  chromic  acid  into  the  pons  at  the  junction  of 
the  medulla  oblongata,  after  which  convulsions  of  the  pos- 
terior extremities  commenced.  They  began  slowly, 
reached  a  maximum,  and  then  decreased.  Their  number 
was  about  120-140  per  minute,  alternating  in  each  posterior 
extremity,  then  becoming  quiet  for  a  short  time. 

Fig.  7  (see  opposite  page)  gives  a  graphic  record  of 
the  convulsive  ijiovements.  They  were  made  by  attaching 
a  posterior  extremity  to  a  Marey's  myograph  registering 
on  a  drum  of  a  Marey-Secretan  apparatus.  While  these 
convulsions  were  going  on,  I  discovered  a  m.eans  of  arrest- 
ing them,  which  has  hitherto  remained  unnoticed.  I  found 
that  by  pinching  the  ear  of  the  cat  the  convulsions  de- 
creased and  were  arrested. 

INFLUENCE    OF     AN     IRRITANT    INJECTION     IN     DIFFERENT     PARTS 
OF    THE    BRAIN    ON    THE    MOVEMENTS    AND    SECRETIONS. 

1.  An  injection  of  chromic  acid  about  the  left  middle 
cerebellar  crus  determined  movements  of  rotation  about 
the  long  axis  of  the  animal,  from  the  side  of  the  lesion 
toward  the  uninjured  side. 

2.  An  injection  of  chromic  acid  into  the  right  thalamus 
and  right  side  of  the  corpus  callosum  caused  dilatation  of 
the  pupils,  straddling  movements  of  the  posterior  extremi- 
ties ;  cries  considerably  ;  diagonal  sweating,  that  is,  the  right 
fore  paw  and  left  hind  paw  sweat  the  most. 

3.  An  injection  of  chromic  acid  into  the  left  side  of  the 
pons  at  its  junction  with  the  medulla  caused  the  head  to 
turn  to  the  right  and  upward  ;  the  animal  lost  all  coordina- 
tion ;  posterior  extremities  have  alternate  epileptiform  con- 
vulsions, anterior  extremities  relaxed  ;  places  hind  feet  in 
rear  of  head  ;  pupils  contracted. 

4.  An  injection  of  chromic  acid  into  both  optic  thalami 
and  right  side  of  nates  caused  straddling  movement  of  the 


226  GEO.  B.    WOOD  FIELD. 

posterior  extremities,  want  of  coordination,  rhythmical 
movements  of  left  posterior  extremity;  pupils  dilated  ;  goes 
to  left  in  progression  ;  rhythm  of  sphincter  ani ;  seems  blind  ; 
cries  during  a  considerable  part  of  the  time  ;  trembling  of 
whole  body ;  when  walking  raises  posterior  extremities 
nearly  to  body  ;  body  twisted  to  right ;  raises  hind  feet  into 
the  air,  and  walks  on  anterior  extremities. 

5.  An  injection  of  chromic  acid  into  the  right  and  left 
corpora  striata  had  no  effect. 

6.  An  injection  of  chromic  acid  into  the  right  optic  thal- 
amus and  right  natis  and  testis  caused  the  animal  to  roll 
from  right  to  left ;  extension  of  the  left  forepaw  ;  head 
twisted  to  the  right.     No  diiTerence  in  sweat  secretion. 

7.  An  injection  of  chromic  acid  into  the  middle  of  the 
right  optic  thalamus  and  part  of  left  caused  paralysis 
of  the  left  posterior  extremity  ;  moves  toward  left ;  sweats 
most  on  left  side.     Can't  coordinate. 

8.  An  injection  of  chromic  acid  into  the  right  lobe  of 
the  cerebellum  and  posterior  surface  of  right  natis,  the  ani- 
mal goes  to  the  right ;  the  feet  are  dry  ;  rhythm  of  sphincter 
ani  preserved  :  pupils  dilated  ;  convulsive  movements  of 
anterior  extremities. 

9.  An  injection  of  chromic  acid  into  the  right  cerebellar 
peduncle,  the  right  side  of  pons  and  cerebellum,  then  pro- 
fuse sweating  ensued.  Oscillation  of  eyeballs,  and  rapid 
breathing. 

10.  An  injection  of  chromic  acid  causing  a  lesion  of  the 
right  natis  and  testis  and  right  lobe  of  cerebellum  ;  the 
right  pupil  was  dilated,  the  left  contracted  ;  tonic  retraction 
of  the  head  ;  mouth  thrown  to  the  left ;  tonic  extension  of 
the  anterior  extremities ;  moves  to  the  left  ;  anterior  ex- 
tremities stiff ;  feet  dry. 

11.  An  injection  of  chromic  acid  into  the  middle  lobe  of 
the  cerebellum  down  to  the  pons  Varolii,  then  retrograde 


PHYSIOLOGY  OF  THE  SPINAL  CORD.  22/ 

movements  ensue ;    falls  to  either  side ;    both  pupils  con- 
tracted ;  feet  moist. 

12.  An  injection  of  chromic  acid  into  the  corpora  quad- 
rigemina,  anterior  surface  of  cerebellum,  and  optic  thalamus 
superficially,  expirations  are  inhibited.  Makes  frequent  in- 
spirations. 

13.  An  injection  of  chromic  acid  into  the  iter  a  tertio  ad 
quartum  ventriculum  causes  the  animal  to  fall  on  either 
side.  No  expiration  ;  jerking  inspiration ;  pupils  dilated  ; 
no  rhythm  ;  feet  dry. 

14.  An  injection  of  chromic  acid  into  the  right  optic 
thalamus  and  right  corpora  striata  causes  a  dilatation  of  the 
pupils  ;  no  coordination  or  voluntary  movement ;  sweating 
normal. 

15.  An  injection  of  chromic  acid  into  the  cerebellum  and 
right  side  of  the  corpora  quadrigemina  causes  the  animal  to 
go  to  the  right ;  pupils  normal ;  want  of  coordination  ;  feet 
nearly  dry ;  no  anal  rhythm. 

Appended  are  the  experiments  upon  which  the  above  ob- 
servations are  based : 

Cat  Experiment  i,  May  20,   1879  (4  p.  m.). 

Two  drops  of  a  one-per-cent.  solution  of  chromic  acid  admin- 
istered on  right  side  of  the  head,  below  and  back  of  the  ear. 

Symptoms. — Tendency  to  go  from  left  to  right  ;  cannot  walk  ; 
lies  on  belly  ;  feet  extended.  Defecation  taken  place.  Extension 
of  right  paw.  Voluntary  movements  over  right  fore  paw  and 
right  hind  paw.  Circular  movement  of  whole  axis  from  left  to 
right.  Sensation  perfect  in  both  posterior  extremities.  Right 
hind  paw  sweats  more  than  left.     Left  fore  paw  sweats  most. 

4.30  p.  M. — Profuse  salivation  ;  commencing  to  get  voluntary 
power  over  all  extremities,  especially  on  right  side  and  in  right 
fore  paw. 

5.30  p.  M. — Animal  lies  in  stupid  state,  but  on  pinching  tail, 
arouses  and  cries. 

May  2 1  St. — Has  better  use  of  right  extremities  than  yesterday. 
No  change  in  color  of  feet  (vaso  motor).     Can  move  left  extremi- 


228  GEO.  B.    WOOD  FIELD. 

ties,  but  has  not  the  power  in  them  to  raise  herself.  Right  hind 
paw  and  left  fore  paw  sweat  more  than  the  other  extremities. 
Seems  to  be  conscious  the  entire  time. 

In  cage,  lies  still  if  left  to  itself,  but  tries  to  walk  out  of  the 
way  when  handled.  When  out  of  cage,  tries  its  best  to  walk,  even 
if  not  touched,  and  drags  itself  along  by  means  of  its  right  fore 
and  hind  paws.     Nurses  a  little. 

May  22d. — Remains  perfectly  conscious  ;  tries  to  walk,  pulling 
itself  along  by  means  of  its  right  extremities  ;  nurses  well  ;  sweat- 
ing remains  same  as  before,  although  not  in  such  a  marked  de- 
gree. 

May  23d. — Better  use  of  right  extremities  than  before,  and  im- 
proving generally. 

May  24th. — Symptoms  the  same. 

May  25th. — Symptoms  the  same. 

May  26th. — Feet  do  not  sweat  more  than  normal  ;  seems  per- 
fectly well  (with  the  exception  of  the  paralysis).  Other  symp- 
toms the  same. 

May  27th. — Symptoms  the  same. 

May  28th. — Post-mortem  :  Lesions  in  left  lobe  of  cerebellum, 
near  left  cerebellar  crus,  just  behind  left  nates. 

Cat  Experiment  2,  May  23,  1879. 

Two  drops  of  a  one-per-cent.  solution  of  chromic  acid  injected 
into  brain. 

Symptoms. — Cat  immediately  walks,  spreading  her  hind  legs 
wide  apart  ;  lies  down  and  cries  ;  makes  no  attempt  to  get  up  ; 
lies  in  a  stupor  ;  when  aroused  and  stood  on  its  feet,  cries  very 
loudly  for  a  moment  or  two,  and  then  passes  into  the  stupor 
again.  Makes  no  attempt  to  walk  when  stood  on  feet  ;  does  not 
seem  perfectly  conscious  of  where  it  is,  but  only  of  pain  (when 
aroused).  Erector  muscles  of  limbs  seem  perfectly  paralyzed  ; 
cries  continually  ;  pupils  dilated  ;  sphincter  ani  partially  re- 
laxed. 

May  24th. — Symptoms  the  same. 

May  25th. — Symptoms  the  same  ;  still  cries. 

May  26th. — Seems  perfectly  well  ;  cries  a  little  ;  otherwise 
same  as  above. 

May  27th,  10.25  •'^•^^- — Injection  of  10  minims  fluid  extract 
jaborandi  in  right  flank.  Salivation  commencing.  Pupils  dilated. 
Feet  sweat  profusely.  Right  fore  paw  and  left  hind  one  sweat  the 
most.     Both  hind  paws  spread  out  when  standing  or  walking. 


PHYSIOLOGY  OF  THE  SPINAL  CORD.  229 

June  13th. — Second  injection  of  chromic  acid. 

Second  injection  into  the  pons. 

Symptoms. — Animal  lost  all  coordination.  Head  turned  to 
right  and  upward.     Turns  body  to  right. 

Agitation  of  posterior  extremities.  Convulsive  attack.  Fore 
extremities  relaxed  and  motionless  during  the  convulsive  attack 
of  hind  extremities.  Places  hind  paws  on  back  of  neck.  The 
convulsive  movements  begin  slowly,  reach  a  maximum,  and  then 
decrease.  They  are  about  120-140  per  minute.  Posterior  ex- 
tremities alternate,  then  they  become  quiet  for  a  short  time,  and 
again  commence.  Pinching  the  ear  on  the  side  where  the  con- 
vulsive movements  take  place,  arrests  them.  Hypersesthesia  of 
posterior  extremities.  No  sweating.  Feet  dry.  No  rhythm.  Color 
of  feet  pale.     Pupils  at  first  very  much  contracted. 

Post-mortem. — Injury  to  right  corpus  callosum,  and  superficial 
lesion  on  the  inner  side  of  right  optic  thalamus,  from  first  experi- 
ment. 

Result  of  2d  Experiment. — Lesion  in  upper  part  of  medulla 
oblongata,  on  left  side  of  floor  of  fourth  ventricle. 

Cat  Experiment  3. 

May  23d. — Injection  of  a  one-per-cent.  solution  of  chromic  acid 
in  the  back  part  of  head. 

Symptoms. — Spreading  of  hind  legs.  Stands  perfectly  still. 
Want  of  coordination.  Rhythmical  movement  of  left  hind  leg. 
Tendency  to  go  from  right  to  left.  Pupils  dilated.  Rhythmical 
movements  of  sphincter  ani.  Lies  in  a  continued  stupor.  Does 
not  cry  when  tail  is  pinched,  but  kicks.  Produces  a  weak  cry 
when  tail  is  trodden  on  by  the  foot. 

May  24th. — Seems  to  be  blind  ;  goes  around  in  a  circle  from 
left  to  right,  crying  all  the  time.  Stops  a  short  time,  and  then 
goes  around  again.  Shakes  constantly,  over  her  entire  body. 
When  she  went  around  in  a  circle  she  spread  out  and  .lifted  up  her 
hind  legs  curiously  (legs  raised  nearly  to  body).  Goes  in  a  cor- 
ner by  herself  and  sits  down.  These  sittings  seem  to  be  periods 
of  stupor,  which  when  aroused  from,  she  immediately  goes  around 
in  a  circle  again,  as  described  before.  Whole  body  twisted  toward 
right.  Raises  left  hind  paw  when  she  bends  to  right  side.  Inco- 
ordination in  posterior  extremities.  Pupils  dilated.  Goes  around 
in  a  circle  from  left  to  right,  throwing  (as  she  walks)  both  posterior 
extremities  in  the  air.  After  each  period  of  rest  succeeding  the 
circle  movement,  the  whole  body  is  turned  toward  the  right. 
Walks  on  front  paws. 


230  GEO.  B.  FIELD   WOOD. 

May  25th. — Symptoms  about  the  same. 

May  26th. — Goes  around  in  a  circle  from  left  to  right ;  cries  ; 
back  legs  spread  a  little  apart  when  walking.  Runs  quite  lively. 
Does  not  seem  to  suffer  any.     Pupils  dilated. 

May  27th. — Drags  herself  around.  Seems  to  be  entirely  free 
from  pain.  Continues  to  go  in  a  circle  from  left  to  right.  Other- 
wise progressing. 

May  28th. — Post-mortem  :  Superficial  lesion  of  right  and  left 
optic  thalami  and  right  natis. 

Cat  Experiment  ^,  J^uly  10,  1879. 

Injection  into  the  brain  of  the  one-per-cent.  solution  of  chromic 
acid.  This  first  injection  had  no  effect,  and  consequently  a  sec- 
ond injection  was  given. 

Symptoms. — Rolls  from  left  to  right  immediately  after  injection. 
Extension  of  left  paw  ;  periods  of  rest,  and  then  rolls  again. 
Head  twisted  toward  right.  Lies  still,  with  head  twisted  as 
just  stated.  On  side,  unable  to  rise.  No  difference  in  sweat 
secretion. 

Post-mo7'tem-. — Superficial  lesion  of  right  and  left  corpora  striata. 
Deep  lesion  of  right  optic  thalamus,  and  right  natis  and  testis. 
The  remaining  parts  intact.  First  injection  involved  corpora 
striata.     No  effect.     Crura  cerebri  intact. 

Cat  Experifnent  5. 

July  isth. — Injection  of  one-per-cent.  solution  chromic  acid. 

Symptoms. — Left  posterior  extremity  paralyzed;  can't  coordinate; 
moves  to  the  left  ;  paralyzed  on  whole  left  side  ;  sweats  most  en 
left  side.    No  rhythm.     No  difference  in  pupils. 

July  i6th. — Symptoms  the  same. 

Post-mortem. — Lesion  of  right  optic  thalamus  in  its  middle,  and 
part  of  left  optic  thalamus. 

Cat  Experhfiefit  6. 

July  13th. — Injection  of  a  coticenirated  so\n\.\on  chromic  acid. 

Symptoms. — Goes  from  left  to  right.  Defecation  taken  place. 
Feet  dry.  Rhythm  of  both  sphincters.  Pupils  widely  dilated. 
(Right  eyeball  projects  more  than  left?)  Convulsive  movements 
of  anterior  extremities.     Urinates. 

July  14th. — Very  slight  rhythm  of  sphincters.  Sweats  more  than 
before,  although  fore  feet  are  rather  dry. 

Post-mortem. — Deep  lesion  of  right  lobe  of  cerebellum,  extend- 
ing to  posterior  surface  of  right  natis. 


PHYSIOLOGY  OF  THE  SPINAL  CORD.  23 1 

Cat  Experiment  7. 

July  13th. — Injection  concentrated  solution  chromic  acid. 

Syinptoms. — Rapid  breathing.  Profuse  salivation.  Oscillation 
of  eyeballs  ;  defecation  taken  place.  Cries  on  pinching  tail.  The 
nystagmus  disappeared  on  next  day.  Sweating  normal.  No 
rhythm  at  any  time. 

Post-mortem. — Deep  lesion  just  in  front  of  right  cerebellar 
peduncle,  involving  right  side  of  pons  and  cerebellum. 

Cat  Experiment  8. 

July  13th. — Injection  of  a  concentrated  solution  of  chromic 
acid  on  right  side  of  head. 

Symptoms. — Right  pupil  dilated,  and  left  contracted.  Defeca- 
tion taken  place.  Tonic  retraction  of  head  with  mouth  thrown 
to  left.  Tonic  extension  of  fore  feet.  Moves  to  left.  Retrac- 
tion great  enough  to  support  the  body  ;  head  still  retracted  ;  does 
not  cry.     Feet  dry  ;  3d  day,  feet  still  dry. 

Post-mortetn. — Lesion  involving  nates,  especially  the  right,  and 
the  posterior  surface  of  testes,  especially  the  right,  and  the  right 
lobe  of  cerebellum. 

Cat  Experiment  ^^  Jiily  i3>  1S79. 

Injection  of  a  concentrated  solution  chromic. acid. 

Symptoms. — Backward  movement.  Falls  to  either  side.  Defe- 
cation taken  place.  Both  pupils  contracted.  On  least  irritation, 
moves  fore  paws  normally.     Feet  moist.     Died  next  day. 

Post-mortem. — Lesion,  middle  lobe  of  cerebellum  to  pons 
Varolii,  not  involving  it. 

Cat  Experiment  10. 

July  13th. — Injection  of  concentrated  solution  chromic  acid  on 
right  side  of  head  behind  right  ear. 

Symptoms. — Feet  were  moist  before  the  injection,  but  afterward 
they  almost  immediately  became  dry.  The  breathing  is  inhibited 
in  expiration.  A  cat  makes  frequent  inspirations  but  no  marked 
expirations.  When  the  tail  is  slightly  pinched,  or  even  touched, 
the  animal  makes  marked  movements  with  the  posterior  extremities. 
Death  took  place  half  an  hour  after  the  injection. 

Post-mortem. — Superficial  portion  of  corpora  quadrigemina 
mainly  the  seat  of  lesion.  Anterior  surface  of  cerebellum  super- 
ficially involved.  The  optic  thalami  very  superficially  and  slightly 
stained  by  the  injection. 


232  GEO.  B.    WOOD  FIELD. 

Cat  Experiment   1 1 . 

July  15th. — Injection  of  concentrated  solution  chromic  acid. 

Symptoms. — Falls  to  left  on  walking  ;  sits  still  and  rolls  on  left 
side  ;  lies  on  right  side  ;  walks,  falling  to  right  and  left.  Cries 
when  tail  is  pinched.  Feet  dry.  Jerking  inspiration  ;  no  expira- 
tion.    Pupils  slightly  dilated.     No  sphincter  rhythm. 

Post-mortem. — Lesion  along  the  length  of  the  iter  a  tertio  ad 
quartum  ventriculum. 

Cat  Experiment  1  2. 

July  i8th. — Injection  of  concentrated  solution  chromic  acid. 

Symptoms. — Pupils  dilated  ;  hardly  any  sensibility  in  tail  or 
posterior  extremities.  No  coordination  or  voluntary  movement. 
No  rhythm.     Sweating  normal. 

Post-mortem. — Lesion  of  left  optic  thalamus  mainly,  and  a 
greater  portion  of  the  corpora  quadrigemina  on  the  right  side. 

Cat  Experiment   13. 

July  i8th. — Injection  of  concentrated  solution  chromic  acid  just 
behind  external  occipital  protuberance. 

Symptoms. — Goes  from  left  to  right  ;  pupils  normal  ;  runs 
around  continually  in  a  circle  ;  sits  still,  with  head  turned  to 
right ;  cannot  stand,  but  still  continues  to  go  from  left  to  right 
by  dragging  herself.  Lies  still  on  rigth  side  ;  struggles  to  drag 
herself  to  the  right,  but  cannot.  Lies  still,  with  head  turned  to 
right.     Want  of  coordination. 

July  19th. — Head  still  turned  to  right.  On  pinching  tail,  cries 
and  goes  around  in  a  circle.  Feet  nearly  dry.  No  rhythm  at  any 
time. 

Post-mortem. — Lesion,  upper  and  anterior  portion  of  cerebel- 
lum, and  right  corpora  quadrigemina. 


CONTRIBUTIONS  TO  PSYCHIATRY. 

By  JAS.  G.  KIERNAN,  M.D., 

CHICAGO.    ILL. 
IV. THE    PSYCHOSES   PRODUCED    BY    RHEUMATISM. 

RHEUMATISM  since  the  days  of  Sydenham  has  been 
recognized  as  capable  of  producing  psychic  disturb- 
ances. The  first,  however,  to  call  special  attention  to  the 
relations  of  rheumatism  to  the  psychoses  was  Griesinger,^ 
who  found  that  rheumatism  produced  not  only  an  acute  but 
also  a  chronic  form  of  insanity  ;  that  this  was  unattended 
by  fever  and  characterized  by  depression  amounting  some- 
times almost  to  melancholia  attonita,  followed  by  or  alter- 
nated with  maniacal  excitement,  and  that  at  times  choreic 
movements  were  present,  prognosis  being  most  favorable 
in  the  acute  cases.  Fleming^  has  expressed  very  similar 
opinions.  Skae^  claims  to  have  noticed  in  1845  a-  case  of 
insanity,  due  to  rheumatism,  which  presented  the  following 
phenomena:  The  patient  was  at  first  delirious,  then  passed 
into  a  condition  of  melancholia  attonita,  then  became  vio- 
lent, and  after  calming  down  expressed  ungrounded  suspi- 
cions. In  other  cases  chorea  was  present,  as  also  hallucina- 
tions of  taste  and  touch.  Skae  regards  the  psychoses  from 
rheumatism  as  being  about  as  well  defined  as  progressive 
paresis,  and  as  having  a  favorable  prognosis.  Mesnet* 
was   the    first    to    use    the    term    rheumatismal    insanity, 

233 


234  J  AS.  G.  KIERNAN. 

giving   under   that   head   cases   very   similar   to    those    of 
Griesinger.       Delioux,''    from    one    case   much    resembling 
Skae's,   draws   conclusions   very    similar   to    those   of  that 
author.     Trousseau^  divides  the  cerebral  complications  of 
rheumatism   into    delirious,  meningitic,  hydrocephalic  and 
apoplectic,  claiming   that    hereditary   predisposition    is   al- 
ways  present.       Simon'     draws    about   the    same    conclu- 
sion regarding  the   rheumatismal  psychoses  as  Griesinger. 
Sander^    cites   Griesinger's   conclusions   as   expressing  his 
own   views,  and   gives,    in    addition,   several    cases    where 
rheumatism   has   led    to   apparent  recovery  from  insanity. 
Wille*    comes   to   substantially   the   same    conclusions   as 
Sander,   citing,  in  addition,  a    case    where    disappearance 
of    the  rheumatic  fever    was    followed    by    a    change    in 
the   psychical    symptoms.     Besser^^    expresses   about  the 
same    opinions,    as    also    does    Girard.^^      Kraepiliner,^^ 
who  has  made  a  very  careful  examination   of  sixty-three 
cases  of  insanity  due  to  rheumatism,  claims  that  at  certain 
seasons  cerebral  complications  of  rheumatism  are  more  fre- 
quent, so  that  cases  may  accumulate  in  a  short  period,  al- 
though unknown  for  a  long  time  before  (they  are  said  by 
Rigler   to  be  more  frequent  in  Turkey),  and  that  rheuma- 
tismal insanity  is  divisible  into  the  following  classes  :  First, 
the  hyperpyretic  form,  the  most  acute  variety,  the  initial 
symptoms  of  which  are  insomnia,  talking  in  sleep,  slight  de- 
lirium, followed  by  severe  delirium  later  ;  after  a  rise  in  the 
temperature  death  results  ;  with  continued  rise  in  the  tem- 
perature the  prognosis  is  bad,  only  eighteen  per  cent,  re- 
covering ;  the   disease  is  sometimes  complicated  by  facial 
spasm.     Second,  less  acute  delirious  cases  occurring  dur- 
ing the"  first  week  of  the  disease,  rarely  during  the  second 
week ;  usually  comes  on  with  maniacal  excitement  at  times, 
though  rarely  with  melancholic  frenzy ;    collapse  or  death 
occurs  in  over  one-half  the  cases.     Choreic  complications 


CON  TRIE  UTIONS  TO  PS  YCHIA  TRY.  235 

occurred  in  a  few  cases.  Three  cases  recovered  after 
spontaneous  epistaxis.  Third,  a  form  which  requires  for 
its  production,  in  addition  to  the  exciting  cause — rheu- 
matism,— certain  predisposing  causes — anaemia,  alcohol  or 
heredity.  This  form  is  divisible  into  two  great  sympto- 
matological  groups.  I.  Active  melancholia,  with  fright 
and  suicidal  tendencies,  sometimes  accompanied  with 
choreic  movements  and  vertigo.  The  prognosis  is  not 
very  favorable.  II.  The  other  symptomatological  group 
lasts  three  or  four  months,  presenting  symptoms  of  con- 
fusion with  depression,  sometimes  chorea  and  sitophobia, 
always  with  hallucinations.  Four  cases  recovered ;  one 
died.  Vaillard,i3  Guislain,^*  Clouston,!^  Pauli,^^  Pos- 
ner,!''  Meissner^^  and  Kelp^'  describe  cases  of  melan- 
cholia attonita  due  to  rheumatism.  Voisin^o  and  Jac- 
coud^i  cite  cases  of  progressive  paresis  due  to  rheuma- 
tism. 

From  the  predominance  of  opinion  among  the  authori- 
ties cited,  it  would  appear  that  rheumatism  does  give  rise 
to  psychoses ;  that  these  are  usually  of  a  depressing  type, 
but  that,  according  to  some,  progressive  paresis  is  produced 
by  the  disease. 

The  cases  coming  under  my  observation  are  eighteen  in 
number,  and  for  purposes  of  comparison  I  have  divided 
them  into  three  classes  :  First,  those  of  an  acute  type  end- 
ing in  either  recovery,  death  or  slight  dementia.  Secondly, 
those  which  culminated  in  progressive  paresis.  Finally, 
those  in  which  rheumatism  complicated  other  psychoses. 

Class  First. — Cases   of  an  acute  character  ending  in   either   re- 
covery, slight  dementia,  or  death. 

Case  i. — T.  O'M.,  set.  40.  Father  and  sister  died  insane  ; 
was  under  treatment  at  Bellevue  Hospital  for  acute  articular 
rheumatism  with  high  fever.  The  joint  affection  together  with 
the  fever  disappeared  soon  after  a  large  dose  of  sodium  salicy- 


236  J  AS.   G.  KIERNAN. 

late,  the  patient  being  in  a  short  time  attacked  by  delirium.  He 
wished  to  escape  from  dogs,  which  he  said  were  pursuing  him, 
called  for  a  gun  to  shoot  them,  and  was  very  restless.  In  the 
course  of  a  week  he  was  transferred  to  the  asylum,  where  he  re- 
mained in  about  the  same  condition  for  three  days.  His  temper- 
ature on  admission  was  98°,  but  it  soon  after  rose  to  102°.  The 
deliriums,  previously  of  a  depressing  type,  became  rather  optimistic, 
varied  by  crude  suspicions  about  the  intentions  of  the  bystanders. 
The  patient  was  placed  under  ^  kali  iod.,  kali  bromid.,  chloral 
hydrat.,  vin.  colchici,  aa  8.  Aqua  qs.  ad  96.  M.  3  ss  omne  tertia 
hora.  This  treatment  was  not  without  effect  on  the  delirium,  as 
the  patient  became  quieter,  although  not  more  lucid.  He  never 
fully  regained  his  normal  mental  condition,  dying  five  weeks  after 
admission.     No  autopsy. 

Case  2. — Jno.  G.,  aet.  50,  admitted  from  the  Tombs  in  a  state 
of  violent  delirium,  much  resembling  that  of  alcohol.  The 
patient,  who  has  a  brother  insane,  had  been  perfectly  well  up  to 
a  week  prior  to  admission  at  the  Tombs,  when  he  was  attacked 
by  rheumatism  involving  the  knees,  ankles  and  wrist,  accompanied 
by  a  high  fever.  The  third  day  after  the  appearance  of  the 
fever,  the  patient  was  exceedingly  delirious  ;  home  treatment  was 
for  a  time  pursued,  but  his  violent  attempts  rendered  transfer  to 
an  asylum  necessary.  On  admission  the  patient  had  a  tempera- 
ture of  101°  F.  His  knees,  ankles  and  wrists  were  swollen. 
Psychically  he  was  much  agitated  and  presented  hallucinations  of 
taste,  hearing  and  sight.  The  day  after  admission  his  tempera- 
ture rose  to  105°  F.  ;  his  agitatijon  increased,  he  being  with  dififi- 
culty  in  bed,  desiring  to  get  up  continually  and  drive  off  a  legion 
of  devils  pursuing  him  ;  he  refused  to  take  egg  nogg  on  the 
ground  that  it  tasted  and  looked  like  blood.  He  was  placed  under 
the  same  treatment  as  the  previous  case.  Within  three  days  after 
this  the  patient  became  comparatively  rational,  and  by  the  end  of 
the  second  week  the  delirium  had  entirely  disappeared.  The 
patient  soon  began  to  improve  physically,  and  was  finally  dis- 
charged.    Recovered  four  weeks  after. 

Case  3. — Jno.  F.  McK.,  set.  40,  intemperate,  a  pauper  work- 
house man  employed  about  the  asylum,  was  attacked  by  acute 
articular  rheumatism,  which,  however,  presented  nothing  abnormal 
for  about  two  days,  when  his  temperature  rose  suddenly  to  106° 
F.,  falling  on  the  same  day  to  99°,  but  followed  by  endocarditis, 
after  the  pronounced  symptoms  of  which,  the  patient  complained 
of  being  poisoned,  and  said  that  workhouse  women  entered  his 


CONTRIBUTIONS  TO  PSYCHIATRY.  237 

room  to  stick  pins  in  him.  The  patient  was  at  length  committed 
to  the  asylum  and  placed  under  a  similar  treatment  to  the  other 
cases  just  mentioned.  He  recovered,  but  exhibited  some  little 
loss  of  memory. 

These  cases  correspond  in  some  respects  to  Kraepiliner's 
acute  hyperpyretic  form,  but  resemble  most  his  second  va- 
riety. What  role  the  salicylate  of  soda  played  in  the  first 
case  it  is  very  difficult  to  ascertain  ;  according  to  certain 
cases  recently  reported, 2  2  the  remedy  has  seemed  to  play 
a  part  in  the  production  of  rheumatic  delirium.  In  their 
length  and  the  presence  of  hallucinations,  these  cases  some- 
what approximate  Kraepiliner's  third  group,  as  they  also  do 
in  the  presence  of  heredity  and  alcohol  as  predisposing 
causes.  The  cases  are  too  few  to  draw  any  conclusion  as 
to  the  influence  of  age.  One  observation  of  Kraepiliner's,2  3 
that  diseases  of  the  heart  produced  peculiar  effects  on  the 
delusions,  is  apparently  corroborated  by  the  third  case,  where 
the  existence  of  cardiac  lesion  was  accompanied  with  delu- 
sions of  poisoning.  These  cases,  however,  taken  as  a  whole, 
cannot  be  said  to  completely  corroborate  either  Griesinger, 
Sander,  Fleming,  Skae  or  Krsepiliner,  although  more  nearly 
agreeing  with  the  last  mentioned. 

Class  Second. — Cases  culminating  in  progressive  paresis. 

Case  i. — J.  McB.,  set.  40,  Celtic,  admitted  to  N.  Y.  C.  Asylum 
for  the  Insane,  1873,  then  in  a  typical  condition  of  melancholia  at- 
tonita.  About  a  week  previous  the  patient  had  been  under  treat-- 
ment  for  acute  articular  rheumatism.  The  present  mental  condi- 
tion made  its  appearance  soon  after  the  disappearance  of  the  fever 
by  which  the  joint  affection  was  accompanied.  For  three  days 
after  admission  the  patient  remained  the  same.  On  the  fourth 
day  he  became  excited,  charged  the  attendant  with  cutting  his  arm 
off,  and  complained  that  his  food  was  poisoned.  This  condition 
was  accompanied  by  insomnia  and  persisted  for  three  days,  the 
patient  sinking  once  more  into  a  condition  of  melancholia  attonita. 
In  the  course  of  a  week  following,  choreic  movements  were  mani- 
fest on  the  right  side,  which  persisted  for  ten  days,  the  patient's 


238  JAS.   G.  K TERN  AN. 

mental  condition  remaining  the  same.  The  week  following,  these 
movements  disappeared,  and  the  patient  became  markedly  ex- 
cited, was  very  suspicious  about  his  food,  and  claimed,  as  before, 
that  his  arm  was  cut  off  and  that  he  was  watched  by  attendants 
having  evil  designs  on  his  person.  This  mental  condition  con- 
tinued three  weeks,  and  was  then  replaced  by  one  of  an  acutely 
maniacal  nature  in  which  ideas  of  suspicion  formed  a  prominent 
part  of  the  patient's  mental  life.  The  patient  gradually  quieted 
down,  sinking  as  before  into  a  condition  of  melancholia  attonita. 
In  this  state  the  patient  remained  for  six  months,  when  he  sudden- 
ly brightened  up  and  became  nearly  rational,  his  manner  only  be- 
ing at  all  peculiar  ;  he  was  discharged  to  the  care  of  friends  after 
eight  months  of  treatment.  In  1875  he  was  again  admitted,  and  it 
was  then  ascertained  that  he  had  a  brother  insane  and  that  a  grand- 
uncle  died  insane.  The  patient  now  displayed  marked  insanity  of 
manner,  had  well-marked  systematized^*  delusions  of  persecution 
on  the  part  of  his  relatives  and  his  partners.  He  had  erect  straight 
hair  and  showed  slight  tendency  to  incoherence.  The  patient 
took  food  very  suspiciously.  There  were  not  any  hallucinations 
to  be  detected.  He  remained  in  the  asylum,  without  change  in  his 
condition,  for  a  month,  when  he  was  discharged  to  his  friends  to 
be  taken  to  Europe.  In  1877  the  patient  was  again  admitted  and 
presented  all  the  mental  and  physical  symptoms  of  progressive 
paresis  tinged  by  slight  traces  of  his  former  condition.  He  had 
marked  hypersesthesia  of  the  lower  extremities,  but  these  were  at 
times  anaesthetic,  and  he  then  complained  that  his  feet  had  been 
cut  off.  He  remained  under  my  charge  for  about  a  year,  and  at 
the  time  I  left  the  asylum  the  progressive  paresis  was  pursuing 
its  usual  course. 

Case  2. — T.  O.  B.,  Celtic,  aet.  41,  was  admitted  to  the  New  York 
City  Asylum  for  the  Insane,  in  1877,  with  the  following  history  : 
During  the  previous  year  (1876)  he  had  been  attacked  by  acute 
articular  rheumatism,  and  in  a  delirium  consequent  on  the  fever 
he  had  attacked  his  sister  and  accused  her  of  being  in  a  plot 
against  his  life,  refusing  to  eat  or  drink  from  her  hands.  He  had 
hallucinations  of  hearing,  and  was  at  times  extremely  violent. 
The  delusions  and  hallucinations  already  mentioned  remained  for 
two  months,  and  then  the  patient's  condition  changed  into  one  of 
stupor.  Six  weeks  after,  the  patient  became  maniacal  and  de- 
pressed alternately.  These  symptoms  all  disappeared,  leaving  the 
patient,  as  his  friends  styled  it,  "  cranky,"  but  able  to  carry  on  his 
usual    avocation.     Six  months    thereafter  he   was   treated  at   an 


CONTRIBUTIONS  TO  PSYCHIATRY.  239 

asylum  in  New  Jersey,  having  what,  from  his  sister's  description, 
were  evidently  systematized  delusions  of  persecution.  In  this 
asylum  he  remained  three  months,  when  his  sister  took  him  home, 
without  apparent  change,  where  he  remained  till  a  month  prior  to 
admission.  On  admission,  the  patient  was  found  to  have  well- 
marked  systematized  delusions  of  persecution,  somewhat  weakened 
by  the  existing  progressive  paresis.  His  pupils  were  "  pin-hole  " 
contracted,  but  dilated  unequally.  There  was  some  hesitancy  in 
speech.  The  facial  folds  were  unequal.  The  patient  had  marked 
insanity  of  manner  and  some  ill-defined  unsystematized  delusions 
of  grandeur.  The  patient's  gait  became  impaired,  and,  having 
some  convulsions  which  reduced  him  very  much,  he  was  taken 
out  to  die,  by  his  sister,  six  months  after  admission. 

Case  3. — T.  McG.,  aet.  45,  Celtic,  had  been  attacked  by  acute 
articular  rheumatism  early  in  the  year  1875.  The  oedema  of  the 
joints  suddenly  disappeared,  and  he  was  almost  immediately  seized 
by  a  violent  delirium,  during  which  he  claimed  that  his  hands  had 
been  cut  off,  and  that  his  food  was  poisoned,  and  that  people  were 
using  instruments  to  burn  the  side  of  his  body.  He  gradually 
passed  from  this  delirium  into  a  condition  of  melancholia  attonita, 
from  which  he  emerged,  a  month  before  admission,  into  a  condi- 
tion presenting  marked  insanity  of  manner  with  well-defined  sys- 
tematized delusions,  together  with  well-defined  hallucinations  of 
hearing  difficult  to  elicit.  His  delusions  chiefly  concerned  his 
wife  and  her  cousin,  whom  he  accused  of  cutting  his  feet  off  and 
attempting  to  poison  him.  During  six  months  these  deliisions 
continued  exceedingly  vivid,  but  at  the  expiration  of  that  period 
the  patient's  manner  became  less  disagreeably  suspicious  and  he 
conversed  with  more  freedom.  His  delusions  of  persecution  were 
less  well-defined,  and  the  patient  seemed,  to  my  intense  surprise, 
on  the  fair  way  to  recovery.  His  pupils  were,  however,  noticed 
to  be  unequal,  and  optimistic  delusions  began  to  make  their  ap- 
pearance, followed  by  the  other  symptoms,  mental  and  physical,  of 
progressive  paresis.  He  was  soon  after  this  removed  to  an  Irish 
asylum,  where  a  brother  and  sister  were  under  treatment. 

Case  4. — J.  G.,  ast.  28,  American,  was  admitted  to  the  New 
York  City  Asylum  for  the  Insane  with  a  history  of  having  been 
attacked  by  rheumatism,  during  the  fever  of  which  he  was  seized 
by  delirium,  passing  soon  after  into  a  condition  of  melancholia 
attonita,  in  which  he  remained  three  years.  During  1874  it  be- 
gan to  be  noticed,  first,  that  there  was  more  intelligence  about  the 
patient's  expression,  then  that  he  took  food  freely,  and  finally  that 


240  J  AS.  G.  KIERNAN. 

he  conversed  with  the  other  patients.  His  facial  folds  were  then 
noticed  to  be  unequal;  then  his  speech  became  hesitant,  his  tongue 
tremulous  and  his  pupils  unequal.  On  examination  he  was  found 
to  have  delusions  of  an  optimistic  type.  He  finally  developed 
into  a  well-marked  case  of  paresis,  dying  early  in  March,  1875,  of 
phthisis. 

Case  5. — J.  D.,  Ger.,  aet.  50,  was  admitted  to  the  N.  Y.  City 
Asylum  in  a  violently  excited  condition.  The  patient's  wife  gave 
the  following  history  :  The  patient's  father  and  grandfather  died 
during  an  epileptic  attack,  and  the  patient's  eldest  brother  is  an 
epileptic.  The  patient  has  been  perfectly  well  up  to  three  weeks 
before  admission,  when  he  was  attacked  by  acute  articular  rheu- 
matism. The  swelling  of  the  joints  was  at  times  extreme,  but 
after  a  month's  duration  suddenly  disappeared,  to  be  followed  by 
a  change  to  the  mental  condition  in  which  the  patient  was 
admitted.  The  patient  continued  excited  and  violent,  the 
violence  being  rather  of  the  nature  of  melancholic  frenzy.  There 
were  marked  hallucinations  present  of  a  very  distressing  character. 
The  patient  continued  excited  for  about  three  weeks  after  admis- 
sion, when  he  suddenly  passed  into  a  cataleptoid  condition  with 
great  waxy  flexibility.  In  this  state  he  remained  for  three  years, 
when  his  pupils  became  unequal,  his  tongue  tremulous,  and  an 
expression  of  content  pervaded  his  face.  He  did  not,  however, 
speak  until  about  three  months  had  elapsed,  when  he  talked 
loudly  about  his  wealth  in  Germany  ;  his  speech  was  hesitant, 
and  he  had  a  great  tendency  to  omit  words.  He  passed  through 
the  usual  stages  of  progressive  paresis,  dying  a  year  after  the 
appearance  of  the  paretic  symptoms.  No  autopsy  was  obtain- 
able. 

Case  6. — C.  L.,  aet.  46,  Ger.,  was  attacked  by  acute  articular 
rheumatism,  which  was  followed  by  acute  melancholic  frenzy  on 
the  sudden  disappearance  of  the  joint  affection,  which  gradually 
shaded  into  a  state  where  well-marked  systematized  delusions  of 
persecution  with  hallucinations  predominated.  This  condition 
continued  for  a  year  and  then  passed  into  general  paresis,  in 
which  state  he  was  admitted  to  the  asylum.  He  was  there  treated 
with  conium,  chloral  hydrate,  kali  iod.  and  colchicum,  and  after 
six  months'  treatment  was  so  far  recovered  as  to  be  discharged 
to  his  usual  avocation.  When  met  with  five  years  after  his  dis- 
charge, presented  no  evidence,  mental  or  physical,  of  general 
paresis  or  other  psychosis. 


CON  TRIE  U  TIONS  TO  PS  YCHIA  TRY.  24 1 

It  is  evident  these  cases  have  one  thing  in  common,  and 
that  this,  the  peculiar  systematized  delusions  of  persecution 
which  marked  one  stage  of  the  disease.  These  delusions  in 
their  character  strongly  resemble  those  of  the  chronic  type 
of  alcoholic  insanity,  which  I  cannot  agree  with  Spitzka^* 
in  regarding  as  unsystematized,  since  many  of  them  are  sup- 
ported with  as  much  detail  as  are  those  of  any  form  of 
monomania.  It  is  true  there  is  a  large  class  of  chronic 
cases  of  alcoholic  insanity  which  have  decidedly  unsystema- 
tized delusions  of  a  character  very  similar,  but  the  element 
of  dementia  is  strong  enough  in  those  cases  to  prevent  con- 
fusion with  the  other  class.  These  cases  corroborate  Gries- 
inger,  Fleming  and  Kraepiliner  to  the  extent  of  showing 
that  rheumatism  may  give  rise  to  chronic  types  of  insanity, 
but  in  their  earlier  stages  most  resemble  Skae's  cases.  In 
their  conclusion  they  most  agree  with  Jaccoud's  and 
Voisin's  opinions.  At  the  same  time,  the  infrequency  of 
chorea  and  the  strongly-marked  systematized  delusions  of 
persecution  give  them  characters  not  hitherto  described  as 
existing  in  insanity  from  rheumatism.  From  these  cases  I 
pass  to  the  third  class,  cases  in  which  rheumatism  has 
exerted  an  apparently  beneficial  effect  on  already  existing 
insanity. 

Class    Third. — Cases    in    ivJiich    rheumatism    complicated   other 

psychoses. 

Case  i. — Chronic  mania  with  confusion. 

A  patient  was  attacked  by  rheumatism  while  laboring. under  the 
form  of  disease  above  given,  and  during  the  rheumatic  hyperpy- 
rexia the  patient  became  perfectly  rational,  resuming  his  old 
condition  on  recovery. 

Case  2. — Hebephreniac  dementia. 

A  patient  suffering  under  the  above  form  of  insanity  was  at- 
tacked with  acute  articular  rheumatism  with  much  swelling  of  the 
joints.  The  oedema  of  the  joints  suddenly  disappeared,  and  a 
condition  of  high  fever  succeeded.     During  this  the  patient  was 


242  J  AS.   G.  KIERNAN. 

very  quiet  and  subdued  in  manner,  talked  rationally,  and  was 
careful  about  his  dress  and  person.  This  improvement  was  but 
temporary  in  character,  the  patient  again  becoming  demented  on 
recovery. 

Case  3. — Melancholia  attonita. 

A  case  of  this  affection  was  attacked  by  acute  articular  rheu- 
matism followed  by  a  fever,  the  temperature  reaching  102°.  The 
patient  during  this  fever  was  decidedly  rational,  and  after  re- 
covery from  the  rheumatism  fully  recovered  from  his  melancholia 
attonita. 

Case  4. — Epileptic  dementia. 

P.  O'F.  was  attacked  by  epilepsy  at  the  age  of  ten,  and  had 
been  in  the  asylum  as  a  case  of  epileptic  dementia  for  ten  years. 
He  was  attacked  by  rheumatism,  during  the  fever  of  which  the 
patient  was  rational  but  rather  juvenile  in  ideas,  but  soon  after 
recovery  resumed  his  usual  dementia. 

Case  5. — Monomania. 

G.  J.  A  case  of  this  disease  was  attacked  by  rheumatism,  dur- 
ing the  progress  of  which  his  delusive  ideas  entirely  disappeared, 
but  again  resumed  their  sway  on  the  patient's  recovery  from  rheu- 
matism. 

Case  6. — Querulent  melancholia. 

R.  J.  F.  A  case  of  this  kind  was  attacked  by  rheumatism, 
during  the  prevalence  of  which  he  became  very  optimistic  in 
ideas.  The  optimism  continued  after  recovery,  the  patient 
finally  becoming  a  case  of  progressive  paresis. 

The  percentage  of  cases  in  which  rheumatism  has  affected  the 
mental  condition  of  patients  is,  in  my  experience,  about  equal  to 
that  of  Kraepiliner,  five  per  cent.  Simon  and  Kelp  have,  how- 
ever, found  a  much  lower  percentage. 

From  these  cases  it  seems  to  me  the  following  conclu- 
sions follow : 

First. — That  rheumatism  produces  certain  psychical 
changes. 

Second. — That  these  changes  are  either  of  an  acute  or 
temporary  kind,  or  else  of  a  chronic  type. 

Third. — That  the  chronic  type  passes  through  three 
stages :  a  stage  of  melancholia,  either  of  the  atonic  variety 
or    with  unsystematized  delusions ;    this  condition   is   fol- 


CONTRIBUTIONS  TO  PSYCHIATRY.  243. 

owed  by  one  in  which  the  delusions  are  decidedly  of  a  sys- 
tematized type,  to  which  succeeds  a  mental  state  closely 
resembling  general  paresis. 

Fourth. — That  rheumatism  often  produces  apparent  im- 
provement in  the  chronic  psychoses  complicated  by  it, 
which  is  usually   but  temporary  in  character. 

Fifth. — That  the  acute  form  has  usually  a  good  prog- 
nosis as  regards  recovery,  but  is  much  more  fatal  than  the 
chronic  form. 

Sixth. — That  the  chronic  form  has  a  bad  prognosis  as 
regards  ultimate  recovery. 

Seventh. — That  heredity  here,  as  in  other  psychoses, 
plays  an  important  part  as  a  predisposing  cause. 

Eighth. — That  intercurrent  cardiac  affections  apparently 
exercise  some  influence  on  the  nature  of  the  delusions. 

v. THE    PSYCHOSES    PRODUCED    BY    HEAT. 

The  literature  of  this  subject  is  exceedingly  scanty.  Bail- 
larger,2  5  Voisin.^e  Griesinger.^^  EIlis,2  8  Bucknill  and 
Tuke,2  9  and  Moreau,3o  are  all  that  have  made  even  brief 
references  to  it.  David  Skae  includes  this  variety  under 
his  "  Traumatic  Insanity,"  concerning  which  he  quotes 
and  endorses  the  following  conclusions  from  Francis  Skae : 

"  First. — Traumatic  insanity  is  generally  characterized  at 
the  commencement  by  maniacal  excitement,  varying  in  in- 
tensity and  character. 

"  Second. — The  excitement  is  succeeded  by  a  chronic 
condition,  often  lasting  many  years,  when  the  patient  is 
irritable,  suspicious,  and  dangerous  to  others. 

"  Third. — In  many  such  cases  distinct  homicidal  impulses 
exist. 

"  Fourth. — The  characteristic  delusions  of  this  form  of 
insanity  are  those  of  pride,  self-esteem  and  suspicion,  melan- 
cholia being  but  rarely  present. 


244  J  AS.   G.  KIERNAN. 

"  Fifth. — This  form  is  rarely  recovered  from,  and  has 
tendency  to  pass  into  dementia  and  terminate  fatally  by 
brain  disease. 

"  Sixth. — That  the  symptoms,  progress  and  termination 
of  this  insanity  are  distinctive  and  characteristic  to  enable 
it  to  be  considered  as  a  distinct  type  of  disease." 

I  have  seen,  in  all,  ten  cases  due  to  heat,  of  which  five 
were  directly  due  to  insolation. 

The  cases  are  as  follows : 

Case  i. — D.  McC,  set.  39,  Irish,  fireman,  was  sunstruck  during 
1872,  this  being  followed  by  an  acute  attack  of  meningitis  ;  when 
the  acute  symptoms  of  which  had  passed  away,  the  patient  was 
very  dignified  and  haughty,  and  was  exceedingly  suspicious  of  his 
fellow-workmen,  whose  familiarity  he  resented.  An  attempt  on 
the  life  of  one  of  them  led  to  his  incarceration  in  the  asylum, 
where  he  was  regarded  as  a  case  of  intellectual  chronic  mania 
with  systematized  depressing  delusions.  During  1874,  the  pa- 
tient's insanity  of  manner,  which  had  hitherto  been  well  marked, 
began  to  disappear,  and  he  manifested  optimistic,  unsystematized 
delusions  of  a  rather  stupid  type.  He  claimed  to  be  the  chief 
fireman  of  the  world,  with  a  salary  of  $15,000,000  per  annum. 
His  pupils  were  unequal,  his  enunciation  was  impaired,  and  his 
tongue  was  tremulous.  He  had  a  series  of  convulsions,  which 
were  checked  by  ergot,  but  being  seized  by  pneumonia,  died 
during  1875.  The  brain  showed  marked  meningitis  of  the  con- 
vexity, on  the  autopsy,  but  decayed  while  undergoing  hardening. 

Case  2. — P.  C,  aet.  40,  clergyman,  unmarried,  was  sunstruck  dur- 
ing the  summer  of  1873,  but  by  the  fall  of  that  year  had  apparently 
recovered,  though  he  became  irritable,  and  finally  had  to  be  de- 
posed from  the  priesthood  because  of  the  existence  of  delusions 
of  persecution  and  hallucinations  of  vision.  His  condition  at 
this  time  was,  according  to  a  medical  observer,  that  of  a  case  of 
chronic  intellectual  mania  with  marked  insanity  of  manner  and 
depressing  delusions,  mingled  with  which  were  ideas  of  his  own 
superior  ability.  During  the  year  1874  he  began  to  have  some 
hesitancy  in  speech,  and  pilfered  articles  of  trifling  value.  At 
length  he  became  markedly  indecent,  and  transfer  to  the  asylum 
was  rendered  necessary.  On  admission,  the  patient  had  marked 
insanity  of   manner,   with   some  faint   delusions   of  persecution, 


CON  TRIE  U  TIONS  TO  PS  YCHIA  TR  Y.  24  5 

but  his  general  mental  condition  was  that  of  a  paretic,  he 
having  stupid,  unsystematized  delusions  that  he  was  Pope  and  at 
the  same  time  President  of  the  United  States.  His  pupils  were 
unequal,  his  lips  tremulous,  there  was  a  slight  hesitancy  in 
speech  and  inequality  of  the  facial  folds.  During  the  fall  of  1874 
he  had  several  convulsions,  which  were  treated  by  ergot  with  ap- 
parently beneficial  results  as  regards  his  mental  condition,  al- 
though his  extreme  uncleanliness  still  persisted.  The  patient  is 
still  alive,  and  varies  only  from  the  average  paretic  in  being  a 
masturbator,  a  peculiarity  common  to  all  insane  theologians. 

Case  3. — Jno.  P.,  set.  43,  American,  clerk,  was  admitted  to  New 
York  City  Asylum  for  the  Insane  during  1873  with  the  history  of 
having  been  sunstruck  three  months  before,  on  recovery  from 
which  the  patient  was  found  to  be  exceedingly  suspicious,  timid 
and  irritable.  He  at  this  time  had  hallucinations  of  taste,  claim- 
ing that  he  could  detect  arsenic  in  his  food.  On  admission  to  the 
asylum  he  had  marked  delusions  of  persecution  and  hallucina- 
tions of  taste,  hearing  and  sight.  During  1874  the  hallucinations 
of  taste  and  sight  disappeared,  together  with  the  insanity  cf  man- 
ner, the  other  hallucinations  being  very  illy  defined.  He  became 
slightly  hesitant  in  speech,  and  his  pupils  responded  unequally  to 
light.  In  October,  1874,  he  had  a  convulsion,  after  which  he 
claimed  to  be  worth  millions  of  dollars  ;  his  face  became  soggy, 
and  his  gait  was  somewhat  impaired.  In  the  course  of  the  next 
two  weeks  he  had  another  convulsion,  and  was  placed  under  ergot, 
resulting  in  a  temporary  improvement  in  his  mental  condition. 
He  died  during  1877,  four  years  after  the  beginning  of  the  disease, 
from  an  intercurrent  lung  disease. 

Case  4. — Jos.  T.,  aet.  42,  American,  was  sunstruck  during  the 
year  1872,  which  was  followed  by  meningitis;  after  the  acute  symp- 
toms of  which  had  disappeared,  the  patient  was  found  to  require 
asylum  custody  because  of  his  marked  delusions  of  persecution, 
his  suspicions  and  violent  disposition.  He  remained  in  this  con- 
dition of  excitement  during  1872  and  1873,  and  sank  into  a  con- 
dition of  dementia  during  1874,  from  which  he  emerged  in  1876 
with  all  the  symptoms  of  general  paresis,  dying  during  that  year 
from  a  convulsion. 

Case  5.— Michael  F.,  Irish,  set.  41.  Patient  was  a  cook,  and 
during  the  summer  of  1873  had  incautiously  exposed  himself  to 
the  sun  in  the  yard  of  his  place  of  employment,  after  which  he 
felt  a  little  dizzy,  but  continued  to  work  before  a  warm  range  for 
an  hour,  when  he  suddenly  fell  down.     This  was  followed  by  an 


246  J  AS.  G.  KIERNAN. 

attack  of  acute  meningitis,  the  acute  symptoms  of  which  having 
subsided,  the  patient  was  found  to  be  suffering  from  delusions  of 
persecution.  The  family  retained  him  at  home  for  four  months, 
during  which  he  displayed  great  irritability,  complained  of 
copper  being  in  his  food,  accused  his  wife  of  being  in  a  con- 
spiracy against  him,  and  conducted  himself  in  a  violent  manner, 
and  was  extremely  dignified.  He  was  taken  to  the  country,  but 
new  symptoms  of  insanity  manifesting  themselves  there,  he  was 
again  removed  to  the  city,  finally  reaching  the  asylum  in  1874. 
The  patient  was  then  a  typical  case  of  general  paresis.  He  had 
several  convulsions  during  1874,  which  were  treated  by  ergot  with 
beneficial  effect.     He  died  early  in  1875  from  phthisis. 

Case  6. — Jno.  G.,  fireman,  Scotch,  set.  39,  employed  on  a  river 
steamer,  was  seized  by  a  fainting  spell  during  a  hot  summer,  fol- 
lowed by  an  acutely  maniacal  condition  ;  on  recovery  from  which 
the  patient  was  found  to  have  systematized  delusions  of  persecu- 
tion, which  remained  for  three  years  and  finally  disappeared  to 
give  way  to  general  paresis,  from  which  the  patient  died  three 
years  after.  The  other  four  cases  have  already  been  cited  else- 
where, for  which  reason  there  is  but  little  necessity  of  quoting 
them  here. 

These  cases  do  not  display  any  marked  evidence  of  hered- 
ity; they  all  have  evidently  occurred  in  people  of  middle 
age,  and  from  them  it  seems  to  me  that  we  may  conclude : 
First,  that  heat,  without  the  predisposing  element  of  hered- 
ity, is  capable  of  giving  rise  to  psychoses ;  second,  that 
Francis  Skae's  opinions  are  to  a  certain  extent  corroborated 
by  them,  but  that  for  his  term,  brain  disease,  must  be  sub- 
stituted general  paresis. 

BIBLIOGRAPHY. 

1.  Geistes  Krankheiten,     Archiv  der  Heilkunde,  i860,  Bd.  i,  H.  3,  p.  235. 

2.  Die  Psychosen. 

3.  Morrisonian  Lectures.     Journal  of  Afetital  Science,  vol.  xx,  y>.  "202. 

4.  Archives  Generales  de  Me'decine,  v,  serie  No.  7,  i,  p.  711. 

5.  Archives  Generales  de  Midecine,  v,  serie  No.  9,  i. 

6.  Clinical  Medicine. 

7.  Archiv  fur  Psychiatric,  x'ili;  Chariti  Annalen,  1869. 

8.  Allgemeines  Zeitschrift  fiir  Psychiatric,  Bd.  xiii,  p.  214, 


CONTRIBUTIONS  TO  PSYCHIATRY.  247 

9.  Allgemeines  Zeitschrift  fur  Psychiatrie,  Bd.  xxiii,  p.  103. 

10.  Allgemeines  Zeitschift  fur  Psychiatrie,  Bd.  xxiii,  p.  252. 

11.  Du  Delire  Rheumatismale. 

12.  Archiv  fiir  Psychiatrie,  Bd.  xi,  H.  2,  1S80. 

13.  Gazette  Hebdomadaire. 

14.  Sur  les  Phrenopathies. 

15.  yournal  Alental  Science,  ^\\. 

16.  Irrenfreund,  xx. 

17.  Allgemeines  Med.  Central  Zeitung,  xxviii,  p.  225. 
1 3.  Schmidt's  yahrbucher,  1867,  p.  43. 

ig.  Deutsches  Archiv  fiir  klinische   Medicin,  1S75,  p.    599;    Irrenfreund, 
xxii. 

20.  Paralysie  Generale  des  Aliene's. 

21.  These  de  Paris,  1866. 

22.  British  Medical  Jourttal,  January  29,  i88r. 

23.  Op.  cit. 

24.  youmal  Nervous  ^  Alental  Disease,  vol.  viii,  p.  45. 

25.  Maladies  Mentales. 

26.  Paralysie  Generale  des  Alienes. 
11.  Treatise  on  Insanity, 

28.  Op.  cit. 

29.  Op.  cit. 

30.  youmal  Mental  Science,  xx. 

31.  Traite  d*  Alienation. 

32.  Edinburgh  Medical  youmal,  xi. 


THE  NERVOUS  MECHANISM  OF  RESPIRATION. 

A    LECTURE    DELIVERED    IN    THE    COURSE    OF    PHYSIOLOGY    AT  THE 
CHICAGO    MEDICAL    COLLEGE.* 

By  Dr.  H.  GRADLE. 

THE  anatomical  details  of  the  nerves  supplying  the 
respiratory  muscles  have  been  fully  pointed  out  to 
you  on  a  previous  occasion.  We  learned,  at  that  time,  that 
they  all  emerge  from  the  spinal  cord  at  different  levels. 
The  fine  coordination  of  the  various  movements  concerned 
in  breathing  leads  us  to  suspect  that  the  various  nerves  are 
all  related  to  one  governing  centre.  The  exact  position  of 
this  centre  can  be  learned  by  a  series  of  sections  through 
the  cerebro-spinal  axis.  These  sections  must  begin  above, 
since,  v^ere  we  to  commence  below,  we  would  cut  off  from 
the  upper  part  of  the  cord  the  different  nerves  which  enter 
it  below  the  point  of  section.  We  can  destroy  or  remove 
the  various  parts  of  the  brain  without  interfering  with  the 
normal  breathing,  until  we  proceed  downward  to  the  medulla 
oblongata.  Any  injury  done  to  this  part,  however,  will  in- 
fluence or  even  arrest  the  respiratory  movements.  Since 
the  teachings  of  Flourens  it  has  been  customary  to  speak 
of  a  respiratory  centre  in  the  medulla  oblongata.  Its  posi- 
tion is  immediately  above  the  lower  end  of  the  calamus 
scriptorius,  extending  upward  as  far  as  the  alae  cinereae. 

*  The  original  lecture  has   been  slightly  condensed  in  some  parts,  so  as  to 
bring  more  into  prominence  the  most  recent  additions  to  our  knowledge. 

248 


THE  NERVOUS  MECHANISM  OF  RESPIRATION.       249 

Whenever  this  point  is  wounded,  the  breathing  stops 
suddenly.  Since  the  maintenance  of  life  depends  upon  the 
continuance  of  breathing,  the  term  "vital  knot"  was  very 
properly  chosen  for  this  so-called  respiratory  centre.  In 
fact,  physiologists  frequently  resort  to  pricking  the  medulla 
with  a  stylet  when  it  is  desired  to  kill  an  animal  very 
quickly.  This  alleged  respiratory  centre  is  really  a  double 
organ  ;  it  consists  of  two  bilateral  halves.  A  longitudinal 
section  through  this  "  vital  knot,"  exactly  in  the  median 
line,  does  not  reveal  itself  in  any  disturbance  of  breathing. 
In  other  words,  each  half  can  act  independently  of  the 
other,  but  as  long  as  no  other  mutilation  exists  the  two  act 
in  concert. 

If,  however,  one  or  both  pneumogastric  nerves  are  divided, 
this  harmony  of  the  two  sides  of  the  body  ceases,  and  the 
respiratory  movements  of  the  two  sides  of  the  chest  and  of 
the  two  halves  of  the  diaphragm  occur  no  longer  synchro- 
nously.* 

Since  section  of  one  vagus  alone  does  not  disturb  the 
harmony  of  the  two  sides  as  long  as  the  "  vital  knot  "  has 
not  been  bisected,  we  conclude  that  the  normal  coordina- 
tion of  the  two  sides  is  enforced  by  transverse  nerve-fibres 
connecting  the  two  halves  of  the  respiratory  centre. 

But  strangely  enough  there  exists  no  anatomical  basis  for 
this  alleged  respiratory  centre.  At  this  spot,  described 
above,  no  ganglionic  cells  are  found  to  justify  the  term 
nerve-centre  from  an  anatomical  standpoint.  Dissection 
reveals  only  bundles  of  nerve-fibres  on  either  side  of  the 
median  line,  which  fasciculi  interchange  fibres  by  decussa- 
tion. These  bundles  can  be  traced  from  the  origin  of  the 
cranial  nerves  arising  in  the  medulla  oblongata  down  into 
the  cervical  part  of  the  spinal  cord.  They  thus  connect  the 
nuclei  of  some  of  the  cranial  nerves,  especially  those  of  the 

*  Langendorff,  Ceniralbl.  f.  d.  Med.   Wissensch.,  1879,  No.  51. 


250  //.   CRADLE. 

vagus,  with  the  origin  of  the  motor  nerves  supplying  the 
respiratory  muscles.  The  real  respiratory  centre  has  lately 
been  shown  to  be  much  larger  in  extent  than  the  spot 
termed  "  vital  knot." 

Some  observations  made  in  Strieker's  laboratory  proved 
that  after  severing  the  cord  from  the  medulla  oblongata  a 
few  irregular  respiratory  movements  could  yet  occur.* 
Especially  was  this  the  case  on  increasing  the  irritability 
of  the  spinal  cord  by  means  of  strychnia.  We  have  learned 
previously,  in  connection  with  the  vaso-motor  centres,  that 
division  of  the  spinal  cord  will  place  the  lower  end  in  a  state 
of  shock  or  temporary  paralysis  which,  in  mammals,  requires 
days  to  recover  from.  A  high  division  of  the  cord  does  not 
permit  the  animal  to  live  long  enough  to  recover,  but  an 
approach  to  the  normal  state  can  be  produced  by  poisoning 
with  small  quantities  of  strychnia.  Hence  spinal  centres 
may  not  reveal  their  existence  after  their  separation  from  the 
higher  centres,  unless  we  exalt  artificially  their  irritability. 

This  condition  of  shock  owes  its  origin,  at  least  in 
part,  to  the  excitation  of  inhibitory  fibres  by  the  mechani- 
cal section.  You  will  learn  later  about  the  existence  of 
fibres  coming  from  the  brain  downward,  which,  when  active, 
diminish  the  irritability  of  the  spinal  cord  below.  This  in- 
hibitory system  is  imperfectly  developed  at  birth.  Hence, 
in  very  young  animals,  the  spinal  cord  is  not  so  much  de- 
pressed by  severing  it  from  the  medulla  oblongata.  In 
new-born  cats  and  dogs  Lautenbach  succeeded  in  keeping 
up  the  respiratory  movements  after  destruction  of  the 
medulla  oblongata,  at  least  for  a  number  of  minutes.f 

By  selecting  new-born  cats  and  rabbits  for  experiment, 
Langendorff:}:  has  recently  succeeded  in  demonstrating  the 

*  Rokitansky,  Wiener  Med.  Jahrbiicher,  1874,  p.  30.  Schroff,  Ibid,  1875, 
p.  324. 

■f-  Philadelphia  Med  Times,  1878,  May  nth,  p.  366. 
X  Arch.  f.  {Anat.  6^  )  Physiologie,  1880,  p.  518. 


THE  NER  VO US  MECHANISM  OF  RESPIRA  TION.       2%  I 

spinal  respiratory  centres  in  a  more  positive  way.  If,  after 
the  separation  of  the  cord  from  the  medulla,  artificial  res- 
piration is  practised  for  some  time,  the  animal  will  resume  a 
perfectly  normal  mode  of  breathing  in  a  few  minutes  after 
stopping  the  bellows.  The  constancy  of  the  result  can  be 
increased  by  poisoning  with  minute  doses  of  strychnia. 
These  breathing  movements,  governed  as  they  are  by  iso- 
lated spinal  centres,  are  perfectly  normal  in  extent  and  co- 
ordination. Moreover,  the  activity  of  these  spinal  centres 
can  be  influenced  in  a  reflex  manner  by  stimulation  of  the 
sensory  nerves,  and  the  results  are  quite  comparable  to  the 
reflex  disturbances  of  breathing  which  can  be  so  easily  pro- 
duced in  the  unmutilated  animal.  The  exact  extent  of  the 
spinal  respiratory  centres  was  not  determined,  but  they 
probably  exist  as  low  as  the  origin  of  the  last  dorsal  nerves, 
innervating  the  intercostal  muscles.  It  is  best,  perhaps,  to 
drop  the  idea  of  a  discrete  respiratory  centre,  and  to  sup- 
pose simply  that  the  central  ends  of  the  different  nerves 
concerned  in  respiration  are  more  or  less  connected  with 
each  other  by  association-fibres.  Moreover,  the  points  of 
origin  of  the  different  nerves  active  in  normal,  undisturbed 
breathing,  must  possess  equal  degrees  of  irritability,  since 
the  same  stimulus  throws  them  alike  into  activity.  Indeed, 
it  can  even  be  seen  that  in  the  severed  head  of  a  young  ani- 
mal the  respiratory  movements  of  the  nostrils  agree  in 
rhythm  with  those  of  the  trunk,  although  the  former  are 
innervated  by  the  isolated  medulla,  and  the  latter  by  the 
separated  spinal  cord  (Langendorff), 

The  next  question  must  be,  how  do  the  impulses  reaching 
the  respiratory  muscles,  originate  ?  We  have  seen  so  many 
instances  of  reflex  action  in  the  regulations  of  nutritive 
movements  as  to  cause  us  to  enquire  whether  breathing  is 
also  a  reflex  process.  But  this  can  be  safely  denied,  al- 
though it  may  be  difificult  to  disprove  it  by  direct  experi- 


252  H.  CRADLE. 

ment.  We  can,  of  course,  not  cut  off  the  respiratory  cen- 
tre from  all  sensory  nerves.  Any  observations  made  on 
narcotized  animals  would  likewise  not  be  conclusive,  since 
narcotic  agents  do  not  abolish  all  reflexes  at  one  and  the 
same  time.  Although  breathing  continues  during  ordinary 
narcosis,  it  will  finally  stop  if  the  state  of  unconsciousness 
is  pushed  far  enough. 

The  conclusive  proof  that  breathing  is  not  a  reflex  move- 
ment consists  in  the  fact  that  we  are  acquainted  with  the 
stimulus  creating  the  impulses  in  respiratory  nerves,  and 
that  we  know  upon  what  organ  this  stimulus  acts.  This 
stimulus  is  the  condition  of  the  blood  of  the  medulla  ob- 
longata, or,  more  properly  speaking,  in  the  respiratory  cen- 
tres. The  activity  of  these  centres  is  in  exact  proportion 
to  the  necessity  for  breathing  as  indicated  by  the  arterial  or 
venous  nature  of  the  blood  sent  to  the  centres.  Whenever 
any  impediment  exists,  interfering  with  the  normal  aeration 
of  the  blood,  the  breathing  movements  are  exaggerated. 
They  become  both  more  frequent  and  more  energetic,  by 
reason  of  a  larger  number  of  muscles  involved.  The  im- 
pediment may  be  of  a  mechanical  nature,  an  obstacle  to 
the  passage  of  air  into  or  from  the  lungs,  or  it  may  be  an 
interference  with  the  aeration  of  the  blood,  due  to  circula- 
tory disturbances.  The  symptoms  of  dyspnoea  or  impeded 
breathing  are  the  same,  whether  the  cause  is  complete 
or  partial  closure  of  the  trachea,  or  complete  or  partial 
obliteration  of  the  pulmonary  artery.  In  either  case  the 
blood  is  not  suf^ciently  aerated,  and  the  respiratory 
centre  feels  the  call  for  a  stronger  ventilation,  and  re- 
sponds to  it  by  increased  activity.  We  can  demon- 
strate directly  that  it  is  only  the  condition  of  the  blood 
in  the  nerve-centres  which  regulates  the  energy  of 
breathing.  If  we  close  suddenly  the -four  arteries  sup- 
plying   the    brain   and    upper  part   of    the  cord,  namely, 


THE  NERVOUS  MECHANISM  OF  RESPIRATION.       253 

the  carotid  and  vertebral  arteries  on  both  sides,  most 
intense  dyspnoea  is  at  once  manifested.  The  energetic 
movements  of  the  chest  resulting  therefrom  certainly  ven- 
tilate the  lungs  thoroughly.  The  aeration  of  the  blood 
is  likewise  not  prevented  by  any  obstacle,  but  the  respira- 
tory centres  do  not  receive  any  of  this  arterialized  blood, 
and  hence  this  artificially  created  condition  leads  to  the 
same  compensatory  consequences  which  would  follow  the 
more  ordinary  interferences  with  aeration  of  the  blood. 
We  find  here  the  same  adaptation  of  the  system  to  variable 
external  conditions  to  be  encountered  in  other  branches  of 
physiology.  The  greater  the  difificulty  of  getting  air,  the 
greater  will  be  the  effort  to  overcome  the  difficulty. 

In  the  same  manner  as  the  respiratory  centre  responds  by 
increased  activity  to  an  inadequate  supply  of  arterial  blood 
or  to  blood  imperfectly  arterialized,  so  it  will,  on  the  other 
hand,  relax  in  its  activity  when  it  receives  a  due  quantity 
of  perfectly  aerated  blood.  The  reverse  of  dyspnoea  or 
labored  breathing  is  the  state  of  apnoea.  During  this  con- 
dition there  occur  no  respiratory  movements,  because  there 
is  no  need  for  them.  Whenever  the  blood  reaching  the 
respiratory  centres  is  perfectly  arterialized,  the  activity  of 
these  centres  ceases.  In  other  words,  the  stimulation  of 
the  respiratory  centre  is  due  to  want  of  oxygen  in  the 
blood.  When  the  bellows  are  vigorously  used,  which  are 
connected  with  the  dog  on  the  table,  you  will  notice,  first 
of  all,  that  the  spontaneous  breathing  ceases,  the  animal 
yields  passively  to  the  inflation,  and  no  movements  occur 
except  those  caused  mechanically  by  our  ventilation.  The 
animal  before  us  is  narcotized,  but  the  same  results  could 
have  been  obtained  in  a  conscious  dog. 

After  a  vigorous  use  of  the  bellows,  we  will  interrupt  the 
artificial  respiration  suddenly.  You  can  notice  no  breathing 
occurs  during  the  space  of  nearly  one  minute.     The  breath- 


254  H.  GRADLE. 

ing  was  not  interfered  with.  It  stopped  simply  because 
there  was  no  need  for  it.  The  animal  was  in  a  state  of 
apnoea.  The  blood  was  so  perfectly  arterialized  by  the 
energetic  inflation  as  not  to  stimulate  the  respiratory  centre 
at  all. 

We  can  perform  the  same  experiment  ourselves. 

On  stopping  your  breathing  voluntarily,  you  will  find  it 
very  difficult  to  maintain  rest  for  a  minute.  The  anguish 
due  to  the  venosity  of  the  blood  compels  you  to  resume 
breathing  in  spite  of  your  will,  but  if  you  take  a  series  of 
unusually  quick  and  deep  inspirations,  you  will  find  it  easy 
to  suspend  breathing  thereupon  for  a  full  minute  or  even 
longer.  The  blood  is  thereby  so  fully  arterialized  that  con- 
siderable time  is  required  before  it  becomes  venous  enough 
in  character  to  stimulate  the  respiratory  centres. 

The  maintenance  of  apnoea  is  not  due  merely  to  sat- 
uration of  the  arterial  blood  with  oxygen,  since  even  nor- 
mally at  least  fifteen-sixteenths  of  the  haemoglobin  in  the 
arteries  is  combined  with  oxygen.  But  the  energetic  ven- 
tilation leading  to  apnoea  necessarily  renovates  the  residual 
air  in  the  lungs  more  thoroughly,  so  as  to  leave  a  store 
of  oxygenated  air  in  the  lungs  from  which  the  blood  can 
draw  its  supply  without  the  need  of  respiratory  move- 
ments.* 

The  activity  of  the  respiratory  centres  varies  thus  in  an 
inverted  ratio  with  the  arterialization  of  the  blood.  The 
mechanism  is  self-regulating.  The  energy  displayed  is  in 
proportion  to  the  energy  required  to  keep  the  blood  arteri- 
alized. But  how  are  we  to  explain  the  regular  alternation 
of  inspiratory  and  expiratory  movements  ?  What  is  the 
mechanism  controlling  the  respiratory  rhythm  ?  Are  we  to 
look  for  separate  inspiratory  and  expiratory  centres?  No 
satisfactory  answer  can  yet  be  given   to   these  questions. 

*Gad,   Habilitatsvorlesung,  Ueber  Apnoea,  etc.     Wurzburg,  1880. 


THE  NER  VO  US  MECHANISM  OF  R  ESP  IRA  TION.       255 

Our  insight  into  the  central  mechanism  is  but  very  incom- 
plete. 

Normally,  the  expiratory  movement  is  almost  wholly 
passive.  You  will  remember  that  it  is  due  mainly  to  the 
elasticity  of  the  lungs  and  the  chest-walls,  the  only  muscles 
involved  being  the  internal  intercostal  muscles.  Hence, 
the  supposition  of  a  separate  expiratory  centre  is  hardly  nec- 
essary. The  central  mechanism  may  consist  simply  in  al- 
ternate discharge  and  rest  of  the  inspiratory  centre.  More- 
over, no  expiratory  movement  can  be  directly  produced  by 
stimulating  the  nerve-centres.  Lately,  Kronecker  and 
Marckwald  have  made  the  following  experiments:  *  They 
severed  the  medulla  oblongata  from  the  pons  in  rabbits. 
The  breathing  is  thereby  not  disturbed  if  the  operation  suc- 
ceeds. On  sending  induction  shocks  through  the  medulla, 
inspiratory  movements  were  produced,  but  no  expiratory 
efforts.  Whenever  the  stimulation  coincided  with  an  in- 
spiratory movement,  it  enforced  it ;  whenever  the  current 
passed  through  the  centre  during  expiration,  it  arrested  it. 
A  point  of  special  interest  in  these  researches  was  the  dis- 
covery that  during  complete  apncea  the  centre  did  not  re- 
spond to  electric  stimulation. 

But  we  must  not  lose  sight  of  the  fact,  that  during  dysp- 
noea the  expiratory  movements  are  indeed  active,  and 
that  muscular  contractions  resulting  in  expiration  can  be 
produced  in  a  reflex  manner  to  be  described  later  on.  No 
explanation  of  these  occurrences  can  be  given. 

While  the  total  energy  of  respiration  depends  on  the 
state  of  the  blood,  the  distribution  of  the  energy  is  influ- 
enced vastly  by  impulses  reaching  the  respiratory  centres 
through  different  nerve-strands.  We  see  but  too  often  the 
effect  of  emotions  on  breathing.  The  movements  are  sus- 
pended  for  a   time  by  terror,  accelerated  by  exciting  emo- 

*Arch.  f.  Phys.,  Heft  5  and  6,  p.  592,    1880. 


256  H.   CRADLE. 

tions.  The  sigh  of  relief  is  but  a  deep  and  slow  inspira- 
tion. Dread  leads,  on  the  other  hand,  to  increased  fre- 
quency of  inspiration.  It  is  quite  likely  that  these  and  nu- 
merous similar  instances  are  due  to  the  influence  of  acces- 
sory respiratory  centres  recently  discovered  in  the  brain  by 
Martin  and  Booker."^  These  observers  learned  that  there 
exists  a  spot  in  the  gray  substance  around  the  aqua^duct  of 
Sylvius,  beneath  the  corpora  quadrigemina,  irritation  of 
which  increases  the  frequency  of  breathing.  This  effect  is 
really  due  to  exalted  activity  of  the  inspiratory  muscles, 
which  do  not  relax  fully  during  the  brief  expiratory  inter- 
vals. On  increasing  the  stimulus,  the  action  of  the  inspira- 
tory muscles  becomes  tetanic  at  last,  so  that  the  chest  is 
kept  in  the  inspiratory  position.  On  shifting  the  electric 
needles,  the  effect  ceases.  The  authors  claim  also  that  an 
expiratory  centre  is  to  be  found  further  back  near  the  pons, 
which  augments  in  the  same  manner  the  expiratory  move- 
ments. These  statements  have  been  confirmed,  apparently 
without  knowledge  of  Martin  and  Booker's  results,  by 
Christiani.f  You  must  not  suppose,  however,  that  these 
centres  assist  in  ordinary  respiration.  As  already  stated, 
the  breathing  is  not  altered  sensibly  by  removing  the 
brain. 

A  most  important  influence  upon  the  respiratory  centre 
is  exerted  by  the  vagus  nerve.  This  is  evident  at  once  on 
severing  the  nerve.  Division  of  one  nerve  alone  does  not 
alter  the  breathing,  unless  the  medullary  "  vital  knot  "  has 
previously  been  bisected  longitudinally,  in  which  case  the 
irregularity  of  breathing  is  confined  to  the  muscles  of  the 
same  side,  while  the  other  side  moves  with  the  normal 
rhythm.  If  both  nerves  are  divided,  the  breathing  be- 
comes very  slow.     Our  dog  on  the  table  breathes  about  30 

*  youmal  of  Physiology,  vol.  i,  p.  370. 

\  Centralblatt  f.  d.   Med.    JViss.,    1 880,  No.    15. 


THE  NER  VOUS  ME  CHA  NISM  OF  RE  SPIRA  TION.       257 

times  a  minute.  Now,  after  having  severed  the  pneumo- 
gastric  nerves,  the  frequency  has  been  reduced  to  6  breaths 
a  minute.  You  may  notice  that  the  retardation  occurs  dur- 
ing the  inspiratory  period.  After  a  long  pause,  there  begins 
a  slow  but  very  deep  inspiration,  sometimes  persisting  even 
as  inspiratory  tetanus.  Suddenly  it  is  interrupted  by  an  ex- 
piration nearly  normal,  or,  if  anything,  very  sudden.  More- 
over, the  breathing  is  irregular.  Two  successive  respira- 
tions vary  often  appreciably  in  duration.  But  the  total 
energy  of  respiration  is  not  altered.  What  the  inspirations 
lack  in  frequency  they  make  up  in  depth.  Voit  has  shown 
by  actual  test  that  the  gaseous  exchange  of  the  animal  is 
not  reduced.  But  while  the  respiratory  centre  does  enough 
work,  the  work  is  not  distributed  uniformly  or  advanta- 
geously. The  centre  lacks  the  regulation  due  to  impulses 
sent  from  the  lungs  to  the  medulla  through  the  pneumo- 
gastric  nerve. 

Breuer  and  Hering  have  shown  that  these  regulating  im- 
pulses originate  fn  the  lungs  from  mechanical  causes. 
These  observers  claim  that  certain  fibres  of  the  vagi  nerves 
are  stimulated  by  expansion  of  the  lungs,  i.  e.,  by  inspira- 
tion, and  that  these  fibres  check  any  further  inspiratory 
movements,  but  favor  expiration.  They  state  further  that 
other  fibres  in  the  same  nerves  are  stimulated  by  the 
mechanical  collapse  of  the  lung  tissue,  and  that  these  latter 
nerve-filaments,  when  active,  excite  a  renewed  inspiratory 
effort.  The  experiments  upon  which  they  base  these  conclu- 
sions are  the  following  :  If,  in  a  tracheotomized  animal,  the 
lungs  are  inflated  with  bellows,  and  the  tracheal  tube  be 
now  closed  to  prevent  collapse  of  the  lungs,  the  first  spon- 
taneous movement  occurring  is  always  one  of  expiration, 
even  though  the  lungs  be  but  moderately  distended.  But 
if  the  artificial  respiration  be  stopped  during  the  collapsed 
state  of  the  lungs,  the  animal  follows  every  time   with   an 


258  H.   GKADLE. 

inspiration.  This  regular  alternation  is  not  dependent 
upon  any  anatomical  restraint.  At  the  end  of  an  ordinary 
inspiration  we  can  easily  make  a  voluntary  stronger  inspira- 
tory effort,  and  we  can  likewise  exaggerate  in  depth  the 
ordinary  expiratory  movement.  The  capital  point  is,  that 
the  regularity  ceases  on  section  of  both  pneumogastric 
nerves.  While  in  the  normal  animal  we  can  predict  with 
certainty  the  next  respiratory  movement,  this  is  no  longer 
possible  after  vagotomy. 

The  experiments  were  repeated  some  years  ago,  with  im- 
perfect result,  by  Guttman  and  Gad.  But,  as  Gad*  himself 
admits,  the  fault  was  in  the  mode  of  observation,  and  es- 
pecially in  the  employment  of  chloral  as  a  means  of  narco- 
sis. The  chloral  simply  prevents  the  influence  of  the  vagus 
upon  the  centre.  Recently,  Langendorfff  has  confirmed 
fully  Breuer  and  Hering's  views  by  the  application  of 
graphic  methods. 

The  existence  of  such  a  double  set  of  fibres,  one  of  which 
arrests  the  inspiratory  action  of  the  centre,  the  other  the 
expiratory,  can  be  demonstrated  by  electric  stimulation  of 
the  vagus  trunk,  i.  e.,  its  central  end  after  section  of  the 
trunk.  Nearly  twenty  years  ago  Rosenthal  pointed  out 
that  the  vagus  nerve  possessed  a  function  antagonistic  to 
that  of  one  of  its  branches,  viz. :  the  superior  laryngeal 
nerve.  Stimulation  of  the  latter  branch  with  a  mild  current 
leads  to  diminished  frequency  of  breathing  by  cutting  short 
the  inspirations  and  prolonging  the  expiratory  pauses.  A 
strong  current  will  arrest  the  chest  altogether  in  the  expi- 
ratory position.  Stimulation  of  the  vagus  trunk,  however, 
below  the  superior  laryngeal  branch,  leads  to  the  opposite 
result.  According  to  Rosenthal,  a  feeble  excitation  will 
accelerate  breathing  by  favoring  the  inspirations,  while  a 

*  Archiv  f.  Physiologic,  1 8 80,  p.  7. 

\  Archiv  f.  Physiologic,  Supplement  Band,  1879,  p.  48. 


THE  NER  VOUS  MECHANISM  OF  RESPIRA  TION.       2$g 

stronger  stimulus  will  throw  the  inspiratory  muscles,  and  es- 
pecially the  diaphragm,  into  tetanus,  and  thus  arrest  the 
chest  in  inspiration,  at  least  for  a  minute  or  so.  Whether 
this  peculiar  property  of  the  laryngeal  nerve  is  called  into 
action  during  ordinary  breathing,  we  da  not  know.  We  are 
ignorant,  likewise,  of  the  manner  in  which  the  impulses 
checking  inspiration  originate  in  this  nerve.  The  existence 
of  this  function,  however,  has  been  confirmed  by  all  ob- 
servers. But  not  so  with  the  trunk  of  the  vagus.  Rosen- 
thal* himself  claimed  recently,  that  stoppage  during  inspi- 
ration is  the  constant  result  of  stimulation  of  the  nerve  with 
not  too  strong  a  current.  This  statement  formerly  met  with 
much  opposition. 

Later  researches  by  other  observers  show  that  the  trunk 
of  the  vagus  does,  after  all,  contain  fibres  which  arrest 
breathing  during  expiration.  Burkartf  claims  that  such 
fibres  exist  in  the  inferior  laryngeal  nerve,  and  hence  also 
in  the  trunk  of  the  vagus,  but  that  these  fibres  act  indirectly 
upon  the  respiratory  centre  through  the  intervention  of  the 
brain.  Their  effect  is,  hence,  prevented  by  narcosis.  Even 
more  positive  statements  are  made  by  Langendorff.:}:  He 
was  able  to  obtain  either  expiratory  or  inspiratory  arrest 
of  breathing  by  electric  irritation  of  the  nerve.  It  is  not 
easy  to  predict  which  result  will  set  in.  But  it  seems  that 
the  fibres  producing  arrest  in  expiration  are  not  so  easily 
fatigued  as  the  other  set,  so  that  after  prolonged  stimula- 
tion inhibition  of  inspiration  is  the  more  constant  phe- 
nomenon. The  latter  result  occurs  invariably  on  irritating 
the  divided  nerve  by  means  of  glycerine. 

A  very  suggestive  mode  of  experimentation  has  lately 
been  pursued  by  Kronecker  and  Marckwald.§    They  severed 

*  Archiv  f.  Physiologie,  Supplement  Band,  1880,  p.  34. 
f  Pfluget's  Archiv,  1878,  vol.  xvi,  p.  427. 

X  Konigsberger  Phys.  Mittheibungen,  1S78,  p.  33,  and  Ceniralblatt,  1879, 
No.  21. 

§  Archiv  f.  Physiologie,   1880,  p.  441. 


26o  H.   GRADLE. 

the  respiratory  centres  from  their  more  important  nerve- 
connections  by  dividing  the  medulla  underneath  the  pons 
and  cutting  the  two  vagi.  Under  these  circumstances  the 
respiration  is  very  irregular  in  rabbits.  It  was  then  learned 
that  stimulation  of  the  central  end  of  the  vagus  could  pro- 
duce either  expiration  or  inspiration  according  to  the  time 
the  stimulus  was  applied.  The  inspiratory  movement, 
however,  could  be  more  easily  obtained.  But  if  the  medulla 
was  divided  so  low  as  to  check  the  natural  breathing,  or  if 
the  breathing  had  ceased  on  account  of  hemorrhage,  a  con- 
tinuous faradization  of  the  pneumogastric  nerves  restored 
the  respiration. 

These  various  facts,  important  as  they  are,  do  not  sufifice 
for  a  theory  of  the  nervous  mechanism.  We  can  only  say 
that  the  activity  of  the  centre  depends  on  the  state  of  the 
blood,  and  that  the  regularity  of  the  movements  are 
influenced  by  the  vagi  nerves.  But  for  the  alternation  of 
the  inspiratory  and  expiratory  movements,  we  lack,  as  yet, 
a  sufficient  explanation. 

Not  only  the  vagus,  but  nearly  all  sensory  nerves  of  the 
body  can  modify  the  breathing  movements.  Sudden 
changes  in  rhythm  are  produced  by  almost  any  strong  or 
painful  impression.  As  a  rule,  feeble  stimulation  of  a  sen- 
sory nerve  will  accelerate,  while  intense  excitation  checks 
the  breathing  (Langendorff),  These  same  changes  can  be 
obtained  even  after  severing  the  spinal  cord  from  the 
medulla  oblongata,  providing  the  animal  still  breathes.  In 
such  instances  in  which  the  shock  of  the  cord  prevents  the 
resumption  of  normal  breathing,  stimulation  of  sensory 
nerves  will  aid  the  centres  in  recommencing  their  activity. 
Indeed,  in  practice  we  avail  ourselves  of  this  susceptibility 
of  the  respiratory  centres  to  sensory  impressions.  Stimula- 
tion of  the  skin  by  dashing  on  cold  water  or  slapping  with 
wet  cloths,  has  aided  in  the  recovery  of  many  an  asphyxiated 


THE  NERVOUS  MECHANISM  OF  RESPIRA  TION.       26 1 

individual.  This  artifice  is  of  particular  value  in  obstetric 
practice,  when  the  child  does  not  breathe  at  birth.  Should 
such  stimulation  fail,  the  rational  course  would  be  to 
heighten  the  irritability  of  the  respiratory  centre  by  supply- 
ing it  with  arterialized  blood  by  means  of  artificial  stimula- 
tion. Quite  recently,  Goyard  presented  a  note  to  the 
French  Academy  -  regarding  a  successful  method  of  resus- 
citation in  the  case  of  a  still-born  child.  After  two  hours 
of  vain  endeavors  with  ordinary  means,  he  plunged  the 
child  into  a  hot  bath  (45"^  to  50'^  C),  and  witnessed  the 
recovery,  although  the  heart  had  stopped  beating  at 
birth. 

A  peculiar  modification  of  breathing  is  produced  by  the 
action  of  heat  on  the  sensory  terminations  in  the  skin.  I 
refer  to  heat  dyspnoea,  commonly  known  as  panting. 
It  consists  in  an  excessive  frequency  of  respiratiort,  the 
movements  being,  however,  quite  shallow.  It  is  not  a 
form  of  asphyxia,  properly  speaking.  There  exists  no  im- 
pediment to  aeration  of  the  blood.  Although  the  dog  may 
breathe  300  times  a  minute,  its  blood  is  in  the  usual  state  of 
arterialization.  The  frequency  is  due  to  the  influence  of 
other  nerves  upon  the  respiratory  centre. 

Panting  does  not  occur  to  any  extent  in  man,  but  readily 
so  in  animals  that  do  not  sweat.  An  animal  devoid  of 
sweat  glands  and  covered  with  hair,  like  the  dog,  regulates 
its  internal  temperature  largely  by  the  dissipation  of  heat 
through  the  lungs.  The  more  air  passing  through  the 
lungs  in  a  given  time,  the  more  heat  will  the  animal  lose  in 
warming  the  inhaled  air,  and  by  evaporation  from  the  lung 
surface.  Hence,  heat  dyspnoea  is  a  regulative  provision  of 
the  economy  in  such  animals,  in  order  to  guard  against 
overwarming  of  the  body.  Panting  is  due  to  heating  of 
the  terminations  of  sensory  nerves  more  than  to  overheated 
*Jan.  17,  1881.     L  Union  Medicak,  No.  11,  18S1. 


262  H.   GRAIXLE. 

blood.  Still,  Fick  and  Goldstein  claimed  to  have  produced 
it  by  warming  the  blood  in  the  carotid  arteries  by  means  of 
hot  tubes  (50°  C.)  placed  underneath  the  vessels.  But  their 
deductions  have  been  contested  by  Sihler.* 

It  is  doubtful  whether  their  method  really  did  warm  the 
rapid  blood-current  to  any  extent,  while  the  panting  was 
actually  due  to  the  pain  produced  by  the  hot  tubes.  Yet 
it  is  fair  to  assume  that  the  heat  dyspnoea  may  be  of  cen- 
tral origin,  since  we  witness  it  during  the  febrile  state,  even 
though  the  air  is  cool.  Sihler,  however,  has  shown  that  it 
is  ordinarily  caused  by  heating  of  the  skin,  and  that  it  may 
occur  even  when  but  a  small  part  of  the  skin  is  still  con- 
nected with  the  respiratory  centre,  for  instance,  after  sec- 
tion of  the  spinal  cord  in  the  cervical  region. 

Notwithstanding  the  excessive  frequency  of  the  move- 
ments during  panting,  the  respiration  is  in  reality  not  more 
efficient  than  ordinarily,  on  account  of  the  shallowness  of 
breathing.  In  some  experiments  which  I  have  never  pub- 
lished, I  learned  that  the  heat  dyspnoea  gives  way  at  once 
to  the  much  more  vigorous  though  slower  movements  of  true 
dyspnoea  on  closing  the  trachea  of  the  animal,  to  return 
when  the  breathing  was  no  longer  impeded.  On  the  other 
hand,  the  condition  of  apnoea  can  readily  be  induced  during 
panting.  On  connecting  the  trachea  with  the  bellows  and 
ventilating  the  lungs  thoroughly,  I  found  that  the  animal 
remained  motionless  even  in  the  hot  chamber.  The  apnoea 
was  of  the  usual  duration,  but  was  followed  at  once  by  the 
breathing  characteristic  of  heat  dyspnoea.  We  are  to  con- 
clude, hence,  that  even  in  heat  dyspnoea  the  condition  of  the 
blood  is  the  ruling  factor,  regulating  the  energy  of  the 
respiratory  centre. 

*  yournal  of  Physiology,  vol.  ii,  No.  3,  p.  191  ;  vol.  iii,  No.  I,  p.  i. 


NERVE-STRETCHING. 

SELECT    TOPICS    OF    MODERN     SURGERY,*     ILLUSTRATED    BY    CASES 

FROM    THE    HOSPITAL    SERVICE    AND    PRIVATE 

PRACTICE    OF 

Drs.  christian  FENGER  and  E.  W.  LEE,  of  Chicago. 

THIS  operation  has  been  known  for  only  about  half 
a  decade.  It  was  originated  accidentally  by  Bill- 
roth, who  cut  down  upon  the  sciatic  nerve,  expecting  to 
find  a  tumor,  but  found  nothing  but  normal  nerve-tissue. 
By  this  very  examination,  however,  the  neuralgia  was  re- 
lieved. Nerve-stretching  as  a  premeditated  surgical  opera- 
tion was  first  carried  out  by  Von  Nussbaum,  in  Munich. 

The  unexpected  success  in  relieving  pain  by  this  opera- 
tive procedure  in  cases  in  which  all  other  remedies  have 
failed,  and  the  almost  absolute  immunity,  not  only  from 
danger  to  the  patient's  life,  but  also  from  the  destruction 
or  impairment  of  the  normal  functions  of  the  nerve  op- 
erated upon,  caused  this  operation  to  be  very  readily 
adopted  by  medical  men  all  over  the  world. 

There  are  already  a  number  of  facts  at  our  disposal  which 
throw  considerable  light  upon  the  therapeutic  value  of  the 
operation  in  certain  diseases  of  the  nerves. 

As  our  knowledge  of  the  subject  is  as  yet  very  imperfect, 

*This  is  the  general  heading  of  a  series  of  articles  published  in  different 
American  journals,  and  is  kept  up  as  such,  because  it  is  the  intention  of  the  au- 
thors, after  a  certain  length  of  time,  and  after  revision,  correction,  and  addition, 
to  publish  the  series  in  one  volume. 

263 


264  FENCER  AND  LEE. 

owing  to  the  scarcity  of  pathologico-physiological  experi- 
ments on  animals,  we  shall  here  give  only  a  brief  account 
of  the  various  nervous  diseases  in  which  nerve-stretching 
has  been  tried,  and  point  out  the  results,  as  far  as  known, 
but  shall  not  be  able  to  state  anything  about  either  the 
pathologico-anatomical  or  the  pathologico-physiological 
side  of  the  question. 

From  a  merely  clinical  point  of  view,  the  different  ner- 
vous diseases  in  which  nerve-stretching  has  been  tried  are 
the  following: 


I.  Neuralgic  Anomalies.  \  3 

'  4 
5 


Sciatica    -^  '^'  Rlieuni^^tic,  idiopathic  or  primary. 

'   \b.  Symptomatic  or  secondary. 
Prosopalgia.     Neuralgia  of  the  fifth  pair. 
Intercostal  neuralgia. 
Idiopathic  neuralgias  of  other  nerves. 
Neuralgias  of  the  peripheral  nerves  caused  by  surgica 
lesions  involving  the  nerve-trunks. 

1  I.    Mimic  spasm.    Spasms  of  the  seventh  pair. 
II.  Spastic  Anomalies.     <  2.    Spasms  of  the  accessory  nerve  of  Willis. 

(  3.    Spastic  contractions  of  the  nerves  of  the  extremities. 

III.  Epilepsy. 

IV.  Paralysis. 
V.  Tetanus. 

VI.  Locomotor  Ataxia. 
VII.  Anaesthetic  Leprosy. 

I.     NEURALGIC    ANOMALIES. 

I. — SCIATICA. 

a.  Rheumatic,  Idiopathic  or  Primary  Sciatica. 

We  have  had  at  our  disposal  reports  of  ten  cases  of 
nerve-stretching  in  this  disease,  eight  of  which  were  suc- 
cessful and  two  unsuccessful  (Bernays). 

Case  i. — (John  Cheyne,  Edinburgh,  1877.''  ^)  A  furnace-man, 
forty  years  of  age,  suffered  for  five  years  from  pain  and  weakness 
in  the  right  leg,  which  increased  to  such  an  extent  that  he  became 
unable  to  walk.  On  April  19,  1877,  the  sciatic  nerve  was  stretched. 
The  nerve  appeared  perfectly  normal.  The  operation  was  fol- 
lowed by  perfect  recovery. 

Case  2. — (John  Cheyne,  Edinburgh,  1877.''  '')  A  furnace-man, 
forty-one  years  of  age,  had  suffered  from  sciatica  of  the  left  side 
for  ten  months.  The  sciatic  nerve  was  exposed  and  stretched 
April  23,  1877.  The  nerve  appeared  to  have  undergone  fatty 
degeneration,  and  large,  tortuous  veins  were  to  be  seen  on  its 
surface.     The  pain  disappeared  entirely,  with  the  exception  of  a 


NER  VE-  S  TRE  TCHING.  265 

small  place  behind  the  great  trochanter,  where  pressure  still  caused 
a  little  pain. 

Case  3. — (Maag,  Denmark,  1878.^)  A  girl,  nineteen  years  old, 
suffered  from  sciatica  of  three  months'  standing.  The  nerve 
was  stretched.  The  wound  did  not  heal  by  first  intention. 
Recovery. 

Case  4. — (Patruban,  Vienna,  1878.")  Sciatica.  Stretching  of 
the  sciatic  nerve,  followed  by  great  amelioration  of  the  symptoms. 

Case  5. — (Bernays,  St.  Louis,  Missouri,  1878.^)  A  man  had 
suffered  for  six  or  eight  months  from  severe  neuralgic  pains  on 
the  outer  aspect  of  the  thigh.  The  sciatic  nerve  was  stretched 
immediately  above  the  knee.  The  pain  was  relieved  for  six  days, 
but  then  returned.  One  and  one-half  inches  of  the  peroneal  and 
external  saphenous  nerves  were  excised.  I'his  operation  was  fol- 
lowed by  entire  relief  of  the  pain,  but  the  muscles  remained 
paralyzed. 

Case  6. — Dr.  Bernays  mentions  another  case,  without  giving  par- 
ticulars, in  which  nerve-stretching  proved  to  be  a  complete 
failure. 

Case  7. — (Hildebrandt,  Neustadt-Magdeburg,  1880.')  'A 
woman,  thirty-two  years  of  age,  suffered  from  sciatica  of  the 
left  side.  The  sciatic  nerve  Avas  stretched  in  the  popliteal  space. 
The  wound  healed  by  first  intention.  The  operation  was  fol- 
lowed by  immediate  relief,  and  the  patient,  after  eight  days,  was 
able  to  do  her  own  work. 

Case  8. — (Esmarch,  Kiel,  1880.'')  Sciatica.  Nerve-stretching. 
Recovery. 

Case  9. — (Purdie,  London,  1880.*)  Severe  sciatica  of  several 
months'  standing,  in  a  miner.  The  sciatic  nerve  was  stretched. 
The  wound  healed  by  first  intention.     Recovery. 

Case  10. — (Fenger,  Chicago,  1880.)  Synopsis. — Sciatica  of 
one  year  s  standing — Stretching  of  sciatic  nerve  between  the  great  tro- 
chanter and  the  tuber  ischii —  Wound  healed  by  suppuration  in  eight 
weeks — Cessation  of  pain  in  the  leg — Temporary  paralysis  of  the 
sphincter  ani  and  ancesthesia  of  anal  region  and  posterior  surface 
of  both  thighs — Recovery.  Mrs.  H.,  thirty-five  years  of  age, 
healthy,  stout,  has  two  healthy  children,  aged,  respectively, 
seventeen  and  eighteen  years.  Her  father  suffered  from  sciatica 
of  the  left  side  at  the  age  of  forty-five,  which  lasted  a  year,  con- 
fining him  to  his  bed  for  six  months,  and  finally  disappeared  after 
treatment  by  sea-baths.  Her  sister  had  sciatica  at  the  age  of 
thirty.     Her  father  died  of  cancer  of  the  liver,  at  the  age  of  fifty. 


266  FENCER  AND  LEE. 

Her  mother  is  still  living,  and  healthy,  with  the  exception  of  occa- 
sionally recurring  muscular  rheumatism. 

In  June,  1879,  while  crossing  the  Atlantic,  Mrs.  H.  was  seized 
with  pain  in  the  right  side  of  the  head,  face,  and  neck,  and  in  the 
right  arm.  An  ointment  was  applied,  and  the  pain  disappeared 
in  two  or  three  weeks. 

November,  1879. — The  patient  awoke  one  night  with  a  sudden 
and  violent  pain  in  the  right  ankle,  which  she  could  trace  to  no 
inducing  cause.  She  was  obliged  to  keep  her  bed  for  eight  days. 
Under  the  use  of  morphine  and  some  ointment,  the  pain  lessened 
so  that  she  was  able  to  be  up  and  around. 

During  the  whole  of  the  following  winter  she  was  able  to  walk 
the  whole  day  long  on  level  ground  without  pain,  but  when  mount- 
ing stairs,  pain  would  set  in,  always  at  the  same  place,  around  the 
external  malleolus,  at  which,  however,  no  swelling  nor  other  in- 
flammatory symptoms  were  to  be  seen.  Every  night  she  would 
be  awakened  several  times  by  vehement  pain  in  the  ankle,  caused, 
as  she  thinks,  by  moving  the  leg  during  sleep.  In  this  way  it  went 
on  until  June,  1880,  when  pain  set  in  in  the  right  knee  and  soon 
extended  along  the  posterior  part  of  the  femur  to  the  hip,  so  that 
she  was  not  able  to  extend  the  leg  at  the  knee,  and  could  not  walk 
without  limping.  When  she  got  out  of  bed  in  the  morning  the 
pain  was  very  severe,  but  would  lessen  after  she  had  walked  around 
a  little.  She  would  soon  become  tired  and  be  obliged  to  sit  down, 
and  when  she  would  start  to  walk  again  the  pain  would  be  very 
severe.  She  was  not  able  to  walk  more  than  about  two  thousand 
feet  before  the  pain  would  become  so  intense  as  to  compel  her  to 
sit  down.  Various  kinds  of  internal  medication,  hypodermic  injec- 
tions of  morphine,  and  Turkish  baths  were  tried,  but  with  no 
effect.  The  pain  became  worse  and  she  had  more  and  more 
difficulty  in  walking,  until  she  finally  determined  to  have  the  pro- 
posed operation  performed. 

On  October  6,  1880,  Dr.  Fenger,  assisted  by  Drs.  Jacobson  and 
Koren,  proceeded  to  stretch  the  right  sciatic  nerve.  The  patient 
was  anaesthetized  with  chloroform.  An  incision  was  made,  four 
inches  in  length,  between  the  great  trochanter  and  the  tuber  ischii. 
The  layer  of  adipose  tissue  was  about  one  inch  in  thickness.  The 
depth  of  the  wound  and  the  hemorrhage  caused  a  little  delay  in 
finding  the  trunk  of  the  nerve,  which,  when  found,  appeared  nor- 
mal. The  nerve  was  now  stretched  vigorously,  centrally  as  well 
as  peripherally,  and  pressed  between  the  fingers  and  the  instru- 
ment with  which  the  nerve  was  held  out  of  the  wound,  namely, 


NER  VE.  S  TRE  TCHING.  26/ 

an  elevator  of  the  palpebrge  used  as  a  retractor.  The  wound  was 
washed  out  with  two  and  one-half  per  cent,  solution  of  carbolic 
acid,  until  the  hemorrhage  ceased.  No  drainage  tube  was  in- 
serted. The  wound  was  closed  with  antisepticized  silk  and  Lister 
dressing  applied. 

The  wound  did  not  heal  by  first  intention,  but  suppuration  set 
in,  which  prevented  it  from  healing  for  eight  weeks,  during  which 
time  the  patient  was  obliged  to  remain  in  bed. 

The  pain  in  the  thigh  and  knee  ceased  entirely  and  has  not 
since  returned,  and  the  knee  could  be  fully  extended  without 
pain  ;  but  for  seven  weeks  after  the  operation  there  were  inter- 
current attacks  of  pain  around  the  right  malleolus,  which  were 
controlled  by  morphine,  and  after  the  above-named  period  ceased 
entirely. 

Four  weeks  after  the  operation,  when  lifting  herself  upon  the 
bed-pan,  she  experienced  a  sudden  and  vehement  pain  in  the 
sacral  region,  and  radiating  down  the  posterior  surfaces  of  both 
thighs.  After  two  days  this  pain  ceased,  but  complete  anaesthesia 
around  the  sacrum,  the  nates,  and  rectum,  and  down  the  posterior 
surfaces  of  both  limbs  remained.  Injections  in  the  rectum  would 
not  be  felt,  and  for  four  weeks  the  passages  were  involuntary. 
There  was  also  a  strong  tendency  to  incontinence  of  urine. 

Eight  weeks  after  tiie  operation  the  wound  was  healed,  and  the 
patient  was  able  to  get  out  of  bed,  but  she  had  to  use  crutches  for 
four  weeks. 

Sitting  on  a  hard  chair  would  cause  severe  pain  in  the  sacral 
region,  which  would  be  relieved  only  by  sitting  upon  an  inflated 
rubber  bed-pan. 

The  sacral  region  and  nates  were  in  no  place  tender  on  pressure, 
and  the  skin  covering  them  was  so  completely  anaesthetic  that  a 
hypodermic  injection  of  morphine  would  not  be  felt  at  all. 

After  four  weeks'  exercise  on  crutches,  during  which  time  the 
right  leg  was  somewhat  weak,  but  otherwise  painless,  she  became 
able  to  walk  with  a  cane,  which  she  was  obliged  to  use  for  about 
two  weeks.  Slight  oedema  around  the  malleoli  of  the  right  leg 
would  show  itself  evenings  and  disappear  in  the  mornings. 

Now,  March  4,  1881,  the  patient  is  able  to  walk  around  the 
whole  day,  and  has  no  pain  whatever  in  the  leg,  even  after  walk- 
ing two  miles.  When  she  gets  tired  after  such  a  walk,  she  will 
sometimes  feel  a  pricking  sensation  along  the  posterior  side  of  the 
leg,  and  occasionally,  in  bad  weather,  slight  pain  in  the  ankle. 
When  she  sits  more  than  two  hours  in  a  hard  chair,  she  feels  pain 


268  FENCER  AND  LEE. 

in  the  sacral  region.  The  usual  sensation  with  the  passages  is  not 
quite  normal.  No  fsecal  matter  will  pass  involuntarily,  but  some- 
times, when  coughing,  flatus  will  pass  without  her  knowledge. 
There  is  incomplete  anaesthesia  along  the  external  border  of  the 
foot  and  external  malleolus,  on  the  nates,  and  the  upper  part  of  the 
posterior  surface  of  the  right  thigh.  The  sensibility  of  the  re- 
mainder of  the  lower  extremity  is  normal  and  the  muscular 
strength  natural. 

In  this  rheumatic  or  idiopathic  sciatica,  nerve-stretching 
may  be  considered  to  have  had  good  results,  and  so  much 
the  more,  since  the  cases  in  which  it  has  been  resorted  to 
have  been  obstinate,  of  from  three  months'  to  fifteen  years' 
duration,  and  the  operation  has  been,  so  to  speak,  the  ulti- 
mum  refugiuin,  every  other  mode  of  treatment  having,  in 
most  of  the  cases,  been  tried  in  vain  before  the  operation  was 
resorted  to.  The  operation,  furthermore,  has  been  so  far 
successful  in  this  disease,  that  in  eight  of  the  cases  the  one 
operation  was  sufificient,  and  no  renewal  of  the  stretching 
was  necessary. 

The  localities  in  which  the  nerve  has  been  stretched  for 
sciatica  are:  i.  The  popliteal  space,  posterior  to  or  above 
the  knee  joint  (Bernays,  Von  Nussbaum,  and  Hildebrandt) ; 
or  more  commonly,  2.  The  inscissura  sciatica.,  that  is,  the 
space  between  the  great  trochanter  and  tuber  ischii,  where 
the  nerve  comes  down  from  beneath  the  gluteus  maximus, 
is  covered  only  by  the  skin,  and  rests  upon  the  quadratus 
femoris  muscle.  The  latter  locality  is  by  far  the  most  con- 
venient for  the  performance  of  the  operation,  partly  because 
the  trunk  of  the  nerve  is  easily  found,  and  partly  because  a 
comparatively  unskilled  operator  may  perform  the  opera- 
tion without  risk,  as  the  vessels  which  accompany  the  nerve 
are  insignificant  in  size.  The  operation  in  the  inscissura 
sciatica  has,  moreover,  the  advantage  that  the  nerve-trunk 
is  stretched  at  a  point  not  far  distant  from  the  nerve-centre. 
Langenbuch  advises  to  stretch  the  nerves  as  near  the  centre 


NERVE-STRETCHING.  269 

as  possible,  even  if  it  is  not  known  in  what  part  of  the  ner- 
vous system  the  action  is  needed.  This  renders  it  more 
certain  that  all  the  nerve-fibres  affected  will  be  reached  by 
the  operation.  In  the  operation  in  the  popliteal  space, 
there  is  some  danger  even  for  the  skilled  operator,  as  has 
been  demonstrated  in  a  case  reported  by  Von  Nussbaum, 
in  which,  although  the  operation  had  been  performed  with- 
out accident,  hemorrhage  set  in  two  weeks  later,  caused  by 
ulceration  through  the  walls  of  the  popliteal  vein,  produced 
by  the  pressure  of  the  drainage  tube. 

As  to  the  amount  of  force  which  should  be  employed  to 
stretch  the  nerve  effectively,  it  is  in  this,  as  in  all  cases  of 
nerve-stretching,  impossible  to  give  specific  rules  for  the 
guidance  of  the  operator.  From  experiments  on  dead 
bodies  we  know  that  the  average  weight  required  to  break 
the  sciatic  nerve  asunder  is  one  hundred  and  thirty  pounds 
(Johnson,  Lymington  ^).  On  another  occasion  the  sciatic 
nerve  was  thoroughly  stretched  by  taking  it  out  of  the 
wound  and  lifting  it  so  that  the  leg  was  also  raised. 

The  advice  most  generally  given,  and  probably  the  best, 
is  to  pull  on  the  nerve-trunk  successively,  both  in  the  pe- 
ripheral and  central  directions,  long  and  vigorously,  until  a 
sensation  as  of  something  giving  way  in  the  trunk  of  the 
nerve  is  experienced.  Care  must  of  course  be  taken  to 
cease  stretching  when  this  sensation  is  experienced,  so  as 
to  avoid  a  rupture  of  the  nerve-trunk.  The  danger  of  rup- 
ture is,  however,  not  very  great,  as  no  case  is  as  yet  on 
record.  The  same  method  may  be  pursued  in  the  stretch- 
ing of  other  nerves. 

b.  Symptomatic  or  Secondary  Sciatica. 

This  disease  is  characterized  by  pain  in  the  territory  of 
the  sciatic  nerves,  dependent  upon  or  complicated  with 
lesions  of  the  spinal   cord.      In   such  cases,  as   might  be 


270  FENGER  AND  LEE. 

expected,  nerve-stretching  has  not  been  as  successful  as  in 
the  former  class.  Out  of  seven  cases  only  one  complete 
recovery  is  reported  (Andrews) ;  in  five  cases  greater  or  less 
complete  relief  followed  the  operation  ;  and  in  one  case 
(Czerny)  no  effect  at  all  was  experienced. 

From  another  standpoint  than  that  of  cure  of  the  disease, 
which  in  this  affection  is  generally  out  of  the  question,  it 
must  be  admitted  that  the  operation  has  even  here  not  been 
performed  in  vain,  for  by  it  the  sufferings  of  the  patients 
have  been  relieved  in  great  measure.  We  consider  that  the 
good  results  obtained  by  this  operation  have  been  amply 
sufificient  to  compensate  for  the  inconvenience  to  the 
patient,  due  to  the  operation  itself. 

Case  i. — (E.  Masing,  St.  Petersburg,  1878.^°)  A  working 
man,  thirty-seven  years  old,  had  suffered  for  eight  years  so 
severely  from  neuralgia  in  both  extremities  that  he  was  about  to 
commit  suicide.  For  seven  years  he  had  been  going  from  one 
hospital  to  another  without  obtaining  relief.  The  muscles  of  both 
legs  were  atrophic  ;  almost  complete  anaesthesia  existed  in  the 
territory  of  the  sciatic  nerves  of  both  sides  ;  the  muscles  of  the 
legs  and  feet  were  paretic  ;  defecation  was  sometimes  spontaneous, 
and  micturition  difficult.  The  sciatic  nerves  of  both  sides  were 
stretched,  under  antiseptic  precautions.  Violent  pain  was  expe- 
rienced in  the  first  week  after  the  operation.  During  the  second 
week  the  pain  gradually  diminished,  and  the  anesthesia  and 
paresis  lessened. 

Two  months  later  the  left  crural  nerve  was  stretched  on  account 
of  pain  on  the  anterior  side  of  the  thigh.  The  final  result  was 
that  the  anaesthesia  and  pain  entirely  disappeared,  and  the  paresis 
was  ameliorated  until  there  remained  only  slight  disturbance  of 
motion  in  the  ankle  joints  and  toes.  The  urinary  trouble,  how- 
ever, continued. 

Case  2. — (E.  Masing,  St.  Petersburg,  1878.  i**)  A  boy,  ten 
years  of  age,  after  a  fall  on  the  sacral  region,  suffered  from  con- 
tractures of  the  muscles  of  the  left  leg,  so  that  the  foot  was  fixed 
in  the  position  oi  pes  varus.  There  was  no  active  mobility  what- 
ever ;  passive  movements  caused  pain  ;  there  was  general  hyper- 
aesthesia  of  the  skin  of  the  foot  and  leg  ;  tenderness  on  pressure 


NER  VE-  S  TRE  TCHING.  2  7 1 

along  the  sciatic  nerve.  During  sleep  and  narcosis  the  spastic 
contractures  relaxed.  All  other  means  having  been  tried  in  vain, 
nerve-stretching  was  resorted  to.  Immediately  after  the  opera- 
tion the  symptoms  increased,  and  no  amelioration  set  in  for  seven 
weeks,  after  which  time  the  pain  and  spasms  gradually  dimin- 
ished. Seven  months  afterward  the  patient's  condition  was  a  little 
better,  but  he  still  had  pain  and  was  unable  to  walk. 

Case  3. — (Edmund  Andrews,  Chicago,  1876.  *)  A  sailor,  who 
had  fallen  down  a  year  previous  to  the  operation  and  fractured 
two  ribs  and  the  right  thigh,  subsequent  to  this  injury  suffered  from 
paresis  and  anaesthesia  of  both  lower  extremities.  When  brought 
into  Mercy  Hospital  he  complained  of  spastic  contractions  and  se- 
vere pain  when  his  legs  were  extended  ;  the  main  symptom  being 
constant  tonic  spasms  of  the  adductioi  both  thighs,  the  contraction 
being  caused,  among  other  things,  by  touching  the  glans  penis. 
In  narcosis  carried  out  even  to  complete  anaesthesia  of  the  cornea, 
extension  of  the  lower  extremities  would  cause  these  spasms  to 
set  in.  On  May  15,  1876,  the  left  sciatic  and  crural  nerves  were 
stretched.  After  the  operation  the  symptoms  on  the  right  side 
ceased,  and  when  on  May  24,  1876,  the  same  operation  had  been 
performed  on  the  right  side,  the  spasms  of  the  left  leg  ceased. 
The  cure  was  perfect  seven  months  after  the  second  operation,  so 
far  as  known  ;  so  far  perfect,  at  least,  as  to  enable  the  patient  to 
perform  a  sailor's  duties  on  his  passage  from  America  to  England. 

Case  4. — (Czerny,  1879.  ^M  Neuralgia  in  the  sciatic  nerves  of 
both  sides  from  myelitis,  caused  by  compression,  in  a  case  of 
Pott's  disease  of  the  vertebral  column.  The  sciatic  nerves  were 
stretched  with  no  perceptible  result. 

Case  5. — (Trendelenburg,  Rostock,  1880.'')  Sciatica  conse- 
quent upon  spinal  injury.  The  sciatic  nerve  was  stretched  with 
incomplete  effect. 

Case  6. — (Fenger,  Chicago,  1880.)  Synopsis. — Severe  sciatic 
pain  of  four  months  standing,  in  a  case  supposed  to  be  central  cancer 
of  the  bones  of  the  pelvis — Stretching  of  the  sciatic  nerve — Cessation 
of  the  pain —  Progressing  cachexia  and  debility — Death.  Miss 
Fogarty,  unmarried,  forty-five  years  of  age,  came  under  the  care 
of  Dr.  Fenger  December  10,  1880.  Family  history  good.  She 
had  had  no  severe  illness  previously,  but  had  always  been  rather 
lean  and  nervous.  Four  months  previous  she  was  seized  with 
what  she  believed  to  be  rheum.atic  pains  at  the  external  and  pos- 
terior side  of  the  left  hip,  and  from  there  radiating  upward  along 
the  right  half  of  he  sacrum  to  the  lumbar  region,  and  downward 


2/2  FENGER  AND  LEE. 

along  the  posterior  side  of  the  thigh  to  the  knee  joint.  The 
pain,  at  first  slight,  made  it  difficult  for  her  to  walk,  and  two 
months  later  she  was  obliged  to  go  around  on  crutches,  as  the  pain 
became  unbearable  when  the  limb  touched  the  ground. 

Many  kinds  of  internal  and  external  treatment  were  tried  by 
different  physicians,  but  the  pain  steadily  increased,  and  paroxysms 
set  in  even  when  she  was  sitting  or  lying  down,  so  that  she  was  not 
able  to  sleep  at  night,  and  the  pain  could  not  be  controlled  even 
by  large  doses  of  morphine.  During  these  four  months  her  appe- 
tite was  poor,  and  she  decreased  considerably  in  weight. 

On  examination,  December  loth,  the  patient  was  lying  on  an 
adjustable  folding  chair,  the  left  leg  slightly  flexed  on  the  hip- 
joint,  and  resting  on  pillows.  The  slightest  movement  from  this 
position  would  cause  intense  pain.  Pressure  upon  the  great  tro- 
chanter would  also  cause  pain,  as  well  as  pressure  anterior  to  the 
joint.  No  swelling  around  the  hip.  The  patient  was  consider- 
ably emaciated.  Pulse  and  temperature  normal.  Lungs,  heart, 
and  abdominal  organs  normal.  The  urine  contained  neither  al- 
bumen nor  sugar.  The  bowels  were  habitually  constipated. 
There  were  no  signs  of  paresis  or  anaesthesia  in  any  part  of  the 
lower  extremities. 

As  the  pain  was  mainly  localized  around  the  hip-joint,  and  the 
patient  would  submit  neither  to  an  operation  nor  to  an  examina- 
tion in  narcosis,  extension  by  means  of  a  weight  and  pulley  was 
tried,  to  relieve  the  pain  in  the  hip.  For  about  a  week  it  seemed 
as  if  this  treatment  would  relieve  the  pain,  as  the  patient  was  able 
to  rest  in  bed  night  and  day,  and  suffered  much  less  at  night,  but  in 
the  second  week  severe  paroxysms  of  pain  set  in,  just  as  before 
the  extension,  and  could  not  be  controlled  by  hypnotics  of  any 
kind.  She  then  consented  to  have  an  examination  made  in  nar- 
cosis, and  then,  if  the  hip-joint  was  found  healthy,  to  have  nerve- 
stretching  performed  at  the  same  time.  Consequently,  prepara- 
tions were  made,  and  on  January  6,  iS8i,  Dr.  Fenger,  assisted  by 
Dr.  Dudley,  performed  the  operation. 

The  patient  was  anaesthetized  with  ether  ;  the  hip-joint  was 
found  perfectly  movable  ;  the  sciatic  nerve  was  cut  down  upon 
between  the  great  trochanter  and  the  tuber  ischii,  taken  out  with- 
out difficulty,  stretched  vigorously  both  in  the  central  and  periph- 
eral directions,  and,  after  having  been  compressed  and  railed  be- 
tween the  finger  and  the  retractor  with  which  it  was  lifted  from 
the  wound,  it  was  replaced,  a  drainage  tube  inserted,  the  wound 
united  with  aseptic  silk,  and  Lister  dressing  applied. 


NE  RVE-S  TRE  TCHING.  273 

The  spontaneous  pain  in  the  legs  disappeared  entirely  from  the 
time  of  the  operation,  so  that  the  patient  could  rest  in  bed  and 
sleep  all  night  long,  but  active  and  passive  movements  of  the 
lower  extremity  would  still  cause  pain  on  the  posterior  side 
of  the  hip  and  in  the  lumbar  region.  For  three  days  after 
the  operation  there  was  incessant  vomiting,  which  afterward 
disappeared.  Pulse  and  temperature  were  always  normal. 
Four  days  after  the  operation  the  drainage  tubes  and  sutures 
were  removed.  Eight  days  after  the  operation  the  Lister  dressing 
was  removed,  and  the  wound  healed  by  first  intention.  In  the 
course  of  the  following  four  weeks  the  patient  wasted  gradually  ; 
the  appetite,  previously  poor,  disappeared  entirely  ;  in  the  mean- 
time the  pulse  and  temperature  continued  normal.  She  would 
sleep  at  night  and  part  of  the  day,  without  hypnotics,  and  never 
complained  of  any  pain  except  when  moved  to  have  a  passage  of 
the  bowels  or  an  injection.  In  the  second  week  of  February  she 
became  somnolent,  apathetic,  no  rise  in  temperature  occurring  at 
any  time,  and  died  February  12th.     An  autopsy  was  not  permitted. 

Case  7. — (Fenger,  Chicago,  1880.)  Synopsis. — Severe  pains 
in  region  of  left  sciatic  nerve,  in  a  case  of  obscure,  central  nervous 
disease — Nerve-stretching — Heali^ig  by  first  intention — Cessation  of 
pain — Progress  of  the  original  disease — Death.  P.  N.,  an  Irishman, 
about  sixty  years  of  age,  was  transferred  August  5,  1880,  from 
the  medical  to  the  surgical  side  of  Cook  County  Hospital,  and  put 
under  Dr.  Fenger's  care,  with  a  view  to  the  performance  of  nerve- 
stretching  for  supposed  sciatica.  The  patient  was  greatly  emaci- 
ated, and  absent-minded  or  idiotic,  so  that  he  was  not  able  to  give 
any  history  of  his  case.  He  complained  of  severe  pain  on  the 
posterior  side  of  the  left  hip-joint,  radiating  from  this  point  down 
the  posterior  side  of  the  thigh.  This  pain  set  in  in  frequent 
paroxysms,  and  did  not  allow  him  to  sleep  at  night.  The  pulse 
and  temperature  were  normal  ;  the  heart,  lungs,  and  abdominal 
organs  normal  ;  urine  normal.  His  mental  condition  was  one  of 
stupor.  He  would  sometimes  pass  urine  and  fasces  involuntarily 
in  bed,  and  his  appetite  was  poor. 

August  7,  1880. — Dr.  Fenger  stretched  the  left  sciatic  nerve  in 
the  manner  described  above.  No  drainage  tube  was  inserted.  The 
wound  was  united  by  aseptic  silk  and  Lister  dressing  applied.  The 
wound  healed  by  first  intention  in  eight  days.  The  spontaneous 
paroxysms  of  pain  ceased,  but  the  patient  wasted  away  gradually, 
and  died  four  weeks  later,  without  any  notable  change  in  the 
symptoms.     An  autopsy  was  not  permitted. 


274  FENCER  AND  LEE. 

2. PROSOPALGIA,  OR  NEURALGIA  OF  THE  FIFTH  PAIR. 

The  branches  of  the  fifth  pair,  operated  upon  in  the  re- 
corded cases,  have  been  the  supra-orbital  and  infra-orbital  of 
both  sides  in  one  case  ;  supra-orbital  and  infra-orbital  of  one 
side,  two  cases ;  infra-orbital  and  mental  of  one  side,  one 
case;  supra-orbital,  four  cases;  infra-orbital,  three  cases; 
and  inferior  dental,  one  case. 

Complete  relief  was  experienced  in  nine  cases,  partial  re- 
lief in  one  case,  and  no  effect  in  two  cases.  In  the  case  in 
which  partial  relief  was  experienced,  the  pain  returned  a 
few  weeks  after  the  operation.  In  two  of  the  cured  cases, 
temporary  painful  sensations  were  felt ;  in  one  case  imme- 
diately, and  in  another  twice  during  the  first  year,  after  the 
operation.  In  three  cases  nerve-stretching  was  combined 
with  excision.  In  one  case,  after  nerve-stretching  had 
been  performed  with  no  effect,  the  nerve  was  divided  and 
relief  followed.  The  duration  of  the  disease  varied  from 
seven  months  to  ten,  and  in  one  case  to  fourteen  years. 
Sensibility  returned  in  the  territory  of  the  nerve  operated 
upon,  almost  immediately  in  two  cases,  after  two  months  in 
one  case,  and  after  five  months  in  one  case. 

Case  i. — (Vogt,  1876.*)  Stretching  of  inferior  dental  nerve 
for  neuralgia,  followed  by  recovery. 

Case  2. — (Crofft,  London,  1877.^^)  Convulsive  neuralgia  in 
the  territory  of  the  infra-orbital  nerve.  Five-eighths  of  an  inch 
of  the  nerve  was  excised,  and  the  nerve  stretched.  During  the 
first  year  after  the  operation,  two  light  attacks  of  the  neuralgia 
were  experienced.     After  that  time  the  recovery  was  complete. 

Case  3. — (Charles  Higgins,  1879.  ^*)  The  patient  was  a  man, 
62  years  of  age,  who  suffered  from  neuralgia  of  the  left  supra- 
orbital and  infra-orbital  nerves  subsequent  to  extirpation  of  the 
eye.  These  nerves  were  stretched.  The  operation  resulted  in 
perfect  recovery,  and  sensibility  soon  returned. 

Case  4. — (Higgins,  1879.  ^*)  A  man,  53  years  of  age,  suffered 
from  neuralgia  of  the  right  supra-orbital  nerve  after  extirpation  of 
the  eye.  The  nerve  was  stretched,  with  the  result  of  permanent 
relief  from  the  pain,  and  a  speedy  return  of  sensibility. 


NERVE-STRETCHING.  2/5 

Case  5. — (Kocher,  Berne,  1879.  ^^)  A  cigarmaker,  32  years  of 
age,  had  suffered  for  fourteen  years  from  neuralgia  of  the  right 
supra-orbital  nerve.  Nerve-stretching  was  performed,  resulting  in 
immediate  recovery  and  the  return  of  sensibility  in  two  months. 

Case  6. — (T.  Grainger  Stewart,  1879. ■^^)  A  man,  70  years  old, 
suffered  from  neuralgia  of  the  second  branch  of  the  left  trigemi- 
nal nerve,  combined  with  clonic  spasms  in  the  facial  muscles  of 
the  same  side.  The  left  infra-orbital  nerve  was  stretched  with  no 
effect.  The  same  nerve  was  afterward  divided,  but  no  relief  from 
pain  was  experienced.  Finally,  the  left  mental  nerve  was 
stretched,  and  the  pain  and  spasms  were  permanently  relieved. 

Case  7, — (Czerny,  1879.")  Neuralgia  of  the  supra-orbital  and 
frontal  nerves.  The  nerves  were  stretched  without  effect.  Two 
weeks  later  resection  was  performed,  followed  by  the  use  of  elec- 
tricity.    This  treatment  resulted  in  complete  relief. 

Case  8. — (Masing,  St.  Petersburg,  1879.")  A  lady,  60  years  of 
age,  had  suffered  from  severe  supra-orbital  neuralgia  for  about 
three  years.  The  supra-orbital  nerve  was  stretched,  and  the  patient 
recovered.  For  one  week  after  the  operation  chemosis  and  diffuse 
superficial  keratitis  were  noticed,  and  anaesthesia  of  the  forehead 
and  cornea  continued  for  eight  months. 

Case  9. — (Hahn,  Berlin,  1880.')  In  a  case  of  supra-orbital  and 
infra-orbital  neuralgia  nerve-stretching  was  resorted  to  with  no 
effect. 

Case  10. — (Purdie,  London,  1880.")  The  patient  had  suffered 
for  years  from  epileptiform  neuralgia  of  the  second  branch  of  the 
fifth  pair.  A  transverse  incision  was  made,  and  the  infra-orbital 
nerve  stretched  by  means  of  a  blunt  hook.  This  operation  was 
followed  by  relapse.  After  five  days  the  nerve  was  again  stretched, 
and  complete  relief  resulted. 

Case  ii. — (Von  Nussbaum,  Munich,  1880.)  Neuralgia  of  the 
supra-orbital  and  infra-orbital  nerves  of  both  sides.  Nerve-stretch- 
ing and  excision  of  the  nerves  affected  were  performed.  Relief  for 
a  few  weeks  followed  the  operation,  but  the  patient  soon  suffered 
relapse  on  the  left  side. 

Case  12. — (Walsham,  1881.")  A  woman  had  suffered  for  more 
than  ten  years  from  severe  pain  in  the  territory  of  the  infra-orbital 
nerve.  The  nerve  was  stretched  at  its  point  of  exit  from  the  in- 
fra-orbital foramen.  The  operation  was  followed  by  erysipelas,  in 
the  course  of  which  two  slight  attacks  of  pain  were  experienced  ; 
after  this  the  patient's  recovery  was  complete.  Five  months  after 
the  operation  no  relapse  had  occurred. 


2^6  FENGER  AND  LEE. 

3. INTERCOSTAL  NEURALGIA. 

Case  i. — (Von  Nussbaum,  Munich,  iSyS.'"'*)  A  man,  20  years 
old,  suffered  from  severe  neuralgia  on  both  sides,  extending  from 
the  sternum  to  the  umbilicus.  Incisions  were  made,  on  both  sides, 
along  the  external  border  of  the-  rectus  abdominis  muscle,  and  the 
eighth,  ninth,  and  tenth  intercostal  nerves  exposed  and  stretched. 
Temporary  relief  was  experienced.  A  relapse  followed,  and  no 
further  history  of  the  case  is  reported. 

4. — idiopathic  neuralgias  of  other  nerves. 

Five  cases  of  nerve-stretching  in  this  class  of  diseases 
have  been  recorded,  two  of  which  resulted  in  complete 
recovery,  while  in  three  cases  the  relief  obtained  was  only 
partial. 

Cases  i,  2,  and  3. — (Langenbuch,  Berlin,  1880.'')  Brachial 
neuralgia.  The  brachial  plexus  was  stretched,  with,  in  each  case, 
only  partial  relief. 

Case  4. — (Hildebrandt,  Neustadt-Magdeburg,  1880.^)  A  man, 
32  years  of  age,  complained  first  of  stiffness  of  the  fingers  of  the 
right  hand  ;  later,  of  pain  along  the  inner  surface  of  the  forearm, 
which  afterward  extended  up  the  arm  and  right  side  of  the  neck. 
The  brachial  plexus  was  stretched,  and  the  patient  obtained  im- 
mediate and  permanent  relief. 

Case  5. — (Schussler,  1880.^^)  A  lady,  53  years  of  age,  had 
suffered  for  three  years  from  severe  neuralgia  in  the  right  half  of 
the  occipital  region.  The  trunk  of  the  occipitalis  major  nerve  was 
laid  open,  from  the  place  where  it  passes  through  the  trapezius 
muscle  up  to  the  spina  occipitalis  externa.  The  sheath  of  the 
nerve  was  thickened  and  injected.  The  nerve  was  then  taken  out 
from  the  sheath,  taken  between  two  fingers,  and  stretched  vigor- 
ously in  both  directions.  The  wound  was  closed,  and  antiseptic 
dressing  applied.  A  few  slight  attacks  of  pain  occurred  during 
the  first  three  days,  after  that  time  the  recovery  was  complete. 
The  wound  healed  by  first  intention. 

5. — neuralgias   of    the  peripheral  nerves  caused  by  sur- 
gical  LESIONS   involving    THE    NERVE-TRUNKS. 

This  class  of  neuralgias  is  represented  by  eleven  detailed 
cases,  of  which  eight  were  cured,  two  improved,  and  one  a 


NERVE-STRETCHING.  ^77 

failure.  In  one  case  it  was  necessary  to  stretch  the  nerve  a 
second  time  before  relief  was  secured.  The  nerves  stretched 
were  the  following :  Brachial  plexus,  one  case  ;  recovery. 
The  median  nerve,  three  cases ;  two  recoveries  and  one  par- 
tial relief.  The  ulnar  nerve,  two  cases ;  one  complete  and 
one  partial  recovery.  The  sciatic  nerve,  two  cases  ;  two  re- 
coveries. The  digital  nerve,  one  case  ;  recovery.  The  per- 
oneal nerve,  one  case ;  recovery./  Nerves  of  the  testicle, 
one  case  ;  no  effect. 

Besides  the  eleven  cases  reported  here,  it  must  be  men- 
tioned that  Esmarch  has  performed  nerve-stretching  several 
times  (the  exact  number  is  not  given)  in  cases  of  neuralgia 
following  amputation,  namely,  in  painful  amputation- 
stumps,  with  invariable  success.  It  seems,  therefore,  pos- 
sible that  in  these  obstinate  cases  nerve-stretching  may  sup- 
plant the  former  treatment  of  excision  of  the  scar  of  the 
stump,  or  re-amputation. 

It  has  been  ascertained  that  the  radial  nerve  of  an  adult 
requires  an  average  weight  of  84  pounds  to  break  it  asun- 
der. 

Case  i. — (Callender,  London,  1875.^)  Neuralgia  in  the  territory 
of  the  median  nerve,  of  one  year's  duration,  subsequent  to  ampu- 
tation of  the  hand  on  account  of  injury  by  a  circular  saw.  The 
median  nerve  was  stretched,  and  the  patient  obtained  permanent 

relief. 

Case  2. — (Maag,  Denmark,  1878.^)  A  girl,  23  years  of  age,  suf- 
fered from  pain  in  the  region  of  the  sciatic  nerve,  of  eighteen 
months'  duration,  subsequent  to  an  abscess  of  the  thigh.  The 
sciatic  nerve  was  stretched  ;  the  wound  did  not  heal  by  first  inten- 
tion.    Recovery. 

Case  3. — (Maag,  Denmark,  1878.  ^)  Intermittent  neuralgia  and 
contracture  of  the  thumb  and  forefinger  of  the  right  hand,  subse- 
quent to  a  punctured  wound  of  the  hand.  The  median  nerve  was 
stretched  in  the  sulcus  bicipitis,  and  the  patient  recovered. 

Case  4. — (Vogt,  1878.  ■*)  Neuralgia  after  wound  on  the  inner 
side  of  the  right  forearm,  involving  the  ulnar  nerve.  The  incision 
was  made  in   the  scar,   and  the  ulnar  nerve  dissected  out  and 


2/8  FENCER  AND  LEE. 

Stretched.  The  operation  was  followed  by  immediate  and  perma- 
nent relief. 

Case  5. — (Czemy,  1879.*^)  Neuralgia  subsequent  to  suppu- 
ration around  elbow  joint.  The  ulnar  nerve  was  stretched  in  the 
axillary  plexus.  The  patient's  condition  was  ameliorated,  but  the 
recovery  was  not  perfect. 

Case  6. — Estlander,  1879.  ^^)  After  a  bullet  wound  through 
the  arm  the  patient  suffered  from  neuralgia  in  the  territory  of  the 
median  nerve.  The  nerve  was  stretched,  and  the  pain  ceased  for 
24  hours.  This  was  followed  by  a  relapse  for  three  weeks.  After 
this  time  the  pain  gradually  decreased,  but  the  recovery  was  not 
perfect. 

Case  7. — (Kiister,  Berlin,  1880.  '')  Sciatica  consequent  upon 
bullet  wound.  The  sciatic  nerve  was  stretched  without  effect. 
Nerve-stretching  was  repeated,  followed  by  recovery. 

Case  8. — (Purdie,  London,  1880.  ^)  Neuralgic  pain  in  the  in- 
dex finger  subsequent  to  suppuration  under  the  nail.  The  digital 
nerves  were  stretched  ;  the  pain  ceased  and  has  not  returned. 

Case  9.  — (Esmarch,  Kiel,  1880.  '')  The  peroneal  nerve  was 
stretched  on  account  of  neuralgia.  The  operation  was  followed 
by  recovery. 

Case  id. — (Esmarch,  Kiel,  1880.  '')  Neuralgia  of  the  testicle 
after  castration.  The  external  spermatic  nerve  was  stretched,  but 
the  operation  gave  no  relief  to  the  pain. 

Case  ii. — (Crede,  1880.^^)  Ascending  neuritis  in  the  territory 
supplied  by  the  left  radial  nerve,  following  traumatic  injury.  The 
radial,  median,  ulnar,  and  cutaneous  axillary  nerves  were  stretched, 
and  the  pain,  which  had  been  intense  for  eighteen  months,  was 
immediately  and  permanently  relieved. 

II.— SPASTIC  ANOMALIES. 

I. — MIMIC    spasm.       spasms   OF    THE    SEVENTH    PAIR. 

The  five  cases  of  mimic  spasm  on  record  were  all  cured 
by  nerve-stretching.  The  disease  was  of  from  two  to  eight 
years'  standing.  The  paralysis  following  the  operation 
lasted,  in  the  four  cases  in  which  it  was  reported,  respective- 
ly two  weeks,  eight  weeks,  two  months,  and  five  months. 
In  one  case  the  nerve  was  stretched  anterior  to  the  ear,  be- 
low the  zygomatic  arch.  In  the  other  cases  a  more  central 
incision  was  made,  that  is,  below  or  behind  the  ear. 


NER  VE.  S  TRE  TCHING.  2/9 

Case  i. — (Baum,  Danzig,  1878.  2^)  A  woman,  35  years  old, 
suffered  from  spasms  in  the  muscles  of  the  left  side  of  the  face, 
subsequent  to  epileptiform  attacks.  An  incision  was  made,  an- 
terior to  the  ear,  and  the  seventh  nerve  stretched.  The  operation 
was  followed  by  paralysis  for  two  weeks,  after  which  time  the  re- 
covery was  perfect. 

Case  2. — (Schiissler,  Bremen,  1879.  ^*)  A  lady,  39  years  of 
age,  had  suffered  for  eight  years  from  spasms  in  the  left  half  of 
the  face  and  soft  palate.  The  trunk  and  descending  branch  of 
the  seventh  nerve  were  vigorously  stretched.  The  relief  was  in- 
stantaneous ;  a  slight  paralysis  continued  for  eight  weeks.  Two 
months  after,  there  had  been  no  relapse. 

Case  3. — (Allan  Sturge  and  "Mr.  Godlee,  London,  1881.  ^^)  A 
lady  had  suffered  from  mimic  spasm  for  over  five  years.  The 
seventh  nerve  was  stretched  below  the  ear.  The  operation  was 
followed  by  paralysis  which  continued  two  months.  After  that 
time  the  recovery  was  complete. 

Case  4. — (Eulenberg,  Berlin,  1881.^^)  Nerve-stretching  was 
performed  in  a  case  of  mimic  spasm.  Paralysis  for  five  months 
and  complete  recovery  were  the  results  of  the  operation. 

Case  5. — Dr.  Putnam  (Boston,  Massachusetts,  1881^^)  re- 
ports one  case  of  mimic  spasm  in  which  nerve-stretching  was  per- 
formed and  recovery  followed. 

2. SPASMS      IN      the      territory     OF      THE     ACCESSORY       NERVE 

OF    WILLIS  ;    THAT    IS,    SPASMODIC    TORTICOLLIS. 

Six  cases  of  nerve-stretching  in  this  disease  are  recorded, 
only  one  of  which  was  cured  by  the  nerve-stretching  alone. 
In  one  case  nerve-stretching  gave  only  partial  relief,  and  in 
two  cases  it  was  of  no  effect.  In  one  of  these  latter  cases 
the  relief  was  subsequently  obtained  by  excision.  In  two 
cases  nerve-stretching  combined  with  excision  resulted  in 
cure.  In  one  of  the  last-named  cases  a  return  of  the  spasms 
occurred  for  about  fifteen  minutes,  and  in  the  other  slight 
spasms  of  about  one  month's  duration  followed  the  opera- 
tion. The  disease  had  persisted  from  six  to  eighteen 
months.  The  incision  was  made  and  the  nerve  stretched,  in 
each  case,  at  the  upper  part  of  the  posterior  border  of  the 
sterno-cleido-mastoid  muscle. 


28o  FENGER  AND  LEE. 

From  the  following  cases  we  conclude  that  nerve-stretch- 
ing in  this  disease  is  not  so  efficacious  as  in  mimic  spasm, 
and  it  seems  to  be  advisable  to  combine  nerve-stretching 
with  excision,  as  was  done  in  the  two  cases  reported  by 
Hansen. 

Case  i. — (Tage  Hansen,  Denmark,  1878.  ^s)  A  woman, 
thirty-one  years  of  age,  had  suffered  for  six  months  from  spas- 
modic torticollis.  The  nerve  was  cut  down  upon  at  the  upper 
part  of  the  posterior  border  of  the  sterno-cleido-mastoid  muscle, 
and  vigorously  stretched,  and  a  piece  of  the  nerve,  twelve  milli- 
metres in  length,  excised.  When  the  patient  awoke  from  the  nar- 
cosis, the  spasms  returned  for  a  quarter  of  an  hour,  then  ceased, 
and  have  not  returned. 

Case  2. — (Tage  Hansen,  Denmark,  1878.  ^s)  A  woman,  thirty 
years  of  age,  had  suffered  for  one  and  a  half  years  from  spasmodic 
torticollis.  Nerve-stretching  was  resorted  to,  and  fifteen  millime- 
tres in  length  excised.  Slight  spasms  continued  for  a  month. 
After  this  time  the  recovery  was  complete. 

Case  3. — (Annandale,  1879.^6)  A  girl,  twenty-four  years  of 
age,  suffered  from  torticollis,  the  head  being  drawn  to  the  left  so 
as  to  look  over  the  shoulder.  When  an  attempt  was  made  to  turn 
the  head  to  its  normal  position  severe  clonic  spasms  set  in.  The 
spinal  accessory  nerves  of  the  left  side  were  stretched.  This 
operation  gave  no  relief.  The  nerves  were  then  divided,  and  im- 
mediate relief  followed.  One  year  after  the  operation  the  mobil- 
ity was  normal  and  the  patient  suffered  no  pain. 

Cases  4  and  5. — D.  E.  Morgan  (1879^^)  reports  two  cases  of 
spasmodic  torticollis,  one  of  which  was  cured  by  nerve-stretching. 
In  the  other  no  effect  was  produced. 

Case  6. — Kiister  (Berlin,  1880')  reports  a  case  of  clonic 
spasms  in  the  muscles  supplied  by  the  spinal  accessory  nerve. 
The  nerve  was  stretched,  but  the  operation  gave  only  partial  re- 
lief. 

3. — SPASTIC     CONTRACTIONS    OF     THE     NERVES     OF    THE    EXTREM- 
ITIES. 

To  the  three  cases  of  this  disease  here  recorded  might  be 
added  the  case  of  Dr.  £.  Andrews,  of  Chicago,  already 
mentioned.     The  case  is  remarkable  as  being  the  only  one 


NER  VE-  ST  RE  TCHIN  G.  2  8 1 

in  which  not  only  the  spasms  but  also  the  contracture 
ceased,  and  complete  cure  was  effected.  Improvement  was 
produced  by  nerve-stretching  in  the  other  three  cases  :  in 
two  of  them  the  tonic  spasms  diminished,  and  in  the  third 
the  spastic  cramps  ceased,  but  the  contracture  remained. 

Case  i. — (Von  Nussbaum,  Munich,  June  23,  1872.*)  Spastic 
contraction  of  the  left  pectoralis  major  and  minor,  flexors  of  the 
left  arm,  forearm,  and  hand,  subsequent  to  bullet  wounds  of  the 
elbow  and  neck.  Nerve-stretching  was  performed,  the  following 
nerves  being  included  in  the  operation  :  the  ulnar  nerve  at  the 
border  of  the  biceps,  the  nerve-trunks  around  the  axillary  artery, 
and  the  inferior  cervical  nerves  in  the  outer  part  of  the  supracla- 
vicular region.  The  patient's  condition  was  greatly  ameliorated 
by  the  operation. 

Case  2. — (Von  Nussbaum,  Munich,  1876.'*)  Tonic  spasms  in  the 
lower  extremity,  of  eleven  years'  duration,  in  a  case  of  paraplegia, 
subsequent  to  an  injury  in  the  sacral  region.  The  sciatic  and 
crural  nerves  of  one  side  were  stretched,  and  two  weeks  later  the 
same  nerves  of  the  other  side.  The  patient's  condition  was  much 
improved  by  the  operation  ;  so  much  so  that  he  was  able  to  walk 
with  the  aid  of  crutches. 

Case  3. — (Czerny,  1879.^^)  A  student  had  suffered  from  birth 
from  hemiplegic  contracture  Vith  spastic  cramps  in  the  right  arm, 
supposed  to  have  been  caused  by  pressure  from  the  forceps  during 
delivery.  The  axillary  plexus  was  stretched  in  the  axilla,  and, 
later,  the  supraclavicular  plexus.  The  painful  spasms  ceased,  but 
the  contracture  remained. 

III.— EPILEPSY. 

It  is  hardly  necessary  to  state  that  it  is  only  in  those 
cases  of  epilepsy  with  an  aura  from  the  territory  of  a 
peripheral  nerve  that  nerve-stretching  can  be  of  use.  We 
have  found  records  of  only  three  cases,  with  recovery  in 
one,  alleviation  of  the  paroxysms  in  one,  and  no  effect  in 
the  other. 

Case  i. — (Von  Nussbaum,  Munich,  1875.'*)  Reflex  epilepsy 
from  leg.  The  tibial  and  peroneal  nerves  were  stretched.  Per 
feet  recovery. 


282  FENCER  AND  LEE. 

Case  2. — (Czerny,  1879.^^)  Epilepsy  with  aura  from  ulnar 
nerve.  No  decided  effect  was  noticeable.  Bromide  of  potassium 
was  now  given,  which  gave  relief. 

Case  3. — (Gillette,  Paris,  1881.^^)  Congenital  epilepsy.  The 
median  and  cubital  nerves  were  stretched  at  the  upper  third  of 
the  arm.  About  ninety  paroxysms  had  occurred  during  the 
month  prior  to  the  operation.  In  the  month  succeeding  the 
nerve-stretching  only  eighteen  spasms  occurred.  The  paroxysms 
diminished  not  only  in  frequency,  but  also  in  intensity  and  dura- 
tion. The  greater  part  of  the  attacks  were  merely  vertiginous, 
continuing  from  two  to  five  minutes.  The  aura  completely  dis- 
appeared. The  wound  healed  by  first  intention.  The  patient  ex- 
perienced a  little  numbness  in  the  area  of  the  cubital  nerve,  which 
disappeared  a  week  after  the  operation. 

IV.— PARALYSIS. 

Case  i. — (Von  Muralt,  1880.^'')  A  boy  suffered  from  paralysis 
of  the  extensor  muscles  of  the  arm,  subsequent  to  a  fracture  of 
the  humerus  which  had  healed  in  a  bad  position.  The  radial 
nerve  was  stretched,  and  complete  recovery  from  the  paralysis  fol- 
lowed. 

v.— TETANUS. 

Of  twenty-one  cases  of  traumatic  tetanus  treated  by 
nerve-stretching,  nine  recoveries  and  twelve  deaths  are  re- 
ported. It  would  be  a  great  mistake,  however,  to  conclude 
that  the  death-rate  in  traumatic  tetanus  had  been  so  dimin- 
ished by  nerve-stretching  as  to  reduce  it  from  the  usual 
eighty  or  ninety  to  about  forty  per  cent.  The  reason  for 
this  apparent  decrease  is  that  all  the  successful  cases  have, 
of  course,  been  reported,  but  a  number  of  the  unsuccessful 
ones  have  not.  In  the  discussion  on  nerve-stretching  at 
the  Congress  of  German  Surgeons  in  Berlin,  in  1880, 
Schede,  Hahn,  and  Sonnenberg  stated  that  they  had  per- 
formed nerve-stretching  in  tetanus  with  no  effect.''  How 
many  unsuccessful  cases  this  statement  is  intended  to  in- 
clude, we  do  not  know. 

The  nerves  stretched  were  always  the   nerves  of  the  ex- 


NER  VE-  ST  RE  TCHING.  283 

tremities.  It  is  difficult  to  state  the  exact  value  of  the 
operation  in  those  cases  which  recovered,  as  presumably  in 
all  cases  some  medicine  had,  in  addition,  been  given. 
This  question  will  probably  never  be  solved,  because  no 
physician  would  be  justified  in  risking  the  life  of  his  patient 
in  this  terrible  disease,  by  omitting  any  of  the  therapeutic 
remedies  at  his  disposal.  We  do  not,  however,  consider  it 
just,  as  some  others  have  done  and  will  do,  to  deny  that 
nerve-stretching  has  had  any  success  at  all  in  tetanus,  and 
we  think  that  Morris  is  not  exactly  right  in  his  opinion, 
that  the  cases  in  which  nerve-stretching  has  proved  suc- 
cessful consist  only  of  those  subacute  and  mild  cases  of 
traumatic  tetanus  in  which  internal  treatment  alone  would 
have  effected  a  cure. 

First,  as  to  the  absolute  denial  that  nerve-stretching  has 
been  productive  of  any  good  results.  It  will  be  seen  from 
the  cases  recorded,  that  in  severe  and  even  in  finally  fatal 
cases  there  has  been  a  marked,  although  only  temporary 
effect  :  namely,  the  paroxysms  have  ceased,  and  the  patient 
has  experienced  relief  for  from  twelve  hours  to  three  days 
before  a  fatal  relapse  set  in. 

Second,  as  to  Morris'  statement  that  only  the  subacute 
and  mild  cases  have  been  cured  by  nerve-stretching.  We 
agree  with  him  to  this  extent,  that  none  of  the  cases  in 
which  recovery  has  taken  place  have  been  cases  of  tetanus 
acutissima.  But  when  the  question  of  severity  is  brought 
up,  it  is  our  opinion  that  the  case  reported  by  D'Ollier, 
which  was  attended  with  opisthotonos,  difficulty  in  swallow- 
ing, and  tetanic  contractions  of  the  muscles  of  the  abdomen 
and  lower  extremities,  can  certainly  not  be  counted  among 
the  mild  forms  of  the  disease. 

Further,  as  to  the  danger  from  traumatic  tetanus,  the 
statistics  of  Taylor  from  Guy's  Hospital  29  have  shown  the 
following  connection  between  the  interval  from  the  receipt 


284  FENCER  AND  LEE. 

of  the  injury  and  the  first  symptoms  of  tetanus,  and  the 
death-rate  : 

In  the  cases  in  which  tetanus  set  in  within  one  week 
after  the  receipt  of  the  injury,  the  death-rate  was  87.5 
per  cent.;  when  the  interval  was  from  one  to  two  weeks, 
the  death-rate  was  88  per  cent.;  and  with  an  interval  of 
from  two  to  three  weeks,  the  rate  of  mortality  decreased 
to  57.2  per  cent.  Consequently,  we  see  that  those  cases  in 
which  the  tetanus  appeared  within  two  weeks  after  the  re- 
ceipt of  the  injury  are  the  more  dangerous. 

Amongst  the  cases  of  recovery  after  nerve-stretching  we 
find  one  interval  of  seventeen  days,  one  of  fourteen,  one 
of  eight,  one  of  seven,  and  one  of  four.  Three  of  these 
cases,  therefore,  as  far  as  the  importance  of  the  intervals 
goes,  belonged  to  the  dangerous  class  of  cases. 

We  willingly  admit  that  the  amount  of  material  at  our 
disposal  does  not  enable  us  to  form  a  decided  opinion  about 
the  value  of  the  operation  as  a  curative  method  in  tetanus, 
but  we  consider  it  as  unquestionably  proved  that  some 
beneficial  effect  has  been  derived  from  nerve-stretching  in 
this  disease. 

It  seems  to  us,  as  a  natural  and  necessary  consequence 
of  this,  that  the  operation  is  imperative  in  each  and  every 
case  in  which  there  is  any  possibility  of  getting  at  the  nerve- 
trunks,  through  which  the  primary  impulse  of  this  terrible 
disease  is  conveyed  to  the  central  nervous  system  ;  and  this 
so  much  the  more  as  nerve-stretching  is  an  innocent  and 
non-mutilating  surgical  procedure  compared  with,  for  in- 
stance, amputation,  which  has  been  so  often  tried  in  vain 
that  it  has  been  abandoned,  not  because  of  the  loss  of  the 
limb,  which  would  be  submitted  to  gladly,  but  because  of 
its  utter  want  of  efificacy  in  checking  the  progress  of  the  dis- 
ease. 

A   question   as   yet  entirely   open    is  this:    Would   not 


NERVE-STRETCHING.  285 

division  or  section  of  the  nerves  be  more  successful  in  cer- 
tain cases  than  nerve-stretching?  Morris  expresses  this 
opinion.  In  one  of  our  own  cases  where  the  axillary  plexus 
above  the  clavicle  had  been  stretched  with  no  effect,  a  sub- 
sequent division  of  these  nerves  caused  the  very  violent  and 
frequent  tetanic  spasms  to  cease  for  twenty-four  hours  in  a 
severe  and  finally  fatal  case  of  tetanus. 

It  seems  to  us  that  it  would  be  worth  while,  in  these  cases, 
either  to  combine  division  of  the  nerves  with  the  nerve- 
stretching,  or  to  perform  division  when  nerve-stretching  has 
been  performed  in  vain.  Nothing  is  lost  in  following  either 
of  these  two  plans  ;  as,  first,  the  ends  of  the  divided  nerve 
will  grow  together  again  in  a  few  weeks  ;  and,  second,  reop- 
ening of  the  wound  under  antiseptic  precautions  will  not  be 
prejudicial  to  the  healing  of  the  wound  by  first  intention. 

Case  i. — (Paul  Vogt,  1876.^°)  A  laborer,  6^  years  oid,  two 
weeks  after  receiving  a  wound  in  the  palm  of  the  right  hand, 
which  had  healed,  was  seized  with  trismus,  severe  opisthotonos, 
and  severe  clonic  convulsions.  There  was  no  tenderness  in  the 
cicatrices  nor  along  the  course  of  the  nerves  in  the  arm  and  fore- 
arm, but  pain  was  experienced  on  pressure  on  the  brachial  plexus 
and  neck.  The  brachial  plexus  of  the  right  side  was  stretched 
above  the  clavicle.  The  cicatrices  in  the  hand  were  also  excised. 
Immediate  relief  of  the  symptoms  was  exp^erienced,  and  recovery 
followed.     Opium  was  the  only  medicine  employed. 

Cases  2,  3,  and  4. — Vogt  (1876  *)  reports  three  cases  of  nerve- 
stretching  in  tetanus,  two  of  which  were  perfectly  successful.  In 
the  third  case  the  patient  died. 

Case  5. — Verneuil  (1876  ^^)  reports  a  case  of  stretching  of 
the  ulnar  and  median  nerves  in  tetanus  with  recovery. 

Case  6. — (Drake,  1876.  31.32^  ^  man,  28  years  of  age,  was 
seized  with  severe  tetanus  from  a  slight  injury  of  the  left  foot. 
The  sciatic  nerve  was  stretched  and  calabar  bean  administered. 
The  convulsions  ceased  for  about  twelve  hours,  then  recurred  in 
a  mild  form  for  three  days,  after  which  time  they  increased  in 
severity,  and  the  patient  died  on  the  twelfth  day  after  the  opera- 
tion. 

Case  7. — (Ransohoff,  Cincinnati,  1879.  ^2)     A  boy,  13  years  of 


286  FENCER  AND  LEE. 

age,  wounded  the  left  foot  by  stepping  upon  a  piece  of  rusty  iron. 
The  wound  healed  quickly.  Eight  days  after  the  injury,  trismus 
and  tetanus  set  in.  The  cicatrix  was  excised,  and  hydrate  of 
chloral   and  calabar  bean  administered,  but  without  effect. 

On  the  fourth  day  after  the  tetanus  set  in,  an  incision  was 
made  behind  the  internal  malleolus,  and  the  posterior  tibial  nerve 
stretched.  The  convulsions  in  the  injured  limb  ceased  im- 
mediately after  the  operation.  There  was  a  gradual  decrease  in 
the  severity  of  the  symptoms,  and  in  three  weeks  the  recovery  was 
complete. 

Case  8. — (Hutchinson,  London,  1879.^^)  Injury  to  right  leg 
by  a  wound  from  a  shot-gun,  followed  by  a  high  degree  of  acute 
tetanus.  The  right  sciatic  nerve  was  stretched  with  consider- 
able force.  After  the  operation  the  patient  passed  a  quiet  night. 
The  next  morning  a  relapse  occurred,  and  twenty  hours  afterward 
the  patient  died  during  a  convulsion. 

Case  9. — (Morris,  London,  1879. 3*)  Ten  days  after  a  superfi- 
cial injury  of  the  right  foot,  in  a  boy  7  years  of  age,  severe  tetanus 
set  in.  The  sciatic  nerve  was  stretched.  A  severe  convulsion 
occurred  immediately  after  awaking  from  the  narcosis,  and  the 
patient  died  six  hours  later. 

Case  10. — (H.  G.  Clark,  1879.  ^^)  A  female,  24  years  of  age, 
suffered  disarticulation  of  the  right  hallux  by  a  street- car  acci- 
dent. Seven  days  later,  trismus,  tetanus,  and  tenderness  along  the 
course  of  the  anterior  tibial  nerve  occurred.  Four  days  later  the 
right  sciatic  nerve  was  stretched.  Immediately  after  awaking 
from  the  narcosis  a  convulsion  occurred.  Calabar  bean  was  ad- 
ministered. The  spasms  ceased  for  twenty-four  hours.  The  pa- 
tient then  relapsed.  Calabar  bean  and  morphine  were  given,  and 
ice  applied  along  the  vertebral  column.  The  patient  recovered  in 
six  weeks.  In  the  author's  opinion,  the  course  of  the  disease  was 
not  influenced  by  the  operation. 

Case  ii. — (Dr.  Fenger,  Chicago,  1880.) 

Synopsis. — Crushing  injury  to  the  left  forearm.  Amputation  at 
lower  third  of  humerus.  Tetanus  after  thirty  six  hours.  Stretch- 
ing of  axillary  plexus  above  the  clavicle.  Little  or  no  effect.  Forty - 
eight  hours  later,  reopening  of  wound  and  division  of  nerves  of 
brachial  plexus.  Paroxysms  of  pain  and  opisthotonos  entirely  stopped 
for  thirty-six  hours.     Relapse,  and  death  after  two  days. 

I.  B.,  a  German  laborer,  fifty-five  years  of  age,  was  brought  to 
Cook  County  Hospital,  Aug.  3,  1880,  and  placed  in  the  care  of 
Dr.  Fenger.     A  few  hours  before,  the  left  hand  had  been   torn 


NER  VE-  S  TKE  TCHING.  28/ 

completely  off  in  a  machine  ;  the  ulna  and  radius  were  broken  at 
about  the  middle  ;  to  the  hand  was  attached  the  skin  of  the  fore- 
arm almost  up  to  the  elbow  joint  ;  the  tendons  and  muscles  of 
the  forearm  were  irregularly  torn.  This  injury  necessitated  im- 
mediate amputation  at  the  lower  third  of  the  humerus. 

August  4th.  The  patient  rested  well  during  the  night  ;  tempera- 
ture and  pulse  normal.  Some  vomiting  followed  the  administra- 
tion of  ether. 

August  5th.  Late  last  night  paroxysms  of  pain  in  the  amputation- 
wound  set  in,  which  were  followed  by  trismus,  contraction  of  the 
posterior  muscles  of  the  neck,  opisthotonos.  Sleep  disturbed  by 
the  paroxysms.  The  patient  can  open  his  mouth  only  about  half 
an  inch.  The  posterior  muscles  of  the  neck  are  moderately  stiff. 
He  does  not  complain  of  any  pain,  except  at  the  time  of  the 
paroxysms,  which  occur  about  every  two  hours  and  conclude  in 
twitchings,  that  is,  painful  contractions  of  the  muscles  of  the 
stump.  As  the  disease  was  manifestly  tetanus,  and  each  paroxysm 
appeared  to  have  its  starting-point  in  the  nerves  of  the  amputated 
arm,  Dr.  Fenger  resolved  to  try  nerve-stretching  of  the  brachial 
plexus. 

The  patient  was  anaesthetized.  An  incision  six  centimetres  in 
length  was  made  in  the  supraclavicular  fossa,  half  an  inch  above, 
and  parallel  with,  the  upper  border  of  the  clavicle.  The  platys7tia 
was  divided  upon  the  guide,  but  after  this  the  dissecting  forceps 
alone  was  used  in  separating  the  tissues  to  reach  the  brachial 
plexus.  The  large  nerve-trunks  were  drawn  out  of  the  wound 
separately  by  means  of  the  blunt  hook,  stretched  by  traction  both 
in  the  central  and  peripheral  ends.  These  thick  nerve-trunks 
were,  furthermore,  compressed  between  the  thumb  and  index 
finger.  They  were  then  slipped  into  the  wound;  a  drainage  tube 
inserted  ;  the  wound  closed  and  dressed  antiseptically. 

August  6th.  Yesterday  afternoon  the  paroxysms  were  fewer  in 
number  and  less  violent.  The  patient  slept  some  during  the 
night.  He  says  that  he  feels  better  than  before  the  operation, 
but  on  examination  it  was  found  that  the  lockjaw  and  stiffness  of 
the  muscles  of  the  neck  were  the  same  as  the  day  before.  Cala- 
bar bean,  morphia,  and  chloral  were  administered, 

August  7th.  The  patient  slept  very  little  during  the  night  on 
account  of  spasms  in  the  arm  and  paroxysms  of  opisthotonos, 
which  rapidly  increased  in  violence  and  frequency,  occurring 
every  fifteen  minutes.     The  patient  looked  haggard  and  anxious. 

As  the  tetanus  was  evidently  progressing  toward  a  fatal  ter- 


288  FENGER  AND  LEE. 

mination,  Dr.  Fenger  resolved  to  divide  the  nerves  in  the  brachial 
plexus,  thinking  that  as  the  paroxysms  had  their  initial  point  in 
the  nerves  of  the  stump,  division  of  the  nerves  might  control 
them. 

The  patient  was  again  anaesthetized.  The  wound,  when  re- 
opened, was  seen  to  be  agglutinated  by  perfectly  healthy-looking, 
coagulated  plasma.  The  large  nerve-trunks  of  the  brachial  plexus 
were  easily  found,  taken  out  of  the  wound,  divided  with  scissors, 
and  then  replaced,  and  the  wound  was  closed  and  dressed  anti- 
septically. 

August  8th.  The  paroxysms  of  pain  in  the  stump,  and  the  opis- 
thotonos have  entirely  ceased  since  the  operation.  The  patient 
slept  well  during  the  night,  feels  much  relieved,  and  talks  hope- 
fully. The  muscles  of  the  neck  are  less  stiff,  but  the  patient  is 
still  unable  to  open  his  mouth  more  than  about  half  an  inch. 
The  internal  treatment  was  continued.  The  amputation-wound 
was  dressed,  and  no  swelling  nor  suppuration  found. 

August  9th.  The  patient  had  a  return  of  the  paroxysms  of 
opisthotonos  last  night,  until  they  recurred  with  their  former  fre- 
quency. The  convulsions  increased  during  the  night,  so  that  they 
occurred  every  five  minutes.  The  trismus  is  unchanged.  The 
patient  still  takes  a  good  deal  of  nourishment. 

August  loth.  Pulse,  130 ;  temperature,  102.75°  The  par- 
oxysms are  increasing  in  violence  and  frequency.  They  occur 
now  every  two  or  three  minutes. 

August  nth.  Last  evening  the  patient  became  delirious.  After 
this  the  paroxysms  stopped.  Toward  morning  the  breathing  be- 
came difficult,  the  pulse  weaker,  and  he  died  a  little  before  nine 
o'clock  this  morning. 

Case  12. — (Dr.  Fenger,  Chicago,  1880.) 

Synopsis. — Crushing  injury  to  left  elbow  joint.  Tetanus  jive 
days  later.  Amputation  at  the  middle  of  the  humerus,  with  vigorous 
stretching  of  all  nerves  in  the  amputation-wound.  No  effect  on  the 
tetanus.     Twelve  hours  after  the  operation,  death. 

Joe  Chastrand,  a  painter,  29  years  of  age,  entered  Cook  County 
Hospital,  July  6,  1880,  and  was  placed  in  my  care.  About  nine 
o'clock  in  the  morning,  while  painting  at  a  distance  of  55  feet 
from  the  ground,  one  of  the  hooks  holding  the  flying-stage  gave 
way  and  precipitated  the  patient  to  the  roof,  40  feet  below.  He 
struck  on  the  head  and  left  side,  producing  an  incised  wound, 
about  two  inches  and  a  half  in  length,  on  the  left  side  of  the  fore- 
head ;  dislocation  of  the  left  elbow  ;    fracture  of  the  right  radius 


NERVE-STRETCHING.  289 

about  one  inch  and  a  half  above  the  wrist,  the  fragments  having 
at  this  point  ruptured  the  skin,  making  a  wound  about  an  inch  in 
length  ;  fracture  of  right  half  of  pelvis.  The  dislocation  was  re- 
duced previous  to  his  admission  to  the  hospital. 

On  admission,  four  hours  after  the  accident,  the  patient  did  not 
show  any  evidences  of  shock,  talked  well,  and  suffered  but  little 
pain. 

The  wound  communicating  with  the  formerly  dislocated  elbow 
joint  was  carefully  cleansed,  a  drainage  tube  inserted,  and  antisep- 
tic dressings  applied.  The  arm  was  placed  in  a  rectangular 
suspension-splint  ;  the  other  wounds  were  also  dressed  antisepti- 
cally. 

July  7th.  Slept  some  during  the  night.  No  fever.  The 
wound  at  the  elbow  was  dressed. 

July  12th.  Last  night  tetanus  set  in.  The  arm  was  amputated 
at  the  middle  of  the  humerus,  and  during  the  operation  the 
nerves  were  stretched  in  the  amputation-wound. 

July  13th.  The  stretching  of  the  nerves  yesterday  had  no  in- 
fluence at  all  upon  the  tetanus,  the  paroxysms  of  which  increased 
during  the  afternoon  and  night.  In  the  night  the  patient  became 
delirious,  and  died  this  morning. 

Case  13. — (Dr.  Fenger,  Chicago,  1880.) 

Synopsis. — Punctured  wound  of  the  right  hand.  Four  days  after 
the  injury,  trismus  and  opisthotonos.  Fourteen  days  after  the  injury, 
stretching  of  medianus  ulnaris,  and  cutaneous  internus  longus  nerves 
in  the  sulcus  bicipitis.  Immediate  relief  of  the  symptoms.  Tris7nus 
and  tetanus  entirely  disappeared  after  four  days.  Paresis  in  the  ter- 
ritory of  the  medianus  and  ulnaris  nerves  for  seven  months.  Neuralgic 
pains  along  the  trunks  of  the  nerves  stretched,  and  hypercesthesia  on 
the  dorsal  side  of  the  third  and  fourth  fingers  for  three  weeks.  Re- 
covery. 

W.  H.  O'Connor,  a  carpenter,  43  years  of  age,  entered  the  hos- 
pital July  10,  1880.  On  June  26th  he  ran  a  rusty  ten-penny  nail 
into  the  palm  of  the  right  hand,  half  an  inch  anterior  to  the  pisi- 
form bone.  The  nail  projected  from  a  board  about  four  inches, 
and  the  wound  was  made  by  striking  the  hand  against  it.  When 
he  pulled  the  nail  out,  the  blood  spurted  in  a  continuous  stream, 
and  he  lost  about  half  a  pint.  He  had  a  stream  of  cold  water 
running  upon  the  wound  the  whole  night  to  "get  the  rust  out," 
and  afterward  put  goose-oil  on  it. 

Four  days  later,  he  experienced  pain  and  swelling  in  the  palm 
of  the  hand,  and  the  fingers  became  stiff.     He  sought  medical  aid 


290  FENGER  AND  LEE. 

at  the  Central  Free  Dispensary,  and  was  there  directed  to  use 
pouhices  of  flaxseed  meal  and  bread-and-milk  on  the  wound. 

The  pain  radiated  upward  from  the  hand  to  the  mouth  and  then 
to  the  neck.  The  trismus  was  so  painful  that  he  pounded  him- 
self on  the  sides  of  the  jaw  to  produce  relaxation  of  the  con- 
tracted muscles,  but  without  effect.  The  night  before  he  entered 
the  hospital,  he  had  two  men  pound  and  squeeze  the  muscles  of 
the  neck  and  jaw,  and  forcibly  open  the  mouth,  but  in  vain.  The 
pain  and  swelling  of  the  hand  subsided  after  three  or  four 
days,  but  the  trismus  and  opisthotonos  increased  to  such  an  ex- 
tent that  he  became  afraid  they  would  choke  him,  and  for  this 
reason  came  to  the  hospital. 

On-  admission,  he  was  found  to  be  a  well-nourished,  robust- 
looking  man.  In  the  posterior  part  of  the  thenar  of  the  fifth  fin- 
ger of  the  right  hand  was  a  small  cicatrix  from  the  punctured 
wound  which  had  healed,  with  no  swelling  around  it,  but  tender 
to  the  touch.  The  pain  radiated  upward  along  the  inner  aspect 
of  the  forearm  and  arm.  The  jaws  could  not  be  separated  more 
than  one-sixth  of  an  inch,  and  the  posterior  muscles  of  the  neck 
were  so  stiff  that  the  head  could  not  be  moved.  He  was  ordered 
calabar  bean,  hydrate  of  chloral,  and  bromide  of  potassium. 

July  nth.  As  the  trismus  and  opisthotonos  were  the  same  as  on 
the  preceding  day,  nerve-stretching  was  resorted  to.  An  incision, 
two  inches  and  a  half  in  length,  was  made  in  the  middle  third  of 
the  arm,  over  the  sulcus  bicipitis.  The  internal  cutaneous,  median, 
and  ulnar  nerves  were  taken  out  of  the  wound,  stretched  vigor- 
ously in  both  directions,  pressed  between  the  fingers  and  an  ele- 
vator of  the  palpebras  with  which  they  were  taken  from  the 
wound,  and  then  re-inserted  in  the  wound.  No  drainage  tube  was 
inserted.  The  wound  was  closed  with  antiseptic  silk,  and  Lister 
dressing  applied. 

July  12th.  Pulse,  64;  temperature,  99.5°.  Last  night,  eight  hours 
after  the  operation,  he  was  able  to  open  the  mouth  a  little  more,  so 
as  to  allow  the  tongue  to  pass  out.  The  stiffness  of  the  neck  con- 
tinued the  same.  He  slept  well  during  the  night,  and  to-day, 
twenty-four  hours  after  the  operation,  he  feels  better,  and  is  able  to 
open  the  mouth  sufficiently  to  admit  two  fingers.  The  neck  is 
much  less  stiff  than  it  was  last  night,  and  he  can  move  the  head  a 
little.     The  internal  medication  was  continued. 

July  13th.  The  patient  slept  well  and  feels  much  better.  He  can 
now  open  the  mouth  freely  and  move  the  neck,  but  the  latter  is 
still  a  little   stiff  and  somewhat  painful  when  moved.     The  third, 


NER  VE-STRE  TCHING.  29 1 

fourth,  and  fifth  fingers  are  painful,  and  so  far  paralytic  that  he 
can  flex  them  but  very  little,  but  is  able  to  extend  them.  Paresis 
of  the  ulnar  and  median  nerves  is  also  present. 

July  14th.  There  is  still  a  little  pain  in  the  nape  of  the  neck  ; 
no  stiffness  in  the  jaws.  There  is  still  pain  in  the  third,  fourth, 
and  fifth  fingers.     The  patient  slept  well  all  night. 

July  15th.  The  patient  complains  of  pain  along  the  course  of 
the  nerves  which  were  stretched,  considerable  enough  to  ren- 
der five  hypodermic  injections  of  morphia  necessary  during  the 
day.  No  stiffness  in  the  jaw  or  neck.  Discontinued  the  calabar 
bean,  hydrate  of  chloral,  and  bromide  of  potassium. 

July  16th.  The  patient  feels  numbness  on  the  flexor  side  of 
the  forearm.  He  can  move  the  thumb  slightly,  but  can  only 
slightly  flex  the  fingers.  There  is  occasionally  stinging  pain  on 
the  dorsal  surface  of  the  hand,  and  shooting  pains  in  the  fingers. 
Pulse,  62  ;  temperature,  98.5°. 

July  i8th.  He  complains  of  twitchings  in  the  fingers,  particularly 
the  middle  and  ring  fingers,  which  are  very  sore  along  the  dorsal 
surface.  There  is  no  pain  along  the  inside  of  the  arm,  but  he 
complains  of  pain  in  the  shoulder  ;  is  up  and  around  the  whole 
day  ;  sleeps  well ;  and  his  appetite  is  good.  The  interrupted  cur- 
rent was  ordered  to  be  applied  once  a  day  to  the  arm  and  hand. 

August  7th.  The  patient  can  move  the  fingers  better,  though 
flexion  is  not  yet  normal.  He  still  occasionally  complains  of  pain 
in  the  palm  of  the  hand  and  the  middle  and  ring  fingers. 

The  patient  was  discharged  to  the  County  Poor-house,  cured. 

March  i,  iSSt.  Ansesthesia  and  paresis  of  the  forearm  com- 
menced to  disappear  rapidly. 

April  15th.  There  is  no  atrophy  of  the  forearm,  no  ansesthesia 
or  pain  ;  there  is  a  little  stiffness  of  the  fingers,  but  active  mobility 
is  normal,  so  that  he  can  flex  the  finger's  until  the  ends  of  the 
fingers  touch  the  palm  of  the  hand.  Sensibility  of  the  fingers  is 
normal,  but  they  are  a  little  colder  than  the  fingers  of  the  hand 
not  operated  upon.* 

Case  14. — (Pepper,  London,  1881.^°)  A  railway  signalman  re- 
ceived a  crushing  injury  of  the  hand,  with  a  lacerated  wound. 
Three  fingers  were  torn  off.  Antiseptic  dressing  was  applied,  and 
the  wound  healed  rapidly.  Two  weeks  after  the  injury  was  re- 
ceived   tetanus    set   in.      The   median    and    radial    nerves   were 

*  As  a  remarkable  feature,  we  here  mention  that,  after  the  anaesthesia  and 
paresis  of  the  nerves  stretched  had  persisted  for  seven  months,  in  spite  of  all 
kinds  of  treatment,  they  disappeared  spontaneously  in  the  course  of  two  weeks. 


292  FENGER  AND  LEE. 

Stretched.  The  paroxysms  were  relieved  for  two  days,  but  on 
the  third  day  after  the  operation  the  spasms  recurred  violently, 
and  the  patient  sank  and  died. 

Case  15. — (H.  D'Ollier,  Paris,  1881.")  A  man,  54  years  of  age, 
received  the  following  injuries  from  a  tree  falling  upon  him  :  flesh 
wound  on  right  forearm;  large,  lacerated  wound  on  the  extensor  side 
of  the  left  forearm,  whereby  the  extensor  tendons  were  denuded  ; 
subcutaneous  fracture  of  the  left  femur.  A  diffuse,  phlegmonous  in- 
flammation took  place,  on  the  third  day  after  the  accident,  in  the  right 
forearm,  which  was  subdued  by  large  multiple  incisions.  On  the 
tenth  day,  at  a  period  when  the  condition  of  the  wounds  was  very 
favorable  for  speedy  healing,  painful  spasms  of  the  flexor  muscles 
of  the  forearm  set  in,  causing  the  fingers  to  be  very  firmly  flexed. 
These  paroxysms  increased  in  number  and  violence  for  a  week, 
and  then  symptoms  of  tetanus  commenced  ;  lockjaw  ;  stiffness  of 
the  neck  ;  difficulty  in  swallowing  ;  and  tetanic  contractions  of  the 
muscles  of  the  abdomen  and  lower  extremities.  The  patient  was 
anaesthetized,  the  median  nerve  laid  bare  in  the  middle  of  the 
arm,  and  stretched  vigorously  in  both  directions.  After  the  oper- 
ation the  pain  and  muscular  spasms  ceased,  and  extension  of  the 
fingers  could  be  more  easily  accomplished.     Recovery. 

Cases  16,  17,  18,  19,  20,  and  21. — (1879.'*)  Nankewell  reports 
two  cases  of  traumatic  tetanus,  in  which  no  effect  followed  nerve- 
stretching.  Langton,  Verneuil,  and  Cowper  each  report  an  unsuc- 
cessful case  of  nerve-stretching  in  tetanus,  and  Ratton  places  on 
record  a  case  of  tetanus,  treated  by  nerve-stretching,  which  was 
followed  by  recovery. 

VI.— LOCOMOTOR  ATAXIA. 

It  was  the  excruciating  and  distressing  pain,  which,  at  a 
certain  period  of  this  disease,  embitters  the  existence  of  the 
patient,  that  furnished  the  indication  to  Langenbuch  to  try 
nerve-stretching.  The  unexpected  effect  of  the  operation, 
namely,  that  not  only  the  pain  was  relieved,  but  also  that 
the  symptoms  of  incoordination  disappeared,  attracted  well- 
merited  attention,  as  all  the  remedies  hitherto  employed  in 
this  disease  had  been  devoid  of  practical  value  and,  in  fact, 
had  appeared  to  exert  no  influence  whatever  upon  the 
course  of  the  disease. 


NER  VE-STRE  TCHING.  293 

The  seven  cases  which  are  reported  below  are  of  too  re- 
cent date  to  enable  us  to  determine  whether  or  not  the 
beneficial  effects  of  the  operation  were  lasting  or  finally 
curative.  But,  nevertheless,  the  operation  has  manifestly 
been  of  benefit  in  two  very  important  directions:  First,  as 
to  the  pain.  The  records  show  that  it  has  been  relieved,  or 
rather  has  entirely  disappeared  in  the  five  cases  in  which 
pain  was  noted  among  the  symptoms.  Second,  as  to  the 
ataxic  symptoms,  especially  incoordination,  loss  of  muscular 
power  in  the  limbs  affected,  and  consequent  inability  to 
walk  or  stand.  These  symptoms  entirely  disappeared  in 
two  cases,  were  markedly  diminished  in  two  cases,  and 
partially  diminished  in  one  case  in  which  the  muscular 
strength  increased.  In  one  case  the  effect  may  have  been 
experienced,  but  is  not  recorded,  and  in  one  case  only  was 
the  operation  of  no  effect  as  regards  these  symptoms. 

The  nerves  stretched  were  both  sciatic  and  crural  nerves 
in  one  case  ;  both  sciatic  nerves  in  three  cases ;  the  left 
sciatic  nerve  in  one  case  ;  the  axillary  nerves  in  one  case; 
and  the  right  median  and  ulnar  nerves  in  one  case. 

It  may  be  that  the  two  cases  in  which  the  ataxic  symp- 
toms entirely  disappeared  were  cases  of  only  short  dura- 
tion, as  in  Langenbuch's  case,  in  which  the  patient  died 
accidentally  during  the  chloroform  narcosis  for  the  second 
operation  upon  the  upper  extremity,  the  autopsy  showed 
no  anatomical  lesion  in  the  posterior  columns  of  the  spinal 
medulla. 

But  that  even  inveterate  cases  may  be  effectually  acted 
upon  by  the  operation  is  shown  by  Debove's  first  case,  in 
which,  although  the  disease  was  of  six  years'  standing,  and 
the  patient  had  been  confined  to  his  bed  for  eighteen 
months  previous  to  the  operation,  the  pain  not  only  disap- 
peared, but  the  severe  ataxic  symptoms  also  diminished  so 
considerably  as  to  allow  the  patient  to  stand  erect  and  walk 
a  few  steps  in  two  weeks  after  the  operation. 


294  FENGER  AND  LEE. 

In  our  own  case  no  effect  upon  the  ataxic  symptoms  was 
experienced.  It  is  possible,  however,  that  the  complica- 
tion with  large  bedsores,  and  the  subsequent  low  condition 
of  the  patient,  masked  a  beneficial  effect  which  might 
otherwise  have  been  apparent.  On  the  other  hand,  the 
most  characteristic  symptom,  namely  the  incoordination, 
may  not  be  affected  at  all,  as  may  be  seen  in  Erlenmeyer's 
case. 

As  to  what  and  how  many  nerve-trunks  it  is  advisable  to 
operate  upon  in  a  case  of  locomotor  ataxia,  we  shall  take 
into  consideration  the  following  facts :  The  very  interest- 
ing and  unexpected  crossed  and  distant  effect  of  the 
nerve-stretching,  which  was  first  seen  as  an  exception  in 
Andrews'  case  of  painful  contractures  of  the  lower  extremi- 
ties, but  which  has  now  been  fully  confirmed,  as  a  rule,  in 
locomotor  ataxia,  and  which  has  been  further  confirmed  by 
Brown-Sequard's  experiments,  leaves  it  an  open  question 
whether  it  might  not  be  sufficient  to  operate  upon  only  a 
limited  number  of  the  nerves  of  the  extremities  affected. 
When  Esmarch  stretched  the  axillary  nerves  for  pain  in  the 
upper  extremities,  the  ataxic  symptoms  of  the  lower  ex- 
tremities ceased.  When  Debove  stretched  the  right 
median  and  radial  nerves,  the  pain  disappeared  in  the 
opposite  arm,  and  diminished  in  the  arm  operated  upon. 
This  crossed  and  distant  effect  is  by  no  means  constant. 
In  has  been  noted  in  none  of  the  other  cases,  and  we  have 
as  yet  no  means  of  determining  beforehand  in  what  cases 
such  an  effect  will  take  place,  and  in  what  cases  it  will 
not. 

It,  therefore,  seems  at  present  to  be  the  most  natural 
plan  to  take  the  indications  for  the  place  of  operation  from 
the  pain,  and  to  commence  to  stretch  the  nerve-trunks  in 
the  territory  in  which  the  most  severe  pain  is  suffered. 
From  the  effects  of  this  first  operation,  indications  for  the 


NER  VE-  S  TRE  TCHING.  295 

stretching  of  other  nerve-trunks  may  be  determined.  As 
the  inconveniences  subsequent  to  the  operation  are  very- 
few  and  insignificant,  and  as  the  course  of  the  disease  is 
sufficiently  chronic  as  not  to  render  any  rapid  surgical 
interference  imperative,  it  seems  to  us  that  no  contra-indi- 
cation  exists  for  this  plan  of  experimental  operating  by 
degrees. 

Case  i. — (Langenbuch,  Berlin,  1879*°'  ^^  >  Westphal,  Berlin, 
1881.*^)  A  merchant,  40  years  of  age,  had  been  several  months 
before  attacked  with  symptoms  of  tabes  dorsalis.  When  he  en- 
tered the  hospital  the  symptoms  were  so  pronounced  that  there 
was  no  doubt  that  the  disease  was  tabes  dorsalis  dolorosa.  Be- 
sides thoroughly  developed  ataxia,  there  were  peculiarly  intense 
shooting  pains  in  all  four  extremities.  Romberg's  symp- 
tom was  present,  and  the  typical  disturbances  of  sensibility,  espe- 
cially in  the  lower  extremities.  In  walking,  the  patient  threw  off 
his  slippers  without  being  aware  of  it,  and  was  unable  to  distin- 
guish what  he  was  walking  on.  From  time  to  time,  constriction, 
as  of  a  belt,  was  felt.  The  reflex  sensibility  was  somewhat  aug- 
mented. The  knee  symptom  was  not  present,  but  a  high  degree 
of  myosis,  and  hyperaesthesia  of  the  skin  were  observed,  especially 
on  the  anterior  surface  of  the  femur.  All  these  disturbances  of 
innervation  were  also  present,  though  in  a  less  degree,  in  the  up- 
per extremities.  The  patient  was  tortured  by  incessant  pain,  in 
spite  of  all  sedative  treatment. 

As  the  pain  was  most  intense  in  the  region  of  the  left  sciatic 
nerve.  Dr.  Langenbuch  proposed  to  stretch  it.  With  the  patient's 
consent  the  operation  was  performed  September  13,  1879.  The 
trunk  of  the  sciatic  nerve  appeared  somewhat  reddish,  injected, 
and  swollen.  Under  anaesthesia,  it  was  thoroughly  stretched,  and 
sutures  and  antiseptic  bandages  applied.  The  wound  healed  in 
a  few  days,  the  patient  having  experienced  entire  absence  of  pain 
from  the  moment  of  the  operation.  The  immediate  consequence 
of  the  stretching  was  motor  and  sensory  paralysis,  which  disap- 
peared in  a  few  days  without  any  return  of  the  pain. 

Twelve  days  after  the  first  operation.  Dr.  Langenbuch  was  able 
to  proceed  to  the  stretching  of  the  right  sciatic  and  both  of  the 
crural  nerves,  in  one  operation.  Under  antiseptic  treatment  the 
wounds  healed  in  a  short  time.  This  operation  was  followed 
by  the   same  results  as  the  former  ;  the  pain  disappeared   perma- 


296  FENCER  AND  LEE. 

nently,  and  the  normal  mobility  and  sensibility  were  regained  in 
the  course  of  a  few  days. 

When  the  patient  made  his  first  essay  at  walking,  he  expressed 
himself  that  he  now  at  least  knew  what  he  had  beneath  his  feet. 
The  first  attempts  at  walking  were  feeble  and  incomplete,  but  im- 
proved rapidly.  The  unexpected  fact  was  soon  discovered  that 
the  ataxic  symptoms  had  disappeared  at  the  same  time.  When 
the  patient  had  so  far  recovered  that  he  was  able  to  walk  moder- 
ately well,  he  left  the  hospital. 

Later  he  entered  another  hospital,  when  it  was  found  on  exami- 
nation that  the  ataxic  symptoms  had  entirely  disappeared,  and 
that  there  was  no  diminution  of  sensibility  in  the  lower  extremi- 
ties. The  patient  was  able  to  walk  with  the  aid  of  a  cane,  and 
complained  only  of  the  above-named  symptoms  in  the  upper  ex- 
tremities. 

As  the  pains  in  the  upper  extremity  were  increasing,  and  as  the 
result  of  the  operations  on  the  lower  extremities  had  been  so  un- 
expectedly favorable,  it  was  resolved  to  stretch  the  nerves  of  the 
upper  extremity,  but  the  patient  died  unexpectedly  during  the 
chloroform  narcosis.  The  autopsy,  made  by  Dr.  C.  Westphal, 
demonstrated  conclusively  that  in  this  case  there  was  no  disease 
in  the  posterior  columns  of  the  spinal  cord. 

Case  2. — (Esmarch,  Kiel,  1880.  ^^)  A  brief  notice  was  made, 
in  the  Ninth  Congress  of  German  Surgeons,  held  in  Berlin  in  1880, 
of  a  case  which  Quinke  had  diagnosed  as  tabes  dorsalts,  in  which 
violent  pains  in  the  upper  extremity  were  experienced.  The 
nerves  in  the  axilla  were  stretched.  The  operation  was  followed 
by  very  satisfactory  results  :  not  only  the  pain  in  the  upper  ex- 
tremities, but  also  the  pain  in  the  lower  extremities,  as  well  as  the 
other  symptoms  of  ataxia  ceased. 

Case  3. — (Erlenmeyer,  1880.  **)  A  man,  thirty-nine  years  of 
age,  suffered  from  so-called  "  rheumatic  "  pains  in  the  right  leg, 
in  187 1,  which  continued  increasing  slowly  until  1878,  when 
manifest  symptoms  of  ataxia  were  noticed.  In  December,  1&78, 
paresis  of  the  bladder  occurred.  In  the  summer  of  1879  the 
patient  became  unable  to  walk  or  stand.  In  November,  1879, 
exquisite  ataxia  of  the  lower  extremities  set  in,  with  a  very  con- 
siderable lack  of  coordination.  The  extremities  were  cold  ;  sen- 
sibility was  diminished  ;  patellar  reflex  absent  ;  the  patient  could 
not  feel  the  position  of  his  legs  at  all.  He  had  very  little  "  druck- 
kraft  "  (pressure-force).  Most  of  the  time  there  was  no  pain  at  all 
in  the  legs.     Incontinence  of  urine  was  present. 


NERVE-STRETCHING.  297 

Diagnosis,  tabes  lumbalis  j  prognosis,  unfavorable.  All  other 
known  remedies  having  been  tried  in  vain,  nerve-stretching  was 
resorted  to. 

June  22,  1880,  the  patient  was  anaesthetized  with  chloroform, 
an  incision  made  between  the  great  trochanter  and  the  tuber 
ischii,  and  the  right  sciatic  nerve  exposed.  It  was  lifted  from  the 
wound,  stretched  vigorously,  and  twisted.  The  nerve  was  flat- 
tened and  of  a  grayish  color. 

July  3d.  The  ataxia,  sensibility,  and  tendon  reflex  were  exactly 
the  same  as  before  the  operation,  but  the  "  druckkraft  "  was  con- 
siderably augmented,  as  might  be  seen  by  comparing  the  right 
leg  which  had  been  operated  upon,  with  the  left  leg  which  had 
not.     The  patient  was  still  unable  to  stand  up. 

At  this  date  the  left  sciatic  nerve  was  stretched  in  the  same 
manner  as  in  the  former  operation,  strict  antisepsis  being  main- 
tained in  each  operation.  In  spite  of  the  antiseptic  precautions, 
however,  erysipelas  set  in  in  the  wound  and  continued  for  three 
weeks.  Examination  then  showed  an  augmentation  of  the 
"  druckkraft,"  but  no  amelioration  whatever  of  the  other  ataxic 
symptoms. 

Case  4. — (Debove,  Paris,  1880.  *")  A  man,  fifty-six  years  of 
age,  was  seized,  in  1874,  with  vehement  pains  in  both  legs,  and  six 
weeks  later  symptoms  of  incoordination  appeared.  This  was  fol- 
lowed by  pains  in  the  upper  extremities,  but  no  incoordination 
was  here  noticeable. 

November,  1880,  the  patient  entered  the  hospital.  He  com- 
plained of  attacks  of  severe  pain  in  the  lower  extremities,  which 
increased  in  violence  at  night.  Subcutaneous  injections  of  mor- 
phine were  ordered,  and  as  much  as  three  grains  was  given  in  the 
course  of  twenty-four  hours.  Every  one  or  two  weeks  attacks  of 
gastric,  urethral,  and  vesical  pain  were  experienced.  Slight  cysti- 
tis also  existed.  Incoordination  was  present  only  in  the  lower 
extremities,  which  were  highly  atrophic.  The  patient  had  been 
obliged  to  remain  in  bed  for  the  previous  eighteen  months. 
There  were  bedsores  on  his  back. 

November  i8th.  An  incision  was  made  in  the  middle  of  the 
thigh,  the  left  sciatic  nerve  retracted,  and  stretched  vigorously  in 
both  directions.  The  nerve  was  replaced,  the  wound  closed,  and 
antiseptic  dressing  applied.  From  the  day  after  the  operation  no 
pain  was  felt  in  any  of  the  extremities,  and  only  slight  pam  m  the 
wound.  Formication,  from  time  to  time,  commenced  m  the  left 
leg,  and  from  there  extended  to   the  right  leg.     Two  days  later 


298  FENGER  AND  LEE. 

there  was  no  pain  whatever.  He  could  feel  his  legs  in  the  bed. 
The  incoordination  in  both  extremities  had  diminished.  Two 
weeks  after  the  operation  no  return  of  the  pain  had  been  expe- 
rienced. The  sensibility  in  the  lower  extremities  was  normal.  He 
could  move  the  legs  so  much  better  that  only  traces  of  the  inco- 
ordination remained.  The  patient  could  now  stand  erect  and 
take  a  few  steps  with  the  support  of  another  person.  The  wound 
did  not  heal  by  first  intention.     The  gastric  trouble  disappeared. 

Case  5. — (Debove,  Paris  1880.*^)  On  December  16,  1880,  a 
case  of  locomotor  ataxia  was  operated  upon,  in  which  the  con- 
stant severe  pains  with  exacerbations  were  mainly  confined  to 
the  upper  extremities.  The  right  median  and  radial  nerves  were 
stretched.  After  the  operation  the  pain  diminished  in  the  right 
arm  and  disappeared  entirely  in  the  left  arm  ;  and  in  the  lower 
extremities  the  plantar  anaesthesia  diminished  considerably  on  the 
left  side.  The  incoordination  was  so  much  ameliorated  that  the 
patient  was  able  to  walk  without  help.  He  is  now  able  to  sleep 
regularly. 

Case  6. — (Fenger,    Chicago,    1880.^'') 

Synopsis. — Locomotor  ataxia  of  two  years'  duration.  Incoordi- 
nation of  muscles  of  lower  and  tipper  extremities.  Oculo-fnotor  pa- 
resis with  diplopia.  Fulgurant  paroxysmal  pains  in  lower  ex- 
tremities. Stretching  of  both  sciatic  and  crural  nerves.  Healing 
of  wounds  by  first  intention.  Cessation  of  paroxysms  of  pain.  No 
change  in  the  rest  of  the  ataxic  symptoms.  Bedsores.  Pycemia. 
Death. 

Charles  Grundin,  a  cabinet-maker,  fifty-four  years  of  age,  was 
admitted  to  Cook  County  Hospital,  September  6,  1880.  The  pa- 
tient states  that  his  family  history  is  good.  His  parents  died  of 
old  age.  No  hereditary  tendencies  ;  no  venereal  disease.  He 
has  used  stimulants  moderately.  Habits  and  surroundings  good. 
Has  had  several  attacks  of  intermittent  fever  of  short  duration  ; 
once  suffered  from  slight  dysentery,  and  once  from  acute  rheuma- 
tism. These  diseases  all  occurred  twenty  years  ago.  Since  that 
time  his  health  has  been  uniformly  good  until  two  years  ago,  when 
he  had  an  attack  of  incoordination  and  numbness  of  the  lower  ex- 
tremities, slight  strabismus  and  ptosis  of  the  left  eye.  These 
symptoms  were  relieved  by  medicinal  treatment  in  six  weeks. 
Since  this  time,  excepting  a  slight  numbness  of  the  feet  and  fin- 
gers, he  has  been  perfectly  well,  until  four  weeks  before  he  en- 
tered the  hospital,  when  he  began  to  have  difficulty  in  walking, 
particularly  in   the  dark.     He  lost  considerable  strength  in  the 


NERVE-STRETCHING.  299 

lower  extremities,  and  the  pain  in  the  feet  and  the  ends  of  the 
fingers  increased. 

On  admission  the  patient  said  that,  generally  speaking,  he  felt 
pretty  well  ;  his  appetite  was  excellent,  bowels  regular,  and  he 
slept  well. 

On  examination  we  found  a  marked  loss  of  coordination  in  the 
lower  extremities  ;  he  was  unable  to  stand  erect  when  his  eyes 
were  closed  or  when  he  looked  upward.  There  was  a  marked 
diminution  of  cutaneous  and  muscular  sensibility,  the  patient  be- 
ing unable  to  perceive  the  contact  of  his  feet  with  the  floor,  the 
feet  seeming  to  rest  on  sand.  There  was  paresis  of  the  motor  oc- 
uli  nerve,  which  was  noticeable  on  account  of  the  diplopia.  The 
patient  stated  that  he  had  noticed  a  diminution  of  his  visual  pow- 
ers, especially  in  the  right  eye.  He  complained  of  occasional 
difficulty  in  micturition,  it  being  more  frequent  and  requiring  con- 
siderable effort.  His  hands  and  arms  were  tremulous,  so  that  he 
was  unable  to  hold  any  object  steadily.  He  did  not  seem  to  be 
annoyed  by  any  undue  irritation  regarding  his  sexual  desire,  al- 
though he  stated  that  previous  to  the  present  illness  he  had  been 
addicted  to  excessive  indulgence  in  sexual  luxuries.  Examina- 
tion of  the  vital  organs  revealed  nothing  of  note. 

September  14th.  Was  given  fluid  extract  of  ergot,  and  iodide  of 
potassium.  The  patient  complains  of  fulgurant  pains  in  the  left 
thigh  and  leg,  which  recur  several  times  daily. 

October  8th.     Feels  as  though  his  legs  were  asleep. 

October  14th.  He  can  obtain  rest  and  sleep  only  by  means  of 
morphine. 

November  6th.  The  patient  has  been  unable  to  walk  for  the 
last  three  weeks,  and  has  been  confined  to  his  bed.  Suffers  pain 
in  both  lower  extremities.  Sleep  can  only  be  obtained  by  the  use 
of  morphine.     His  appetite  is  poor  and  he  is  getting  weaker. 

December  28th.  The  patient  was  anaesthetized  with  ether,  and 
Dr.  Fenger  proceeded  to  stretch  the  nerves  of  the  lower  extrem- 
ity. An  incision  was  made  on  each  side,  just  below  Poupart's 
ligament,  the  crural  nerves  exposed,  stretched,  replaced  in  the 
wounds,  drainage  tubes  inserted,  the  wounds  closed  with  aseptic 
silk,  and  Lister  dressing  applied.  The  patient  was  then  turned  on 
his  face  and  both  sciatic  nerves  stretched  simultaneously,  the  left 
by  Dr.  Fenger  and  the  right  by  Dr.  Verity.  Drainage  tubes  were 
inserted,  the  wounds  closed  with  aseptic  silk,  and  Lister  dressing 
applied. 

December  29th.     Temperature,  101°.     Some  pain   in  the  right 


300  FENCER  AND  LEE. 

thigh  and  leg,  which  was  controlled  by  a  hypodermic  injection  of 
one-fourth  grain  of  morphine. 

December  30th.  Pulse,  112;  temperature,  99°.  The  patient 
has  less  pain. 

January  3,  1881.  The  wounds  were  dressed.  They  looked 
well  and  were  agglutinated.  No  suppuration.  The  sutures  and 
drainage  tubes  were  removed.  He  does  not  complain  of  any 
pain. 

January  loth.  The  wounds  are  entirely  healed,  and  the  Lister 
dressing  was  removed. 

January  20th.  The  patient's  appetite  is  poor  ;  strength  gradu- 
ally failing.  He  is  not  able  to  stand  up.  There  is  no  increase  of 
strength  in  the  legs,  but  he  does  not  complain  of  pain  in  the 
extremities  any  longer. 

February  ist.  A  bedsore  was  found  over  the  sacrum.  The 
patient  feels  weak,  has  no  appetite,  but  no  pain. 

February  loth.  Pulse,  no  ;  temperature,  103°.  The  bedsore 
is  considerably  enlarged  and  suppurating.  The  patient  is  slightly 
delirious. 

February  15th.  The  patient  died  this  morning  on  account  of 
pyaemia  from  the  extensive  bedsores. 

Case  7. — (Socin,  Basle,  1881.''')  A  man,  33  years  of  age,  was 
affected  with  ataxia,  which  was  characterized  by  marked  troubles 
of  coordination,  constricting  pain  in  the  body,  and  violent  pain  in 
both  lower  extremities.  The  right  sciatic  nerve  was  stretched.  The 
wound  did  not  heal  by  first  intention,  but,  notwithstanding  the 
suppuration,  the  pain  on  the  right  side  ceased  entirely.  The  same 
operation  was  now  performed  on  the  left  side.  Fourteen  days 
after  the  second  operation  was  performed,  the  patient  died  from 
multiple  embolism,  caused  by  thrombosis  in  the  right  popliteal 
vein. 

Vn.— ANESTHETIC    LEPROSY. 

Cases  i  and  2. — James  R.  Wallace  (1881*^)  reports,  in  the 
Indian  Medical  Gazette,  two  cases  of  advanced  anaesthetic  leprosy, 
which  were  both  greatly  benefited  by  nerve-stretching.  In  the 
first  case  the  disease  manifested  itself  in  the  arm.  After  the 
operation  the  recovery  of  sensation  was  perfect,  and  the  patches 
of  discolored  anaesthetic  skin  recovered  their  normal  color  and 
sensation.  The  pain,  numbness,  etc.,  disappeared,  and  at  the 
end  of  two  months  the  improvement  seemed  confirmed  and  com- 
plete. 


NER  VE-  ST  RE  TCHING.  3  O I 

From  the  resume  given  above  of  the  different  affections 
of  the  nervous  system  in  which  nerve-stretching  has  been 
tried,  with  the  added  abstracts  of  cases,  imperfect  as  it  may 
be,  as  only  a  limited  portion  of  the  literature  has  been  at 
our  disposal,  it  will  easily  be  seen  that  each  class  of  these 
diseases  or  affections  of  portions  of  the  nervous  system  will 
have,  in  future,  to  be  treated  of  in  a  separate  chapter  of  its 
own,  as  each  of  these  diseases  is  different,  not  only  as  to 
the  indications  for  the  operation,  but  also  as  to  the  progno- 
sis, the  effects  of  the  operation,  etc. 

It  is  illogical  to  speak  of  or  discuss  indications,  effects, 
and  results  of  nerve-stretching  in  general,  or  to  talk  enthusi- 
astically for  or  against  the  operation  as  such.  Von  Nuss- 
baum,  only  two  years  ago,  stated  that  relapse  of  the  suffering 
for  which  nerve-stretching  had  been  performed  had  not  yet 
been  observed,  although  in  some  cases  four  to  five  years  had 
elapsed  since  the  operation.  It  will  readily  be  seen  that  this 
remark  was  far  too  enthusiastic  from  the  present  status  of  our 
knowledge  of  the  matter.  It  was  only  a  very  short  time 
after  this  assertion  of  Von  Nussbaum  was  published,  that 
Czerny  made  the  much  less  enthusiastic  remark,  that  he 
would  not  place  any  extravagant  and  exaggerated  hopes  on 
the  nerve-stretching,  but,  on  the  other  hand,  that  he  would 
not  deny  that  the  operation  was  a  powerful  remedy  for  the 
depression  of  vitality  in  a  nerve-trunk,  without  its  annihila- 
tion, and  that  he  would  consequently  resort  to  the  opera- 
tion as  an  ultiimim  refugium  in  cases  in  which  motor  and 
mixed  nerve-trunks  had  been  roused  to  an  abnormal  condi- 
tion of  activity  from  one  or  another  cause.  For  the  sen- 
sory nerves  he  would  prefer  excision. 

Our  preceding  remarks  regarding  the  necessity  of  indi- 
vidualization do  not  permit  us  to  agree  with  Czerny.  This 
will  be  seen  from  several  of  the  facts  stated  above,  namely : 
A  motor  nerve,  as  the  seventh,  is  stretched  with  perhaps  in- 


302  FENCER  AND  LEE. 

variably  good  results  in  mimic  spasm.  Another  principally 
motor  nerve,  the  twelfth,  shows  better  results  by  excision 
than  by  stretching  in  spasmodic  torticollis.  In  entirely  sen- 
sory nerves,  as  the  fifth  pair,  nerve-stretching  has  shown 
somewhat  better  results  than  excision,  and,  finally,  the 
crossed  and  distant  effects  from  nerve-stretching  indicate 
with  sufficient  clearness  that  the  benefit  of  the  operation 
does  not  depend  merely  upon  the  depression  of  activity  in 
the  nerve-trunk  stretched,  but  rather  upon  its  effect  upon 
the  nerve-centres,  of  which  we  are  as  yet   entirely  ignorant. 

We  should  not  be  surprised  if  future  observers  should 
show  that  from  this  effect  of  nerve-stretching  upon  the 
brain  and  spinal  medulla,  extensive  benefit  might  be  derived 
from  the  operation,  and  give  further  indications  for  its  ad- 
visability in  diseases  in  which  it  had  not  previously  been 
tried. 

A  few  remarks  only  remain  before  we  leave  this  subject. 

The  duration  of  the  disease  of  the  nerve  does  not  appear 
to  have  any  direct  influence  upon  the  effect  of  the  opera- 
tion, as  it  has  sometimes  proved  successful  in  most  inveter- 
ate cases.  The  condition  in  which  the  nerve-trunk 
stretched  has  been  found,  namely :  injection,  swelling, 
atrophy,  anaemia,  or  apparent  health,  has  been  of  equally 
slight  importance  as  regards  the  results. 

Whether  the.  wound  necessitated  by  the  operation  has 
healed  by  first  intention,  or  after  suppuration,  or  even  af- 
ter complication  with  erysipelas,  it  has  not  affected  the 
final  result  of  the  nerve-stretching.  The  -two  latter  com- 
plications, therefore,  have  done  no  further  harm  than  the 
causing  of  inconvenience  to  the  patient. 

As  to  the  question  of  possible  danger  attributable  to  the 
nerve-stretching,  it  must  be  said  that,  so  far  as  the  records 
go,  there  has  been  no  danger  at  all  from  the  stretching  of 
the  nerve  itself ;  that  is,  there  has  been  no  neuritis,  no 
tetanus,  no  permanent  paralysis,  etc. 


NER  VE- S  TRE  7  CHING.  303 

As  far  as  the  question  of  danger  from  the  wound  is  con- 
cerned, it  may  be  stated  that  there  is  no  more  and  no  less 
danger  than  from  any  other  incised  wound  of  the  same 
size.  It  will  be  almost  always  in  the  power  of  the  surgeon 
to  obviate  any  grave  or  dangerous  complication,  by  using 
strictly  antiseptic  precautions,  by  being  careful  of  the  ad- 
joining organs,  by  choosing  the  most  appropriate  anatom- 
ical locality  for  the  operation,  etc. 

In  conclusion,  we  think  that  nerve-stretching  deserves  to 
have  a  fair  trial,  not  only  in  the  nervous  diseases  above  re- 
ferred to,  but  also  experimentally  in  others,  as  well  of  the 
central  as  of  the  peripheral  nervous  system. 

When  numerous  observations  shall  be  in  the  future  col- 
lected, and  the  cases  of  homologous  affections  classified,  we 
shall  then  have  more  sharply-defined  indications  for  opera- 
tion than  we  have  had  up  to  the  present  time,  when  neu- 
ralgic pains  or  spasms  have,  with  few  exceptions,  been  the 
main  and  only  indications  for  nerve-stretching. 


BIBLIOGRAPHY. 

1.  Practitioner,  vol.  cix,  1877,  p.  417. 

2.  Deahna,  Stuttgart,  Schmidt's  yah7-biicher,  B.  184,  No.  10,  1879,  p.  50. 

3.  Hospitals- Tidende,  ii  R.,  B.  5,  1B78,  p.  44. 

4.  Chicago  Medical  Journal  and  Examiner,  vol.  xxxvi,  No.  3,  1878,  p.  225. 

5.  St.  Louis  Medical  and  Surgical  youmal,  vol.  xxxviii,  No.  4,  1880,  p.  24. 

6.  Deutsche  Medicinische  Wochenschrift,  No,  36,  1880,  p.  487. 

7.  Deutsche  Medicinische  Wochenschrift,  No.  19,  1880,  p.  258. 

8.  Lancet,  vol.  i,  Feb.  14,  1880,  p.  248. 

9.  Lancet,  June,  1878,  p.  904. 

10.  St.  Petersburger  Medicinische  Wochenschrift,  vol.  iii,   No.  34,  1878,  p. 
23i. 

11.  Archiv  fUr  Psychiatrie  und Nervenheilkunde,  1879,  p.  284. 

12.  British   Medical   jfournal;    Chicago   Medical  Journal  and  Examiner, 
March,  1881,  p.  313. 

13.  British  Medical  Journal,  June  14,  1879,  p.  893. 

14.  Schweizerisches  Correspondenz-Blatt,  B.  ix,  No.  11,  1879,  p.  324. 


304  FENCER  AND  LEE. 

15.  British  Medical  Journal,  May  31,  1879,  p.  803. 

16.  St.  Petersburger  Medicinische  Wochenschrift,  No.  49,  1879. 

17.  Medical  Times  and  Gazette;  Progres  Medical,  January  22,  1880,  p.  66. 

18.  Bayerisches,  yErztliches  Ititelligenz-Blatt,  vol.  xxv,  No.  53,  1878,  p.  558. 
ig.  Berliner  Klinisc he  Wochenschrift,  No.  39,  1880,  p,  554. 

20.  Laticet,  June  26,  1875. 

21.  Schmidt's  Jahrbiicher,  B.  184,  1879,  p.  258. 

22.  Deutsche  Medicinische  Wochetischi-ift,  No.  5,  1880. 

23.  Berliner  Klinisc  he  Wochenschrift,  1878,  p.  595. 

24.  Berliner  Klinische  Wochenschrift,  No.  46,  1879,  p.  184. 

25.  Hospitals- Tidende,  ii  R.,  B.  5,  1878,  p.  45. 

26.  Lancet,  April,  1879,  p.  555. 

27.  Correspondenz-Blatt  fiir  Schweizer yErzt,  Nov.  5,  1880. 

28.  Progres  Medical,  February  5,  1881. 

29.  Guy's  Hospital  Reports,  from  1866  to  1877,  No.  xxiii. 

30.  Centralblatt  fiir  Chirurgie,  lSj6. 

31.  Canada  Medical  and  Surgical  fournal,  October,  1876. 

32.  Cincinftati  Lancet  and  Clinic,  January  18,  1879,  p.  41. 

33.  Medical  Times  and  Gazette,  June  7,  1879.  p.  618. 

34.  British  Medical  fournal,  June  21,  1879,  p.  933. 

35.  Glasgow  Medical  yournal,  July,  1879,  p.  10. 

36.  American  Practitioner,  March,  1881,  p.  157. 

37.  Progres  Medical,  February  26,  1881,  p.  166. 

38.  Lancet,  December  27,  1879,  p.  964. 

39.  Gazette  des  Hopitaux;  Chicago  Medical  Review,    March  20,  i83l,  p.  125. 

40.  Berliner  Klinische  Wochenschrift,  No.   48,  1879. 

41.  Chicago  Medical  Review,  July  5,  1880,  p.  291. 

42.  Deutsche  Medicinische  Wochenschrift,  No.  9,  r88l,  p.  116. 

43.  Deutsche  Medicinische  Wochenschrift,  No.  19,  1880,  p.  258. 

44.  Centralblatt  fiir  Nen'enheilhmde,  No.  21,  1880,  p.  441. 

45.  H Union  Medicate,    No.  165,  1880,  p.  973. 

46.  Progres  Medical,  No.  52,  1S80,  p.  1054. 

47.  Chicago  Medical  Review,  February  20,  1881,  p.  88. 

48.  Medical  Herald,  March,  1 88 1,  p.  502. 


TUMOR  OF  THE  CENTRUM  OVALE. 

By  a.  B.  ARNOLD,  M.D.. 

BALTIMORE. 

CASES  of  circumscribed  lesion  of  the  centrum  ovale 
that  give  rise  to  marked  symptoms  are  of  great  in- 
terest in  regard  to  the  general  question  concerning  the  lo- 
calization of  distinct  functions  of  the  brain.  The  follow- 
ing case  is  particularly  instructive  in  respect  to  its  clinical 
features,  which  fairly  admitted  of  a  precise  diagnosis.  Al- 
though the  severe  criticism  of  Nothnagel  forbids,  in  our 
present  state  of  knowledge,  a  discrimination  between  the 
symptomatology  of  cerebral  lesions  involving  the  pars  fron- 
talis of  the  centrum  ovale  and  that  of  the  cortex  of  the 
same  region,  yet,  on  the  strength  of  F'errier's  experiments, 
I  ventured  to  localize  the  disease,  in  this  case,  in  the  upper 
extremity  of  the  ascending  frontal  convolution  of  the  left 
hemisphere. 

A  colored  man,  about  50  years  of  age,  was  presented  at  the 
clinic,  who  gave  the  following  history  :  About  eight  months  ago, 
while  at  work,  his  right  arm  was  suddenly  seized  with  convulsive 
movements,  and  a  few  minutes  afterward  he  lost  his  consciousness 
for  a  short  time.  On  recovering  from  this  state  of  coma  he  found 
that  his  right  arm  was  paralyzed.  Since  then  he  had  several  such 
attacks.  The  apoplectiform  seizures  were  always  of  short  dura- 
tion, but  the  spasmodic  affection  of  his  arm  lasted  much  longer, 
and  occurred  more  frequently.  Fifteen  years  ago  he  contracted 
syphilis.     There  are  a  number  of  suspicious  cicatrices  on  his  legs, 

305 


306  A.  B.  ARNOLD. 

but  no  other  visible  signs  of  the  constitutional  disease.  The  only 
symptom  which  the  case  presented  at  the  time  of  the  examination 
was  an  incomplete  paralysis  of  the  right  arm.  None  of  the 
cranial  nerves  were  affected,  and  no  psychical  disturbances  were 
noticed. 

The  man  remained  in  the  hospital  until  his  death,  which  oc- 
curred at  the  end  of  the  fifth  week  from  the  date  of  his  admission. 
During  that  time  he  got  large  doses  of  the  iodide  of  potassium. 
Under  this  treatment  the  spasms  of  the  affected  limb  ceased,  but 
the  paralysis  persisted.  On  the  day  preceding  his  death  he  be- 
came delirious,  and  finally  fell  into  a  stupor  from  which  he  could 
not  be  roused. 

Autopsy  fourteen  hours  after  death.  The  cranial  bones 
and  membranes  have  a  normal  appearance.  The  substance 
of  the  brain  is  of  an  unusually  firm  consistence.  On  making 
several  sections  of  the  centrum  ovale  of  the  left  hemisphere, 
a  tumor  of  the  size  of  a  large  hazel-nut  was  discovereH,  oc- 
cupying the  uppermost  regions  of  the  pars  frontalis  and  pars 
posterior  of  the  fissure  of  Rolando,  in  close  proximity  to 
the  cortex.  The  greater  portion  of  the  adventitious  growth 
was  situated  in  the  ascending  frontal  convolution.  It 
seemed  to  consist  of  a  central  portion,  having  all  the  marks 
of  a  gummata,  surrounded  by  a  grayish,  softened  mass.  A 
similar  tumor,  but  not  enveloped  by  softened  tissue,  was 
found  embedded  in  the  centrum  ovale  of  the  right  hemi- 
sphere, occupying  the  median  portion  of  the  superior  parie- 
tal lobule. 


THE  NATURE  AND  TREATMENT  OF  HEAD- 
ACHES.* 

By  J.  S.  JEWELL,  M.  D. 
{Continued  from     "January    number.) 

THE  management  of  true  migraine,  or  the  pure  vaso- 
motor type  of  headaches,  presents  a  number  of  diffi- 
culties. Hitherto  but  few  disorders  have  proved  to  be  more 
intractable.  But  in  the  last  few  years  some  advance  has 
been  made,  especially  in  the  direction  of  curative  treatment. 
I  may  say  to  you,  with  a  tolerable  degree  of  assurance,  that 
the  majority  of  such  cases  may  be  considered  as  curable, 
that  is,  if  not  associated  with  some  other  form  of  serious 
disease,  more  particularly  of  the  nervous  system. 

The  treatment  falls  naturally  under  two  heads,  the  palli- 
ative and  the  curative.  The  former  is  applicable  only  to 
the  attack. 

Usually,  as  already  said,  there  are  certain  premonitory 
symptoms  by  which  the  patient  learns  to  know  that  an  at- 
tack is  imminent.  In  the  majority  of  cases  nothing  of  im- 
portance is  done  until  the  headache  sets  in,  and  in  many 
instances  hopeless  of  relief,  but  little  is  done  to  alleviate 
the  pain  or  shorten  the  seizure.  The  suggestions  now  to 
be  made  embrace  what  I  have  found  as  most  useful  in  a  re- 
liance upon  the  experience  of  others  and  by  my  own  inde- 
pendent observations. 

*A  lecture  delivered  in  the  Chicago  Medical  College. 

307 


308  J.  S.   JEWELL. 

In  those  cases  in  which  the  head  is  hot,  in  which  there 
are  signs  of  vascular  dilatation  and  a  tolerably  firm  pulse, 
rather  large  doses  of  the  bromides  of  sodium  or  potassium 
(from  twenty  to  forty  grains  at  a  dose  to  an  adult),  to  be 
duly  diluted  with  water,  and  to  be  repeated  once  or  twice 
in  three  or  four  hours,  have  often  resulted  (if  given  early)  in 
diminishing  the  force  of  the  attack.  This  treatment,  how- 
ever, is  only  applicable  to  those  cases  in  which  there  is  not 
much  nausea,  and  in  which,  as  already  said,  there  are  dis- 
tinct signs  of  vascular  dilatation  and  increased  heat  about 
the  head.  If  the  pain  is  in  part  paroxysmal,  as  in  neuralgia, 
something  can  be  done  toward  alleviating  the  headache  by 
giving,  in  connection  with  the  bromide  of  sodium  or  of 
potassium,  or  of  ammonium,  moderate  but  decisive  doses 
of  the  tincture  of  gelsemium,  or  the  tincture  of  aconite,  more 
especially  the  latter.  Duquesnel's  aconitia,  which  seems 
to  possess  peculiar  properties  in  relation  to  trigeminal  neu- 
ralgias (to  which  these  headaches,  in  a  measure,  belong),  is  to 
be  preferred.  From  the  one  hundred  and  fiftieth  to  the 
three  hundredth  of  a  grain  may  be  given  every  half  or  one 
hour,  until  the  effect  of  the  drug  is  experienced. 

But  in  cases  in  which  there  is  a  decided  tendency  to  dis- 
turbance of  the  stomach,  and  nausea,  these  measures  will 
not  be  found  so  useful. 

If  the  headache  is  not  attended  by  perceptible  elevation 
of  temperature  about  the  head,  or  by  signs  of  vascular  dila- 
tation, one  of  the  speediest  ways  to  procure  relief  is  to  give, 
either  by  the  mouth  or  by  hypodermic  injection,  a  prepara- 
tion of  morphia  and  atropia  in  which  nineteen  grains  of 
morphia  and  one  of  atropia  are  rubbed  with  i8o  grains  of 
sugar  of  milk.  The  mixture  should  be  very  thoroughly 
made.  Of  this  mixture,  from  one  to  two  or  three  grains  may 
be  given  by  the  mouth  every  hour,  until  two  or  three  doses 
have  been  taken,  if  necessary,  and  in  most  instances  the 
pain  will  be  pretty  well  relieved. 


NATURE  AND  TREATMENT  OF  HEADACHES.         309 

If,  however,  on  account  of  nausea,  or  for  any  other  rea- 
son, the  powder  cannot  be  taken  and  retained,  a  mixture 
may  be  made  which  shall  contain  nineteen  grains  of  mor- 
phia and  one  grain  of  atropia  in  one  ounce  of  distilled 
water.  A  drop  or  two  of  some  dilute  acid  may  be  added 
to  aid  in  effecting  thorough  solution.  The  mixture  should 
be  filtered  and  a  drop  of  strong  carbolic  acid  added  to  pre- 
vent the  development  of  microscopic  germs  in  the  mixture. 
Of  this  from  one  to  four  minims  may  be  given  subcuta- 
neously,  a  dose  every  half  hour,  until  two  or  three  doses  have 
been  taken,  by  which  time  the  pain  and  the  nausea  will  be, 
in  some  measure,  if  not  entirely,  under  control. 

In  giving  this  or  any  similar  mixture  hypodermically, 
great  care  should  be  taken  to  begin  with  very  small  doses. 
If  the  toleration  of  the  patient  toward  the  drugs  is  not  well 
known  to  the  physician. 

Still  other  doses,  at  longer  intervals,  may  be  employed  for 
the  relief  of  pain.  In  some  instances,  after  the  pain  is  al- 
layed and  the  nausea  in  some  measure  abated,  it  is  found 
difficult  for  the  patient  to  sleep.  In  such  cases,  from  ten  to 
thirty  grains  (according  to  the  circumstances  of  the  case)  of 
hydrate  of  chloral  in  a  tablespoonful  of  water  may  be  in- 
troduced into  the  rectum  by  means  of  a  small  syringe,  such 
as  the  ordinary  aural  syringe.  As  a  rule,  after  the  patient 
is  under  the  influence  of  the  opiate,  so  that  the  pain  is  re- 
lieved or  abated,  the  chloral  will  induce  a  prolonged  and 
comfortable  sleep,  at  the  end  of  which  the  attack  will  usu- 
ally be  found  to  have  passed. 

In  those  cases  in  which  the  head  is  not  hot,  and  in  which 
there  are  no  signs  of  cranial  congestion,  and  in  which  there 
is  but  little  nausea,  some  reliable  preparation  of  guarana, 
or  of  the  citrate  of  cafTein,  or  a  cup  of  strong  coffee  drank 
when  quite  hot,  will  aid  in  relieving  the  pain.  But  of  all 
the  means  I  have  employed   to  relieve  the  pain   of  these 


3IO  y.   5.   JEWELL. 

headaches,  I  know  of  none  to  compare  with  the  combina- 
tion of  morphia  and  atropia  that  has  been  mentioned, 
especially  if  used  hypodermically.  It  may  be  employed 
moderately  with  advantage,  even  in  those  cases  in  which 
there  are  signs  of  congestion  about  the  head  with  elevated 
temperature.  But  in  such  instances  it  is  well  to  associate 
it  with  one  of  the  bromides. 

In  some  cases  where  the  attacks  are  exceedingly  severe, 
inhalations  of  chloroform,  to  a  moderate  degree,  may  be 
employed,  until  other  remedies,  less  rapid  in  their  action, 
may  be  brought  to  bear.  So  far  as  medicine  is  concerned, 
for  the  immediate  relief  of  pain  in  migraine  I  have  nothing 
further  to  observe  that  is  worth  mentioning  to  the  exclu- 
sion of  the  palliatives  just  described. 

Besides  the  medical  treatment,  it  is  necessary  to  seclude 
the  patient,  as  far  as  may  be,  from  all  excitement,  whether 
sensorial  or  emotional.  The  room  should  be  darkened. 
All  noise  should  cease,  and,  as  far  as  possible,  nothing  said 
or  done  by  either  the  patient  or  attendants  that  can  excite 
or  disturb  the  nervous  system. 

There  are  some  cases,  however,  in  which  some  relief  is 
apparently  obtained  by  moving  about.  Such  cases,  how- 
ever, are  rare,  especially  if  placed  under  the  action  of  the 
remedies  described. 

Relief  is  sometimes  obtained  by  making  the  patient  quite 
warm,  especially  in  the  application  of  warmth  to  the  lower 
extremities,  and  by  making  warm,  as  a  rule,  rather  than 
cold  applications  to  the  head.  Occasionally  relief  is  ob- 
tained by  drawing  a  band  tightly  about  the  head. 

An  Esmarch  bandage  may  be  sometimes  employed  for 
this  purpose  with  benefit, — drawn  around  across  the  fore- 
head, occiput,  etc.,  and  permitted  to  remain  as  long  as  it  is 
comfortable  to  the  patient.  In  some  instances  in  which 
there  is  a  strong  tendency  to   nausea,  a  large  draught  of 


NA  TURE  AND   TREA  TMENT  OF  HEADACHES.         3  I  I 

quite  hot  water  will  afford  relief,  especially  if  it  leads  to 
vomiting. 

Such,  in  my  experience,  are  the  more  important  palliative 
means  to  be  employed  just  before  or  during  the  attack.  I 
should  not  omit  to  state  that  in  some  cases  attacks  of  this 
form  of  headache,  especially  of  the  congestive  type  or  kind, 
are  much  benefited  by  the  passage,  very  cautiously,  of  a 
galvanic  current  through  broad  moist  electrodes,  from  the 
forehead  to  the  nape  of  the  neck,  for  a  few  minutes,  and 
through  the  cervical  sympathetics  to  the  feet.  It  should 
never  be  passed  in  the  opposite  direction,  that  is,  through 
the  head,  in  this  class  of  cases. 

Next  as  regards  the  curative  treatment. 

In  the  first  place,  it  is  necessary  for  physician  and  patient 
to  understand  that  cure  of  a  case  of  migraine  is  almost  as 
dif^cult  as  that  of  a  moderate  epilepsy.  It  can  seldom  be 
accomplished  in  less  than  from  six  months  to  two  years  of 
faithful  attention  to  all  reasonable  details  of  treatment.  In 
some  cases  a  cure  is  impossible,  where  the  general  health  of 
the  nervous  system  is  hopelessly  broken. 

It  is  better  not  to  commence  treatment  at  all  until  the 
patient  is  brought  thoughtfully  to  understand  that  a  less 
term  than  one  year  of  faithful  trial  of  the  plan  decided  upon 
is  likely  to  be  useless.  This  is  the  first  thing  to  be  under- 
stood. It  is  necessary,  in  the  next  place,  to  consider  most 
rigidly  the  question  of  diet.  It  should  be  nutritious,  but  of 
the  simplest  kind.  All  marginal  or  side  dishes,  as  a  rule, 
should  be  cut  off,  and  under  no  circumstances  should  any- 
thing be  taken  which  has  been  proved,  in  the  candid  experi- 
ence of  the  patient,  to  disagree  with  the  stomach.  Care 
should  also  be  taken  not  to  overload  the  stomach.  In  these 
cases  it  is  absolutely  necessary  to  avoid  the  use  of  strong 
coffee  or  strong  tea.  If  these  drinks  are  taken  as  beverages 
the   infusions    should    be    weak.      If  the    patient    will    not 


312  y.   S.   JEWELL. 

agree  to  follow  advice  in  this  respect  I  decline  promptly  to 
undertake  the  case.  As  a  rule,  all  alcoholic  stimulants 
should  be  laid  aside.  A  little  claret,  however,  during  or 
after  the  principal  meals,  is  sometimes  attended  with  appar- 
ent benefit,  or  at  least  leads  to  no  apparent  harm.  It  is 
necessary,  in  the  next  place,  as  far  as  possible,  rigidly  to 
avoid  serious  fatigue,  whether  bodily  or  mental,  to  avoid 
all  undue  emotional  or  other  excitement,  that  the  nervous 
system  may  not  be  exhausted  either  by  voluntary  action  or 
by  excitement.  This  is  a  point  of  great  importance.  A 
large  amount  of  sleep  should  be  secured,  if  necessary,  by  the 
use  of  artificial  means.  It  is  necessary  also  that  the  surface 
of  the  body  shall  be  protected  thoroughly  by  a  suitable 
dress,  so  that  sudden  chilling  shall  not  take  place,  so  as  to 
avoid,  in  this  way,  unfavorable  vascular  fluctuations. 

Great  care  should  be  taken  to  secure  thorough  move- 
ments from  the  bowels.  Under  no  circumstances  should 
constipation  be  permitted.  At  this  point,  I  think  it  neces- 
sary to  drop  a  word  of  caution.  It  frequently  happens 
that  the  patient,  upon  inquiry,  will  inform  the  physician 
that  regular  movements  take  place  daily ;  but  in  a  surpris- 
ingly large  number  of  cases  strict  inquiry  will  reveal  the 
fact  that  either  at  one  or  both  ends  of  the  colon  faecal  accu- 
mulations are  habitual,  notwithstanding  some  portion  of 
the  same  is  voided  daily.  These  faecal  accumulations  are 
oftentimes  the  cause  of  intestinal  irritation,  which,  in  its 
turn,  may  bring  on  an  attack  of  headache.  I  have  seen 
many  such  cases.  It  is  necessary,  finally,  to  prevent  this 
class  of  patients  from  fixed  use  of  the  eyes,  as  in  much 
reading,  or  as  in  the  work  of  a  seamstress,  or  in  any  other 
occupation  which  implies  minute  and  continuous  exercise 
of  vision. 

I  would  recommend,  especially  before  retiring,  protracted 
hot    mustard    foot   baths,  if   the    feet    are    cold    and,  in  a 


NA  TURE  AND  TREA  TMENT  OF  HE  AD  A  CHES.         3 1 3 

measure  bloodless,  as  they  so  often  are  in  this  class  of  cases. 
Every  pains  should  be  taken  to  keep  them  warm.  A  light, 
cool  sponge  bath,  of  mornings,  followed  by  thorough  fric- 
tions, when  the  bath  is  well  borne,  if  persisted  in  daily 
undoubtedly  leads  to  good  results  in  strengthening  the 
nervous  system. 

Such  are  the  more  important  hygienic  measures  to  be 
faithfully  and  minutely  observed  in  the  treatment  of  this 
class  of  cases.  Without  attention  to  them  the  best 
directed  course  of  purely  medical  treatment,  as  a  rule,  will 
fail. 

I  now  come  to  the  question  of  curative  treatment. 

If,  as  so  frequently  proves  to  be  true,  the  patient  has 
a  light  gastric  catarrh  and  more  or  less  imperfect  digestion, 
I  would  recommend  the  use  of  some  such  prescription  as 
the  following : 

Sodium  bromidi,  3  vi 

Acid  hydrobromic, 


[!iii 


Fothergill  solution, 

Bismuth  subnit.  3  v 

Pepsin  sacch.  3  vi 

Tr.  digitalis,  3  iii 

Infus.  colombae,  §  vi  Til, 

Sig.     Keep  in  a  cool  place.     Shake  well.     Take  a  large 
teaspoonful,  in  water,  after  meals. 

The  action  of  the  bromide,  given  as  it  is  in  small  doses, 
seems  to  be  sufTficient  to  diminish  reflex  excitability,  more 
particularly  of  the  vaso-motor  and  cardiac  nervous  systems, 
to  improve  the  condition  of  the  mucous  membrane  of  the 
stomach,  and  to  aid  digestion.  Of  course,  the  use  of  such 
a  prescription  is  recommended  only  in  that  rather  large 
class  of  cases  in  which  there  is  gastric  or  gastro-duodenal 
disorder.  Under  the  use  of  this  prescription  patients  are 
less  excitable,  the  circulation  of  the  blood  about  the  head 
is  less  fluctuating  and  tricky,  sleep  upon  the  whole  is 
better,  and,  in  general,  comfort  is  promoted. 


314  7-   S-   JEWELL. 

Besides  this  it  has  been  my  habit  the  last  few  years  to 
advise  (according  tb  the  plan  pursued  by  Dr.  E.  C.  Seguin 
and  others)  rather  large  doses  of  a  reliable  extract  of  can- 
nabis Indica.  This  may  be  either  fluid  or  solid,  but  if  a 
reliable  solid  extract  can  be  obtained  it  is  the  most  conve- 
nient. To  an  adult  it  may  be  given  in  doses  of  one- 
third  to  one-half  a  grain  three  times  a  day  ;  once  in  the 
middle  of  the  forenoon,  and  once  in  the  middle  of  the  after- 
noon, and,  as  a  rule,  on  retiring.  It  may  be  given  alone  or 
in  association  with  other  remedies  in  a  pill.  From  one- 
third  of  a  grain  the  advance  may  be  made  to  one-half  or 
even  three-fourths  of  a  grain,  until  the  point  is  reached  of 
easy  toleration  of  the  drug.  But  the  advance  of  the  dose 
of  the  drug  should  be  continued  until  indubitable  signs  are 
had  of  a  beginning  of  its  intoxicating  effects  upon  the  ner- 
vous system.  Whenever  this  limit  is  reached,  one-fourth 
to  one-third  the  dose  necessary  to  produce  immediate 
symptoms  may  be  taken  off,  and  at  this  point  the  dose 
fixed,  just  below  the  point,  as  already  said,  of  easy  tolera- 
tion of  the  drug.  The  remedy  should  be  given  without 
fail  two  or  three  times  a  day  ;  if  need  be,  for  six  months  to 
one  year.  When  from  three  to  six  months  shall  have 
passed  without  a  severe  attack,  the  dose  may  be  given 
twice  daily  instead  of  three  times,  the  quantity  may  be  di- 
minished and  its  use  continued,  say  three  months  longer, 
at  the  end  of  which  time  it  may  be  discontinued.  If  at 
the  end  of  the  three  to  six  months,  all  reasonable  care  being 
taken  meanwhile  to  avoid  an  attack,  if,  I  say,  at  the  end  of 
this  time  the  headaches  do  not  return,  we  may  feel  toler- 
ably certain  that  a  cure  has  been  effected.  Of  course  this 
does  not  insure  that  the  patient  will  never  again  have  an 
attack  of  headache,  but  the  series  of  attacks  is  broken,  and, 
with  care,  will  never  return. 

I  am  in   the  habit,  however,  of  associating  other  reme- 


NA  TURE  AND   TREA  TMENT  OF  HE  A  DA  CUES.  3  I  5 

dies  in  various  cases  with  the  cannabis  Indica.  Where  there 
is  a  great  tendency  to  violent  fluctuations  tending  toward 
congestions  about  the  head,  I  have  found  benefit  to  accrue 
from  the  use  of  from  one  to  two  grains  of  a  reliable  ex- 
tract of  ergot  given  with  each  dose  of  the  cannabis  Indica. 
In  other  cases  I  have  associated  with  it  tonics,  as  they  ap- 
pear to  be  needed,  such  as  nux  vomica,  quinine,  or  iron.  In 
some  cases  I  have  found  it  beneficial  to  combine  with  the 
hasheesh  moderate  doses  of  podophyllin,  or  of  aloes,  or  of 
belladonna,  to  fulfil  some  special  indications,  but  especially 
to  remove  constipation. 

But  in  order  to  be  successful,  the  treatment  must  be 
faithfully  pursued.  Other  plans  have  been  suggested,  other 
remedies  proposed  and  tried,  but  without  that  measure  of 
success  which,  in  my  own  hands,  the  plans  of  treatment  just 
described  have  yielded. 

As  regards  the  other  class  of  headaches  belonging  to  the 
vaso-motor  class,  which  depend  less  upon  fixed  disease  of 
the  nervous  system  than  upon  the  violence  of  action  of 
their  occasional  exciting  causes,  I  shall  find  it  necessary 
to  say  but  little. 

Of  course,  the  first  step  in  the  treatment  of  such  cases 
consists  in  the  removal  of  the  cause,  whatever  that  may  be. 
If  the  stomach  is  filled  with  undigested  and  indigestible 
food,  it  should  be  removed  by  the  operation  of  an  emetic. 
If  the  headache  depends  upon  undue  acidity  of  the  stomach 
the  acid  should  be  neutralized.  If  it  depends  upon  consti- 
pation this  should  be  relieved  by  appropriate  means.  If  it 
depends  upon  the  loss  of  sleep  and  consequent  brain  wear 
and  tear,  rest  should  be  had.  If  it  depends  upon  excessive 
brain  work  or  upon  great  and  prolonged  emotional  excite- 
ment, if  possible,  these  conditions  should  be  removed.  But 
whatever  the  cause,  let  it  be  removed.  Nevertheless,  it  is 
necessary  to   do  something   for  the  relief  of  the   headache. 


3l6  y.   5'.   JEWELL. 

It  is  perhaps  sufficient  for  me  to  say  to  you  that  the  same 
measures  used  to  reHeve  the  pain  in  cases  of  true  migraine 
will  be,  according  to  the  situation  of  the  case,  useful  in  re- 
lieving pain  in  these  occasional  vaso-motor  headaches. 
Rest,  abstinence  from  food,  the  avoidance  of  labor  or  ex- 
citement, and  the  use  of  some  one  of  the  means  already 
described  as  useful  in  migraine,  constitute  all  that  can  be 
profitably  laid  before  you  at  this  time. 

I  should  not  omit  to  mention  that  there  are  cases  in 
which  a  true  migraine  is  mixed  up  with  a  headache  depend- 
ing upon  painful  organic  disease,  such,  for  example,  as  that 
already  described  as  arising  from  affections  of  the  dura.  In 
such  cases  I  have  found  it  necessary  to  associate  small 
doses  of  opium  or  morphia,  especially  the  watery  extract  of 
opium,  or  at  times,  instead  of  the  opium,  codeia,  with  the 
cannabis  Indica  in  order  to  allay  persistent  pain.  Such 
cases  require  a  combination  of  plans  of  treatment,  and  their 
management,  after  what  has  been  said,  should  be  left  to  your 
own  good  sense  when  you  meet  with  them  in  the  rounds  of 
clinical  experience. 


CONTRIBUTIONS    TO    ENCEPHALIC    ANATOMY. 

PART    10. NOTE    IN     REGARD    TO     THE     DIMENSIONS      OF     NERVE- 
CELLS     AND      THEIR     NUCLEI. 

By  EDWARD  C.  SPITZKA, 

NEW   YORK. 

THE  view  has  been  recently  advanced,  that  the 
average  size  of  the  nuclei  in  certain  nerve-cells 
having  connections  with  motor  nerves,  is  proportionate  to 
the  power  developed  in  the  muscles  placed  under  the  in- 
nervation of  the  latter.  «In  various  papers  *  devoted  to  the 
announcement  of  this  theory,  other  inferences  are  drawn  or 
hinted  at,  which  also  have  a  physiological  bearing,  and  certain 
objections  to  such  inferences  which  were  made  by  the  present 
writer  are  taken  up  in  the  last  paper  of  the  series  quoted.  It 
may  not  be  improper,  therefore,  to  review  the  argumentative 
aspect  of  the  questions  involved  in  the  light  of  some  well- 
known  facts  of  neuro-anatomy  which  seem  to  have  escaped 
the  scrutiny  of  the  writer  of  the  papers  referred  to. 

In  regard  to  the  main  conclusion  of  the  latter, — that,  as  a 
rule,  the  nerve-cell  nucleus  of  cells  related  to  the  innervation 
of  large  muscular  masses  is  larger  than  that  of  cells  related 
to  small  muscular  masses, — it  may  be  well  to  say  that  it  has 
not  been  questioned  by  any  one.  It  has  probably  been  an 
unenunciated   idea  dwelling   in   the  minds  of   most   neuro- 

*"  Microscopic  Studies  on  the  Central  Nervous  System  of  Reptiles  and  Ba- 
trachians."  By  John  J.  Mason,  M.D.  Journal  of  Nervous  and  Mental 
Disease,   Jan.   and    July,  1880,  Jan.,  1881. 

317 


3l8  EDWARD  C.   SPITZKA. 

anatomists,  and  one  so  self-evident  that  it  was  not  consid- 
ered deserving  of  special  formulation.  It  is  an  old  observa- 
tion that  nerve-cells,  as  a  ivJiolc,  are  larger  in  the  lumbar  in- 
tumescence of  man  than  in  the  cervical,  and  larger  in  the 
latter  than  in  the  oculo-motor  nucleus.  What  more  natural 
than  that  the  nuclei  should  vary  with  the  cells  as  a  whole  ? 
As  connections  of  the  nuclei  with  the  conducting  paths  of 
nerve-force  have  never  been  demonstrated,  while  those  with 
the  protoplasm  (so-called)  are  clear,  those  who  are  accus- 
tomed to  draw  physiological  inferences  from  structural  re- 
lations could  well  afford  to  rest  satisfied  with  the  older 
observation  that  the  cell,  as  a  whole,  varied.  Even  granting 
the  nerve-cell  nucleus  its  greatest  possible  role,  there  is 
nothing  in  its  structure,  development,  or  its  reaction  under 
pathological  circumstances,  that  justifies  one  in  looking  upon 
it  as  the  most  important  constituent  of  the  nerve-cell. 

The  observation  made  that  the  nerve-cell  nucleus  is  larger, 
averagely,  at  the  origin  of  the  crural  nerves  than  at  that  of 
the  brachial  nerves  of  the  frog,  adds  nothing  to  our  knowl- 
edge of  the  relations  existing  between  dimensions  and  func- 
tion, beyond  a  histological  confirmation,  which,  to  many, 
will  naturally  appear  of  but  a  secondary  value.  The  dimen- 
sions involved  are  extremely  minute;  this  by  itself  consti- 
tutes no  drawback,  but  it  becomes  one  when  we  take  into 
account  the  fact  that  the  variations  in  the  size  of  the  nu- 
cleus have  not  been  shown  to  be  constantly  proportionate 
to  the  demonstrably  important  part  of  the  nerve-cell, — its 
protoplasmic  mass.  A  careful  scrutiny  of  nerve-cells  from 
different  parts  of  the  nervous  system  (and  I  am  now  speak- 
ing of  nerve-cells  irrespective  of  their  real  or  presumed 
functional  role)  will  show  that,  side  by  side,  cells  of  the 
same  shape  and  dimensions  have  nuclei  varying  consider- 
ably in  size  ;  it  would  not  be  difificult  to  demonstrate  small 
nuclei  in  some  large,  and   large  nuclei  in  some   small  cells. 


C  ox  TRIB  UTIONS  TO  EN  CEP  HA  L/C  A  NA  TOM  V.         3 1 9 

Few  would,  I  believe,  be  willing  to  follow  the  author  re- 
ferred to  where  he  leaves  his  measurements  to  indulge  in 
speculation.  Even  he  himself  will  on  reflection  admit  the 
statement  that  the  nucleus  "  probably  constitutes  the  true 
cell  "  *  to  be  an  altogether  gratuitous  assumption.  That 
the  nucleus  is  the  one  permanent  ingredient  of  the  nerve- 
cell,  present  from  the  embryonic  period  throughout  life, 
and  serving  as  a  centre  for  fibril  condensation,  as  the  re- 
searches of  Schmidt  on  the  human,  of  Hensen  on  the  rab- 
bit's embryo,  and  of  myself  on  the  Menobranchus  have 
shown,  proves  the  nucleus  to  be  an  importaiat  morphologi- 
cal element,  but  it  does  not  prove  it  to  be  anything  more  nor 
less  than  a  nucleus  for  all  that.  Few  things  in  histology  are 
so  well  established  as  that  the  nerve-cell  nucleus  is  a  true 
nuclear  body. 

In  mentioning  the  very  sound  conclusions  of  Stieda,  who 
seems  to  have  clearly  established  that  the  nuclei  vary  with 
the  cells  containing  them  in  the  different  attitudes  of  the 
cord,  prior  to  the  undertaking  of  the  measurements  which 
form  the  basis  of  the  papers  referred  to,  their  author  claims 
that  Stieda  does  not  fairly  state  the  ordinary  view,  when 
he  cites  his  observations  as  having  *•  great  weight  against 
the  conclusion  that  only  the  large  nerve-cells  are  connected 
with  motor  fibres."t  Now  a  perusal  not  only  of  the  older 
neuro-anatomical  literature,  but  of  many  recent  essays  will 
show  the  critic  that  Stieda  has  fairly  stated  not  the  ordi- 
nary view — for  that  he  does  not  claim, — but  a  very  prevalent 
one,  fostered  by  the  ambiguous  statements  of  standard 
authors.:*;  In  exposing  the  error  of  that  view  he  therefore 
did  a  substantial  service.     The  writer  of  the  papers  under 

*  Journal  of  Nervous  and  Mental  Disease,  Jan.,  i83i,  p.  83. 

f  Journal  of  Nervous  and  Mental  Disease,  Jan.,  1881,  p.  83. 

J  Dr.  Richet  commits  himself  to  the  view  of  Charcot  that  "  where  there  are 
motor  centres  there  are  large  cells,  this  is  true  of  the  cerebral  cortex  as  well 
as  of  the  spinal  axis." — "  Physiology  and  Pathology  of  the  Cerebral  Convolu- 
tions," by  Charles  Richet,  translated  by  E.  P.  Fowler,  M.D,  See  also  Luys' 
"  Recherches,  xc,"  Paris,  1865. 


320  EDWARD  C.   SPITZKA. 

consideration  does  not  himself  seem  to  be  altogether  free 
from  a  very  similar  error,  for  he  says  "  it  may  be  true  that 
all  large  cells  connect  with  motor-nerve  filaments,"  which, 
unless  I  am  mistaken,  he  has  advanced  more  positively  in  a 
verbal  communication  to  the  American  Neurological  Asso- 
ciation, when  both  Dr.  Putnam  and  myself*  cited  observa- 
tions conflicting  with  it.  These  observations  and  other 
well-established  facts  I  herewith  present  in  detail,  and  I 
shall  open  with  the  single  one  which  the  writer  in  question 
discusses  in  his  last  contribution. 

On  a  former  occasionf  I  stated  that  in  the  Iguana  "  the 
average  dimensions  of  the  cell  nuclei  of  the  auditory-nerve 
nucleus  equal  those  of  the  motor  nuclei  of  the  medulla  and 
cord,  and  exceed  some  of  them,  and  that  the  same  state- 
ment applies  to  the  cells  as  a  whole."  I  had  also  made  the 
same  statement  regarding  the  large-celled  division  of  the 
auditory  nucleus  in  man,  on  the  occasion  when  one  of  the 
papers  under  notice  was  read.  In  evident  reply  to  this 
statement,  but  without  any  disfiguring  reference  to  myself 
or  any  one  else  as  the  source  of  the  objection,  it  is  stated::}: 
"  1  would  suggest,  however,  to  those  who  may  feel  disposed 
to  regard  these  cells  as  connected  with  the  sense  of  hearing, 
that  such  a  view  involves  giving  to  this  apparatus,  in  its 
central  portion,  a  structure  almost  universally  admitted  to 
be  motor,  like,  for  example,  that  concerned  in  raising  the 
lower  jaw  ;  whereas  in  the  central  structures  for  vision  and 
olfaction  the  cells  are  all  very  small." 

I  am  somewhat  embarrassed  as  to  the  propriety  of  accept- 
ing this  suggestion  as  one  directed  to  my  individual  address, 
for  the  customary  reference  to  the  source  of  the  opposing 
view,  has  been  omitted.     But  as  I  am  not  aware  of  any  one 

♦Journal  of  Nervous  and  Mental  Disease,  i8So,  pp.  476,  477. 
f  The  brain  of   the  Iguana.     JOURNAL  OF  Xervous  and  Mental  Disease, 
1880,  July. 

X  Loc.  cit.,  p.  81. 


CONTKIB  UTIONS  TO  ENCEPHALIC  A  NA  TOM  Y.         3  2 1 

else  having  made  the  same  objection  in  connection  with  the 
theories  involved  in  the  papers  under  consideration  I  shall 
treat  them  as  directed  to  myself,  leaving  the  responsibility 
of  an  eventual  error  with  the  author.  In  the  first  place, 
without  insisting  on  fine  verbal  distinctions,  I  would  make 
the  counter  suggestion,  that  there  is  nothing  in  the  structure 
of  any  nerve-cell,  whether  it  have  demonstrable  connections 
with  the  motor  periphery  or  not,  which  the  wildest  physio- 
logical fancy  could  even  remotely  construe  as  a  "  motor  " 
structure  ;  muscles  and  cilia  have  motor  structures,  not 
nerve-cells. 

It  is  known,  as  positively  as  anything  is  known,  that  a 
nerve  nucleus  of  the  human  oblongata,  which  has  no  pos- 
sible connections  with  any  other  nerve-root  than  that  of  the 
auditory  nerve,  contains  cells  rivalling  in  size  the  largest 
known  cells  of  the  nervous  system,  and  presenting  in  their 
shape  some  resemblance  to  what  are  ordinarily  termed 
motor  cells.  I  therefore  consider  them  as  related  to  the 
sense  of  hearing,  and  their  dimensions,  so  long  as  no  other 
connections  than  with  a  sensory  nerve  are  found  to  exist,  as 
conflicting  with  any  view  which  would  regard  size  as  neces- 
sarily limited  to  cells  having  motor  connections.  The 
author  quoted  does  not  seem  to  have  considered  the  possi- 
bility of  these  cells  being  related  to  motor  fields  as  reflex 
cells  mediating  the  reflexes  from  the  auditory  to  the  muscu- 
lar periphery,  which  would  harmonize  with  the  view  he 
follows,  and  not  necessitate  the  questioning  of  a  universally 
accepted  fact  of  anatomy  for  the  sake  of  a  theory.* 

The  appended  clause  :  "Whereas,  in  the  central  structures 
for  vision  and  olfaction,  the  cells  are  all  very  small,"  involves 
the  turning-point  of  the  inquiry.  It  is  surprising  that  such 
a  statement  could  be  made.  Leaving  out  of  sight  for  a 
moment  all  central  structures,  and  limiting  ourselves  to  the 

*  This  large-celled  nucleus  is  identifiable  in  the  iguana. 


322  EDWARD  C.   SPITZKA. 

nervous  layer  of  one  of  these  very  peripheries,  what  do  we 
find?  That  the  retina  itself  contains  nerve-cells  of  decid- 
edly large  dimensions;  namely,  of  twenty  to  forty  micro- 
millimetres  and  beyond  that.  Here  there  is  no  room  for  a 
quibble  as  to  other  problematical  connections  of  the  cells  ; 
they  are  a  part  of  the  immediate  recipient  area  itself !  This 
fact  alone  disposes  of  the  question  raised. 

But  let  us  go  further.  The  acoustic  ganglia  of  fish  con- 
tain large  fusiform  elements.  The  ganglion  of  Gasser  and 
the  intervertebral  ganglia  on  the  posterior  nerve-roots  con- 
tain cells  of  the  larger  size,  and  with  very  distinct  and  large 
nuclei.  The  same  is  true  of  the  cerebellum.  Now,  what- 
ever function  the  intervertebral  and  analogous  ganglia 
exercise,  it  is  safe  to  exclude  any  relation  to  the  voluntary 
muscles !  Whatever  distant  and  indirect  connection  the 
cerebellar  cell  of  Purkinje  has  to  cerebral  "  motor  "  centres, 
it  is  certainly  not  connected  with  any  centrifugal  tract !  In 
the  light  of  all  we  at  present  know  about  the  cell-forms 
mentioned,  we  are  bound  to  consider  their  proximal  connec- 
tion to  be  with  sensory  nerves  and  with  sensory  tracts. 

The  researches  of  Flechsig  have  shown  that  all  the  great 
tracts  connected  with  the  cerebellum  develop  toward  that 
brain  segment,  with  one  exception.  Those  tracts  are  centrip- 
etal, and  therefore  sensory.  One  is  the  restiform  column, 
another  the  inner  peduncular  division,  a  third  a  great  part 
of  the  auditory-nerve  root.  The  nucleus  fastigii,  with  which 
the  auditory  nerve  connects,  has  cells  which  cannot  be 
classed  among  the  smaller  variety.  One  tract  which  con- 
nects the  cerebellum  with  the  cerebrum  and  the  subthalmic 
region, — the  brachium  conjunctivum,  developing  like  other 
centripetal  tracts  toward  the  cerebrum,  is  connected  with 
the  beautiful  ganglion  tegmenti,  composed  of  cells  of  45 
micromillimetres.  Here  again  are  large  cells  connected 
with  a  centripetal,  i.  e.,  sensory  tract. 


CONTRIBUTIONS  TO  ENCEPHALIC  ANA  TOMY.         323 

The  cells  of  the  ganglion  geniculatum  externum,  exclu- 
sively connected  with  the  optic  tract,  are  also  of  a  large 
size  ;  namely,  from  thirty  to  fifty  micromillimetres  in 
length,  and  ten  to  twenty  in  width. 

The  following  cells  of  large  dimensions  have  demonstra- 
bly only  sensory  or  centripetal  connections,  as  far  as  their 
relations  to  the  periphery  are  concerned:  i.  The  cells  of 
the  intervertebral  ganglia.  2.  Those  of  the  ganglion  of  Gas- 
ser.  3,  Those  of  the  acoustic  ganglion  in  fishes.  4.  Those 
of  the  ganglion  geniculatum  externum.  5.  Those  of  the 
nucleus  tegmenti.  6.  Those  of  the  visual  area  of  the  occipi- 
tal cortex  (solitary  cells  of  Meynert). 

The  following  cells  of  large  dimensions  are,  as  far  as 
anatomical  and  other  facts  permit  us  to  adopt  a  conclusion, 
also  connected  with  sensory  peripheries  :  i.  The  large  cells 
in  the  deep  division  of  the  external  thalamic  zone.  2. 
The  inflated  giant-cells  of  the  probably  auditory  centre  in 
the  cortex  in  the  cat,*  recently  described  by  one  of  my 
pupils.  3.  The  flasked-shaped  cell  of  Purkinje.  4.  The 
cells  of  Clarke's  columns. 

The  following  are  undoubtedly  or  very  probably  con- 
nected, at  least  at  one  pole,  with  sensory  peripheries  :  i. 
The  gigantic  cells  of  the  auditory  nucleus  (100  micromilli- 
metres by  20).  2.  The  large  cells  of  the  deep  gray  of  the 
optic  lobes.  Concerning  the  latter  I  have  already  expressed 
the  view,  that  they  mediate  reflexes  to  lower  rnotor  alti- 
tudes governed  by  retinal  impressions. 

Either  the  statement  that  all  large  cells  are  probably 
connected  with  motor  filaments,  if  it  requires  to  be  made  at 
all,  should  be  accompanied  by  so  many  qualifying  clauses 
as  would  render  it  practically  void  of  any  meaning,  or,  bet- 
ter, it  should  be  left  unsaid. 

It   is  true   that  we   have   large  nerve-cells  in   the   giant- 

*A  new  cortical  centre  by  Graeme  M.  Hammond,  M.D.,  N.  Y.  Medical 
Recofd,  March  19,  l88r. 


324  EDWARD  C.   SPITZKA. 

pyramids  of  the  paracentral  lobule  and  in  the  lumbar  en- 
largement, but  to  pick  these  out,  to  base  a  theory  on  them, 
and  to  force  some  conflicting  facts  under  the  conception  of 
"  doubtful,"  and  to  ignore  others  altogether,  is  not  a  logical 
procedure. 

If  any  generalization  is  to  be  attempted  as  to  the  relation 
between  the  size  of  a  nerve-cell,  or  that  subsidiary  element, 
its  nucleus,  and  the  periphery  with  which  the  former  is  con- 
nected, a  fairer  comparison  should  be  made  than  has  been 
attempted  in  the  papers  under  criticism. 

The  cells  and  their  nuclei  in  the  lumbar  enlargement 
should  be  compared  with  those  of  the  lumbar  interverte- 
bral ganglia,  those  of  the  cervical  enlargement  with  those  of 
the  cervical  intervertebral  ganglia,  those  of  the  facial  with 
those  of  the  auditory  nucleus,  those  of  the  trigeminal  mo- 
tor nucleus  with  those  of  the  Gasserian  ganglion,  those  of 
the  hypoglossal  with  those  of  the  glosso-pharyngeal  nu- 
cleus, the  giant  pyramids  of  the  paracentral  lobule  with  the 
solitary  cells  of  the  occipital  lobe — and  so  on. 

If  the  researches  on  which  the  statements  criticized  ap- 
pear to  have  been  based  had  not  been  limited  to  reptiles 
and  frogs,  the  facts  would  have  been  recognized  :  ist.  That 
the  cells  of  the  "sole  "  auditory  origin  are  not  "  uniformly 
small,"*  but  that  there  are  three  calibres,  a  small,  a  large, 
and  a  gigantic;  the  former  two  having  no  other  even  prob- 
able peripheral  connection  than  with  the  auditory  nerve. 
2.  That  the  cells  of  the  facial  nucleus  are  of  the  large  kind 
in  man.  3.  That  the  large  cells  scattered  near  the  raphe 
and  in  the  reticular  field  have  not  been  confounded  with  the 
cranial  nerve  nuclei  by  any  one  ;  they  are  the  essential  gan- 
glionic elements  of  the  general  reflex  field  of  the  oblon- 
gata.f 

*  Loc.  cit,  pp.  80,  81. 

f  And  it  is  well  to  bear  in  mind  that  cells  corresponding  to  and  exceeding  the 
dimensions  of  those  of  every  altitude  of  the  cord  are  here  found. 


CON  TRIE  U  TIONS  TO  EN  CEP  HA  LIC  A  NA  TOM  V.         3  2  5 

So  far  as  shape  and  dimensions  of  nerve-cells  are  con- 
cerned, I  can  see  nothing  in  the  measurements  given  or  the 
basis  of  the  conclusions  criticized,  that  either  adds  to  our 
existing  knowledge  or  conflicts  with  the  following,  which  I 
stated  about  a  year  ago,  and  which  still  seems  to  me  to 
represent  our  existing  state  of  knowledge  on  the  subject : 

"  The  central  tubular  gray  masses  vary  in  size  with  the  periphery 
projected  in  those  masses.  A  large  muscle  or  group  of  muscles 
will  have  a  larger  nucleus  than  a  small  muscle  or  group  of 
muscles. 

"  There  is  a  tendency  in  higher  animals  to  a  differentiation  of 
the  motor  cell-groups  into  sub-nuclei  related  to  separate  muscles 
or  groups  of  muscles. 

"  Hypertrophied  segments  of  the  body,  such  as  the  extremities, 
are  accompanied  by  lateral  extensions  of  the  cornua,  in  which 
flexor  and  extensor  muscles  probably  occupy  the  same  relative 
position  as  the  one  stated  for  the  general  flexor  and  extensor 
masses. 

"  In  this  direction  a  gross  error  has  been  committed,  and  is  re- 
peated every  day,  one  for  whose  origin  the  French  anatomists, 
particularly  Luys,  are  largely  responsible  ;  while  to  Charcot  and 
his  followers  we  owe  its  dissemination.  They  have  stated  the 
large  nerve-cells  to  be  motor,  and  per  contra,  the  small  cells  to  be 
sensory.  Now,  I  can  show  that  very  small  cells  are  found  in  un- 
questionably motor  nuclei  (origin  of  third  pair),  and  very  large 
ones  in  patently  sensory  centres,  such  as  the  ganglion  geniculatum 
externuffi.  So  that  any  differentiation  of  nerve-cells  as  to  func- 
tions, based  on  dimensions  solely,  is  fallacious.  It  has  been  also 
predicated  as  characteristic  of  the  motor  cell,  that  it  is  richly  mul- 
tipolar ;  but  there  are,  on  the  one  hand,  richly  multipolar  cells  in 
the  sensory  nuclei,  such  as  the  auditory  ;  and,  on  the  other,  we  find 
that  undoubted  motor  cells  in  very  low  vertebrates  have  few  pro- 
cesses. So  that  this  line  of  demarcation  m.ust  be  overturned.  So 
far  there  is  but  one  character  which  I  should  be  willing  to  predi- 
cate for  the  so-called  motor  cell,  namely,  that  the  transition  from 
the  body  to  the  processes  is  so  gradual  that  it  is  difficult  to  say 
where  the  body  ends  and  the  process  begins,  while  in  unquestion- 
ably sensory  cells  the  transition  is  always  abrupt.  Viewing  the 
question  in  the  abstract,  there  is  no  a  priori  reason  why  sensory 
elements  should  differ  from  motor  ones.    Comparing  a  large  num- 


326  EDWARD  C.  SPITZKA. 

ber  of  sensory  with  motor  cells,  we  may  say  that  the  character 
above  given  seems  to  be  the  only  one  on  which  an  anatomical 
differentiation  can  be  based  ;  exceptions*  there  seem  to  be,  but 
not  in  the  case  of  any  cells  whose  physiological  role  is  clearly  es- 
tablished. 

"  Quite  a  notable  feature  in  many  of  the  sensory  nuclei  is  the 
presence  of  fusiform  elements,  whose  bodies  are  inflated,  and 
which  have  two  processes — one  at  each  end — and  few  or  no  pro- 
cesses otherwise.  There  is  a  greater,  resemblance  between  the 
trophic  and  these  sensory  nerve-cells  than  between  the  trophic 
and  the  motor  ones. 

"The  cells  in  the  anterior  spinal  cornu  of  the  frog  are  very  rich 
in  processes  ;  those  of  the  salamander,  and  still  more  so  those  of 
the  siren,  are  therein  poor  ;  the  spinal  co-ordination  of  the  frog  is 
correspondingly  higher  than  that  of  the  urodela.  The  nerve-cell 
of  the  cerebral  cortex  is  a  free  nucleus  in  the  monobranchus, 
bipolar  in  the  amphiuma  (Schmidt),  has  but  few  more  processes 
in  the  scaly  reptiles,  fewer  in  the  rabbit  than  in  the  dog,  in  the  dog 
than  in  the  ape,  and  in  the  ape  than  in  man.  (Herbert  Major  states 
in  his  paper  on  the  cortex  of  a  cynocephalus  baboon,  that  he  could 
discover  no  other  difference  between  the  nerve-pyramids  of  the  hu- 
man and  simian  cortex  than  the  lesser  richness  in  processes  of  the 
latter.  I  can  confirm  this  observation  for  macacus  and  cebus  ;  in 
the  chimpanzee  I  could  discover  no  difference,  taking  into  ac- 
count that  the  staining  was  imperfect.)  The  proteus,  amphiuma, 
reptile,  rabbit,  dog,  ape,  and  man,  occupy,  with  regard  to  the  re- 
spective number  of  processes  appended  to  the  cortical  cell,  the 
sa77ie  order  which  they  occupy  in  the  intellectual  series  ! 

"  Here  we  perceive  that  the  nerve-cell,  following  the  law  which 
we  have  announced  for  the  entire  nervous  systcffi,  gains  in  func- 
tional dignity  with  the  increase  of  its  associations. 

"  The  lumbar  enlargement  is  more  marked  in  animals  possess- 
ing powerful  posterior  extremities  (man,  kangaroo)  than  in  those 
possessing  weak  or  rudimentary  ones  (bat,  porpoise).     The  cer- 

*\Vhen  writing  this  clause  I  omitted  considering  the  fact  that  alt  the  nerve- 
cells  of  certain  insects  are  inflated,  have  few  processes,  and  resemble  the  cells  of 
the  intervertebral  ganglia  of  vertebrates.  \  believe  that  a  careful  study  of  this 
branch  of  the  subject  will  overturn  all  demarcations,  even  the  tentative  one 
set  forth  by  myself.  In  fact,  when  we  take  into  account  the  possibility,  nay, 
great  probability,  of  one  and  the  same  cell  having  different  connections,  and 
that  specialization  of  connections  is  a  feature  of  higher  development,  we  will  be 
led  to  expect  that  in  the  lowest  animals  presenting  nerve-cells,  these  will  be 
alike,  and  in  the  highest  ones  more  unlike.  So  we  actually  find  it,  but  the  dis- 
similarity is  not,  as  the  writer  criticized  would  have  it,  one  of  dimensions  at  all. 


CONTRIBUTIONS  TO  ENCEPHALIC  ANATOMY.         327 

vical  enlargement  is  proportionately  larger  in  the  bat,  with  its  an- 
terior extremities  over-developed,  and  in  the  mole  (for  a  similar 
reason),  than  in  the  dog  and  rabbit.  The  oculo-motor  and  troch- 
learis  nuclei  are  almost  absent  in  the  pipistrella  bat,  aijd  entirely 
so  in  the  mole,  since  the  eyes  of  the  former  are  poorly  developed, 
and  those  of  the  latter  rudimentary.  The  lower  facial  nucleus  of 
the  elephant  follows  the  hypertrophy  of  the  facial  muscles  (trunk)  ; 
the  hypoglossal  nucleus  in  the  seal  is  reduced,  just  as  the  tongue 
is  limited  in  motion.  The  anterior  tubercles  of  the  corpora  quad- 
rigemina  are  atrophic  in  the  bat  and  mole,  for  the  same  reason 
assigned  in  the  case  of  the  oculomotor  nuclei ;  and  in  the  land 
turtles  the  extreme  atrophy  of  the  parietal  muscles  in  the  dorsal 
region  is  accompanied  by  a  greater  diminution  in  the  area  of,  and 
number  of  cells  in,  the  dorsal  gray  matter,  than  in  any  other  ani- 
mal. Per  contra^  in  the  axolotl  and  other  urodela,  as  well  as  in 
the  apodal  lacertians  (pseudopus)  and  snakes  (anaconda,  boa, 
rattlesnake),  the  cervical  and  lumbar  enlargements  are  either 
scarcely,  or  not  at  all  perceptible,  just  as  the  limbs  are  absent  or 
insignificant."* 

The  industrious  observer  whose  view^s  are  here  contra- 
dicted, will,  with  the  excellent  preparations  and  the  leisure 
at  his  disposal,  find  that  the  most  sluggish  of  the  urodela, 
the  inenopoma,  the  nienobranchus,  and  the  amphiuma,  have 
far  larger  nuclei  in  their  nerve-cells  than  the  active  anolis, 
and  alligator  or  serpents.  It  is  the  protoplasm  of  their 
cells  and  the  processes  that  are  poorly  developed  in  the 
urodela,  a  fact  which  is  in  favor  of  the  current  view,  and 
against  the  doctrine  announced  by  him. 

I  would  further  call  attention,  not  in  a  hypercritical  spirit, 
but  with  all  fairness,  that  such  statements  as  the  follow- 
ing f :  "In  the  chelydra  serpentina  (snapping  turtle,  weigh- 
ing 245^  pounds)  all  the  motor  nuclei  were  much  larger  than 
those  of  the  smaller  specimens.  The  same  rule  holds  true 
in  frogs  and  alligators.  The  smaller  the  animal,  the  smaller 
the  cell-nuclei.      I   have  not  seen  any  mention  of  this  fact 

*Architecture  and  Mechanism  of  the  Brain.     Journal   of   Nervous   and 
Mental  Disease  (pp.  4,  17,  45,  76  of  reprint),  1879-1880. 
f  Loc.  cit.,  p.  84. 


328  EDWARD  C.   SPITZKA. 

in  any  works  on  anatomy," — run  some  risk  of  being  con- 
sidered as  entering  the  domain  of  the  trivial.  No  work  on 
anatomy  has  probably  made  this  special  statement,  for  it  is 
well  known  that  the  permanent  organs  of  the  body  grow, 
and  that  their  cells  grow  with  the  general  growth  of  the 
body.  It  would  be  just  as  original,  and  precisely  as  valu- 
able, for  an  observer  to  measure  the  length  of  the  tail,  the 
dimensions  of  the  scales  and  tubercles  on  the  skin,  the  area 
of  the  carapax  scales,  and  the  diameter  of  the  eyeball,  in  a 
young  and  old  snapper,  and  to  deduce  the  fact  that  they 
grow  with  age.  It  is  well  known  that  the  nervous  system, 
and  that  naturally  includes  the  component  elements,  grows 
with  the  rest  of  the  body,  though  at  a  gradually  decreasing 
rate  from  the  date  of  birth. 

It  does  not  seem  to  have  been  considered  that  ti  there  is 
a  constant  connection  between  the  size  of  nerve-cell  nuclei 
and  of  the  muscular  masses  in  supposed  relation  with 
them,  that  there  should  be  some  nuclei  of  the  smallest  size 
in  the  crural  enlargement,  for  there  are  exceedingly  small 
muscular  masses  in  the  foot,  as  small  as  any  found  in  the 
body,  and  smaller  even  than  the  musculus  choanoides,  which 
is  under  the  oculomotor  innervation. 

A  very  remarkable  fact,  one  which  seems  to  conflict  with 
the  establishment  of  any  absolute  laws  in  this  field,  is  the 
relation  to  each  other  of  the  different  nuclei  of  the 
muscles  which  move  the  eyeball  in  different  animals. 
In  man  the  cells  of  the  abducens  origin  are  far  larger  than 
those  of  the  third  pair,  but  in  the  iguana  the  relations  are 
reversed.  The  cells  of  the  third-  and  fourth-pair  origins  are, 
in  the  latter,  among  the  larger  cells  of  its  isthmus ;  those 
of  the  abducens  cells  among  the  most  minute.  It  is  to  be 
also  borne  in  mind  that  the  rectus  externus  of  man  receives 
a  larger  supply  of  nerve-fibres  than  any  other  of  the  oculo- 
motor muscles,  though  it  is  not  proportionately  larger. 


CON  TRIE  (JTIONS  TO  ENCEPHA  LIC  ANA  TOM  Y.         3  29 

The  greater  size  of  the  lumbar  enlargement  in  birds  is 
not  necessarily  accompanied  by  an  increase  in  the  actual 
ganglionic  matter.  The  researches  of  a  French  investigator 
have  shown  that  much  of  the  enlargement  of  the  region  of 
the  sinus  rhomboideus  is  due  to  a  non-nervous  development. 
A  priori,  one  should  infer  that  the  cervical  enlargement 
should  preponderate  in  its  nerve-cells  in  those  birds  w^hich 
have  feeble  legs  and  powerful  v/ings,  while  the  reverse  would 
hold  good,  particularly  in  the  struthionidae. 

The  development  of  a  peculiar  non-nervous  structure  in 
the  lumbar  enlargement  of  birds,  especially  well  marked  at 
an  embryonic  period,  is,  I  think,  of  some  bearing  on  the 
recently  agitated  question  of  a  so-called  lumbo-sacral  brain 
in  the  extinct  sauranodon,  based  on  the  great  calibre  of  the 
spinal  canal  at  that  point.  In  all  embryos  there  is  a  tem- 
porary enlargement,  and  even  an  indication  of  a  rhomboid 
sinus  at  this  region,  and  it  is  not  necessary  to  go  beyond 
this  fact  and  the  established  development  of  a  non-nervous 
structure  in  other  sauropsida  at  the  same  point,  in  attempt- 
ing to  account  for  the  dilatation  of  the  spinal  canal  there 
found.  This  matter  is  not  germane  to  the  present  sub- 
ject, but  as  it  has  recently  been  attempted  to  bring  both 
into  correlation,  randomly  as  this  was  done,  I  take  the  lib- 
erty of  referring  to  it  here. 

PART    XI. THE    "  ASSOCIATION  "    CELL. 

About  twelve  years  ago  Meynert  *  described,  as  the 
typical  structural  element  of  the  fifth  or  deepest  stratum  of 
the  frontal,  and  the  eighth  of  the  occipital  cortex,  certain 
fusiform  nerve-cells.  These  elements  are  at  the  apices  of 
the  gyri,  parallel  in  direction  with  the  pyramidal  cells  of 
other  layers,  but  at  the  sides  of  the  gyri  and  the  bot- 
tom  of  sulci   they   occupy   a   different    position,    and    are 

*  Der  Bau  der  Grosshimrinde  und  ihre  ortlichen  Verschiedenheiten.  Viertel- 
jahfsch?ift  fur  Psychiatric,  1868. 


330  EDWARD  C.  SPITZKA. 

parallel  instead  of  vertical  to  the  surface,  with  their  long 
axes. 

The  student  examining  cortical  sections  from  man,  will 
be  unable  to  find  a  sufiflcient  number  of  these  cells  in  many- 
regions  to  justify  the  designation  of  their  aggregate  as  a 
special  layer.  He  will,  however,  find  one  statement  of 
Meynert's  confirmed,  that  they  accurately  follow  in  direc- 
tion the  arched  fibre-bundle  which,  under  the  name  of  a 
fasciculus  proprins,"*  appears  to  unite  the  apices  of  neigh- 
boring gyri.  It  is  evident  that  these  cells  are  forced  into 
parallelism  with  the  fibres  of  that  bundle.  Where  the  pro- 
cesses of  the  cells  are  seen  connected  with  fibres,  this  is 
usually  at  the  extremities  of  the  long  axis,  and  the  fibres 
are  then  a  part  of  the  arched  fasciculus;  rarely  can  a  con- 
nection of  lateral  processes  (which  are  generally  absent), 
with  fibres  penetrating  to  other  cortical  layers,  be  dis- 
covered. From  their  position  and  their  relations  to  what 
are  evidently  functional  associating  tracts,  Meynert  was 
led  to  look  upon  the  cells  as  connection  points  in  the  func- 
tional association  of  distinct  innervations  and  impressions. 
Everything  so  far  known  justifies  this  view. 

Now  it  might  be  anticipated,  in  agreement  with  the  well- 
known  principle  that  the  development  of  a  given  mechan- 
ism is  greater  where  the  functional  role  is  more  important, 
that  in  the  human  brain,  the  seat  of  the  most  numerous 
and  intricate  associations,  these  cells  should  be  also  more 
abundant  and  well  developed  than  in  any  other  animal. 
Whether  this  anticipation  would  be  a  just  one  as  it  stands, 
I  shall  now  consider. 

In  a  section  from  the  cortex  of  an  ungulate, f  I  find  the 
largest,  most   numerous  and,  in   every   respect,  best   differ- 

*  Fibrse  proprise.      Arnold. 

•(•  I,  unfortunately,  had  the  cortical  segments  from  an  ox,  a  calf,  and  a  sheep 
in  the  same  jar,  and  am  unable  to  state  from  which  of  the  three  it  was  obtained. 
The  general  type  of  all  is,  however,  the  same. 


CON TRIR  U TIONS  TO  ENCEPHALIC  A NA  TOM  Y.         331 

entiated  fusiform  cells ;  they  are  closely  crowded,  and  the 
very  distinct  layer  they  constitute  is  in  places  half  as  thick 
as  the  layer  of  pyramidal  cells  (excluding  the  barren 
ependymal  stratum).  Their  structure  is  the  same  as  that 
of  the  cells  described  by  Meynert.  In  no  other  animal 
have  I  found  them  so  well-marked  ;  those  of  the  human 
brain  will  not  bear  comparison  with  them. 

This  fact  might,  on  first  sight,  be  considered  as  a  fatal 
blow  to  the  theory  of  Meynert.  And,  indeed,  if  Meynert's 
theory  were  to  be  taken  up  strictly  as  announced  by  that 
author,  without  duly  considering  a  complementary  theory 
or  rather  principle  announced  in  this  JOURNAL  two  years 
ago,*  it  would  be  difficult  to  ward  it  off. 

It  was  announced  on  the  occasion  referred  to,  that  in 
higher  development  the  nerve-tracts  show  a  tendency  to 
emancipate  themselves  from  the  interruptions  offered  by 
intercalated  ganglionic  matter.  That  the  tendency  is  to  the 
development  of  uninterrupted  tracts,  interrupted  tracts 
being  maintained  to  a  certain  extent,  in  obedience  to  or- 
ganic needs  that  do  not  vary  much  in  the  animal  range. 
That  in  obedience  to  this  law,  the  long  tracts  of  the  cord 
replace  the  fibrillary  and  interrupted  network  of  and  near 
the  gray  substance,  and  that  the  internal  capsule  and  the 
optic  radiations  encroach  on  the  interrupted  fibre-systems 
running  through  the  great  ganglia. 

If  this  is  true  of  the  projection-system,  the  same  must  be 
true  of  the  association-system.  No  special  associating  tracts 
can  be  identified  in  the  reptilian  brain ;  functional  associa- 
tion is  mediated  by  the  hypothetical  union  of  c^ll  with 
cell,  and  the  few  fibrils  of  the  white  substance,  which  are 
seen  to  run  apparently  from  one  cortical  area  to  another, 
are   probably  interrupted  detachments   of   the   projection- 


*  Architecture  and  Mechanism  of  the  Brain.  Preliminary  considerations. 
Journal  of  Nervous  and  Mental  Disease,  October,  1879.  Also,  Contri- 
butions to  Encephalic  Anatomy.     Ibidem,  July,  1878. 


332  EDWARD  C.   SPITZKA. 

system.  Next,  we  find  associating  tracts  developed  and 
richly  provided  with  a  special  form  of  cell ;  and  in  highest 
development  the  association-tract  loses  its  interrupting  sta- 
tions, for  every  ganglionic  element  to  be  traversed  delays 
the  transmission  of  the  nerve-current.  The  uninterrupted 
associating  tract  is  a  more  perfect  mechanism  than  the  in- 
terrupted one.  If  it  is  asked  why  such  interruptions  are 
ever  developed,  the  answer  is  that  they  constitute  etappes  in 
phyllogenetic  development ;  that  no  fibre  was  ever  devel- 
oped in  the  central  nervous  system,  for  which  a  nerve-cell 
interruption  must  not  be  surmised  to  have  existed  ances- 
trally, and  that  the  interrupting  association-cell  is  nothing 
but  a  specialization  of  the  same  cell-group,  which,  in  the 
main,  remains  a  projection-field. 

I  have  observed  another  fact  in  this  connection.  The 
associating  fasciculi  are  better  marked  in  large  animals  than 
in  small  animals  of  the  same  zoological  order.  It  seems  as 
if  with  the  diminished  distance  of  cortical  area  from  cortical 
area,  that  the  intracortical  fibrillae  suffice  for  the  perform- 
ance of  those  functions  which  necessitate  distinct  tracts  with 
greater  cortical  distances, 

PART  XII. — THE  CONTESTED  ORIGIN  OF  THE  TRIGEMINUS. 

While  the  origin  of  the  lesser  motor  root  of  the  trigemi- 
nus from  the  motor  trigeminal  nucleus  and  the  raphe  is  well 
established,  and  that  of  the  sensory  root  from  the  ascending 
radicle  and  the  gelatinous  nucleus  in  the  level  of  exit  is 
now  universally  adopted,  considerable  doubt  enshrouds  the 
question  as  to  which  of  the  two  roots  receives  the  descend- 
ing radicle,  which  is  known  to  be  derived  from  the  mesen- 
cephalis  nucleus  of  the  fifth  pair. 

Meynert*  traces  the  external  detachment  of  the  descend- 
ing radicle  into  the  sensory  root.     I  have  never  seen  any- 

*  Vom  Gehime  der  Sauge  thiere,  p.  775. 


CON  TRIE  U  TIONS  TO  ENCEPHA  LIC  A  NA  TOM  Y.         333 

thing  in  hundreds  of  sections  taken  through  every  level 
concerned  in  this  question,  and  from  a  number  of  different 
animals,  that  could  conflict  with  this  view.  It  was  with  con- 
siderable surprise,  therefore,  that  I  read  Forel's  statement* 
that  this  detachment  reaches  the  motor  root,  and  forms  a 
part  of  it,  undergoing  complete  admixture  with  its  fibres. 
There  is  such  an  affectation  of  accuracy  and  detail  in  the 
treatise  of  the  latter  author,  and  I  was  able  to  confirm  so 
many  of  his  other  observations,  that  in  my  larger  treatise 
I  adopted  his  view.  In  this,  as  in  some  other  respects,  I 
fear  that,  like  others  of  Gudden's  pupils,  Forel  has  needlessly 
complicated  a  very  simple  question.  Such  a  contradiction 
as  he  made  should  have  been  based  upon  only  the  clearest 
appearances,  especially  as  experimental  confirmation  of 
Meynert's  views  had  been  furnished  by  Merkel.f 

But  aside  from  the  question  of  personal  equation  which 
has  entered  into  the  consideration  of  this  matter,  there 
has  lately  entered  another  which  presents  some  amusing 
features. 

In  a  very  full  compilation  of  the  recent  results  obtained 
in  brain  anatomy,  Schwalbe:}:  quotes  Henle  as  one  of  those 
entertaining  the  same  view  as  Forel,  opposing  Meynert,  in 
regard  to  this  matter.  In  his  first  edition  Henle  makes  no 
such  statement  ;  the  second  edition  is  not  at  my  disposal, 
but  I  feel  certain  that  whatever  the  text  may  contain,  the 
very  excellent  and  truthful  figure  155  has  not  been  ex- 
punged. The  figure  in  question  represents  a  powerful  bun- 
dle of  the  sensory  root  derived  from  above  and  arching 
over  the  motor  nucleus.  Any  one  familiar  with  the  sub- 
ject, could  give  the  figure  but  one  interpretation,  namely, 
that  of  the  strongest  confirmation  of  Meynert's  views.  If 
Schwalbe    saw    this    figure,    he    must    have    supposed    the 

*  A  rchiv  fuer  Psychiatric,  vii. 

\  Untersuchungen  aus  dem  Anatomischen  Institut,  zu  Rostock,  1S74. 

\  Hoffmann-Schwalbe,  ii. 


334  EDWARD  C.   SPITZKA. 

motor  nucleus  to  lie  behind  the  sensory  root,  in  failing  to 
correct  the  evident  misinterpretation  of  the  figure.  Henle 
does  commit  one  actual  error  ;  he  denies,  in  his  first  edition, 
the  participation  of  the  ascending  radicle  in  the  building 
up  of  the  sensory  root.  This  was  due  to  the  fact  that  his 
longitudinal  sections  are  at  the  same  time  directed  forward 
and  inward.  Such  sections  may  be  better  calculated  to  re- 
veal the  relations  of  the  descending  radicle  than  those  I  am 
about  to  describe,  but  it  is  evident  from  the  fact  that  the 
ascending  radicle  runs  cephalad*  and  laterad,  that  sections 
running  candad  and  laterad  must  fail  to  show  its  continuity. 
In  a  series  of  sections  made  parallel  to  the  direction  of  the 
ascending  radicle,  I  can  demonstrate  the  correctness  of  the 
generally  accepted  view,  that  the  ascending  radicle  is  a 
true  trigeminal  fasciculus ;  in  fact,  I  have  transverse  sec- 
tions that  were  conclusive  to  my  mind  on  this  head  before 
I  prepared  the  longitudinal  series  referred  to. 

But  I  was  also  able  to  demonstrate,  in  the  latter  series, 
that  not  only  the  descending  radicle  sends  at  least  a  great 
mass  of  its  fibres  to  the  sensory  root,  and  this  so  clearly 
that  it  is  remarkable  Forel  could  question  this  relation, 
but  that,  in  addition,  the  processes  of  cells  appertaining  to 
the  mesencephalic  nucleus  of  the  fifth  enter  that  bundle 
in  the  same  section.  Although  I  cannot  trace  a  single  pro- 
cess all  the  distance  to  the  sensory  root,  yet  I  can  trace 
such  beyond  the  level  of  the  motor  root,  and  the  course  of 
the  fasciculus,  as  a  whole,  is  perfectly  clear.  While  I  am  not 
able  to  exclude  a  participation  of  the  descending  radicle  in 
the  formation  of  the  motor  root,  I  would  insist  that  there 
is  every  ground  for  stating  that  that  division  which  is  de- 
rived from  the  mesencephalic  nucleus  passes  altogether 
into  the  sensory  root. 

*  Cephalad  equals  forward  ;  candad,  backward  ;  dorsad,  upward  ;  ventrad, 
downward  ;  laterad,  outward.  These  terms  are  gaining  ground  in  compara- 
tive anatomy,  which  science  has  generally  been  in  advance  of  human  anatomy 
in  respect  to  terminology. 


CONTRIBUTIONS  TO  ENCEPHALIC  ANATOMY.         335 

I  would,  therefore,  correct  the  contrary  statement  which 
in  excessive  deference  to  authority  I  was  induced  to  incor- 
porate in  the  larger  essay  referred  to.  The  following  facts 
concerning  the  cells  of  the  mesencephalic  nucleus  seem  to 
me  well  established  : 

1.  The  cells  of  this  nucleus  are  equally  well  developed 
in  all  the  mammalia  so  far  examined,*  and  of  the  same 
shape  and  relations  in  all  of  them. 

2.  They  are  also  present  (more  dorsally  though)  in  rep- 
tiles. 

3.  Their  efferent  processes  accumulate  in  the  outer  part 
of  the  descending  radicle  of  the  trigeminus  and  leave  the 
brain  in  the  sensory  root  of  that  nerve. 

4.  Other  processes  of  the  same  cells  seem  to  be  con- 
nected with  the  radiatory  fibres  of  the  optic  lobes. 

*  Forel  says  "  well  developed  "  in  the  mole  ;  this  fact  may  conflict  with  my 
theory  that  the  innervation  of  the  lachrymal  gland  resides  in  these  cells.  I  do 
not  know  in  the  first  place  whether  the  atrophy  of  the  eye  in  the  mole  is  ac- 
companied by  atrophy  of  the  lachrymal  gland.  The  statements  of  Gudden  and 
his  pupils  about  the  optic  lobes  in  the  mole  have  been  contradicted  by  Tartu- 
feri,  as  that  this  observation  requires  confirmation  and  future  study. 


^jexrijeuJB  nnii  giMtOQrap^Txical  Hotlcjcs. 


I.— On  the  construction,  organization  and  general 
arrangements  of  hospitals  for  the  insane,  with  some 
remarks  on  insanity  and  its  treatment.  By  Thomas  S. 
KiRKBRiDE,  M.  D.,  LL.  D.  Second  edition,  with  remarks,  addi- 
tions and  new  illustrations.  Philadelphia  :  J.  B.  Lippincott,  i8So; 
Chicago  :  Jansen,  McClurg  &  Co. 

The  republication  of  this  book,  after  a  lapse  of  twenty-six  years 
since  its  first  and  only  previous  edition,  is,  at  the  present  time,  a 
matter  of  considerable  interest  and  calls  for  special  notice.  The 
questions  as  to  the  best  methods  of  construction  and  organiza- 
tion of  hospitals  and  asylums  for  the  insane  are  now  attracting 
particular  attention  among  specialists,  and  views  in  some  respects 
directly  opposed  to  those  contained  in  this  volume  have  of  late 
years  found  many  advocates.  The  public  also,  with  the  admitted 
increase  of  cases  of  insanity  and  the  consequent  demand  for 
further  means  for  their  accommodation,  has  begun  to  take  an  in- 
terest in  the  matter,  and  tax-payers  are  beginning  to  ask  if  there 
cannot  be  less  expensive  methods  and  plans  of  hospital  construc- 
tion at  least  for  a  portion  of  the  insane, — the  admittedly  incurable 
and  chronic  cases.  The  belief  is  also  gaining  ground  in  the  pro- 
fession and  also  amongst  some  of  the  laity,  who  have  to  do  with  the 
administration  of  our  public  charities,  that  this  class  of  the  insane 
forms  a  much  larger  proportion  of  the  whole  than  was  formerly 
thought  to  be  the  case,  and  that  our  expensive  hospitals,  built  on 
the  claim  that  they  were  for  the  curative  treatment  of  mental 
disease,  have  become  and  indeed  always  have  been  mere  places  of 
detention  for  by  far  the  greater  number  of  their  inmates, — a  pur- 
pose that  could  be  much  better  served  by  less  expensive  establish- 
ments. Questions  have  also  arisen  as  to  the  organization  of  our 
hospitals  and   asylums,  as  to  the  qualifications  and  functions  of 

336 


HOSPITALS  FOR    THE  INSANE.  337 

their  ofificers,  and  the  systems  and  conditions  now  existing  in  these 
regards  have  been  the  subjects  of  a  very  large  amount  of  criticism. 
The  reiteration,  therefore,  of  the  older  and  long  dominant  views, 
in  this  second  edition  of  Dr.  Kirkbride's  work,  at  the  present 
time,  challenges  at  least  a  careful  examination. 

The  conclusions  here  embodied  are,  he  sdys,  "the  result  of  forty- 
two  years'  residence  among  the  insane,  with  the  personal  responsi- 
bility of  more  than  eight  thousand  patients  in  three  institutions, 
varying  greatly  in  their  character  and  form  of  organization,  the 
last  thirty-nine  years  being  in  that  with  which  the  author  is  now 
connected  and  of  which  he  has  had  the  immediate  direction  since 
its  opening.  During  this  last-named  period,  too,  the  author  had 
the  experience  of  eleven  years'  active  service  as  a  trustee  of  a 
large  State  hospital. 

"  These  opportunities  for  observation,  with  a  desire  to  subject 
everything  seeming  to  give  a  reasonable  prospect  of  success  to 
practical  tests,  and  a  pretty  general  knowledge  of  what  has  been 
done  elsewhere  in  the  care  of  the  insane  in  and  out  of  hospitals, 
have  not  only  confirmed  the  writer's  opinion  as  to  the  correctness' 
of  the  principles  in  which  he  has  again  expressed  his  confidence, 
but  have  also  tended  steadily  to  increase  his  interest  in  all  classes 
of  the  insane  and  his  desire  to  secure  for  them  such  a  provision 
as  will  be  certain  to  give  them  every  advantage  they  can  receive 
from  the  most  enlightened  care  and  treatment.  Nothing  will  be 
found  advocated  in  this  book  that  has  not  been  fairly  tested  in  the 
author's  own  experience/' 

The  above  statement  is  in  evidence  of  the  author's  unabated 
convictions  of  the  correctness  of  his  views,  but  it  does  not  neces- 
sarily force  us  to  share  them.  We  need  not  deny  Dr.  Kirkbride's 
ample  experience  with  the  care  of  the  insane  and  his  success  with 
his  own  methods,  while  still  admitting  a  doubt  whether  these 
methods  are  the  best  that  can  be  devised,  and  whether  success 
would  not  have  been  much  greater  had  other  plans  prevailed. 
Moreover,  in  medicine,  more  than  anything  else  with  which  we 
are  acquainted,  it  is  difficult  to  judge  correctly  of  the  merits  of 
any  plan  by  its  apparent  results,  especially  when  the  means  for  a 
comparison  with  other  methods  are  wanting.  The  post  hoc  ergo 
propter  hoc  argument  is  often  as  valid  to  uphold  the  most  arrant 
quackery  as  it  would  be  in  the  present  case,  and,  therefore,  we  do 
not  consider  it  worthy  of  the  slightest  respect.  The  views  advo- 
cated here  must  stand  or  fall  on  their  intrinsic  merits,  and  we  pro- 
pose to  give  them  a  perfectly  fair  but  thorough  examination. 


338  HE  VIEWS. 

The  following  are  the  fundamental  propositions  on  which  the 
whole  work  is  based,  as  we  have  been  able  to  glean  them  from 
the  opening  chapters  :  i.  Insanity  is,  if  treated  with  sufficient 
promptness  and  appliances,  a  curable  disease  in  a  great  majority 
of  cases  (80  per  cent.,  according  to  Dr.  Kirkbride's  estimate).  2. 
It  can  be  best  treated  in  special  hospitals  adapted  for  the  purpose, 
and  only  in  such  exceptional  cases  can  it  be  successfully  man- 
aged out  of  these  that  practically  all  require  hospital  treatment. 
3.  It  is  the  better  economy  to  cure  insanity  by  prompt  hospital 
treatment  than  to  neglect  it  and  to  allow  it  to  become  chronic.  4. 
It  is  the  duty  of  the  State  to  provide  for  the  proper  custody  and 
treatment  of  all  its  insane,  and  as  all  classes  have  a  common  inter- 
est in  this  question  the  provisions  should  be  for  all  alike. 

We  have  endeavored  to  state  these  propositions  fairly,  and,  in- 
deed, cannot  make  any  other  interpretation  of  the  first  eight  chap- 
ters than  that  embodied  in  them.  The  author  states  them,  in 
substance,  as  almost  self-evident  facts,  and  covers  them  with  very 
little  verbiage,  and  practically  supports  them  with  no  argument. 
There  is  no  question  but  that  it  is  better  economy  to  cure  insanity 
than  to  support  it  at  public  expense  after  it  has  become  incurable, 
but  this  is  almost  the  only  statement  conveyed  in  them  with  which 
we  can  fully  agree.  As  to  the  curability  of  insanity,  it  is  very  far 
from  correct  or  safe  to  assume  that  a  majority  of  cases,  developed 
to  the  extent  that  they  must  necessarily  be  to  be  admitted  to  a 
State  hospital,  are  curable.  The  safeguards  required  for  the 
proper  committal  of  such  persons,  themselves  prevent  them  from 
reaching  the  hospitals,  as  a  rule,  till  after  the  preliminary  stages 
of  the  disorder  have  passed  by,  and  it  is  already  become  well-de- 
veloped insanity.  The  disease  cannot  be  nipped  in  the  bud  by 
any  such  appliances,  and,  therefore,  we  are  of  the  opinion  that  the 
value  of  these  institutions,  in  this  respect,  is  greatly  over-estimated. 
Their  statistics  certainly  do  not  exhibit  any  such  success  as  this. 
Dr.  Kirkbride's  own  institution  has,  from  its  opening  in  1841  to 
1880,  discharged  as  cured  only  3,681  patients  (or  cases)  out  of 
8,982  admitted,  or  about  47  per  cent. — certainly  not  a  majority. 
This  number  would  probably  be  much  reduced  if  readmissions 
were-  excluded,  for  we  find,  from  the  same  report,  that  only  about 
72  per  cent,  of  the  admissions  were  first  attacks.  Dr.  Kirkbride's 
institution  is  exceptional  in  many  respects,  and  we  presume  that 
insanity  is  fully  as  successfully  treated  there  as  it  is  anywhere  in 
this  country,  its  percentage  of  recoveries  on  admissions  is  better 
than  that  of  many,  indeed,  by  this  showing  is  far  better  than  that 


HOSPITALS  FOR   THE  INSANE.  339 

of  the  majority  of  hospitals  at  the  present  day,  but  it  does  not  jus- 
tify the  first  proposition  given  above.  We  need  not  follow  the  ar- 
gument further;  it  may  be  put  down  that  the  curability  of  insanity 
in  State  hospitals  is  not  by  any  means  so  great  as  is  stated  in  this 
work.  The  second  proposition  depends  somewhat  upon  the  cor- 
rectness of  the  first  ;  if  it  is  found  by  statistics  that  the  hospitals 
discharge  as  cured  only  a  minority  of  those  that  come  to  them  for 
treatment,  while  it  is  claimed  that  a  majority  of  cases  are  curable, 
then  it  falls  to  the  ground,  for  it  proves  that  they  do  not  accom- 
plish the  best  possible  results,  and,  consequently,  that,  for  some 
reason  or  other,  they  are  not  the  best  places  for  the  treatment  of 
insanity.  When  this  can  be  said  of  the  richest  and  best  equipped, 
and  presumably  the  best  in  other  respects,  such  as  the  institution 
under  the  charge  of  the  veteran  author  of  this  work,  the  case  is 
made  still  stronger  against  them. 

The  special  hospital  function  of  all  public  institutions  for  the 
insane  maintained  in  this  book,  has  been,  we  believe,  a  leading 
doctrine  of  the  Association  of  Superintendents,  and  has  been  with 
them  the  plea  for  the  style  of  expensive  institutions  specified  in 
their  propositions  given  in  the  appendi.x.  Dr.  Kirkbride  is  in 
this  volume  only  their  spokesman  and  commentator.  It  is  re- 
freshing, therefore,  to  find,  occasionally  a  leading  member  of  that 
Association  taking  the  opposite  ground,  like  Dr.  Hughes  in  the  last 
number  (January,  1881)  of  his  journal,  The  Alienist  and  Neurolo- 
gist., where  he  enunciates  a  number  of  different  classes  of  the  in- 
sane, forming  altogether,  when  we  come  to  consider  them,  no 
mean  proportion  of  the  whole,  who  can  be  equally  well  or  better 
treated  outside  of  public  institutions. 

There  is,  as  we  have  said,  no  dispute  as  to  the  economy  of  cur- 
ing the  insane  rather  than  allowing  them  to  become  chronic 
charges  upon  the  community.  The  only  question  is  :  How  are  we  to 
provide  for  the  curable  and  the  incurable  cases?  Chronic  dements 
and  many  other  cases  of  chronic  insanity  who,  when  in  mental 
health,  lived  in  hovels  and  cottages,  do  not  require,  in  our  opin- 
ion, when  insane,  to  be  housed  in  a  palace  and  surrounded  by  com- 
forts and  appliances  that  they  are  unable  to  appreciate.  All  they 
reasonably  need  is  to  be  cared  for  humanely  and  efficiently,  to  be 
adequately  fed,  clothed,  warmed  and  housed,  and  protected  from 
harm  to  themselves  and  from  injuring  or  annoying  others.  What 
they  need  is  an  asylum,  not  a  hospital,  a  place  where  they  are  well 
provided  for,  a  due  care  being  taken  to  supply  them  with  proper 
medical  treatment  when  required,  and  suitable  care  at  all  times, 


340  RE  VIE  ws. 

not  the  barbarous  quarters  and  treatment  they  now  too  often  re- 
ceive in  county  poor-houses  and  jails.  The  chance  of  the  possi- 
ble improvement  or  recovery  of  many  apparently  chronic  cases 
must  not  be  lost  sight  of,  but  it  is  not  worth  while  to  put  them, 
as  a  class,  on  the  same  plane  as  recent  and  hopeful  cases.  There- 
fore, the  fourth  proposition,  that  provision  should  be  made  for 
all  classes  alike  does  not  appear  to  us  to  be  correct  ;  if  it  is  as- 
sumed that  a  portion  of  the  insane  require  hospital  treatment,  it 
need  not  be  so  extended  as  to  cover  all  classes.  It  is  plainly  useless 
to  increase  the  expense  of  caring  for  all  the  insane  on  the  pretense 
of  curing  the  admittedly  incurable,  and  the  notion  that  it  is  neces- 
sary to  equalize  the  treatment  of  all  classes  seems,  when  we  con- 
sider how  large  a  proportion  are  often  unable  to  appreciate 
the  differences,  unworthy  of  consideration.  The  practical  work- 
ing of  this  idea  is  to  provide  elegant  buildings  for  officials,  and,  it 
may  be,  luxurious  quarters  for  a  portion  of  the  insane,  leaving  an- 
other portions  in  conditions  that  are  too  often  a  disgrace  to  our 
boasted  civilization  and  humanity. 

But  one  style  of  asylum  building  is  discussed  in  the  first  part  of 
this  volume,  and  that  is  the  one  that  is  familiar  to  almost  every 
one  who  has  visited  one  of  these  State  institutions  ;  there  are, 
thanks  perhaps  to  the  influence  of  this  work  and  the  Associa- 
tion whose  views  it  embodies,  very  few  exceptions  to  the  plans 
recommended  here.  It  is  not  necessary  for  us  to  go  into  the  de- 
tails of  construction  here  given  ;  the  reason  for  condemnation 
of  the  plans  is  contained  in  the  general  remarks  on  the  leading 
idea  of  this  book,  their  expense.  This  has,  in  some  recently 
built  asylums,  reached  three,  four,  and  even  five  thousand  dollars 
for  each  insane  inmate  for  whom  they  have  accommodations,  and 
in  the  immediate  vicinity  of  these  we  have  such  instances  as  one 
mentioned  by  a  Massachusetts  State  official,  of  the  pauper  insane 
sitting  naked  in  straw  in  a  town  almshouse,  in  sight  almost  of 
the  Danvers  palace,  one  of  the  most  expensive  modern  asylums 
on  the  Kirkbride  plan. 

If  these  plans  are  to  be  followed,  the  specifications  are  well 
enough,  for  the  most  part,  and  in  some  particulars  they  will  apply 
to  other  plans.  But  the  prevailing  monotony  of  expensive  linear 
hospitals  for  all  classes  of  the  insane  alike  should  be  broken  in 
upon,  and  we  are  disposed  to  emphasize  this  point  as  we  notice 
the  reissue  of  the  present  volume.  The  destruction  of  a  few  of 
these  establishments  by  fires,  such  as  those  at  St.  Joseph,  St. 
Peters,  or  Danville,  ought  to  teach  a  lesson  that  this  work  cannot 


HOSPITALS  FOR  THE  INSANE.  34 1 

counteract,  though  they  emphasize  only  a  single  one  of  the  ob- 
jections that  can  be  urged  against  them.  We  see  also,  from  the 
report  of  the  superintendent  of  the  St.  Joseph  Asylum,  Dr.  Cat- 
lett,  that  in  the  experience  of  the  authorities  of  that  institution, 
the  temporarily  providing  for  the  insane  in  outlying  cottages  and 
buildings  has  proved  a  valuable  therapeutic  measure.  The  acci- 
dent of  the  fire  thus  doubly  points  a  moral,  showing,  as  it  does, 
not  only  the  disadvantages  of  the  old  plan,  but  also  the  advan- 
tages of  the  new.  Dr.  Catlett  comes  out  strongly  in  his  last  re- 
port as  an  advocate  of  the  cottage  or  detached  ward  system  for 
the  chronic  and  homeless  insane. 

The  second  part  of  the  work  relates  to  the  organization  of 
State  hospitals  for  the  insane,  and  here  also  we  find  abun- 
dant opportunity  to  differ  with  the  author.  The  whole  system 
of  asylum  management  in  this  country  is,  we  think,  based  on 
wrong  principles,  and  the  evidence  of  this  is  daily  accumulating 
through  State  legislative  investigations  and  otherwise.  Political 
appointments  and  changes,  and  the  irresponsible  and  absolute 
power  so  generally  vested  in  superintendents  and  boards  of  trus- 
tees, cannot  fail  to  work  out  disastrous  results  while  human  nature 
is  so  constituted  as  we  know  it  to  be.  We  do  not  mean  to  infer 
that  men  in  these  positions  are  necessarily  unworthy  ;  we  only 
wish  to  state,  as  ayplied  to.  this  question,  the  well-known  truth 
that  it  is  dangerous  to  entrust  such  unlimited  power  to  any  man 
or  set  of  men,  a  fact  that  the  experience  of  all  the  world  has  long 
since  abundantly  demonstrated  in  other  matters.  There  is  no 
power  which  one  man  can  exercise  over  his  fellow-men,  not  even 
that  of  military  and  naval  commanders  or  prison  authorities,  that 
is  more  absolute  than  that  of  an  asylum  physician  over  those  en- 
trusted to  his  charge.  There  is  no  other  class  of  persons  in  this 
country  since  the  abolition  of  Southern  slavery  that  are  so  legally 
disqualified  for  self-defence,  and,  therefore,  of  none  whose  rights 
the  general  public  should  be  more  justly  jealous.  And  yet  there 
is  no  class  more  irresponsible  to  the  general  public  under  the 
present  system  of  non-oversight  in  most  of  the  States  of  our  Union 
than  the  superintendents  who  have  these  unfortunates  in  their 
charge.  It  is  only  by  some  irregular  and  extraordinary  method 
that  asylum  abuses  come  to  light,  some  special  legislative  investi- 
gation, or  some  glaring  scandal  that  cannot  be  hushed  or  white- 
washed, and  then  it  is  naturally  unfortunate  for  all  parties  con- 
cerned. How  many  equally  damaging  facts  to  those  occasionally 
exposed,  exist  and  are  suppressed  can  only  be  inferred  from  the 
possibilities. 


342  RE  VIE  WS. 

We  cannot  better  state  the  present  system  and  its  opprotunities 
for  abuses  than  by  a  quotation  from  a  recently  published  essay  by 
Mr.  Dorman  B.  Eaton  in  the  North  Ainerican  Review,  which  con- 
tains a  large  amount  of  truth  very  strongly  stated.  He  says,  after 
noticing  the  extraordinary  powers  given  to  the  trustees  of  the  lunatic 
asylum  at  Utica,  N.  Y., — a  typical  American  institution  in  its  or- 
ganization :  "  But  the  authority  of  the  asylum  superintendent  is,  if 
possible,  more  dangerous  and  unchecked  than  that  of  the  trustees. 
He  is  an  autocrat, — absolutely  unique  in  this  republic, — supreme 
and  irresistible  alike  in  the.  domain  of  medicine,  in  the  domain  of 
business,  and  in  the  domain  of  discipline  and  punishment.  He  is 
the  monarch  of  all  he  surveys,  from  the  great  palace  to  the  hen- 
coops, from  pills  to  muffs  and  handcuffs,  from  music  in  the  par- 
lors to  confinement  in  the  prison  rooms  ;  from  the  hour  he  re- 
ceives his  prisoner  to  the  hour  when  his  advice  restores  him  to 
liberty.  Here  is  the  almost  incredible  power  given  by  statute  to 
an  asylum  superintendent.  He  assigns  all  officers  and  employes 
to  duty.  He  prescribes  all  diet  and  treatment.  He  appoints 
(subject  to  the  managers'  approval)  as  many  assistants  and  at- 
tendants as  he  thinks  proper.  He  prescribes  them  duties  and 
places.  He  (subject  to  the  managers'  approval)  fixes  their  com- 
pensation. He  discharges  any  of  them  '  at  his  sole  discretion.' 
He  suspends  any  resident  officers.  He  cz.n  gwo.  '  all  orders  he 
may  Judge  best  *  *  *  in  every  department  of  labor  and  ex- 
pense.' He  is  authorized  to  '  maintain  discipline  '  and  to  '  en- 
force obedience  '  to  all  his  own  orders.  He  keeps  the  only  re- 
quired accounts,  and  the  only  record  of  his  doings  '  and  of  the 
entire  business  operations  of  the  institution.'  He  approves  the 
bills  he  has  contracted.  He  makes  the  only  report  of  his  own  ad- 
ministration. He,  too,  is  the  person  who  gives  the  permit  upon 
which  his  prisoners  may  be  restored  to  liberty. 

"  This  unparalleled  despotism — extending  to  all  conduct,  to  all 
hours,  to  all  food,  to  all  medicine,  to  all  conditions  of  happiness, 
to  all  connection  with  the  outer  world,  to  all  possibilities  of  re- 
gaining liberty — awaits  those  whose  commitments  may  easily  be 
unjust  if  not  fraudulent,  whose  life  is  shrouded  in  a  secrecy  and 
seclusion  unknown  beyond  the  walls  of  an  insane  asylum, — is  over 
prisoners  the  most  pitiable  of  human  beings,  whose  protests  and 
prayers  for  relief,  their  keepers  declare  and  many  good  people 
believe,  no  man  is  bound  to  respect.  When  Frederick  the  Great 
defined  his  despotism  as  one  under  which  he  did  what  he  was  a 
mind  to  and  his  subjects  said  what  they  were  a  mind  to,  his  sub- 


HOSPITALS  FOR    THE  INSANE.  343 

jects  were  able  to  speak  for  themselves  and  could  make  theif  com- 
plaints ring  through  the  kingdom.  It  would  be  almost  incredible 
that  such  authority  should  be  conferred  upon  any  officer  in  this 
country  had  not  the  public  for  a  long  time  supinejy  accepted  their 
theories  about  insanity  from  asylum  superintendents,  by  whom 
this  statute  was  so  naturally  dictated  in  their  own  interests.  It 
assumes  superintendents  to  be  saints,  with  whom  passion,  selfish- 
ness, revenge  and  neglect  are  impossible." 

It  is  true,  Mr.  Eaton  says  a  little  further  on,  that,  in  spite  of 
this  vicious  system,  there  have  been  under  it  admirable  asylum 
officers,  and  we  think  that  at  the  present  time  a  very  large  majority 
of  the  superintendents  are  far  better  than  could  reasonably  be 
hoped  for.  There  are  also  differences  in  the  laws  of  different 
States  from  that  in  New  York  above  referred  to,  but  the  variations 
are,  in  the  main,  only  in  degree  of  badness,  not  in  kind.  If  we 
find  officers  faithful,  conscientious,  and  humane  anywhere,  we  can 
credit  it  to  their  innate  moral  sense  and  feeling  of  responsibility  as 
citizens,  not  to  their  environment.  The  men  are  better  than  the 
system,  which  many  of  them  honestly  but  mistakenly  uphold. 
Among  these  we  include  Dr.  Kirkbride  himself,  for  we  cannot 
ignore  his  honorable  personal  record  of  so  many  years.  The  fact 
also  that  this  despotism  exists  in  a  society  with  which  it  is  alto- 
gether incongruous,  and  that  exposure  of  abuses  will  be  disastrous, 
is  itself  no  small  check  on  a  prudent  man,  but  that  it  is  not  always 
sufficient  is  demonstrated  by  facts  that  are  constantly  coming  to 
light  in  different  parts  of  the  country. 

The  volume  before  us  in  every  respect  defends  the  present  sys- 
tem of  absolutism  on  the  part  of  the  superintendents.  Even  the 
trustees,  who  have  the  general  supervision  of  the  establishments, 
must  apparently  defer  to  him.  Their  functions,  according  to  Dr. 
Kirkbride,  seem  to  be  decidedly  general,  not  special,  in  their  char- 
acter.    A  few  quotations  will  show  the  drift  of  his  opinions. 

"  One  of  the  most  important  duties  connected  with  the  trust  of 
these  officers  will  be  the  appointment  of  the  physician-in-chief  and 
superintendent  of  the  institution,  and,  on  his  nomination  and  not 
otherwise,  of  suitable  persons  to  act  as  assistant  physicians,  stew- 
ard and  matron.  *  *  *  While  giving  the  strictest  attention  to 
their  own  appropriate  functions,  they  should  most  carefully  refrain 
from  any  interference  with  what  is  delegated  to  others,  and  med- 
dling with  the  direction  of  details  for  which  others  are  responsible. 
*  *  *  Under  no  circumstances  should  a  trustee  so  far  forget 
the  proprieties  of  his  station  as  to  resort  to  subordinates  for  in- 
formation that  should  come  from  the  superintendent,"  etc. 


344  RE  VIE  ws. 

TH%  proposition  of  the  Superintendents'  Association  in  regard  to 
the  functions  of  the  superintendent  is  quoted  and  amplified  upon, 
and  the  present  system,  in  vogue  in  most  of  our  asylums,  which 
practically  makes  that  official  a  despotic  executive  rather  than  a 
medical  officer,  is  defended  at  length.  We  have  already  in  former 
numbers  of  this  Journal  expressed  our  views  on  this  subject,  and 
therefore  it  is  not  absolutely  necessary  for  us  to  enter  again  upon 
this  phase  of  the  subject  here.  We  will,  however,  say  that  to  our 
mind  the  chief  function  of  such  an  institution  is  its  medical  one, 
and  all  others  are  subordinate.  A  really  scientific  medical  man,  who 
has  the  proper  professional  qualifications  for  the  care  and  treatment 
of  insanity  and  the  proper  professional  spirit  that  it  necessarily  re- 
quires, will  feel  a  natural  dislike  to  having  all  his  powers  turned 
in  other  directions.  Dr.  Kirkbride  is  evidently  of  the  opposite 
opinion,  for  he  says  :  **  The  physician-in-chief  who  voluntarily 
confines  his  attention  to  the  mere  medical  direction  of  the  patients 
must  have  a  very  imperfect  appreciation  of  his  true  position  or  of 
the  important  trust  confided  in  him.  He  becomes,  in  reality,  a 
very  secondary  kind  of  an  officer,  and  his  functions  will  be  pretty 
sure  to  be  considered  by  many  around  him  as  quite  subordinate 
in  importance  to  those  of  some  others  concerned  in  the  manage- 
ment of  the  establishment,  which,  under  such  an  arrangement,  can 
hardly  keep  permanently  a  high  character." 

When  we  consider  how  much  the  medical  (and  hygienic)  direc- 
tion of  the  inmates  of  an  insane  asylum  implies,  the  above  pas- 
sage does  not  appear  to  contain  a  very  large  amount  of  valuable 
truth.  The  medical  superintendent  must  necessarily  have  author- 
ity over  everything  relating  to  the  care  of  his  patients,  and  as  the 
only  reason  for  the  existence  of  the  establishment  is  to  provide 
for  this,  especially  if  we  maintain  the  exclusive  hospital  function 
advocated  in  this  work,  the  superintendent  should  have  the  pre- 
dominant voice  in  its  management.  This  much  may  be  admitted. 
But  it  is  none  the  less  a  perversion  of  his  functions  that  he  should 
be  made  at  once  steward,  bookkeeper,  farmer,  architect,  engineer 
or  overseer  of  shops,  to  the  exclusion  of  any  part  of  his  proper 
professional  duties. 

The  medical  charge  of  a  great  hospital  requires  a  higher  and 
more  special  grade  of  talent  than  is  needed  to  conduct  the  finan- 
cial and  commissary  departments  of  the  concern.  If  a  superin- 
tendent voluntarily  devotes  himself  to  these  latter  details  exclu- 
sively or  for  the  most  of  his  time,  the  inference  in  not  unjustifia- 
ble  that  he  knows  what  he  is  best   qualified  for,  and  virtually 


HOSPITALS  FOR  THE  INSANE.  345 

admits  his  professional  incompetency.  If  the  system  of  organiza- 
tion of  these  institutions  is  such  as  to  force  these  duties  upon  him 
to  the  extent  of  depriving  him  of  time  for  his  proper  medical 
oversight  of  his  patients,  then  it  should  be  condemned,  and  pro- 
fessional public  opinion  should  be  so  strong  against  it  as  to  com- 
pel its  alteration.  A  sentiment  has  grown  up  in  this  country, 
largely  due,  we  think,  to  the  influence  of  the  Superintendents'  Asso- 
ciation, that  administrative  ability  is  the  chief  requisite  in  an  asy- 
lum superintendent,  and  boards  of  charities  and  asylum  trustees 
largely  act  on  this  assumption  in  the  choice  of  these  officials. 
Notwithstanding  the  fact  that  many  good  men  obtain  positions  in 
spite  of  this  sentiment,  its  effect  is  seen  in  the  reactionary  and  un- 
scientific spirit  of  the  Superintendents'  Association,  and  the  gen- 
eral low  grade  of  American  psychiatry.  This  notion  also  is  a 
main  support  of  the  miserable  system,  which  every  right-minded 
person  regrets,  of  political  control  of  these  institutions  that  is  in 
vogue  in  several  States  of  the  Union. 

We  have  said  that  the  medical  scperintendent  of  an  asylum 
should  have  the  predominant  voice  in  its  management.  We  do 
not  mean  by  this  that  he  should  be  an  irresponsible  or  despotic 
chief  official  ;  there  should  always  be  a  careful  supervision  by  a 
competent  and  upright  officer  or  commission  on  the  part  of  the 
State.  Dr.  Kirkbride's  remarks  on  this  point  are,  in  the  main,  cor- 
rect ;  the  value  of  the  services  of  these  inspecting  officers  will  de- 
pend upon  the  men,  their  competency  and  integrity.  We  believe, 
however,  that  the  fear  of  a  poor  appointment  should  not  stand  in 
the  way  of  there  being  such  a  supervision  ;  the  office  may  be  un- 
worthily filled  for  a  time,  but  public  opinion  should  be  and  would 
be  sufficiently  awake  to  prevent  this  being  a  permanent  condition 
of  affairs,  after  it  had  once  been  aroused  to  a  knowledge  of  the 
usefulness  and  need  of  such  inspection.  On  the  other  hand,  a 
public  opinion  that  is  altogether  quiescent  on  this  matter  is  much 
less  desirable  and  hopeful.  The  inspection,  as  Dr.  Kirkbride 
says,  should  not  be  made  with  the  presumption  that  it  is  to  dis- 
close dishonesty  and  unfaithfulness,  nor  should  it,  on  the  other 
hand,  assume  beforehand  that  this  is  necessarily  not  the  case,  but 
it  should  be  vigilantly  critical  and  thorough  in  all  respects,  as 
well  as  perfectly  fair  and  unprejudiced.  Only  by  such  an  inspec- 
tion can  the  best  results  be  obtained. 

The  appendix  at  the  close  of  the  work  contains  the  much 
lauded  propositions  of  the  Association  of  Superintendents  of 
American  Institutions  for  the  Insane.     We  might  notice  these  but 


346  RE  VIE  ws. 

that  their  objectionable  features  have  already  received  attention 
in  this  review.  The  association  itself,  however,  deserves  a  few 
words.  As  is  well  known,  and  indeed,  is  indicated  in  its  title, 
this  body  is  composed  exclusively  of  those  who,  through  political 
influence  or  otherwise,  have  obtained  the  position  of  chief  officer 
of  an  asylum.  It  is,  therefore,  not  strictly  a  scientific  nor  even  an 
orthodox  medical  society,  for  by  its  organization  representatives 
of  any  school  of  medical  practice  that  has  sufficient  political  in- 
fluence, and  even  non-graduates  in  medicine  may  become  its 
members.  It  is,  as  Mr.  Eaton  says  in  the  essay  already  quoted, 
"  a  combination  for  mutual  support  and  self-defence  by  a  large 
number  of  isolated  officials,"  a  trades-union  rather  than  a  scien- 
tific professional  association.  It  has  no  analogue,  so  far  as  we 
know,  in  any  other  country.  And  to  quote  again  from  the  same 
essay,  it  is  self-evident  that,  "  as  average  human  nature  is,  it  was 
inevitable  that  an  association  thus  organized  should  crystallize  old 
methods  and  abuses  and  become,  in  itself,  an  obstacle  to  re- 
form." 

We  say  this  with  the  kindliest  feelings  toward  the  individual 
members  of  the  association,  a  majority  of  whom  we  believe  wor- 
thy of  membership  in  a  better  organization.  It  is  to  be  hoped 
that  the  time  will  soon  come  when,  instead  of  this  close  corpora- 
tion, there  will  be  only  one  society  that  can  include  not  only 
superintendents  but  assistant  physicians  of  asylums  and  all  other 
persons  interested  in  the  medical  cure  of  insanity  and  allied  con- 
ditions. The  beginning  of  this  is,  we  believe,  now  to  be  seen  in 
the  recently  organized  Association  for  the  Protection  of  the  In- 
sane and  the  Prevention  of  Insanity,  which  held  its  first  session 
last  year.  The  old  organization  may  go  on,  eating  and  drinking, 
and  marrying  and  giving  in  marriage,  as  heretofore,  but  judg- 
ment will  certainly  come,  if  it  continues  to  be  an  active  obstacle 
to  reform. 

We  have  given  as  much  space  as  we  have  to  the  notice  of  this 
book,  not  so  much  because  of  its  medical  or  scientific  impor- 
tance as  because  the  ideas  it  contains  are  those  that  have  pre- 
vailed so  long  in  this  country  to  the  damage,  we  think,  of  scien- 
tific medicine  and  of  the  interests  of  the  insane.  We  have 
noticed  especially  the  points  in  regard  to  the  organization  of  asy- 
lums or  hospitals  where  we  differed  with  the  author  for  this  rea- 
son. In  many  of  the  minor  details  here  discussed  we,  with  every 
other  person  who  wishes  well  for  the  helpless  insane,  must  agree 
with  him.     There  is  not  much,  however,  that  is  particularly  novel 


FE  VER.  347 

or  suggestive  in  these,  and  the  main  features  of  the  work  are  the 
ones  to  which  we  have  made  objection.  Its  republication  at  the 
present  time,  when  agitation  for  reform  in  these  matters  is  fairly 
under  way,  makes  its  reiteration  of  the  old-time  views  appear  like 
an  attempt  to  stay  the  tide  of  progress  and  to  defeat  reform. 
The  methods  approved  by  the  Superintendents'  Association  have 
had  a  fair  trial  now  for  a  generation  and  their  success  has 
not  been  so  great  as  to  justify  their  continuance  without  modifi- 
cation. All  knowledge  of  insanity  is  not  confined  to  that  body,  as 
some  of  its  members  would  have  us  believe,  and  the  experience  of 
foreign  countries  would  itself  suffice  to  teach  us  better  ways  than 
they  have  so  far  led  us  in. 

While  advocating  reform  and  change  we  can  give  full  credit  to 
Dr.  Kirkbride  and  many  of  his  associates  for  good  intentions  and 
perfect  honesty  of  purpose.  It  is  not  to  be  expected  that  men 
who  have  grown  up  with  a  system  and  who  have  worked  under  it 
till  they  have  lost  their  mental  flexibility  of  youth  should  be  able 
to  see  any  benefits  in  a  change.  Indeed,  their  conservatism  may 
be  of  some  little  service  in  checking  some  possibly  inconsiderate 
and  ill-advised  movements.  But  there  can  be  no  question  of  the 
fact  that  reform  is  needed  and  that  it  will  surely  be  brought  to 
pass. 

II. — I.  Fever.  A  study  on  morbid  and  normal  physi- 
ology. By  H.  C.  Wood,  A.M.,  M.D,  Smithsonian  contributions 
to  knowledge,     J.  B.  Lippincott  &  Co.,  Nov.  1880. 

2.  Contribution  ^  1'  etude  des  temperatures  peripheri- 
ques  et  particuli^rement  des  temperatures  dites  cere- 
brales  dans  les  cas  de  paralyses  d'  origine  encephal- 
iques.  Par  le  Dr.  Henri  Blaise.  (^Peripheral  and  the  so-called 
cerebral  temperatures  in  paralyses  of  cerebral  origin^  Paris,  1880, 
G.  Masson,  pp.   275. 

I.  It  is  with  special  interest  that  we  begin  this  review  with  one  of 
those  rar(z  aves,  an  American  contribution  based  wholly  on  orig- 
inal research.  Dr.  Wood  is  well  known  as  an  investigator  in  the 
front  ranks  of  his  department.  A  large  work  from  his  pen  on  so 
important  a  topic  should,  hence,  not  fail  to  command  general  at- 
tention, especially  in  the  really  elegant  garb  which  this  possesses. 
The  present  volume  is  a  continuation  of  the  author's  former  pub- 
lications on  heat-stroke  and  fever.  (The  latter  was  reviewed  in 
this  Journal,  July,  1875.) 

In  the  first  chapters  he  repeats  a  part  of  his  previous  publica- 
tions. He  points  out  that  the  essential  symptom  of  fever  is  the 
elevated  temperature,  and  shows  experimentally  that  all  febrile 


348  REVIEWS. 

symptoms  can  be  produced  by  augmenting  the  bodily  temperature. 
His  (not  very  numerous)  experiments  showed  that  a  temperature 
of  113°  to  117°  F.  is  incompatible  with  the  life  of  the  mammalian 
brain.  He  does  not  claim  that  all  the  clinical  manifestations  in 
feVers  are  due  to  the  heat  of  the  body.  But  it  seems  to  us  that 
not  enough  stress  is  placed  on  the  difference  between  the  disor- 
ders due  to  the  temperature  alone  and  the  accompanying  symp- 
toms referable  to  some  other  cause.  The  difference  is  illustrated 
especially  in  the  comparison  between  the  aseptic  fever  of  subcu- 
taneous injuries  or  disinfected  wounds  and  the  ordinary  surgical 
fever.  As  Genzmer  and  Volkmann  have  pointed  out,  the  former 
state  is  accompanied  by  scarcely  any  subjective  complaints. 

Wood  examines  hereupon  the  cause  of  the  rise  in  temperature. 
He  shows  experimentally  that  the  bodily  temperature  rises  when 
an  animal  is  placed  into  a  chamber  of  about  the  temperature  of 
the  body,  or  above,  but  that  the  rise  is  more  marked  after  a  high 
section  of  the  spinal  cord.  On  the  other  hand,  an  animal  with 
divided  cord  will  lose  in  temperature  when  surrounded  by  air 
cooler  to  any  extent  than  its  body.  These  results  are  not  new  ; 
they  agree  with  previous  observations. 

In  order  to  learn  the  total  amount  of  heat-production  and  heat- 
dissipation  under  these  circumstances,  a  calorimeter  was  con- 
structed. According  to  the  test  experiments,  the  apparatus  seems 
quite  reliable  as  long  as  it  possesses  about  the  temperature  of  the 
surrounding  air.  Above  or  below  the  degree  of  the  atmosphere 
its  indications  are  mistrusted  by  the  author  himself.  A  glance  at 
the  numerous  tables  of  figures  in  the  volume  must  convince  the 
reader  of  the  immense  amount  of  work  involved,  and  the  faithful- 
ness with  which  it  was  executed.  The  author  acknowledges  in 
this  connection  the  valuable  aid  of  his  two  promising  assistants, 
Drs.  Hare  and  Lautenbach,  both  now  deceased. 

By  means  of  the  calorimeter  it  was  determined  that  the  amount 
of  heat  lost  through  the  skin  is  considerably  augmented  for  some 
hours  by  section  of  the  spinal  cord,  but  that  the  dissipation  of 
heat  subsequently  falls  below  the  normal  amount. 

In  these  experiments  the  temperature  of  the  calorimetric  chamber 
was  equal  to  that  of  the  ordinary  air.  Hence,  the  animal  tempera- 
ture did  not  rise  under  these  circumstances.  The  total  amount 
of  heat  produced  in  the  body  is  lessened,  probably  on  account  of 
the  depressing  effect  of  the  subnormal  temperature  of  the  tissues 
on  tissue-change.  However,  on  placing  the  animals  in  a  warmer 
chamber,  so  as  to  allow  their  bodies  to   gain  in  temperature,  the 


FE  VER.  349 

production  of  caloric  is  increased.  The  augmented  loss  of  heat 
the  author  attributes  to  the  relaxation  of  the  cutaneous  vessels, 
caused  by  the  section  of  vaso-motor  nerves  of  the  cord.  This  ex- 
planation is  logical,  and  borne  out  by  the  observation  that  the  loss 
of  heat  increases  with  height  of  the  section  ;  in  other  words,  with 
the  number  of  vaso-motor  nerves  cut  off  from  the  centre.  Here- 
upon the  author  enters  upon  a  long  discussion  about  a  heat-centre, 
alleged  by  Tscheschichin  to  exist  above  the  medulla  oblongata. 
He  still  maintains  the  views  announced  in  his  Toner  lecture  on 
fever  (1875).  By  severing  the  medulla  oblongata  from  the  pons, 
the  temperature  usually  rises,  even  when  the  air  is  cool,  provided 
the  vaso-motor  centre  in  the  medulla  is  not  paralyzed  by  the  in- 
jury. The  latter  point  can  be  decided  by  the  possibility  of  a  re- 
flex rise  in  the  blood-pressure  on  irritating  a  sensory  nerve.  In 
some  instances  no  fever  occurs,  although  the  experiment  seems  suc- 
cessful in  other  respects.  The  cause  of  these  apparent  excep- 
tions is  revealed  by  the  calorimeter.  There  is  always  increased 
heat-production,  but  the  accumulation  of  caloric  is  prevented  in 
such  cases  by  an  even  greater  dissipation  of  heat  through  the 
relaxed  vessels  of  the  skin.  In  rabbits  no  rise  of  temperature 
was  ever  observed  on  severing  the  medulla  from  the  pons,  prob- 
ably on  account  of  the  impossibility  of  avoiding  a  lesion  of  the 
vaso-motor  centre  in  this  small  animal.  In  his  review  of  the 
literature  Wood  has  evidently  overlooked  the  confirmatory  experi- 
ments of  Schreiber  reported  in  Pfliigers  Archiv.  (vol.  viii). 

Wood  assumes,  on  the  strength  of  his  researches,  that  there  ex- 
ists in  the  pons,  or  even  higher  up  in  the  brain,  a  centre  regula- 
ting the  production  of  heat.  On  severing  the  tissues  from  this 
centre,  the  heat-production  is  increased.  The  centre  is,  hence,  in- 
hibitory. That  the  increased  temperature  is  not  due  to  irritation 
of  the  medulla  by  the  lesion,  the  author  tries  to  prove  by  irritation 
of  the  medulla  with  needles.  The  results  were  not  constant,  and 
the  experiments  uncertain  as  they  were,  were  not  numerous  enough 
to  prove  the  point. 

Heidenhain  had  previously  announced  that  when  a  sensitive 
nerve  is  stimulated,  a  fall  of  temperature  occurs  simultaneously 
with  the  rise  of  blood-pressure.  This  result  he  attributed  to  a  more 
rapid  flow  of  the  blood  through  the  cutaneous  vessels.  Wood 
attacks  this  explanation,  but  on  entirely  erroneous  physical  no- 
tions. Moreover,  the  explanation  seems  even  better  justified 
since  the  researches  of  Ostroumoff  (in  Heidenhain's  laboratory), 
who  showed  that  the  cutaneous  and  internal  blood-vessels  do  not 


350  REVIEWS. 

contract  alike  on  stimulation  of  sensitive  nerves,  but  that,  in  fact, 
the  skin  becomes  hyperaemic  by  vaso-dilator  reflexes.  Hence 
Wood's  attack  on  the  view  of  Heidenhain  is  not  successful.  Wood 
himself  attributes  the  fall  of  temperature  on  irritating  sensory 
nerves,  to  a  reflex  activity  of  the  alleged  heat-inhibitory  centre. 
In  order  to  prove  his  point,  he  examined  the  temperature  on  irri- 
tating sensory  nerves  after  a  previous  section  of  the  upper  part  of 
the  medulla.  The  results  were  indeed  negative,  but  they  do  not 
prove  anything,  since  in  his  comparative  experiments  in  which 
the  medulla  had  not  been  touched,  likewise  no  definite  results 
were  obtained.  The  author  attempted  to  locate  the  heat-centre 
more  accurately  by  means  of  caustic  injections  into  different  parts 
of  the  brain,  but  found  the  method  unreliable. 

Eulenburg  and  Landois,  as  well  as  Hitzig,  have  found  that  de- 
struction of  the  motor  centres  in  the  cerebral  cortex  causes  a  rise 
in  the  temperature  (of  the  skin)  of  the  other  side  of  the  body. 
Wood  repeated  these  experiments  on  a  large  scale,  but  measured 
the  total  heat-production  of  the  body  with  the  colorimeter  instead 
of  observing  the  cutaneous  temperature.  His  results  were,  that 
"  destruction  of  the  first  cerebral  convolution  in  the  dog,  posterior 
to  and  in  the  vicinity  of  the  sulcus  cruciatus,  is  followed  at  once 
by  a  very  decided  increase  of  heat-production,  whilst  after  irrita- 
tion of  the  same  nervous  tract  there  is  a  decided  decrease  of  heat- 
production."  The  motor  centres  seem  to  be  irritated  by  lesions 
in  other  parts  of  the  cerebral  surface,  since  in  such  experiments 
the  production  of  heat  was  always  reduced.  The  effects  of  de- 
struction of  motor  centres  are,  however,  transitory,  probably  not 
lasting  over  twenty-four  hours.  The  author  justly  argues  that 
this  does  not  overthrow  the  existence  of  these  centres,  since  the 
paralytic  effects  on  muscular  movements  and  coordination  are 
likewise  but  transitory  in  the  dog.  He  supports  his  position  by  a 
very  appropriate  discussion  of  the  theory  of  "  localization." 

In  the  next  place  the  author  claims  that  the  influence  of  the 
cerebral  centres  is  not  exerted  through  the  vaso-motor  nerves, 
but  is  due  to  direct  effect  upon  the  tissue  change.  The  experi- 
ments he  quotes  in  proof  of  this  view  are  novel  and  interesting, 
but  we  fail  to  see  how  they  can  justify  his  conclusions. 

He  found,  in  the  first  place,  that  the  reflex  rise  of  blood-pres- 
sure produced  by  irritation  of  sensory  nerves  can  still  be  ob- 
tained in  the  curarized  animal  after  section  of  the  vagi  and 
splanchnic  nerves.  It  is,  of  course,  not  great,  since  the  division  of 
the    splanchnic    nerves   lowers    the    blood-pressure    enormously. 


FEVER.  351 

The  rise  which  he  did  obtain,  he  attributes  to  reflex  contrac- 
tion of  vessels  others  than  those  of  the  abdominal  cavity  (territory 
of  the  splanchnic  nerve). 

If  the  contraction  of  these  vessels  alone  can  raise  the  arterial 
tension,  he  argues,  irritation  or,  on  the  other  hand,  destruction  of 
motor  centre  in  the  cortex  would  alter  the  blood-pressure  if  the 
cortical  centres  controlled  these  vessels.  But  neither  electric 
stimulation  of  the  cortical  centres  nor  their  destruction  had  any 
effect  upon  the  blood-pressure  (before  or  after  section  of  the 
splanchnic  nerves).  Hence  the  influence  of  the  cerebral  gray 
substance  upon  the  temperature  does  not  depend  on  vaso-motor 
action.  But  this  conclusion  is  illegitimate.  The  reflex  rise  of 
pressure  on  stimulating  sensory  nerves  after  previous  division  of 
the  splanchnics  is  due  to  contraction  of  all  the  vessels  still  con- 
nected with  the  vaso-constrictor  centre.  Moreover  it  is  not  cer- 
tain that  the  splanchnic  nerves  contain  all  the  vaso-motor  fila- 
ments of  the  abdominal  cavity  (Asp).  In  operating  on  the  cor- 
tical surface,  on  the  other  hand,  we  evidently  do  not  influence  all 
vessels  of  the  body,  and  contraction  or  relaxation  of  a  limited 
number  of  vessels,  for  instance,  those  of  one  or  even  several  ex- 
tremities, does  not  change  the  general  blood-pressure,  as  can  be 
shown  by  experimental  ligation  of  vessels.  However  ingenious 
Wood's  experiments  are,  they  do  not  prove  the  point  he  claims. 
In  fact,  the  experiments  of  Eulenburg  and  Landois  show  directly 
that  the  motor  centres  (or  at  least  adjoining  centres  in  the  hemi- 
spheres) control  the  local  circulation  in  the  vicinity  of  the  mus- 
cles which  they  command. 

The  following  chapter  is  devoted  to  a  discussion  of  fever. 

The  more  important  results  of  other  observers  are  critically 
examined.  But  we  miss  in  this  place  a  reference  to  some  of  the 
most  valuable  contributions  to  literature,  for  instance,  the  re- 
searches of  Murri  and  of  Leyden  and  Frankel.  Wood's  own  ex- 
periments are  about  half  a  dozen  in  number,  but  bear  the 
stamp  of  conscientious  accuracy.  The  animals  received  injec- 
tions of  stale  blood  or  pus  and  were  examined  in  the  calori- 
meter for  several  days,  many  hours  or  even  a  whole  day  at  a 
time.  The  conclusions  may  be  stated  in  his  words,  since  they 
seem  to  be  the  natural  inferences  of  the  experiments. 

"  In  the  pyaemic  fever  of  dogs,  the  heat-production  is  usually  in 
excess  of  the  heat-production  of  fasting  days,  but  less  than  that 
which  can  be  produced  by  high  feeding  ;  usually  the  production 
of  animal  heat  rises  in  the  febrile  state  with  the  temperature   and 


352  REVIEWS. 

with  the  stage  of  the  fever,  but  sometimes  the  heat-production 
becomes  very  excessive,  although  the  temperature  of  the  body 
remains  near  the  normal  limit.  In  rabbits  with  pyaemic  fever  the 
heat-production  seems  to  be  even  greater  than  it  is  in  health, 
when  food  is  taken.*  Fever  is  a  complex  nutritive  disturbance 
in  which  there  is  an  excessive  production  of  such  portion  of  the 
bodily  heat  as  is  derived  from  chemical  movements  in  the  ac- 
cumulated material  of  the  organism,  the  overplus  being  some- 
times less,  sometimes  more  than  the  loss  of  heat-production  re- 
sulting from  abstinence  from  food.  The  degree  of  bodily  temper- 
ature in  fever  depends,  in  greater  or  less  measure,  upon  a  disturb- 
ance in  the  natural  play  between  the  functions  of  heat-produc- 
tion and  heat-dissipation,  and  is  not  an  accurate  measure  of  the 
intensity  of  the  increased  chemical  movements  of  the  tissues." 

In  the  last  chapter  Wood  discusses  the  theory  of  fever.  He  ad- 
mits that  most  fevers,  which  we  observe  clinically,  are  due  to  the 
existence  of  pyrogenic  agents  in  the  blood,  and  that  the  purely 
neurotic  origin  has  never  been  proven  in  any  fever.  Still,  he 
thinks  it  likely  that  such  temporary  febrile  movement  as  results 
from  teeth-cutting  or  intestinal  disturbance  may  be  due  to  nerve 
irritation.  In  aid  of  his  view,  he  points  out  the  increased  produc- 
tion of  heat  and  formation  of  COg,  resulting  from  the  application 
of  stimulants  to  the  skin,  especially  cold. 

So  far  his  conclusions  are  well  justified  by  the  facts,  but  when 
he  claims  that  the  fever-producing  agents  existing  in  the  blood 
exert  their  influence  primarily  upon  the  heat-centre,  he  seems  to 
pass  beyond  proof.  The  experiments  of  Murri,  who  elevated 
the  temperature  by  the  injection  of  pyrogenic  substances  after  a 
high  division  of  the  cord,  certainly  contradict  such  an  exclusive 
view.  Still  Wood  does  not  claim  absolute  paralysis  (except  in 
cerebral  rheumatism)  of  his  heat-inhibitory  centre  in  fever,  but 
only  a  state  of  paresis.  He  tries  to  disprove,  indeed,  the  paraly- 
sis by  reducing  the  febrile  temperature  by  means  of  stimulation  of 
sensory  nerves.  But  the  experiments  are  just  as  inconclusive  as 
similar  ones  on  non-febrile  animals  referred  to  above.  The  tables 
do  not  show  any  immediate  or  constant  depression  of  temperature 
from  the  pain,  beyond  the  usual  diminution  of  the  heat  in  fettered 
animals,  to  which  Wood  does  not  call  attention.  Finally,  the  au- 
thor explains  the  role  of  the  vaso-motor  system  in  fever,  claiming 
that  it  is  benumbed  so  as  not  to  respond  readily  to  the  necessity 

*  The  completion  of  digestion  in  the  rabbits  requires  a  number  of  days,  the 
alimentary  canal  being  filled  even  when  no  food  is  eaten  for  several  days. 


FEVER.  353 

for  the  dissipation  of  the  excessive  heat.  Again  we  must  differ 
from  him.  Clinical  experience  as  well  as  experimentation  has 
shown  that,  during  the  febrile  state  the*  vaso-motor  nerves  of  the 
skin  are  really  abnormally  excitable. 

While  thus  many  of  the  conclusions  are  not  fully  supported  by 
the  experiments,  the  book,  as  a  whole,  is  really  one  of  the  most 
valuable  American  contributions  to  experimental  pathology. 
Apart  from  the  original  portion,  it  consists  of  a  thoroughly  critical 
review  of  literature  not  easily  accessible  otherwise.  Though  the 
size  is  not  very  convenient,  the  appearance  of  the  work  is  truly 
elegant. 

2.  The  French  work,  above  noticed,  is  of  an  entirely  different 
character.  It,  too,  contains  some  original  research,  purely  clini- 
cal, but  the  bulk  of  the  volume  consists  of  a  voluminous  critical 
review  of  literature.  The  author  begins  with  a  history  of  obser- 
vations on  cerebral  and  cranial  temperature  from  the  earlier  re- 
searches of  A.  Davy  down  to  the  last  statements  by  Amidon.  These 
results  are  criticised  on  the  basis  of  Frank's  experiments.  By 
direct  test  the  latter  observer  found  that  it  requires  a  chajige  of 
temperature  of  at  least  3°  C.  in  the  cranial  cavity  in  order  to  ob- 
tain any  decisive  indication  by  a  thermometer  applied  to  the  out- 
side of  the  skull.  Since  the  cerebral  tissue  conducts  heat  better 
than  the  cranial  bones  it  is  physically  evident  that  any  differences 
in  temperature  of  adjoining  regions  of  the  scalp  cannot  be  referred 
to  the  actual  temperature  of  the  brain.  The  author  himself 
quotes  Frank  in  extenso,  but  does  not  add  anything  further  him- 
self. If  such  differences  in  the  temperature  of  adjoining  parts  do 
exist,  as  has  been  claimed,  they  must  be  accounted  for  by  the  va- 
riations in  the  vascularity  of  the  scalp.  Blaise  has  taken  the 
cranial  temperature  in  a  number  of  healthy  persons  and  obtained 
results  comparable  to  those  of  his  predecessors.  He,  too,  found 
the  frontal  region  warmer  than  the  parietal,  and  the  occipital  cool- 
est of  all,  there  being  a  difference  between  the  two  sides  in  favor 
of  the  left.  But  the  differences,  according  to  Blaise,  are  very 
small,  his  extremes  in  six  instances  ranging  from  35.75°  to  36.75° 
C.  The  discrepancies  existing  between  his  and  the  much  lower 
figures  of  Broca  (as  low  as  33°),  he  refers  to  the  method.  He 
kept  his  instruments  in  contact  for  45  minutes.  The  extreme 
limits  which  he  admits  as  occurring  in  health,  may  range  from 
34    to  37    C. 

The  following  chapter  contains  the  record  of  numerous  pains- 
taking observations  in  various  nervous  diseases,  especially  cere- 


354  REVIEWS. 

bral  softening  and  apoplexy.  The  reward  for  so  much  labor, 
however,  was  very  small,  the  differences  found  between  the  two 
sides  being  but  very  small  and  by  no  means  constant.  More 
positive  results  have  been  obtained  by  American  authors.  Gray 
and  Mills  have  both  found  elevation  of  the  cranial  temperature  on 
the  side  of  a  tumor,  while  Mary  Putnam  Jacobi  has  seen  a  marked 
increase  in  heat  over  spots  of  tuberculous  meningitis.  Blaise  con- 
siders the  number  of  such  instances  as  yet  too  small  for  diagnostic 
conclusions. 

In  the  following  part  Blaise  discusses  a  more  important  and 
practical  topic,  viz.,  the  course  of  the  temperature  in  the  axilla  and 
the  limbs  in  paralyses.  His  own  researches  are  always  preceded 
by  an  excellent  resume  of  the  literature,  which  alone  renders  the 
work  valuable  for  reference. 

In  cerebral  hefuorrhage  three  stages  have  been  described  by 
Charcot  and  Bourneville  and  confirmed  by  the  author.  In  the 
first  stage,  lasting  at  the  most  some  three  hours,  the  temperature 
often  sinks  several  degrees,  especially  in  the  limbs,  less  so  in  the 
head.  The  paralyzed  limbs  are  the  cooler,  especially  at  their 
periphery.  During  the  second  stage  the  axillary  temperature  re- 
mains about  normal,  oscillating  within  narrow  limits  for  some 
hours  or  days.  This  stage  is  absent  in  very  severe  cases,  in  which 
the  cooling  is  followed  at  once  by  a  rather  sudden  rise,  lasting 
rarely  beyond  one  day,  and  preceding  death.  The  repetition  of 
hemorrhage  causes  a  reappearance  of  the  first  stage.  During  the 
stationary  period  there  is  little  or  no  difference  between  the  two 
sides  as  to  the  temperature. 

In  cerebral  softenings  on  the  other  hand  (from  embolism  or 
thrombosis),  the  stage  of  falling  temperature  does  not  exist. 
Within  a  short  time  the  temperature  begins  to  rise,  but  in  a  vari- 
able manner.  Sometimes  it  rises  slowly  but  steadily  ;  in  other 
instances  the  elevation  is  sudden  but  very  transitory.  A  rapid  re- 
turn to  the  normal  figure  is  of  favorable  prognostic  significance, 
while  death  usually  occurs  after  a  steady  rise.  The  temperature 
is  thus  an  aid  in  diagnosis  between  cerebral  hemorrhage  and  em- 
bolism. In  the  latter  affection  there  is  but  a  slight  and  no  con- 
stant difference  between  the  tw^o  axillae. 

ThQ  post-mortem  rise  of  temperature  is  hereupon  discussed  very 
fully.  The  most  striking  results  may  be  thus  summarized  :  In 
most  cases  of  apoplexy  there  occurs  a  considerable  rise  after  death, 
especially  after  cerebral  hemorrhage  ;  less  so  after  embolism,  un- 
less the  territory  of  the  brain  implicated   was  a  very  large  one. 


FE  VER.  355 

This  rise  is  not  noticed  when  death  is  the  immediate  consequence 
of  the  hemorrhage.  When  the  apoplexy  is  due  only  to  congestion 
the  rise  is  not  marked.  The  post-mortem  elevation  is  due  to  the 
chemical  changes  persisting  in  the  tissues  until  cellular  death  is 
complete,  while  loss  of  heat  is  prevented  by  stoppage  of  the  circu- 
lation (in  the  skin)  and  the  perspiration.  The  author  attributes  a 
share  also  to  the  onset  of  rigor  mortis,  and  to  the  coagulation  of 
the  blood  (?). 

Finally,  Blaise  observed  the  temperature  in  the  limbs  in  various 
forms  of  paralyses,  supplementing  his  observations  by  a  very  full 
review  of  the  results  of  physiological  experimentation.  His  own 
results  can  be  summarized  in  about  the  following  words  :  In  pa- 
ralysis of  cerebral  origin  not  beginning  with  apoplexy,  the  tempera- 
ture remains  about  normal,  or  does  not  rise  much.  In  hemiplegia 
the  paralyzed  side  is  usually  cooler  than  the  normal  extremity, 
though  a  few  exceptions  in  favor  of  the  paralyzed  side  can  be 
observed.  No  absolute  distinction  was  found  by  the  author 
between  recent  and  old  forms.  This  difference  between  the  two 
sides  is  not  always  permanent  ;  it  may  increase  or  diminish.  Any 
difference  between  the  two  sides,  if  it  exists,  is  most  marked  in  the 
periphery  of  the  limb  ;  much  less  so  at  its  root  (axilla).  This  is 
due  to  the  sluggish  circulation  on  the  injured  side,  revealed  by 
the  purple  coloration  of  the -skin.  Hence  the  more  exposed  parts 
are  apt  to  cool  more  readily. 

The  presence  of  contractures  did  not  affect  the  local  tempera- 
ture. In  hemianaesthesia  a  difference  was  always  found,  the  anaes- 
thetic side  being  the  cooler,  though  the  difference  never  surpassed 
1°  C.  This  lower  temperature  co-exists  with  diminished  perspira- 
tion and  anaemia  of  the  parts.  The  nature  of  the  cerebral  lesion 
causing  the  paralysis  did  not  seem  to  influence  the  local  tempera- 
ture. 

Lastly,  the  author  relates  some  experiments  consisting  in  the 
application  of  sinapisms  to  paralyzed  limbs,  showing  that  the  re- 
sulting congestion  causes  the  temperature  of  the  skin  of  that  part 
to  rise,  as  might  have  been  expected.  The  rise,  however,  was  very 
slight,  but  was  always  accompanied  by  a  phenomenon  of  transfer, 
a  corresponding  reduction  in  the  temperature  of  the  symmetrical 
part  of  the  other  side. 

The  last  chapter  contains  a  detailed  and  wearisome  report  of 
the  cases  observed.  The  memoir,  as  a  whole,  does  not  add  very 
much  of  a  positive  nature  to  our  knowledge,  but  this  is  no  fault  of 
the  author's.     His  labor  in  so  many  and  accurate  observations  of 


35^  REVIEWS. 

clinical  cases  deserves  to  be  appreciated,  even  though  the  results 
were  often  negative  as  far  as  far-reaching  conclusions  are  con- 
cerned. The  work,  however,  contains  full  information  on  all  the 
topics  discussed.  [h.  g.] 

III. — On  certain  conditions  of  nervous  derangement, 
somnambulism,  hypnotism,  hysteria,  hysteroid  affec- 
tions, etc.  By  William  A.  Hammond,  M.D.  New  York  : 
G.  P.  Putnam's  Sons.  Chicago  :  Jansen,  McClurg  &  Co.  Pages, 
256. 

This  may  be  regarded  as  a  new  edition  of  the  author's  work  on 
"  Spiritualism  and  Other  Causes  of  Nervous  Derangement."  (1876.) 
He  says  : 

"  A  book  published  in  1876,  having  for  the  last  two  years  been 
out  of  print,  I  have  taken  the  opportunity  afforded  by  the  demand 
for  a  new  edition — which  would  long  ago  have  been  complied 
with  but  for  the  stress  of  other  engagements — to  thoroughly  re- 
vise the  work,  and,  while  adding  largely  to  the  subjects  now  con- 
sidered, to  make  it  more  homogeneous  by  omitting  everything 
specially  relating  to  spiritualism." 

In  the  brief  preface  from  which  the  above  extract  is  taken,  he 
continues  : 

"  The  interesting  conditions  of  which  the  present  volume  treats 
are  being  attentively  studied  both  in  this  country  and  in  Europe, 
and  ought  to  be  brought  to  the  knowledge  of  the  general  reader. 
They  are  the  fields  upon  which  the  miracle-worker  expends  his 
most  energetic  labor  ;  for  he  knows  something  of  the  forms  under 
which  they  are  manifested,  and  he  also  knows  that  by  making  ad- 
roit use  of  them  he  can  deceive  thousands  of  innocent  but  ignor- 
ant people  to  his  own  advantage,  and  that  of  any  system  which  re- 
quires miracles  for  its  establishment  or  aggrandizement.  As  a 
knowledge  of  the  conditions  in  question  becomes  more  diffused, 
the  ability  to  work  miracles  will  be  correspondingly  diminished  ; 
and  in  the  hope  of  contributing  to  these  ends  this  little  book  is 
written." 

Such  is  the  account  given  by  the  author  himself  of  the  origin 
and  design  of  the  present  work.  It  is  divided  into  seven  chapters, 
with  titles  as  follows  : 

I.  Certain  Conditions  of  Nervous  Derangement.  II.  Some 
Phases  of  Hysteria.  III.  Another  Phase  of  Hysteria.  IV.  The 
Hysteroid  Affections — Catalepsy,  Ecstasy,  and  Hystero-Epilepsy. 
V.  Stigmatizatian.  VI.  Supernatural  Cures.  VII.  Some  of  the 
Causes  which  lead  to  Sensorial  Deception  and  Delusional  Beliefs 


NERVOUS  DERANGEMENT.  357 

The  portion  of  the  work  relating  to  natural  and  artificial  som- 
nambulism is  an  interesting  collection  of  cases,  but  with  no  very 
serious,  or  at  least  successful  attempt  to  explain  the  phenomena 
involved.     The  author  says  : 

"  Now,  after  this  survey  of  some  of  the  principal  phenomena  of 
natural  and  artificial  somnambulism,  are  we  able  to  determine  in 
what  their  condition  essentially  consists  ?  I  am  afraid  we  shall  be 
obliged  to  answer  this  question  in  the  negative,  and  mainly  for 
the  reason  that  with  all  the  study  which  has  been  given  to  the 
subject,  we  are  not  yet  sufficiently  well  acquainted  with  the  nor- 
mal functions  of  the  nervous  system  to  be  in  a  position  to  pro- 
nounce with  definiteness  on  their  aberrations.  Nevertheless,  the 
matter  is  not  one  of  which  we  are  wholly  ignorant.  We  have 
some  important  data  upon  which  to  base  our  investigations  into 
the  philosophy  of  the  condition  in  question,  and  inquiry,  even  if 
leading  to  erroneous  results,  at  least  promotes  reflection  and  dis- 
cussion, and  may  in  time  carry  us  to  absolute  truth." 

The  mind  is  said  by  Dr.  Hammond  to  be  "  a  force  developed 
by  oervous  action."  He  draws  a  distinction  quite  commonly 
made  in  classifying  mental  operations,  that  is,  between  those  of 
which  the  subject  is  conscious  and  those  of  which  the  subject  is 
unconscious.  To  this  latter,  according  to  Dr.  Hammond,  the 
phenomena  of  somnambulism  belong.     He  says  : 

"  Somnambulism,  natural  or  artificial,  appears  to  be  a  condition 
in  which  consciousness  is  subordinated  to  automatism  ;  the  sub- 
ject performs  acts  of  which  there  is  no  complete  consciousness, 
and  often  none  at  all.  Consequently  there  is  little  or  no  recollec- 
tion. There  is  diminished  activity  of  those  parts  of  the  nervous 
system  which  preside  over  the  .faculties  of  the  mind,  while  those 
which  are  capable  of  acting  automatically  are  unduly  exalted  in 
power. 

"  The  condition  is,  therefore,  analogous  to  sleep  ;  for  in  all 
sleep  there  is  in  reality  something  of  somnambulism.  For  the 
higher  mental  organs,  as  the  sleep  is  more  or  less  profound,  are 
more  or  less  removed  from  the  sphere  of  action,  leaving  to  the 
others  the  duty  of  performing  such  acts  as  may  be  required,  or 
even  of  initiating  others  not  growing  out  of  the  immediate  wants 
of  the  system.  If  this  quiescent  state  of  the  brain  is  accompanied, 
as  it  often  is  in  nervous  and  excitable  persons,  by  an  exalted  con- 
dition of  the  spinal  cord,  we  have  the  higher  order  of  somnambu- 
listic phenomena  produced,  such  as  walking,  or  the  performance 
of  complex  and  apparently  systematic  movements  ;  if  the  sleep  of 


358  REVIEWS. 

the  brain  be  somewhat  less  profound,  and  the  spinal  cord  less  ex- 
citable, the  somnambulistic  manifestations  do  not  extend  beyond 
sleep-talking  ;  a  still  less  degree  of  cerebral  inaction  and  spinal 
irritability  produces  simply  a  restless  sleep  and  a  little  muttering  ; 
and  when  the  sleep  is  perfectly  natural  and  the  nervous  system  of 
the  individual  well  balanced,  the  movements  do  not  extend  be- 
yond changing  the  position  of  the  head  and  limbs,  and  turning 
over  in  bed. 

"  But  the  actions  of  the  spinal  cord — which  is,  I  conceive,  the 
organ  chiefly  controlling  the  mind  in  somnambulism — are  not 
always  automatic  in  character,  as  I  have  endeavored  to  show  in 
another  place.*  The  motions  of  frogs  and  of  some  other  animals, 
when  deprived  of  their  brains,  exhibit  a  certain  amount  of  intel- 
lection or  volition.  That  they  are  not  more  extensive  is  probably 
due  to  the  fact  that  all  the  organs  of  the  senses,  except  that  of 
touch,  have  been  removed  with  the  brain,  and  hence  the  mechan- 
ism for  coming  into  relation  with  the  external  world  is  necessarily 
diminished. 

"  In  profound  somnambulism  the  whole  brain  is  probably  in  a 
state  of  complete  sleep,  the  spinal  cord  alone  being  awake.  In 
partial  or  incomplete  somnambulistic  conditions,  certain  of  the 
cerebral  ganglia  are  not  entirely  inactive,  and  hence  the  individual 
answers  questions,  exhibits  emotions,  and  is  remarkably  disposed 
to  be  affected  by  ideas  suggested  by  others.  The  ability  to  origi- 
nate trains  of  thought  exists  only  in  very  imperfect  somnambulistic 
states."     (P.  30  et  seq.) 

We  have  made  this  long  extract  partly  because  it  contains  the 
author's  explanation  of  the  curious  phenomena  of  somnambulism, 
and  partly  because  it  contains  several  partial,  and  what  we  regard 
as  erroneous,  statements. 

We  would,  first  of  all,  direct  attention  to  the,  to  say  the  least, 
awkward  expression  in  which  it  is  said  "  Consciousness  is  subordi- 
nated to  automatism."  "  Consciousness  "  and  "  automatism  "  are 
here  put,  in  fact  and  by  implication,  into  unnatural  and  false  rela- 
tions. Voluntary  action,  not  "  consciousness,"  is  the  natural  coun- 
terpart of  "  automatism  "  in  the  present  case.  The  statement  we 
have  just  quoted  from  Dr.  Hammond  would  seem  to  imply  that 
automatism  necessitates  the  absence  of  consciousness  or  overrides 
it.  But  any  one  who  has  considered  the  familiar  automatic  acts 
of  sneezing  and  coughing  knows  better.     The  somnambulist,  even, 

*"The  Brain  not  the  Sole  Organ  of  Mind." — Journal  of  Nervous  and 
Mental  Disease,  January,  1876. 


NERVOUS  DERANGEMENT.  359 

is  often  conscious  of  what  he  is  doing,  and,  within  certain  narrow 
limits,  consciously  directs  or  controls  his  movements.  It  is  ad- 
mitted that  the  contrary  seems  to  be  true,  as  a  rule,  if  we  are  to 
judge  by  the  absence  of  a  memory  on  the  part  of  the  somnambu- 
list of  what  he  has  been  doing. 

But  it  is  to  the  description  given  of  the  physiology  of  somnam- 
bulism that  we  would  particularly  direct  the  attention  of  the 
reader.  Dr.  Hammond  is  correct  in  saying  that  somnambulism  is 
"  analogous  to  sleep."  It  is  incomplete  sleep,  from  one  point  of 
view.  It  is  true  also  that  the  brain,  as  a  whole,  is  in  a  "  quiescent 
state  "  during  profound  sleep.  In  dreaming  or  in  somnambulism 
the  brain  is  asleep  only  in  parts  ;  in  parts  it  is  awake  ;  but  this  is 
not  Dr.  Hammond's  view.  He  says  (referring  to  the  state  in 
which  the  brain  is  during  sleep)  : 

"  If  this  quiescent  state  of  the  brain  is  accompanied,  as  it  often 
is  in  nervous  and  excitable  persons,  by  an  exalted  conditiofi  0/  the 
spinal  cord,  we  have  the  higher  order  of  sonambulistic  phenomena 
produced,  such  as  walking,  or  the  performance  of  complex  and  ap- 
parently systematic  movements,"  etc,  (p.  33). 

Somnambulism  depends  on  "an  exalted  condition  of  the  spinal 
cord  "  while  the  brain  is  "  quiescent  "  or  in  a  state  of  profound  rest. 
The  somnambulist  is  practically  in  the  same  condition  m  which  he 
would  be  if  the  brain  had  been  removed,  at  least  so  far  as  the  ac- 
tions performed  are  concerned.  From  this  view  we  dissent  entirely. 
In  the  first  place,  we  do  not  see  by  what  means,  in  this  case  of  Dr. 
Hammond's,  the  "exalted  condition  of  the  spinal  cord  "  is  pro- 
duced. There  are  just  two  ways  in  which  such  a  condition  may 
be  brought  to  pass  :  either  by  way  of  the  peripheral  (sensitive) 
nerves,  which  proceed  from  all  sensitive  surfaces  and  parts  of  the 
body  to  enter  the  gray  matter  of  the  cord  and  medulla,  or  by  the 
excitations  which  enter  this  same  gray  matter  by  the  way  of 
fibres  which  descend  from  the  brain.  So  far  as  is  known  to  nerve 
physiology,  there  are  no  other  directions  from  which  excitations 
can  come  by  which  the  spinal  cord  can  be  aroused  to  activity. 
Then  it  must  be  remembered  that  the  cord  is  not  a  self-acting, 
self-determining  mechanism.  It  must  be  excited  to  action,  ab 
extra,  or  it  remains  inactive.  But  if  the  brain  is  "  quiescent,"  the 
excitation  to  activity  cannot  come  from  that  source.  It  certainly 
does  not  come  by  the  way  of  the  peripheral  nerves  directly  to  the 
cord,  without  the  intervention  of  the  brain.  Our  own  opinion  is, 
that  in  somnambulism  the  brain  is  only  in  part  asleep.  Certain  por- 
tions are  awake  and  in  a  state  of  intense  activity  ;  and  from  these 


360  REVIEWS. 

excited  regions  (its  cortex)  the  stimuli  pass  along  fibre-systems 
which  extend  from  the  cerebral  cortex  down  to  the  motor  mechan- 
isms in  the  spinal  cord,  through  which,  in  their  turn,  the  muscles 
are  set  in  action  which  produce  the  motions  involved  in  the  acts 
of  the  somnambulist.  To  fully  discuss  this  question,  however, 
would  require  a  statement  of  the  modern  doctrine  of  localization 
of  function  in  the  brain,  of  the  singular  peculiarities  in  blood- 
supply  to  the  brain,  and,  besides,  at  least  the  statement  of  certain 
facts  in  regard  to  the  mechanism  and  modes  of  action  of  subor- 
dinate parts  of  the  nervous  system,  for  which  we  have  no  space  in 
the  present  brief  notice.  But  all  that  is  known  would  go  to  make 
clear  that  limited  parts  of  the  brain  may  be  awake  and  active, 
while  others  are  asleep  ;  that  certain  parts  of  the  brain  may  be  in 
a  condition  of  hyperaemia,  and  hence  active;  while  others  may  be 
at  the  same  time  in  a  state  of  relative  anaemia,  and  hence  of  inac- 
tivity, as  in  sleep  ;  finally,  that  the  acts  of  the  somnambulist  im- 
peratively require  that  the  spinal  cord  must  be  excited  from  the 
brain,  and,  hence,  that  it  is  not  in  the  "  quiescent  state  "  asserted 
by  Dr.  Hammond. 

Dr.  Hammond's  explanation  is  not  in  accord  with  the  facts  of 
somnambulism,  nor  with  those  of  nerve  physiology  ;  in  short,  it 
is  not  correct.  The  subsequent  chapters  are  very  interesting,  es- 
pecially in  those  parts  which  are  descriptive.  From  this  point  of 
view  the  book  is  as  exciting  as  fiction.  With  the  explanations 
given  of  the  curious  phenomena  described,  we  could  seldom  agree, 
either  as  adequate  or  correct. 

In  succeeding  chapters  on  "  Some  Phases  of  Hysteria  "  and 
"  Hysteroid  Affections  "  are  highly  graphic  recitals  of  histories  of 
cases  of  nervous  and  emotional  excitement  under  varying  circum- 
stances, among  others,  that  which  has  attended  religious  revivals. 

In  describing  the  demonstrations  accompanying  some  of  the 
revivals  of  John  Wesley,  particular  mention  is  made  of  those 
which  occurred  at  Everton,  in  England,  in  which  it  is  said  Mr. 
Wesley  preached  from  the  text,  "  having  a  fear  of  godliness, 
but  denying  the  power  thereof."  It  may  not  be  needless  to  re- 
mark that  the  text  referred  to,  both  in  the  Bible  (2  Tim.  iii:5)  and 
in  the  works  of  Mr.  Wesley  (Works,  vol.  4,  p.  25)  reads, 
"  having  a  form^''  etc. 

In  a  former  work  of  Dr.  Hammond  the  same  erroneous  quota- 
tion is  made,  and  comment  is  inspired  by  a  transient  feeling  of 
wonder  that  such  an  error  should  have  continued  to  escape  the 
eye  of  so  diligent  and  reverent  a  student  of  Bible-lore  as  is  the 
author  of  this  interesting  volume. 


THE  FEELING  OF  EFFORT.  3^1 

Dr.  Hammond  says  that  "  catalepsy  is  characterized  by  the 
suspension  of  the  understanding  and  sensibility,"  etc.  (p.  114). 
This  statement  is  certainly  not  always  correct,  if  we  understand 
its  scope. 

We  have  known  a  case  of  catalepsy  in  which  general  sensibility 
was  abolished  (chiefly  the  pain-sense)  and  in  which  the  peculiar 
muscular  phenomena  were  perfect,  but  in  which  the  sense  of 
hearing  was  perfectly  preserved,  and  at  .the  end  of  months  when 
recovery  took  place  the  patient  was  able  to  recall  the  principal 
occurrences  about  her  during  the  whole  period  of  her  illness,  and 
declared  that  while  she  appreciated  perfectly  most  things  said 
and  done  about  her,  so  far  as  certain  of  the  special  senses  were 
concerned,  yet  she  was  powerless  to  control  the  organs  of  expres- 
sion— that  is,  the  muscles. 

The  remainder  of  the  work  is  filled  with  accounts  of  exceedingly 
interesting  cases  of  various  sorts  of  nervous  and  mental  disorders 
and  conditions  which  will  greatly  interest  and  instruct  the 
reader. 

The  work  is  greatly  lacking  in  discussions  of  the  curious  phe- 
nomena described.  As  usual  with  the  productions  of  Dr.  Ham- 
mond, the  style  is  agreeable  and  clear,  and,  on  the  whole,  the 
work  is  as  exciting  as  live  fiction. 

IV. — The  feeling  of  effort.  (Anniversary  memoirs  of  the  Bos- 
ton Society  of  Natural  History)  By  William  James,  M.D., 
Assistant  Professor  of  Physiology  in  Harvard  University,  Boston, 
1880,  pages  32. 

This  is  an  attempt  to  work  out  the  physiology  of  the  feeling  or 
sense  of  effort  experienced  when  a  healthy  individual  executes  a 
muscular  act  which  is  purposive,  and  to  the  execution  of  which 
the  individual  gives  his  particular  attention.  In  physiological 
psychology,  but  few,  if  any  other  questions  are  of  equal  import- 
ance. Its  determination  is  the  most  vital  single  step,  perhaps,  in 
the  philosophy  of  perception.  On  having  missed  this  point  com- 
pletely, depended  largely  the  utter  failure  of  Berkeley  and  his 
followers  to  construct  a  sound  theory  of  perception. 

The  more  important  steps  in  a  history  of  the  advance  of  the 
physiological  side  of  the  subject  are  given,  and  due  reference  is 
made  to  the  psychology  of  volition  and  consciousness  as  they  are 
related  to  muscular  action.  The  author  denies  that  the  "  feeling 
of  effort "  arises  out  of  the  mere  mental  movement  (or  volition) 
at  the  point  where  nerve-action  is  initiated.  But  it  arises  rather 
from  the  resulting  muscular  contraction,  which  affects  the  sensory 


3^2  RE  VIE  WS. 

nerves  of  the  muscle,  which,  in  turn,  convey  to  the  sensorium 
certain  impressions  produced  on  their  peripheral  ends  during 
the  contraction.  A  sort  of  sensation  is  experienced  in  the  mind 
which  refers  to  the  tense  muscles  engaged  in  the  muscular  effort 
as  its  source.  Of  course  this  position  necessitates  what  may  be 
called  a  "  muscular  sense,"  and  if  so,  the  presence  of  sensory 
nerves  for  the  muscles.  Both  these  positions  are  admitted  by  the 
author.  We  have  been  unable,  for  a  long  time  past,  to  see  how 
any  other  positions  could  be  rationally  assumed,  in  view  of  the 
phenomena  of  voluntary  muscular  action,  and  in  view  of  what  has 
been  long  known  or  could  be  inferred  in  regard  to  the  nerves  of 
the  muscles. 

The  conclusions  of  this  clear  and  valuable  paper,  by  Dr.  James, 
are  as  follows  : 

"  I.  Muscular  effort,  properly  so  called,  and  mental  effort, 
properly  so  called,  must  be  distinguished.  What  is  commonly 
known  as  '  muscular  exertion '  is  a  compound  of  the  two. 

"  2.  The  only  feelings  and  ideas  connected  with  muscular 
motion  are  feelings  and  ideas  of  it  as  effected.  Muscular  effort 
proper  is  a  sum  of  feelings  in  afferent  nerve-tracts,  resulting  from 
motion  being  effected. 

"3.  The  pretended  feeling  of  efferent  innervation  does  not  exist 
— the  evidence  for  it,  drawn  from  paralysis  of  single  eye  muscles, 
vanishing  when  we  take  the  position  of  the  sound  eye  into 
account. 

"4.  The  philosophers  who  have  located  the  human  sense  of 
force  and  spontaneity  in  the  nexus  between  the  volition  and  the 
muscular  contraction,  making  it  thus  join  the  inner  and  the  outer 
worlds,  have  gone  astray. 

"  5.  The  point  of  application  of  the  volitional  effort  always  lies 
within  the  inner  world,  being  an  idea  or  representation  of  afferent 
sensations  of  some  sort.  From  its  intrinsic  nature  or  from  the 
presence  of  other  ideas,  this  representation  may  spontaneously 
tend  to  lapse  from  vivid  and  stable  consciousness.  Mental  effort 
may  then  accompany  its  maintenance.  That  (being  once  main- 
tained) it  should,  by  the  connection  between  its  cerebral  seat  and 
other  bodily  parts,  give  rise  to  movements  in  the  so-called  volun- 
tary muscles,  or  in  glands,  vessels,  and  viscera,  is  a  subsidiary  and 
secondary  matter,  with  which  the  psychic  effort  has  nothing  im- 
mediately to  do. 

"  6.  Attention,  belief,  affirmation,  and  motor  volition  are  thus 
four  names  for  an  identical  process,  incidental  to  the  conflict  of 


SHORTER  NOTICES.  363 

ideas  alone,  the  survival  of  one  in  spite  of  the  opposition  of 
others. 

"  7.  The  surviving  idea  is  invested  with  a  sense  of  reality 
which  cannot  at  present  be  further  analyzed. 

"  8.  The  question  whether,  when  its  survival  involves  the  feel- 
ing of  effort,  this  feeling  is  determined  in  advance,  or  absolutely 
ambiguous  and  matter  of  chance  as  far  as  all  the  other  data  are 
concerned,  is  the  real  question  of  the  freedom  of  the  will,  and 
explains  the  strange  intimateness  of  the  feeling  of  effort  to  our 
personality. 

"9.  To  single  out  the  sense  of  muscular  resistance  as  the 
'  force-sense '  which  alone  can  make  us  acquainted  with  the  re- 
ality of  an  outward  world  is  an  error.  We  cognize  outer  reality 
by  every  sense.  The  muscular  makes  us  aware  of  its  hardness 
and  pressure,  just  as  other  afferent  senses  make  us  aware  of  its 
other  qualities.  If  they  are  too  anthropomorphic  to  be  true,  so  is 
it  also. 

"  10.  The  ideational  nerve-tracts  alone  are  the  seat  of  the 
the  feeling  of  mental  effort.  It  involves  no  discharge  downward 
into  tracts  connecting  them  with  lower  executive  centres,  though 
such  discharge  may  follow  upon  the  completion  of  the  nerve-pro- 
cesses to  which  the  effort  corresponds." 


SHORTER    NOTICES. 


I.  Die  Provixzial-Irren-,  Blinden-  und  Taubstummen- 
AusTALTEN  DER  Rheinprovinz,  in  ihrer  Entstehung,  Entwick- 
elung  und  Verfassung.  Dargestellt  auf  grund  eines  Beschlusses 
des  26.  Rheinishen  Provinzial-Landtages,  von  3  Mai,  1879.  Mit 
48  in  den  Text  gedruckten  Holzschnitten.     Diisseldorf,   1880. 

II.  A  Practical  Treatise  on  Diseases  of  the  Skin. 
By  Louis  A.  Duhring,  M.D.  Second  edition,  revised  and  en- 
larged. Philadelphia  :  J.  B.  Lippincott  &  Co.,  1881.  Chicago  : 
Jansen,  McClurg  &  Co. 

III.  Medical  Diagnosis,  with  Special  Reference  to 
Practical  Medicine.  A  Guide  to  the  Knowledge  and  Dis- 
crimination of  Diseases.  By  J.  M.  DaCosta,  M.D.  Illustrated 
with  engravings  on  wood.  Fifth  edition,  revised.  Philadel- 
phia:  J.  B.  Lippincott  &  Co.,  1881.  Chicago  :  Jansen,  McClurg 
&  Co. 

IV.  Food  for  the  Invalid,  the  Convalescent,  the 
Dyspeptic    and  the  Gouty.      By  J.  Milner  Fothergill,  M.D., 


364  RE  VIE  WS. 

Edinburgh,  and  Horatio  C.  Wood,  M.D.     New  York  :  Macmillan 
&  Co.,  1880.     Chicago  :  Jansen,  McClurg  &  Co. 

V.  A  Practical  Treatise  on  the  Medical  and  Surgi- 
cal Uses  of  Electricity  ;  including  Localized  and  General 
Faradization  ;  Localized  and  Central  Galvanization  ;  Electrolysis 
and  Galvano-Cautery.  By  Geo.  M.  Beard,  A.M.,  M.D.,  and  A. 
D.  Rockwell,  A.M.,  M.D.  Third  edition.  Revised  by  A.  D. 
Rockwell,  M.D.  New  York  :  Wm.  Wood  &  Co.,  1881.  Chicago  : 
W.  T.  Keener. 

VI.  Diseases  of  the  Pharynx,  Larynx  and  Trachea. 
By  Morell  Mackenzie,  M.D.,  London.  New  York  :  Wm.  Wood 
&  Co.,  1880.     Chicago  :  W,  T.  Keener. 

Vn.  A  Practical  Treatise  on  Nasal  Catarrh.  By 
Beverly  Robinson,  A.M.,  M.D.,  (Paris).  New  York  :  Wm. 
Wood  &  Co.,  1880.     Chicago  :  W.  T.  Keener. 

VIIL  Minor  Surgical  Gynecology.  A  Manual  of  Uterine 
Diagnosis  and  the  lesser  Technicalities  of  Gynecological  Practice, 
for  the  use  of  the  advanced  Student  and  general  Practitioner.  By 
Paul  F.  Mund^,  M.D.  New  York  :  Wm.  Wood  &  Co.,  1880. 
Chicago  :  W.  T.  Keener. 

I.  This  is  an  elaborate  general  report  of  the  insane,  blind,  and 
deaf  and  dumb  establishments  of  West  Prussia,  published  by  au- 
thority of  a  resolution  of  the  Rhenish  Provincial  Landtag,  at  its 
26th  session  in  1879.  The  first  and  by  far  the  largest  portion  of 
the  volume  is  devoted  to  the  description  of  the  five  provincial  asy- 
lums at  Grafenberg,  Bonn,  Audernach,  Diiren  and  Merzig. 
It  commences  with  a  historical  sketch  of  the  care  of  the  insane  in 
the  Rhine  Province,  from  the  foundation  of  the  provincial  asylum 
at  Sugburg  to  its  closure  as  a  receiving  hospital  in  1878,  from  the 
pen  of  Dr.  Nasse,  director  of  the  new  establishment  at  Andernach. 
This  is  interesting  as  showing  the  growth  and  movement  of  the 
insane  population  of  that  territory. 

The  second  section,  of  over  one  hundred  and  forty  pages,  gives 
a  description  of  the  five  new  asylums,  their  construction,  architec- 
ture, material,  water  supply,  heating,  ventilation,  sewerage,  lighting, 
etc.,  in  quite  complete  detail,  and  is  illustrated  by  numerous  dia- 
grams and  plans.  After  this  come  the  descriptions  and  reports  of 
four  of  the  establishments  by  their  directors  or  superintendents, 
Dr.  Nasse  reporting  for  Andernach,  Dr.  Pelman  for  Grafenberg, 
Dr.  Ripping  for  Duren,  and  Dr.  Noetel  for  Merzig.  Though 
brief,  they  afford  a  very  fair  idea  of  the  management  of  the  dif- 
ferent institutions  and  indicate,  so  far  as  can  be  seen,  on  the  whole, 
a  scientific  treatment  of  the  insane.     We  cannot  say,  however, 


SHORTER  NOTICES.  3^5 

that  the  classification  here  given  is  altogether  any  better  than  that 
of  the  majority  of  American  asylum  reports.  Where  the  subject 
is  mentioned  at  all,  the  disuse  of  mechanical  restraint  seems  to  be 
the  rule. 

The  third  section  gives  the  financial  statements  as  to  the  cost 
of  administration  of  the  asylums,  the  expense  of  each  single 
inmate,  etc.  Naturally  we  expect  to  find  these  figures  less  than 
the  corresponding  ones  in  this  country,  and  are  not  disappointed. 
The  annual  cost  per  patient  of  the  lower  class  in  these  four 
asylums  ranges  from  about  one  hundred  and  twenty-eight  to  one 
hundred  and  seventy  dollars,  the  amount  being  reduced  as  the 
number  cared  for  is  increased. 

The  volume  concludes  with  similar  accounts  and  figures  of 
the  institutions  for  the  blind  and  for  the  deaf  and  dumb  in  the 
Rhine  Province,  as  were  given  of  the  establishments  for  the 
insane.  Taken  altogether  it  affords  a  very  excellent  means  for 
the  comparison,  in  very  many  respects,  of  the  method  employed 
in  Germany  and  those  in  use  in  this  country.  In  this  light  it 
deserves  a  longer  notice  than  we  are  able  to  give  it  here.  We 
may,  and  indeed,  expect  to  have  occasion  to  refer  to  it  in  another 
review  in  a  future  number  of  this  Journal. 

II.  We  expressed  our  opinion  of  this  work,  on  the  appearance 
of  its  first  edition  several  years  since,  that  it  was  about  the  best 
manual  of  the  kind  in  our  language.  We  see  no  reason  to  modify 
this  opinion  now,  except  to  say  that  in  its  present  form  it  is  even 
better  than  before.  As  to  the  changes  that  have  been  made  in 
this  new  edition,  we  cannot  better  inform  our  readers  than  by 
quoting  the  author's  preface.  Says  Dr.  Duhring  :  "  The  present 
edition  has  been  thoroughly  and  carefully  revised,  many  chapters 
having  been  entirely  rewritten.  It  is  also  considerably  enlarged, 
to  the  extent  of  about  one  hundred  pages,  the  type  being  some- 
what smaller  than  in  the  first  edition.  New  matter  has  been 
liberally  added,  and  will  be  found  upon  almost  every  page, 
together  with  critical  remarks  where  such  seem  to  be  called  for. 
The  effort  has  been  faithfully  made  throughout  the  volume  to 
present  the  subject  in  the  light  of  the  latest  dermatological 
researches.  The  forward  strides  of  dermatology  within  the  past 
few  years  have  been  remarkable.  No  specialty  of  medicine  has 
grown  so  rapidly.  Formerly  a  decade  comprised  comparatively 
few  important  discoveries,  but  now  each  year  adds  materially  to 
our  fund  of  knowledge.  Frequently  revised  editions  of  works  on 
diseases  of  the  skin,  therefore,  are  demanded. 


3^6  RE  VIE  ws. 

"  The  chapter  on  the  anatomy  of  the  skin  has'been  largely  re- 
written, and  two  new  illustrations  have  been  added,  one  showing 
the  general  anatomy  of  the  integument,  the  other  the  minute 
structure  of  the  epidermis.  Both  were  drawn  by  Dr.  Van  Har- 
lingen.  Considerable  matter  pertaining  to  the  physiology  of  the 
skin  has  also  been  incorporated  with  this  chapter. 

"  The  new  articles  are  uridrosis,  phosphorescent  sweat,  urticaria 
pigmentosa,  dermatitis  circumscripta  herpetiformis,  impetigo  herpeti- 
formis, pityriasis  maculata  et  circinata,  dermatitis  exfoliativa,  der- 
matitis medica-mentosa,  dermatitis  gangrcznosa,  dermatitis  papillaris 
capillitii,  fungoid  neoplasmata,  tuberculosis  cutis,  podelcoma,  ainhum, 
perforating  ulcer  of  the  foot,  and  myoma  cutis. 

"  Among  the  chapters  which  have  been  enlarged  and  to  which 
important  editions  have  been  made,  I  may  specially  refer  to 
dysidrosis  and  po?npholyx,  hcematidrosis,  scleroderma,  morphoea, 
atrophia  cutis,  hypertrophy  of  the  hair,  scrofuloderma,  syphiloderma 
and  carcinoma.'' 

It  will  be  seen  from  the  above  that  the  book  is  not  a  mere 
reprint,  but  is  really  an  improved  and  revised  edition  of  what  was 
before  an  excellent  work.  We  repeat  that  we  know  of  none  bet- 
ter of  its  kind. 

III.  This  fifth  edition  of  the  well  known  work  of  Da  Costa  on 
medical  diagnosis  is  likely  to  continue  in  the  favor  it  has  so  far 
enjoyed.  As  a  students'  manual  of  diagnosis,  it  is  conveniently 
arranged  and  clearly  and  pleasantly  written  and  tolerably  com- 
plete. The  changes  in  the  present  edition  are  principally  in  the 
chapters  on  the  diagnosis  of  diseases  of  the  nervous  system  and 
of  the  blood.  In  the  first  of  these  the  author  has  embodied  the 
results  of  recent  clinical  and  pathological  researches  to  a  con- 
siderable extent,  and  yet  there  are  many  points  in  which  it  is  open 
to  criticism.  Thus  the  space  given  to  the  diagnosis  of  certain 
conditions  denominated  here  "  softening  of  the  brain  "  does  not 
impress  us  favorably  and  appears,  indeed,  ancient  and  unscientific, 
at  least  in  the  nomenclature  of  nervous  diseases.  There  may  be, 
and  probably  is  a  condition  that  may  be  properly  called  softening 
of  the  brain  apart  from  other  recognized  pathological  species,  but 
it  must  be  extremely  rare,  and  probably  not  easily  diagnosed  from 
directly  opposite  physical  conditions.  The  term,  as  popularly 
used,  however,  and  to  some  extent  as  used  here  in  this  work,  is  a 
misnomer,  and  the  space  given  it,  together  with  a  few  other 
defects  that  we  need  not  notice,  detracts  somewhat  from  our 
estimate    of    the    scientific   value    of    this    section.      Apart   from 


SHORTER  NOTICES.  3^7 

these,  however,  and,  indeed,  we  may  say  in  general,  the  work  is 
a  good  one  and  likely  to  be  of  value  to  the  student  and  prac- 
titioner. The  present  edition  is  a  decided  advance  on  the  pre- 
ceding ones. 

IV.  This  little  book,  if  it  carries  out  the  idea  of  its  projectors, 
is  likely  to  be  profitable  to  authors  and  publishers.  The  "  fertile 
brain  of  Dr.  Fothergill "  has  a  thrifty  practical  turn,  and  the  de- 
vice of  a  book  that  could  be  prescribed  like  a  dose  of  medicine, 
the  prescriber  ticking  off  the  special  diet  list  for  his  patient,  as  he 
would  the  items  on  a  wash  bill,  is  not  a  bad  one  from  this  point 
of  view.  It  is  a  little  surprising  that  the  idea  was  not  struck  out 
long  before.  Dr.  Fothergill's  American  associate's  work  is  not 
nearly  so  conspicuous  in  this  volume.  Besides  the  introductory 
remarks,  which  are  admitted  by  the  former,  the  receipts  them- 
selves have  very  largely  an  English  aspect.  The  book  will  be 
none  the  less  useful,  however,  on  this  account,  if  it  adds  anything 
to  the  culinary  resources  of  the  native  housekeeper.  We  can 
easily  see  how  it  can  be  very  serviceable  to  the  physician  and  his 
patients,  and  expect  it  to  have  a  large  circulation. 

V.  This  third  edition  of  Beard  and  Rockwell's  "  Medical  Elec- 
tricity" calls  for  only  a  short  notice.  We  have  already  expressed 
an  opinion  in  regard  to  the  work  in  a  former  number  of  this 
Journal,  and  the  present  edition  does  not  differ  sufficiently  from 
the  former  one  to  materially  change  our  views.  We  will  only  say 
that  it  contains,  on  the  whole,  about  as  much  information  on  the 
subject  of  electro-therapeutics  as  any  work  in  our  language,  and 
the  discriminating  and  intelligent  reader  will  find  it  often  useful 
and  suggestive. 

VI.  This  is  an  excellent  work,  and  one  of  the  best  issues  of 
Wood's  library  for  1880.  The  ideas  are  good,  the  style  clear,  and 
the  illustrations  numerous  and  helpful.  It  is  well  worthy  a  place 
in  any  physician's  library. 

VII.  This  is  a  pretty  fair  practical  treatise  on  a  limited  subject. 
Nasal  catarrh  in  its  various  forms  is  so  frequent  and  troublesome 
a  complaint  that  such  a  book  as  this,  if  of  any  merit  whatever,  is 
likely  to  be  useful.  It  is  very  neatly  gotten  up,  well  printed,  and 
quite  fully  illustrated. 

VIII.  This  work  is  intended  for  the  general  practitioner,  not 
for  the  specialist  in  gynecology,  and  it  will  fulfil  the  purpose  for 
which  it  was  written.  The  physician  who  follows  it  will  be  able 
to  act  the  more  intelligently  in  many  cases,  but  he  is  not  much 
more  independent  of  the  consulting  or  operating  gynecologist  for 


368  REVIEWS. 

the  information  it  conveys.  It  does  not  represent  the  most  ad- 
vanced ideas  in  the  specialty  ;  many  of  the  appliances  here  de- 
scribed and  figured,  with  more  or  less  of  approval  or  lack  of  con- 
demnation, are,  or  ought  to  be,  obsolete  in  any  well  regulated 
practice. 

The  book  will  be  a  useful  one,  we  do  not  doubt,  but  it  is  hardly 
a  fair  representation  of  many  things  in  its  department  of  medical 
science,  and  we  wish  it  were  a  better  one. 


%dxtovml  ^cpKxtmtnt 


T  N  preceding  numbers  of  this  Journal  we  have  repeatedly 
taken  occasion  to  speak  favorably  and  hopefully  of  the  Asso- 
ciation for  the  Protection  of  the  Insane  and  the  Prevention  of 
Insanity  as  a  timely  and  needed  organization.  We  wish  here  to 
express  our  opinion  as  to  the  work  which  that  association  must 
accomplish  if  it  is  to  fulfil  the  expectations  of  the  friends  of  re- 
form. That  it  will  do  good  we  do  not  doubt.  There  is  no  fear, 
as  at  present  constituted,  of  its  becoming  a  reactionary  agency, 
like  the  Superintendents'  Association.  Its  simple  existence  is  a 
protest  against  the  policy  that  has  controlled  that  body.  But  it 
may  act  far  below  its  possibilities  and  even  be  deservedly  damned 
for  its  sins  of  omission,  if,  through  the  inaction  of  its  members  or 
wrong  counsels,  it  should  fail  to  do  its  whole  duty.  The  work  it 
was  founded  to  accomplish  is  more  than  sufficient  to  absorb  all  its 
energies,  and  there  should  be  no  abatement  in  its  activity  as  long 
as  it  is  still  unfinished.  Its  principal  points  for  attack  in  the  pres- 
ent systems  and  conditions  are,  in  our  opinion,  as  follows  : 

First,  the  association  should  make  a  vigorous  movement  on 
the  present  systems  of  practical  irresponsibility  of  asylum  authori- 
ties in  most  of  the  States  of  the  Union.  The  Association  of 
Superintendents  has  so  long  and  persistently  promulgated  the 
notion  that  in  its  members  is  embodied  all  the  wisdom  and  infor- 
mation worth  having  in  this  country  on  the  subject  of  insanity, 
that  the  public  has  practically  accepted  it  as  a  fact,  and  the  result 
is,  that  there  are  no  possibilities  of  despotism  greater  than  those 

369 


370  EDITORIAL  DEPARTMENT. 

of  a  lunatic  asylum  at  the  present  time.  *  It  will  need  some  very 
steady  and,  perhaps,  at  first  apparently  fruitless  labor  to  bring 
about  reform  in  this  matter,  but  there  is  no  other  way  in  which  it 
is  more  certain  to  be  finally  achieved. 

Secondly,  the  association  should  make  an  earnest  effort  against 
the  political  control  of  the  care  of  the  insane.  This  can  only  be 
reformed  by  educating  public  sentiment.  Appointments  must 
necessarily  be  in  the  hands  of  public  officials,  and  will  be  in- 
fluenced by  political  considerations,  unless  the  moral  sense  of  the 
community  is  strongly  against  such  perversion  of  a  public  trust. 
This  is  a  much  more  difficult  task  than  the  other  already  men- 
tioned, but  this  association  can  very  materially  assist  in  bringing 
about  this  desired  result. 

These  are  the  first  two  objects  that  should  engage  the  attention 
of  the  association,  and  with  them  once  gained  the  rest  of  its  work 
will  be  comparatively  easy,  and  it  will  have  accomplished  enough 
to  justify  the  highest  expectations  of  its  friends.  With  proper 
supervision  by  competent  inspectors,  and  freedom  from  political 
appointments  and  control,  the  remaining  questions  of  the  proper 
scientific  treatment  of  the  insane,  the  use  and  abuse  of  restraint, 
the  functions  of  the  officers,  and  all  the  needed  reforms,  will  be 
matters  very  easily  dealt  with.  We  do  not  mean  to  say  that  these 
are  not  subjects  that  should  also  engage  the  association  from  the 
first.  But  assaults  on  the  present  order  should  be  made  along 
the  whole  line,  for  the  victory  will  never  be  obtained  until  the 
two  great  evils — the  main  supports  and  originators  of  abuses, — 
the  irresponsibility  of  officials,  and  political  patronage,  are  done 
away  with. 

To  bring  about  the  reforms  needed,  the  association  will  have  to 
be  more  than  a  mere  debating  society  ;  it  must  act  as  well  as  talk. 
It  should  agitate,  educate  public  opinion,  petition  legislatures,  and 
attack  abuses  wherever  they  are  to  be  found.  Differences  of  in- 
dividual opinion  on  minor  matters  should  not  interfere  with  the 
progress  of  the  good  work  on  the  greater  ones,  and  if  there  is 
any  attempt  or  tendency  to  obstruct  it  in  these  it  should  not  be 
compromised  with  in   the  slightest   degree.     Principles,  not  men, 


EDITORIAL  DEPARTMENT.  37 1 

must  be  the  ruling  idea,  and  personal  feeling  must  not  stand  in 
the  way  of  the  interests  of  reform.  We  mention  this  because  it  is 
readily  to  be  seen  how  possible  it  is,  in  this  matter,  through  a 
kindly  spirit  to  individuals,  to  perpetuate  a  wrong  against  a  class. 
We  offer  these  remarks,  not  as  doubting  the  association,  for  we 
have  full  faith  in  its  good  intent,  but  simply  to  state  our  own 
views  as  to  its  functions.  We  shall  watch  its  progress  and  move- 
ments with  great  interest,  and  this  Journal  will  give  it  its  cordial 
support  in  every  movement  for  reform. 


We  have  received  the  prospectus  of  a  new  French  journal  on 
nerve  and  mental  diseases,  the  first  number  of  which,  it  is  an- 
nounced, will  appear  in  Paris,  the  25th  of  March.  The  title  is  as 
follows  :  Z'  Ence'phale.  jf^ournal  des  Maladies  Mentales  et  Nerveu- 
ses,  sous  la  direction  de  MM.  B.  Ball  and  J.  Luys,  aided  by  Ernest 
Chambard. 

It  has  thus  borrowed  the  title  of  Brain,  published  in  London, 
as  the  projectors  of  this  new  journal  admit.  Its  editors  declare 
that,  with  similar  journals  established  in  America,  England, 
Germany,  and  Italy,  it  is  time  for  France  to  rouse  herself,  and  take 
a  more  active  part  in  furthering  the  progress  of  neurological  med- 
icine in  establishing  and  maintaining  live  journals  in  that  depart- 
ment. The  editors  proclaim  that  its  characteristics  will  be  im- 
partiality, a  practical  spirit,  and  scepticism.  It  is  to  adhere  to 
facts  and  avoid  speculation. 

The  plan  is  certainly  good,  and  the  names  of  its  accomplished 
editors  are  guarantees  that  the  new  journal  will  be  conducted  with 
ability  and  in  the  best  interest  of  medicine. 

We  are  in  receipt  of  a  communication  from  Dr.  H.  Schuele,  the 
Medical  Director  of  the  Asylum  of  Illenau,  in  which  reference  is 
made  to  the  foot-note  on  page  36  of  the  January  number  of  this 
Journal,  accompanying  the  article  contributed  by  Dr.  E.  C. 
Spitzka,  of  New  York.  Dr.  Schuele  states  that  his  views  on  the 
relation  of  cortical  malformation  to  certain  forms  of  insanity  were 
laid   down  in  the  manuscript  of   his  hand-book   as  early  as    1877, 


372  EDITORIAL  DEPARTMENT. 

and  appeared  in  print  in  the  first  half  of  the  year  1878.  He  adds 
that  it  is,  therefore,  evident  that  they  appeared  at  least  independ- 
ently of  Dr.  Spitzka's  publications,  and  perhaps  even  before  the 
latter. 

The  concluding  surmise  would  be  incorrect.  The  brief  provis- 
ional statement  to  which  Dr.  Spitzka  refers  will  be  found  on  page 
161  of  the  number  of  this  Journal  for  January,  1878,  and  noth- 
ing could  have  been  published  much  earlier  than  that  date  in  the 
same  year.  The  writer  of  the  letter  seems  to  us  to  have  misinter- 
preted the  drift  of  Dr.  Spitzka's  foot-note  to  some  extent.  A 
careful  perusal  has  convinced  us  that  but  one  inference  was 
intended  to  be  or  can  be  drawn  from  the  foot-note  in  question  : 
namely,  that  Dr.  Spitzka  claims  the  view  as  original  with  himself, 
and  as  formed  independently  of  any  other  source,  with  the  ex- 
ceptions specified.  It  does  not  convey  any  insinuation  that  his 
views  have  been  adopted  by  others.  From  a  perfectly  impartial 
standpoint,  and  in  view  of  the  almost  simultaneous  appearance  of 
the  statements  published  by  Drs.  Schuele  and  Spitzka,  it  seems  to 
us  that  neither  can  be  held  to  quote  his  own  views  from  the  other. 
This  appears  to  us  to  have  been  the  position  of  Dr.  Spitzka,  taken 
by  him  in  the  aforesaid  foot-note.  His  manuscript  was  certainly 
in  the  hands  of  our  printers  in  the  latter  part  of  the  year  1877. 

Dr.  Schuele  further  protests  against  Dr.  Spitzka's  statement  : 
"  The  first  observations  on  cortical  malformation  with  the  insane 
of  this  class,  as  well  as  certain  imbeciles,  were  made  by  Jessen  in 
1875,  and  on  these  Schuele  seems  to  have  based  his  views."  He 
states  that,  on  the  contrary,  they  are  based  on  his  own  observa- 
tions, dating  back  as  far  as  1863.  We  are  not  able  to  comment 
on  this  aspect  of  the  question,  but  give  space  to  Dr.  Schuele's 
declaration.  He  does  not  state  that  his  own  observations  were 
published  at  any  time  prior  to  the  appearance  of  his  hand- 
book, and,  as  far  as  the  date  of  publication  is  concerned,  Jessen's 
cases  were  certainly  the  first  brought  to  the  attention  of  the  pro- 
fession. Whether  Dr.  Spitzka's  surmise  had  any  basis  or  not  we 
cannot  say,  and  have  submitted  the  letter  to  him  in  order  that  any 
doubt  on  the  matter  may  be  cleared  up. 


EDITORIAL  DEPARTMENT.  373 

Dr.  Isaac  Ray,  one  of  the  great  lights  of  American  forensic 
psychiatry,  has  passed  away.  Dr.  Ray,  who  was  widely  and  favor- 
ably known  as  the  author  of  the  "  Medical  Jurisprudence  of  In- 
sanity," died  at  his  residence  in  Philadelphia,  having  reached  the 
very  mature  age  of  seventy-five.  He  was  one  of  the  earliest 
physicians  in  the  United  States  to  follow  the  example  of  Rush, 
and  pay  special  attention  to  the  subject  of  psychiatry.  Dr.  Ray 
did  not  enter  the  specialty  a  full-fledged  alienist,  but,  after  some 
time  spent  in  the  general  practice  of  his  profession,  was  appointed, 
in  1841,  to  the  medical  superintendency  of  the  Maine  Hospital 
for  the  Insane.  He  took  an  active  part  in  stamping  on  that  insti- 
tution the  peculiar  system  of  management  afterward  adopted  as 
the  policy  of  the  Association  of  Medical  Superintendents  of  the 
Institutions  for  the  Insane.  Of  this  organization  Dr.  Ray  was 
one  of  the  original  thirteen  members,  and  contributed  much,  if 
not  most,  of  its  really  scientific  work.  Soon  after  Dr.  Ray's 
superintendency  of  the  Maine  Asylum  had  begun,  he  was  offered 
and  accepted  the  superintendency  of  the  Butler  Hospital,  at 
Providence,  Rhode  Island.  The  hospital  was  opened  for  the  re- 
ception of  patients  in  1847,  ^"<i  o^  i^  Dr.  Ray  continued  superin- 
tendent until  1867,  when  he  settled  in  Philadelphia  to  engage  in 
the  private  practice  of  his  specialty,  and  remained  a  resident  of 
that  city  till  his  death,  which  occurred  March  31,  1881.  He  was 
a  very  voluminous  writer,  and,  as  the  Journal  of  Mental  Science 
correctly  remarked  concerning  one  of  his  articles,  all  his  writ- 
ings were  marked  by  clear  good  sense.  His  style  was  pleasant 
and  agreeable,  and  his  work  on  "  Mental  Pathology  "  can  be  read 
by  almost  any  cultivated  layman  with  pleasure. 

An  article  of  his  in  the  January,  1878,  number  of  this  Journal, 
on  the  "  Cost  of  Construction  of  Asylums  for  the  Insane,"  while 
upholding  the  association  theory  of  asylum  construction,  was  a 
practical,  sensible  protest  against  the  extravagances  to  which  that 
theory  had  carried  superintendents.  Dr.  Ray  was  by  nature  ex- 
ceedingly conservative,  and  clung  with  great  tenacity  and  honesty 
of  purpose  to  the  theories  of  asylum  construction  and  manage- 
ment prevalent  in  his  early  medical  life.      To  the  association  of 


374  EDITORIAL  DEPARTMENT. 

which  he  was  one  of  the  founders  he  was  strongly  devoted,  and 
regarded  with  suspicion  any  attack  on  it  as  being  an  attack  on  the 
best  interests  of  the  insane.  Aside  from  this  narrowness  respect- 
ing asylum  management  and  control,  easily  explicable  in  one  who 
had  grown  up  under  a  specified  system.  Dr.  Ray  was  a  man  of 
broad  scientific  views,  holding  pronounced  opinions  as  to  the  ex- 
istence of  monomania,  moral  insanity,  and  mania  transitoria,  and 
on  certain  points  in  forensic  psychiatry,  in  which  he  was  fully 
abreast  of  the  most  advanced  European  psychiatrists.  He  was 
one  of  the  best  exemplars  of  the  old  school  of  asylum  superin- 
tendents,— men  somewhat  inclined  to  conservatism,  but  having 
regard  to  the  scientific  branches  of  their  specialty.  He  was  a 
man  of  spotless  integrity,  and  capable  of  forming  firm  attach- 
ments. His  opus  magmwi,  the  "  Medical  Jurisprudence  of  In- 
sanity," will  long  remain  a  standard  authority  on  forensic  psy- 
chiatry, and  will  be  long  admired  for  the  purity  of  its  diction.  In 
it  he  has  a  most  enduring  monument. 


^^tviscopt. 


a. — ANATOMY     AND     PHYSIOLOGY     OF    THE     NERVOUS 

SYSTEM. 

Vaso-Dilators  in  the  Sympathetic. — At  the  session  of  the 
Soc.  de  Biologic  December  ii  (rep.  in  Gaz.  des  Hopitaux),  M. 
Onimus  stated  that  he  had  not  heretofore  intervened  in  the  discus- 
sion between  MM.  Dastre  and  Morat  and  Laffont,  only  because 
he  was  convinced  that  these  authors  would  be  obliged  to  admit 
finally  the  explanations  given  by  M.  Legros  and  himself  in 
1865.  It  was  almost  by  a  redudio  ad  absurdum  that  they 
had  been  led  to  propose  and  sustain  the  theory  of  the  autonomous 
contraction  of  the  vessels.  Before  1867  there  was  only  the  no- 
tion of  paralysis  of  the  vaso-motors  in  case  of  augmentation,  and 
of  their  excitation  in  case  of  ischsemia.  To-day  it  is  admitted 
that  excitation  of  the  nerves  causes  congestion  ;  the  only  differ- 
ence of  opinion  is  in  regard  to  the  explanation  of  these  phenom- 
ena. Claude  Bernard  at  first  admitted  a  direct  dilatation  of  the 
vessels,  but  soon  renounced  this  opinion  as  not  justified  by 
anatomy.  Then  the  theory  of  reflex  paralysis  was  proposed. 
MM.  Legros  and  Onimus  have  shown  that  the  phenomena  pro- 
duced by  excitation  are  not  the  same  as  those  that  cause  the  par- 
alysis, and  that,  consequently,  there  could  be  no  reflex  neuro- 
paralytic hyperaemia.  Moreover,  said  he,  the  experiments  of  MM. 
Dastre  and  Morat  have  confirmed  this.  We  have  varied  our  ex- 
periments in  different  ways,  and  have  shown  that  by  exciting 
moderately  the  sympathetic  fibres  a  considerable  hypergemia  is 
always  produced,  much  greater  than  passive  hyperaemia.  We  have 
therefore  proved  an  active  direct  congestion,  which  is  the  same 
thing  as  direct  vascular  dilatation,  only  differing  in  that  this  last 
expression  infers  the  existence  of  vaso-dilator  nerves. 

There  is  to-day  no  possible  difference  of  opinion  in  this  regard. 

375 


37^  PERISCOPE, 

This  fundamental  fact  seems  well  established,  and  MM.  Dastre 
and  Morat  have  proved  it  in  an  incontestable  manner  ;  the  dilata- 
tion is  direct,  that  is,  there  is  no  intervention  of  any  reflex  par- 
alytic influence  in  these  phenomena. 

This  much  admitted,  and  active  dilatation  being  possible  neither 
anatomically  nor  physiologically,  we  see  only  one  possible  ex- 
planation ;  it  is  dilatation  by  the  autonomous  movements  of  the 
vessels  themselves.  There  are,  then,  no  vaso-dilator  nerves,  prop- 
erly so  called,  but  there  is  an  increased  sanguine  afflux  on  account 
of  the  increased  peristaltic  action  of  the  vessels. 

All  observers  who  have  watched  the  circulation  through  the 
microscope  at  the  commencement  of  an  inflammation,  have  ob- 
served alternate  contractions  and  dilatations  of  the  capillaries. 
On  the  other  hand,  we  should  especially  remark  that  a  healthy 
muscle  not  only  contracts  energetically,  but  is  easily  relaxed  after 
contraction,  while  a  muscle  in  an  abnormal  condition  never  relaxes 
completely,  but  remains  always  slightly  contracted.  However  it 
may  be  in  all  the  muscular  tubes,  we  see  perfectly  well  a  dilatation 
following  after  contraction,  and  this  dilatation  is  always  more  pro- 
nounced than  that  which  exists  in  the  condition  of  repose.  This 
normal  relaxation  not  only  permits  the  arterial  tension  to  dilate 
the  vascular  tube  and  permit  a  larger  amount  of  blood  to  enter 
it,  but  it  also  makes  it  possible  to  utilize  all  the  force  of  the  heart, 
since  it  does  not  receive  its  impulse  like  the  elastic  tissues  of  the 
great  trunks  and  cause  retardation.  It  opposes  no  obstacle,  ren- 
ders necessary  no  expenditure  of  power  ;  the  contraction  directly 
following  the  relaxation  is  itself  a  reinforcing  impulse  for  the  pro- 
pulsion of  the  blood.  I  am  persuaded  that  no  theory  can  explain 
as  well  as  this  one  the  physiological  and  especially  the  pathologi- 
cal facts. 


MM.  Dastre  and  Morat  reply  to  M.  Onimus  in  the  Gaz.  des 
Hdpitaux,  No.  lo,  January  25.  First,  they  claim  to  have  estab- 
lished satisfactorily  the  fact  of  direct  vascular  dilatation  of  the 
bucco-labial  region  from  irritation  of  the  cervical  sympathetic  ;  a 
fact  admitted,  indeed,  by  M.  Onimus.  Their  interpretation  of  the 
fact  only  had  been  questioned  by  him.  A  vaso-dilator  nerve  is 
one,  according  to  any  reasonable  definition,  that,  being  excited, 
causes  a  direct  vascular  dilatation.  There  is,  therefore,  no  ques- 
tion of  interpretation  about  it ;  it  is  merely  a  statement  of  a 
fact. 

Vulpian  and  Claude  Bernard  have  shown  that  there  are  for  the 


ANATOMY  AND  PHYSIOLOGY.  177 

tongue  and  submaxillary  gland  two  orders  of  nerves,  anatomi- 
cally distinct  and  following  different  tracks — the  constrictors  in  the 
hypoglossal  and  sympathetic,  the  dilators  in  the  lingual  and  chorda 
tympani.  MM.  Dastre  and  Morat  claim  that  their  experiments 
show  that  instead  of  its  being  necessary  for  these  two  orders  to 
be  separated  from  each  other  in  different  nerve-trunks  belonging 
to  separate  morphological  systems  (cerebro-spinal  and  sympa- 
thetic), they  may  be  united  in  the  same  trunk  in  the  sympathetic. 
But  this  is  not  admitting  that  they  cease  to  be  distinct.  The  same 
excitation  of  the  cervical  sympathetic  that  causes  simultaneous 
pallor  of  the  tongue  and  reddening  of  the  lip,  distinguishes  phy- 
siologically, so  to  speak,  in  this  complex  trunk,  the  special  ele- 
ments contained,  and  reveals  their  different  actions — constrictive 
for  the  tongue  and  dilator  for  the  lips.  The  cervical  filaments  for 
each  special  region  always  act  in  the  same  way,  and  alternately  in 
both  ways,  as  M.  Onimus  presumes. 

Not  only  is  it  the  case,  as  in  the  cervical  sympathetic,  that  vaso- 
motor nerves  of  opposite  functions  may  exist  in  the  same  general 
nerve-trunk  for  different  regions,  but  it  may  contain  both  vaso- 
constrictors and  vaso-dilators  for  the  same  regions.  The  ex- 
citation of  such  a  nerve-trunk  will  give  rise  to  a  resultant  action, 
which  will  be  vaso-dilator  or  vaso-constrictor  according  as  one  or 
the  other  is  predominant,  and  it  is  conceivable  that  there  might 
be  voluntarily  either  a  constriction  or  a  dilatation.  But  it  is  un- 
reasonable to  conclude  that  the  component  elements  of  such  a 
mixed  nerve  possess  alternately  both  kinds  of  activity.  At  least 
this  is  the  opinion  of  MM.  Dastre  and  Morat  in  reply  to  M.  Onimus. 


The  Reflex  of  Snellen. — At  the  session  of  the  Soc.  de 
Biologic,  of  January  29th  (rep.  in  Le  Frogrh  Medical),  MM. 
Dastre  and  Morat  reported  further  experiments  on  the  sympa- 
thetic vaso-dilator  nerves.  The  auriculo-cervical  nerve  is  very 
easily  reached  in  the  dog,  the  rabbit  and  the  goat,  when  we  dis- 
place the  external  portion  of  the  ear.  Its  section  and  excitation 
of  its  peripheral  portion  give  rise  to  phenomenon  that  have  been 
often  studied.  The  excitation  of  its  central  portion  gives  rise  to 
what  is  known  as  the  reflex  of  Snellen.  When  the  excitation  is 
strong  (Rouget)  this  phenomenon  consists  in  a  congestion  of  the 
corresponding  ear,  remarkable  from  its  intensity  and  its  uni- 
laterality. 

This  vaso-dilatation  is  reflex,  since  the  nerve  excited  is  no  longer 
in  connection  with  the  spinal  cord.     MM.  Dastre  and  Morat  have 


378  PERISCOPE. 

discovered  the  route  of  this  reflex,  its  centripetal  route,  its  central 
track  in  the  cord,  and  its  centrifugal  course,  i.  The  centripetal 
route,  which  conducts  the  excitation  to  the  cervical  cord,  is  formed 
by  the  second  pair  of  spinal  nerves  which  give  out  the  auriculo- 
cervical.  2.  Experiment  demonstrates  that  the  excitation  follows 
in  the  cord  a  descending  track,  leaving  it  below  the  seventh  cer- 
vical pair  of  nerves.  Indeed,  if  we  cut  the  cervical  cord  anywhere 
between  the  third  and  seventh  pairs  of  nerves,  the  reflex  is  de- 
stroyed. If  only  hemisection  is  done,  the  reflex  is  abolished  on 
the  corresponding  side  It  is  certain,  therefore,  that  the  excita- 
tion finds  the  nervous  centre  for  the  reflex  vascular  dilatation  be- 
low the  seventh  cervical  vertebra.  3.  The  excitation  leaves  the 
cord  by  way  of  the  rami  communicantes,  which  leave  the  last 
cervical  pair  to  pass  to  the  lower  cervical  and  first  thoracic  ganglia. 
When  these  filaments  are  cut  the  reflex  is  abolished,  and  when  the 
end  attached  to  the  ganglion  is  irritated  it  reappears. 

These  rami  communicantes  are,  therefore,  veritable  vaso-dilator 
nerves  for  the  ear,  and  the  portion  of  the  cervical  cord  which 
transmits  to  them  the  excitation  contains  the  vaso-dilator  centre 
for  the  ear. 

In  Snellen's  experiment  this  centre  is  put  in  action  by  exciting 
the  central  end  of  the  auriculo-cervical  nerve.  It  may  be  put  in 
action  by  all  other  excitations  that  reach  it.  Among  these  ex- 
citations, MM.  Mathias  Duval  and  Laborde  have  noticed  those 
which,  made  on  the  trigeminus,  are  conducted  directly  by  the 
roots  of  this  nerve  (ashy  tubercle  of  Rolando)  to  the  vaso-dilator 
centre  described  by  MM.  Dastre  and  Morat.  Arrived  at  the  first 
thoracic  and  lower  cervical  ganglion,  these  auricular  vaso-dilator 
fibres  terminate,  or  rather  they  continue  their  route  in  the  cervical 
sympathetic,  mixed  with  vaso-constrictor  fibres  known  to  exist 
there,  and  with  these  gain  the  vessels  of  the  ear.  In  the  first  case 
the  ganglia  of  the  sympathetic  chain  will  be,  like  the  peripheral 
ganglia,  centres  of  reaction  or  of  interference  of  the  two  kinds  of 
nerves,  one  upon  the  other. 

However  it  may  be,  the  vascular  innervation  of  the  ear  is  now 
known.  The  auricular  dilators  and  constrictors  have  distinct 
origins  in  the  cord  ;  there  is  a  cervical  vaso-dilator  centre  and  a 
thoracic  vaso-constrictor  centre.  Both  classes  of  nerves  have  an 
equal  title  to  the  name  sympathetic,  which  is  only  a  new  instance,  in 
particular,  of  the  general  law  formulated  by  MM.  Dastre  and  Morat, 
viz.  :  "  The  great  sympathetic  is  a  mixed  or  double  system  contain- 
ing vaso-dilator  and  vaso-constrictor  nerves  for  all  the  organs." 


ANA  TOM  V  AND  PH  YSIOL OG  Y.  3 79 

The  Excitability  of  the  Motor  Nerves. — At  the  session 
of  the  Societe  de  Biologie,  December  i8  (rep.  in  Le  Pr ogres 
Medical),  a  communication  by  M.  Marcacci  was  read.  In  study- 
ing the  character  of  the  reflex  impulse  produced  by  the  excitation 
of  a  motor  nerve  in  connection  with  the  cord,  M.  Maracacci  ob- 
served a  new  fact  of  interest  as  regards  the  question  of  the  excita- 
bility of  the  motor  nerves.     The  following  is  the  experiment  : 

Opening  the  spinal  canal  of  a  frog,  he  cut  all  the  roots,  motor 
and  sensory,  on  one  side,  reserving  only  one  pair  (motor  root  and 
sensory  root).  Placing  the  excitor  on  the  motor  root,  it  is  irritated 
by  an  induction  discharge,  the  minimum  current  that  will  pro- 
duce a  muscular  contraction  at  the  opening  being  found. 

This  having  been  done,  the  sensory  root  is  then  cut,  and  the 
irritation  again  made.  Now  the  current  that  was  before  too  feeble 
to  produce  any  effect,  produces  an  energetic  contraction  ;  the 
minimum  current  of  before  becomes  a  powerful  excitant  in  this 
new  condition.  The  section  of  the  sensory  root  apparently  in- 
creases considerably  the  excitability  of  the  motor  root. 


Cerebral  Thermometry. — Dr.  R.  W.  Amidon  notices,  N.  Y. 
Med.  Recoj-d,  Dec.  25th,  the  criticisms  by  Franck  on  the  experi- 
ments in  cerebral  thermometry,  and  gives  the  results  of  further 
investigations  on  the  subject  by  himself.  He  repeated  Franck's 
experiments  with  greater  precautions  against  error.  Using  the 
freshly  prepared  cranium,  with  scalp  attached,  brought  up  to  a 
temperature  of  95.5°  F.,  he  injected  warm  water  directly  against 
the  inner  surface  of  the  cranium,  the  thermometer  being  applied 
to  the  shaven  scalp  outside.  The  results  of  these  experiments, 
one  of  which,  performed  in  the  presence  of  Drs.  Seguin,  Putnam- 
Jacobi,  A.  B.  Ball,  and  W.  R.  Birdsall,  is  given  in  detail,  appears 
to  demonstrate  the  following  facts  : 

1.  "  That  heat  can  be  transmitted  through  the  dead  human 
cerebral  envelopes  in  very  appreciable  quantities. 

2.  "  That  it  is  better  transmitted  when  the  envelopes  are  them- 
selves warmed  to  more  nearly  simulate  the  living  textures. 

3.  "  That  the  rise  of  temperature  commences  externally  in  from 
four  to  eight  minutes  after  the  internal  elevation,  and  attains  its 
maximum  in  eight  to  twelve  minutes,  and  that  the  fall  of  the  two 
temperatures  pursues  the  same  course. 

4.  "  The  average  of  eighty  temperatures  taken  shows  a  ratio  of 
the  internal  temperatures  to  the  external  of  2:1. 

"  This  ratio  is  much  diminished  when  the  media  are  warmed, 


380  PERISCOPE. 

hence  it  is  natural  to  suppose  that  in  the  warm,  living  state  the 
ratio  would  be  smaller  still." 

Dr  Amidon  next  takes  up  the  exceptions  that  had  been  made 
to  his  experiments  on  cerebral  thermometry,  in  connection  with 
willed  muscular  movements,  and  gives  details  of  an  experiment 
performed  by  him  in  the  presence  of  Drs.  T,  A.  McBride  and  W. 
H.  Halsted,  which  bore  out  his  former  statements.     He  says  : 

"  In  experiments  properly  performed  I  have  found  the  invaria- 
ble results  : 

I  St.  "  That  within  the  first  two  minutes  a  fall  of  temperature 
takes  place  on  the  same  side  of  the  head  as  the  muscular  move- 
ments. 

2d.  "  That  this  fall  continues  during  the  succeeding  four  or 
five  minutes,  and  may  attain  the  amount  of  1°  F. 

3d.  "  That  at  the  end  of  the  sixth  or  seventh  minute  it  begins 
to  rise,  and  at  the  eighth  to  the  fifteenth  minute  will  regain  its  old 
position,  and  even,  perhaps,  a  slightly  higher  one. 

4th.  "  That  the  temperature  on  the  side  of  the  head  opposite  the 
muscular  movements  sometimes  slightly  falls  at  first,  but  on  or 
before  the  fifth  or  sixth  minute  begins  to  rise,  and  finally  attains 
a  temperature  %°  to  1°  F  higher  than  it  started  with. 

"  These  results  are  deduced  from  an  immense  number  of  ob- 
servations, and  must  be  explained  as  each  one  sees  fit.  I  myself 
adduce  no  theory  to  explain  them.  One  thing,  however,  I  will 
say,  and  that  is,  if  this  rise,  of  temperature  is  produced  by  cerebral 
activity  (and  the  time  of  the  commencement  of  the  rise  of  tem- 
perature, after  the  movements  commence,  is  identical  with  the 
time  consumed  by  the  heat  of  water  to  traverse  the  cerebral  en- 
velopes), the  ultimate  rise  of  temperature  on  the  same  side  may  be 
caused  by  diffuse  radiation  from  the  opposite  side — the  brain,  as 
is  well  known,  being  a  good  conductor  of  heat. 

"  A  final  word  as  to  the  cautions  to  be  exercised  to  make  an  ex- 
periment succeed  : 

1.  "  The  subject  should  be  strong. 

2.  "  The  movements  must  be  vigorous. 

3.  "  The  hair  must  be  thin  or  short. 

4.  "  The  temperature  of  the  room  low  (56°  to  60°  F.,  12.5°  to 
16°  C.)  and  equable."  

The  Reflex  Connections  between  the  Lungs,  Heart  and 
Blood-vessels. — Preliminary  communication  by  Prof.  Dr.  Som- 
merbrodt,  of  Breslau,  in  the  Centralblatt  f.  d.  Med.  Wissensch., 
1880,  No.  49. 


ANATOMY  AND  PHYSIOLOGY.  S^I 

1.  Every  increase  of  intrabronchial  blood  pressure  in  man 
(loud  speech,  singing,  coughing,  running,  climbing,  compressed 
air,  etc.),  causes  irritation  of  the  sensory  nerve  of  the  lungs. 

2.  Hence  follows  [a)  depressive  reflex  action  on  the  vaso- 
motors (diminution  of  vascular  tonus,  dilatation  of  the  blood- 
channels,  lowering  of  the  blood  pressure)  ;  {J))  depressive  reflex 
action  on  the  inhibitory  nerves  of  the  heart  (acceleration  of  the 
heart's  action). 

{a)  and  {!))  increase  the  speed  of  the  blood  current,  and  with  it 
also  the  secretion  of  urine. 

3.  The  utility  of  this  combination  of  reflexes  is  : 

(a)  Compensation  of  the  hindrance  to  the  circulation,  the 
venous  stasis,  due  to  increased  intrabronchial  pressure. 

(/^)  The  securing  of  increased  supply  of  oxygen  and  formative 
material  to  meet  the  more  pronounced  waste  from  action  of  the 
muscles  (in  singing,  etc.),  and  probably  also  of  the  central  organs 
(speaking). 

The  intrabronchial  pressure  is  thus,  through  the  intermedia- 
tion of  the  sensory  nerves  of  the  lungs,  the  regulator  of  the 
rapidity  of  the  circulation. 

4.  Irritation  of  the  sensory  nerves  of  the  lungs  may  also,  with 
the  action  of  2,  {a)  and  (<^),  under  certain  conditions  (probably  in- 
creased irritability  of  the  heart),  in  a  reflex  way  alter  the  cardiac 
rhythm. 

5.  The  retardation  and  alteration  of  the  rhythm  of  the  heart 
found  with  increased  arterial  blood  pressure  by  Knoll  in  experi- 
ments on  animals,  can  also  be  experimentally  produced  in  healthy 
human  beings. 

The  following  are  a  few  of  the  recently  published  articles  on 
the  anatomy  and  physiology  of  the  nervous  system  : 

Holmgren,  Subjective  Color-Sensations  in  the  Color-blind. 
Centralbl.  f.  d.  Med.  Wissenschaft,  Nos.  49  and  50.  iSSo.  Ott. 
The  Inhibition  of  Sensibility  and  Motion.  N.  Y.  Mid.  yonru., 
Jan.  Clevenger,  Central  Anatomy  Simplified.  Cliidigo  Med. 
y^ourn.  ^  Exam.,  Nov.  Cole,  Conjecture  on  Tactile  Sensibility. 
St.  Louis  Med.  &  Surg,  yourn.,  Feb.,  1S81.  Spitzk.\.  Further 
Notes  on  the  Brain  of  the  Iguana  and  other  Sauropsida.  Scicu^i. 
Feb.  19th.  BuFALiM,  On  the  Preparation  of  the  Cylinder  Axis  ot 
the  Nerve-Fibre.  Lo  Speriinentale,  Nov.,  iSSo.  Skf.nk.  Studios 
of  the  Relations  Existing  between  the  Organs  of  ReproductiiMi 
and  the  Brain  and   Nervous  System  in  Women.     Ann.  Anai.  <r' 


382  PERISCOPE. 

Surg.  Soc,  Brooklyn,  Nov.  Hack  Tuke,  Hypnosis  Redivivus. 
y^ourn.  Ment.  Set.,  Jan.  Edgren,  Contributions  to  the  Knowl- 
edge of  the  Temperature  Diseases  Induced  through  the  Influence 
of  the  Nervous  System.  Ibid.  Fisher,  Habitual  Drunkenness. 
Boston  Med.  6^  Surg.  J^ourn.,  Dec.  30th  and  Jan.  6th.  Seguin, 
The  Localization  of  Diseases  in  the  Spinal  Cord.  Ann.  Anat.  6^ 
Surg.  Soc,  Brooklyn,  Dec.  Elliott,  On  Spinal  Irritation,  with 
Deformities  of  the  Limbs  and  other  Affections  Resulting  from  it, 
with  their  Treatment.  Dublin  y^ourn.  of  Med.  Set.,  Nov.  Flem- 
ing, Antero-lateral  Sclerosis.  Am.  J^ourn.  Med.  Sei.,  Jan. 
Crothers,  The  Clinical  Study  of  Inebriety.  7V^.  Y.  Med.  Rec, 
Jan.  15th.  Clark,  Brain  Lesions  and  Functional  Results.  Can. 
y^ourn.  Med.  Sei.,  Jan.  K.eichert,  Notes  on  a  Case  of  Hysteri- 
cal Arthritic  Hyperaesthesia.  JV.  V.Med. Ree.,  Feb.  12th.  Rosen- 
bach,  Remarks  on  the  Theory  of  the  Cheyne-Stokes  Phenomenon. 
Deutsche  Med.  Wochenschr.,  No.  4.  Johnson,  A  Lecture  on 
Backache  and  the  Diagnosis  of  its  Various  Causes,  with  Hints  on 
Treatment.  Brit.  Med.  'yourn.,  Feb.  12th.  Day,  Clinical  Lec- 
ture on  Some  Varieties  of  Nervous  Headache.  Ibid.  Hughes 
Bennett,  Clinical  Lectures  on  Diseases  of  the  Nervous  System  ; 
Lecture  IV,  Chronic  Hemiplegia  Originating  during  the  Puerperal 
State.  Ibid,  Feb.  19th.  Clark,  Brain  Lesions  and  Functional 
Results.  Can.  J^ourn.  Med.  Sei.,  Jan.  and  Feb.  FiTZ,  Diabetic 
Coma  :  its  Relation  to  Acetonsemia  and  Fat- Embolism.  Boston 
Med.  6^  Surg,  y^ourn.,  Feb.  loth.  Williams,  Notes  on  Changes 
Seen  in  the  Eyes  of  Ten  Cases  of  General  Paralysis  of  the  Insane 
Ibid,  Jan.  13th.  Solis  Cohen,  Extreme  Opisthotonos  in  a  Case 
of  Hystero-Epilepsy.  Ibid.  Rockwell,  A  Case  of  Complete 
and  Prolonged  Loss  of  the  Senses  of  both  Taste  and  Smell  ; 
Rapid  Recovery  under  the  Influence  of  Galvanism.  Ibid. 
Abbott  and  Fitz,  A  Case  of  Hydrophobia  of  Doubtful  Origin, 
Boston  Med.QT'  Surg,  yourn.,  Feb.  17th.  Bjerrum,  Hemianopsia 
for  Colors.  Hospitals- Tidende,  Jan.  19th.  Seelegmuller,  On 
the  Pathogenesis  of  Peripheral  Convulsions.  St.  Petersb.  Med. 
Wochenschr.,  No.  2,  Jan.  2 2d.  Putnam,  The  Diagnosis  of  Loco- 
motor Ataxia  in  the  Early  Stages.  Boston  Med.  cr'  Surg,  yourn., 
Nos.  8  and  9.  Echeverria,  Alcoholic  Epilepsy,  yourn.  Ment. 
Sei.,  Jan.  Millberg,  Observations  on  Color-Blindness.  Nord- 
iskt.  Med.  Arkiv,  xii,  1880,  No.  24.  De  Fontenay,  Statistics  of 
Congenital  Daltonism  in  Denmark,  Ibid,  No.  18.  Medin,  On 
Epidermic  Cerebro-spinal  Meningitis  in  Children.  Ibid,  No.  16. 
Wising,  On  a  Case  of  Chronic  Mercurialism,  Simulating  Multiple 


PATHOLOGY.  3^3 

Sclerosis.  Ibid,  No.  17.  Beard,  Nervous  Diseases  Connected  with 
the  Male  Genital  Function  ;  VI.  N.  Y.  Med.  Record,  Feb.  19th. 
DiTZEL,  Tetanus  Puerperalis.  IIosp.-Ttdende,]3.x\.  5th.  Preyer, 
On  the  Theory  of  Color-Blindness.  Centralbl.  f.  d.  Med.  Wis- 
sensch..  No.  i.  Mommsen,  On  the  Alterations  of  Irritability  of 
the  Nerves  from  Various  Agencies,  especially  Poisons.  Virchow's 
Archiv,  Ixxxiii,  2  Heft,  p.  243.  Beck,  A  Case  of  Myelitis 
Lateralis  Dextra  Traumatica  Ascendens  (Hemiplegia  Spinalis), 
Complicated  with  Osteomyelitic  Coxitis  and  Luxatio  Spontanea, 
etc.     Ibid,  p.  301. 


^. — PATHOLOGY  OF  THE  NERVOUS  SYSTEM  AND  MIND, 
AND  PATHOLOGICAL  ANATOMY. 


Trophic  Disorders  with  Cerebral  Paralysis. — Erb  has 
stated,  Zmsns.  Hdbch.,  xii,  ii,  2d  Anfi.,  p.  420  that  trophic  dis- 
orders are  rare  with  cerebral  paralysis,  and  that,  excepting  with 
bulbar  paralysis,  atrophy  almost  never  occurs.  Forster  of  Dres- 
den, Deutsche  Med.  Wochenschr.,  Dec.  nth,  takes  issue  with  this 
statement.  Within  two  years  he  had  had  six  well-marked  cases 
of  cerebral  hemiplegia  in  children,  all  six  with  characteristic  im- 
plication of  the  facial  and  hypoglossal  nerves  and  with  retention 
of  the  faradic  muscular  irritability.  Four  of  these  six  cases  had 
been  under  observation  for  considerable  periods  after  the  onset  of 
the  paralysis  :  one  seven  months,  one  a  year  and  ten  months,  and 
the  other  two,  five,  and  six  and  a  quarter  years  respectively.  In 
all  these  cases  he  found  a  shortening  of  both  limbs  on  the  para- 
lyzed side  :  in  two  cases  of  one,  in  one  of  one  and  a  half,  and  in 
one  of  two  centimetres.  One  child,  examined  three  weeks  after 
the  attack,  had,  on  the  paralyzed  side,  ^  centimetre  less  circum- 
ference around  the  calf,  a  difference  that  five  months  later  had 
increased  to  one  centimetre.  Another,  five  weeks  after  the  attack, 
showed  a  difference  of  one  centimetre,  and  the  three  older  cases 
exhibited  from  ^  to  2  centimetres  less  circumference.  In  only 
one  out  of  the  six  was  no  change  noticeable. 

These  discrepancies  in  the  circumference  of  limbs  which  at 
most  were  only  of  from  sixteen  to  eighteen  centimetres  around, 
are  sufficiently  prominent.  But  there  were  other  marked  signs  of 
atrophy  ;  flaccidity  and  doughy  muscles  and  very  obvious  wasting 
of  individual  muscles,  such  as  the  deltoid,  abductor  pollicis,  etc. 


384  PERISCOPE. 

In  two  of  the  cases  there  was  notable  increase  of  the  tendon 
(patellar  reflex)  on  the  paralyzed  side.  These  facts  would  seem  to 
indicate  an  implication  of  the  anterior  spinal  cornua  and  of  the 
lateral  columns  in  certain  regions  in  the  diseased  processes,  and 
make  it  appear  advisable  to  institute  special  researches  into  the 
condition  of  the  cord  in  such  cases  whenever  opportunity  is 
afforded.  But  in  ordinary  poleomyelitis  the  atrophy  of  the 
muscles  is  not  always  attended  with  a  diminution  of  the  length  of 
the  limbs.  Forster  has  recently  examined  cases  of  two  years' 
standing  and  with  notable  muscular  atrophy,  in  which  there  was 
not  the  least  degree  of  shortening.  It  may  be  presumed,  there- 
fore, that,  whether  the  centres  governing  longitudinal  growth  are 
situated  in  the  anterior  horns  with  those  for  the  nutrition  of  the 
muscles,  they  are  not  always  simultaneously  or  at  least  not  pro- 
portionately affected  with  these  latter  in  the  cases  mentioned. 


Grave's  Disease. — Dr.  Chas.  Abadie,  Z'  Union  Me'dicale,  Nov. 
28,  describes  a  case  of  imperfectly  developed  exophthalmic  goitre 
in  which  the  prominence  of  the  right  eye  was  the  only  marked 
special  symptom  apart  from  the  general  anaemia  and  constitutional 
disturbance.  He  offers,  as  a  hypothesis  to  account  for  these  un- 
developed cases,  the  idea  that  the  symptoms  in  this  disease  depend 
upon  the  portion  of  the  cervical  sympathetic  especially  involved. 
Thus,  he  thinks,  pronounced  disorder  in  any  one  of  the  cervical 
ganglia  will  produce  the  symptoms  of  Grave's  disease  in  the  part 
most  directly  connected  with  that  ganglion  ;  if  the  superior  cervi- 
cal is  mainly  affected,  then  exophthalmus  will  be  the  most  pro- 
nounced ;  if  the  middle,  thyroid  enlargement  will  be  the  predomi- 
nant symptom,  and  if  the  lower  cervical  ganglion  is  most  diseased, 
then  the  cardiac  innervation  will  suffer.  In  this  way  he  seeks  to 
account  for  the  various  partially  developed  syndromes  of  this 
affection.  

Color-Blindness  in  Diseases  of  the  Optic  Nerve. — Ed- 
ward Nettleship,  F.R.C.S.  (London),  read  a  paper  on  this  sub- 
ject at  the  forty-eighth  annual  meeting  of  the  British  Medical  As- 
sociation (reported  in  Brit.  Med.  /our.,  Nov.  13,  1880),  held  at 
Cambridge,  August,  1880. 

This  paper  contained  a  summary  of  observations  in  seventy- 
nine  cases  of  uncomplicated  disease  of  the  optic  nerves,  including 
cases  of  tobacco-amblyopia  and  some  cases  of  atrophy  following 
neuritis.      Cases   of   glaucoma   and  of  retinitis  pigmentosa,   and 


PATHOLOGY.  -  385 

certain  cases  of  congenital  amblyopia  with  color-blindness  and 
day-blindness,  were  not  included.  In  fifty,  the  visual  field  was 
carefully  measured  on  the  perimeter  ;  and  the  observations 
offered  to  the  meeting  bore  chiefly  on  the  various  relations  existing 
in  these  cases  between  the  three  factors  :  color-perception,  acute- 
ness  of  vision,  and  condition  of  the  visual  field.  The  following 
groups  were  then  mentioned  :  i.  color-blindness  of  a  high  degree 
is  always  present  when  acuteness  of  sight  is  low,  and  the  field  of 
vision  presents  a  high  degree  of  sharply-defined  but  irregular  con- 
traction. This  group  includes  the  common  cases  of  progressive 
atrophy  often  associated  with  early  locomotor  ataxy,  but  also  fre- 
quently occurring  without  spinal  symptoms.  The  author  had 
never  seen  atrophy  of  the  optic  nerves  in  locomotor  ataxy  without 
color-blindness.  2.  When  the  visual  field  shows  a  uniform  con- 
traction, moderate  in  degree,  but  not  very  sharply-defined,  and 
perhaps  only  relative,  though  acuteness  of  sight  may  be  very -low 
(as  low  as  -g^),  color-perception  is  seldom  much  affected,  and  may  be 
quite  perfect.  Such  cases  were  considered  rare.  3.  If  the  alter- 
ation of  the  field  take  the  form  of  a  central  defect  (central  rela- 
tive scotoma),  its  circumference  being  of  full  size,  though  acute- 
ness of  sight  may  be  as  low  as  -jV,  or  even  yV)  color-perception  of 
large  objects  is  but  little,  and  often  not  at  all,  damaged  ;  but  par- 
tial or  complete  color-blindness  for  small  spots  of  red  and  green 
exists  ;  and  such  patients  are,  therefore,  likely  to  mistake  colored 
signal  lights.  Nearly  all  these  cases  of  central  amblyopia  are 
caused  by  tobacco.  4.  The  visual  field  may  show  a  high  degree 
of  sharply  defined  irregular  contraction,  but  with  perfect  acute- 
ness of  vision.  In  such  cases,  {a)  there  may  be  marked  color- 
blindness (two  cases  were  mentioned)  ;  (3)  there  may  not  be  the 
slightest  defect  for  colors,  of  which  condition  also  two  cases  in 
men  were  mentioned,  and  two  others  in  women,  lately  recorded 
from  Hirschberg's  clinique,  referred  to.  The  difference  between 
the  subgroups  {a)  and  {b)  in  regard  to  color-perception  was  most 
striking.  5.  The  field  of  vision  may  be  perfect  in  size  and  free 
from  any  scotoma,  with  acuteness  of  vision  as  low  as  y^,  and  {a) 
perfect  color-perception  (as  in  a  woman  whose  case  was  men- 
tioned) ;  or  {b)  color-blindness,  sometimes  of  considerable  degree, 
may  be  present,  two  cases  in  young  men  being  mentioned  in  con- 
firmation. 

Mental  Failure  from  Strain. — The  Medical  Press  atid  Cir- 
cular states  that  Dr.  Maclaren,  superintendent  of  a  prominent  in- 


386  PERISCOPE. 

sane  asylum,  has  observed  among  the  patients  sent  to  that  asylum 
a  form  of  insanity  which  is  not  melancholia  and  v/hich  is  not  de- 
mentia, although  it  may,  at  first  sight,  be  taken  for  one  or  the 
other  of  these,  but  which  seems  to  be  grave  nervous  exhaustion. 
It  persistently  appears  in  men  who  belong  to  the  skilled  artisan 
class.  It  must  be  remembered  that  the  intelligent  workman  of 
the  present  day  is  a  very  different  person  from  the  labor  of  a  for- 
mer one,  and  uses,  and  probably  overtaxes  his  brain  nearly  as 
much  as  professional  or  business  men  do.  The  attack  to  which 
Dr.  Maclaren  refers,  especially  affects  the  middle-aged,  whose 
previous  history  is  that  they  have  been  steady  hard-working  men 
who  have  saved  a  little  money,  and  who  have  always  been  of  an 
anxious  turn  of  mind.  In  almost  all  instances  they  have  been 
men  of  aspiring  temperament,  but  without  the  intellectual  ability 
which  has  enabled  a  few  of  their  class  to  rise  entirely  above  it. 
Yet  they  are  not  content  to  remain  in  their  station  and  so  they 
plod  and  toil,  and  become  a  prey  to  anxieties.  Ultimately  the 
prospect  of  obtaining  a  high  position  is  lost,  and  then  they  con- 
centrate their  desires  on  accumulating  money.  Their  whole  time  is 
occupied  in  laboring  and  planning  to  increase  their  store,  and  they 
are  vexed  by  apprehensions  lest  their  schemes  should  miscarry. 
The  hours  which  should  be  devoted  to  sleep  are  given  up  to  work 
or  to  miserly  calculations,  and  then  when  an  illness  or  a  grief  comes 
upon  them,  they  break  down  miserably.  They  are  reduced  to  a 
state  of  utter  and  complete  prostration,  mental  and  physical.  The 
surface  of  the  body  is  cold  and  pale,  the  pulse  is  feeble,  and  the 
mental  condition  is  listless  to  an  extraordinary  degree.  Power 
and  force  seem  gone  forever,  and  the  stalwart,  well  set-up,  acute- 
looking  artisan  of  a  short  time  ago,  is  reduced  to  a  gray,  bent, 
nerveless  invalid. 

In  this  utter  loss  of  physical  power  is  one  of  the  marked 
distinctions  between  this  variety  of  mental  disease  and  mel- 
ancholia. The  cases  of  this  kind  which  Dr.  Maclaren  has 
seen  improved  under  treatment,  but  never  recovered  the  tone 
of  former  days.     Med.  and  Surg.  Reporter,  Feb.  5  th. 


The  Pathological  Anatomy  of  Hallucinations. — Luys 
{Gaz.  des  Hopitaux^  1880,  No.  142)  states  that,  as  the  result  of 
many  years  of  study  of  the  brains  of  subjects  of  hallucinations  and 
illusions,  he  has  discovered  certain  interesting  peculiarities  in  the 
cortex  and  optic  thalami.     Those  in  the  former  location  are  of 


PATHOLOGY.  S^/ 

two  kinds,  localized  hypertrophy  and  atrophic  conditions  more  or 
less  marked.  The  meninges  are  found  somewhat  congested,  but 
the  adhesions  met  with  in  general  paralysis  are  lacking.  In  the 
cortex  itself  the  characteristic  lesion  is  a  prominence  of  the  para- 
central lobule  when  viewed  on  the  internal  face  of  the  hemisphere. 
In  the  normal  brain  the  curve  of  the  superior  edge  of  the  hemi- 
sphere is  regular,  but  in  these  cases  it  becomes  even  gibbous  in 
this  isolated  cortical  region.  On  incision  it  is  seen  that  the  cere- 
bral substance  is  increased  and  the  folds  more  developed.  On  the 
convex  face  of  the  hemisphere  it  is  seen  that  the  two  marginal 
convolutions  are  also  swollen  and  more  sinuous. 

This  peculiarity  may  appear  on  one  or  on  both  cerebral  hemi- 
spheres, but  it  most  frequently  shows  itself  on  only  one.  It  is 
more  liable,  M.  Luys  thinks,  to  be  double  in  old  cases. 

This  peculiarity  in  this  particular  region  in  the  brains  of  certain 
lunatics  had  been  already  noticed  by  Parchappe  {Tratte  de  Folic, 
p.  147),  but  had  not  been  associated  with  these  special  symptoms 
during  life. 

The  atrophic  alterations  claimed  by  Luys  to  be  associated  with 
hallucinations  are  most  noticeable  in  the  first  frontal  convolution, 
which  is  diminished  in  size  and  the  fissures  enlarged  and  patent. 
The  second  frontal  also  shares  frequently  in  the  change,  and  the 
Rolandic  sulcus  and  the  parieto-occipital  are  widened  and  gaping. 
Sometimes  the  calloso-marginal  convolution  is  notably  atrophied. 
Microscopic  examination  reveals  the  superior  cortical  layers 
grayish  and  gelatinous,  and  infiltrated  with  serum,  the  deeper  ones 
often  reddened  and  with  strongly  injected  and  abundant  vessels. 
The  nerve  cells  are  scattered,  and  those  that  are  seen  are  covered 
with  yellowish  granulations,  or  in  a  more  or  less  advanced  con- 
dition of  degeneration. 

The  optic  thalami  in  subjects  of  chronic  hallucinations  exhibit 
certain  degenerations  that  indicate  that  marked  circulatory  dis- 
turbances have  occurred.  Sometimes  these  changes  are  minute 
hemorrhagic  foci  in  various  phases  of  absorption,  showing  them- 
selves in  minute  brownish  or  wine-colored  spots  ;  or  again,  there 
are  areolar  cavities  disseminated  through  the  nuclei,  constituting 
foci  of  softening,  connected  with  atheromatous  degeneration  of 
the  walls  of  the  capillaries. 

A  special  form  of  chronic  alteration,  sometimes  met  with  in 
these  cases,  is  sclerosis  degeneration.  In  some  cases  the  thalami 
are  found  pale  and  almost  exsanguined,  and  on  section  the  blood- 
vessels are  seen  gaping,  as  if  there  existed  a  veritable  interstitial 


388  PERISCOPE. 

sclerosis.  Microscopic  examination  reveals  sclerosis,  which,  start- 
ing in  a  morbid  thickening  of  the  ependyma,  insinuates  itself  into 
the  central  mass  in  the  form  of  perivascular  trabecules,  and  finishes 
by  invading  the  different  nuclei  and  crowding  out  the  nervous 
elements.  This  interstitial  sclerosis  is  accompanied  by  partial 
hyperaemias  and  a  large  proportion  of  amyloid  corpuscles.  Its 
tissue  is  formed  by  a  very  fine  reticulum,  very  compact,  and  form- 
ing a  homogeneous  mass.  This  invading  neoplasm  produces  all 
the  usual  disturbances  of  nutrition  in  the  active  nervous  elements. 
The  nerve  cells  become  more  or  less  scattered,  so  that  in  some 
parts  they  are  met  with  only  in  clusters  here  and  there.  Those 
that  do  remain  are,  generally,  granular,  attenuated,  and  in  various 
stages  of  degeneration. 

In  the  acute  forms  of  the  hallucinatory  process,  and  in  cases 
that  succumb  during  the  period  of  excitation,  we  find  a  very  in- 
tense vascularization  in  the  central  portions  of  the  nuclei,  and  par- 
ticularly in  the  gray  substance  of  the  third  ventricle.  Occasionally 
in  the  external  regions  of  the  optic  thalami,  where  the  fibres  of  the 
radiant  crown  of  Reil  are  lost  in  the  substance  of  the  ganglion,  the 
nerve  cells  are  found  notably  increased  in  volume,  and,  con- 
sequently, apparently  in  a  condition  of  functional  super-activity. 

In  a  certain  number  of  hypochondriacs  who  have  had  during  life 
either  illusions  or  hallucinations  of  the  visceral  sensibility,  M.  Luys 
has  observed  that  the  networks  of  the  central  gray  substance,  which 
represent  the  localities  of  transmissions  of  impressions  irradiated 
from  the  visceral  periphery,  were  the  seat  of  patches  of  hypercemia, 
of  diffuse  reddened  spots,  which  indicate  the  persistent  traces  of 
foci  of  hyperaemia,  neatly  localized.  In  these  cases  the  walls  of 
the  third  ventricle  were  more  or  less  rose-tinted  and  exhibited 
scattered,  discrete,  vascular  striations,  and  here  and  there  patches 
of  very  intense  hyperaemia. 

In  the  above  pathological  findings  we  have,  as  M.  Luys  points 
out,  evidences  of  chronic  hyperaemia  ;  traces  of  old  congestions  in 
the  central  gray  matter  of  the  optic  thalami  and  the  third  ventricle  ; 
and  also  similar  traces  of  hyperaemia  with  concomitant  degenera- 
tions in  various  portions  of  the  cortex.  These  two  centres  of 
cerebral  activity  are  found  associated  in  their  morbid  conditions 
as  in  their  functions.  In  the  physiological  conditions  it  is  the  cells 
of  the  nuclei  of  the  optic  thalami  that  transmit  to  the  various  cor- 
tical regions  the  impressions  that  pass  by  their  networks.  In 
pathological  conditions  the  same  cellular  elements  enter  tnotu 
propria  into  action,  under  the  influence  of  local  excitation,  of  per- 


PATHOLOGY.  389 

sistence  of  certain  vibrations,  and  of  special  circulatory  troubles, 
and  transmit  to  the  cortex  incitations  created  in  themselves  and 
having  no  connection  whatever  with  the  external  world.  These 
fictitious  incitations  are  then  dispersed  over  the  receptive  tracts  of 
the  cortex,  and  produce  in  the  sensorium  their  special  sensorial 
disorders  and  appropriate  emotional  states.  Hence  the  various 
concepts  of  the  subjects  of  hallucinations  and  their  obstinate  ab- 
normal emotive  conditions.  The  hallucinatory  stimulus  is  always 
in  its  beginning  sensorial  in  its  nature  according  to  the  special  set 
of  cells  in  which  it  takes  rise,  whether  auditory,  visual,  gustatory, 
etc.  But  like  all  similar  normal  stimulations  destined  to  lose 
themselves  in  the  sensorium,  it  is  natural  for  this  to  diffuse  and 
implant  itself  there,  and  in  the  centre  of  psychic  activity  it  gradu- 
ally loses  its  primary  sensorial  character  and  takes  on  a  different 
form  of  existence,  losing  all  apparent  traces  of  its  origin.  What 
was  first  a  simple  morbid  excitation  of  the  sensory  cells  in  the 
thalamus,  is,  according  to  this  theory  of  M.  Luys,  transmitted  to 
the  cortex,  where  it  elaborates  itself  into  complete  psychic 
conceptions. 

The  unilateral  character  of  the  cortical  changes  observed  is 
noteworthy,  and  may  possibly  help  to  explain,  M.  Luys  thinks, 
certain  unilateral  hallucinations  and  the  co-existence  of  hallucina- 
tions with  perfect  sanity. 

As  to  the  etiology  of  hallucinations  it  will  be  readily  seen  from 
the  above  that,  according  to  M.  Luys'  views,  lively  impressions 
which,  made  upon  the  senses,  leave  their  impress,  may  be  revived 
through  morbid  irritations  of  the  portions  of  the  brain  involved, 
by  arjything,  for  example,  that  can  disturb  sufficiently  their  circu- 
lation, such  as  cerebral  congestion  from  any  cause,  certain  drugs, 
etc. 

The  Relation  of  the  Ovaries  to  the  Brain  and  Ner- 
vous System,  is  the  subject  of  a  paper  read  before  the  New 
York  Academy  of  Medicine,  December  i6th,  by  Dr.  Alex.  J.  C. 
Skene,  and  printed  in  full  in  the  American  jf^ournal  of  Obstetrics, 
for  January.  After  speaking  of  the  general  functional  connec- 
tions of  different  organs  and  their  influence  upon  each  other  in 
health  and  disease,  he  discussed  the  ovaries  in  their  relations  to 
the  other  sexual  organs.  Everything  pointed  to  the  conclusion 
that  they  were  paramount  in  reproduction  and  in  the  mainte- 
nance of  the  relationship  between  the  general  and  the  sexual  sys- 
tems of  women.     He  accepted,  without  qualification,  the  state- 


390  PERISCOPE. 

ment  of  Virchow  and  others  that  the  ovaries  give  to  woman  all 
her  characteristics  of  body  and  mind. 

Then  referring  to  the  reciprocal  influence  of  the  nervous  sys- 
tem and  the  reproductive  functions,  attention  was  directed 
to  the  fact  that  the  sexual  organs,  while  dependent  on  the 
general  nutritive  system  for  support,  reacted  again  upon  the  or- 
ganism as  well  as  were  affected  by  its  conditions.  From  a  some- 
what extended  consideration  of  the  subject  he  was  convinced  that 
a  great  many  affections  of  the  brain  and  nervous  system  were  due 
to  disease  of  the  ovaries.  Their  imperfect  development  not  only 
modified  the  physical  peculiarities  of  woman  but  also  retarded  the 
development  of  the  higher  nerve  centres.  A  large  part  of  the 
brain  and  nerve  power  of  woman  is  devoted  to  reproduction,  and 
when  a  woman  is  deprived  of  her  sexual  organs,  the  nutritive  sys- 
tem might  attain  a  normal  development  but  the  nervous  system 
does  not.  There  is  usually  mental  weakness  and  often  mental 
disorder  among  those  whose  ovaries  are  imperfectly  developed. 
Twelve  out  of  sixteen  young  women  under  his  observation  in  an 
insane  asylum,  had  imperfectly  developed  sexual  organs.  Some 
of  them  had  never  menstruated  and  others  only  imperfectly,  and 
the  history  of  these  cases  led  him  to  think  that  defective  develop- 
ment of  the  ovaries  is  an  important  factor  in  the  production  of 
insanity.  At  any  event,  there  was  enough  in  them  suggesting  this 
to  invite  further  investigation  to  settle  the  question  as  to  the  rela- 
tions between  the  ovaries  to  insanity  and  other  nervous  disor- 
ders occurring  at  puberty. 

Next  speaking  of  the  effects  of  derangements  of  menstruation 
on  the  nervous  system.  Dr.  S.  holds  that,  in  estimating  these 
effects,  the  relative  power  of  the  different  sexual  organs  has  not 
been  adequately  considered.  In  the  forms  of  dysmenorrhoea  con- 
nected with  ovarian  derangements,  he  thinks  the  nervous  system 
is  much  more  disturbed,  as  a  rule,  in  proportion  to  the  local  pain, 
than  in  those  due  to  uterine  lesions  of  flexion  or  displacement. 
The  ovaries  also  act  directly  on  the  uterus,  and  we  find  menstrual 
derangements  with  perfectly  normal  conditions,  except  evidence 
of  imperfect  ovarian  development  or  ovarian  disease.  When  such 
patients  suffer  from  nervous  affections  it  is  common  to  hear  it 
said  that  they  are  due  to  the  menstrual  disorder,  while  in  reality 
tlje  point  of  departure  from  health  is  in  the  ovaries. 

Degenerations  of  the  ovaries,  including  neoplasms,  do  not  seem 
to  be  attended  with  nervous  derangement,  beyond  such  as  is  due 
to  the  mechanical  disturbance  by  tumors,  etc. 


PATHOLOGY.  39 1 

He  believes  that  inflammatory  affections  and  displacements  of 
the  ovaries  are  more  likely  to  cause  serious  remote  effects,  than 
disease  of  any  other  pelvic  organs.  Indigestion,  spinal  irritation, 
neuralgias,  headaches,  insanity,  etc.,  attributed  to  uterine  disease, 
can  often,  by  careful  search,  be  referred  to  some  accompanying 
trouble  with  the  ovaries.  The  conclusion  reached  by  him,  from 
years  of  observation  and  experience,  is  that  while  uterine  disorder 
does  often  disturb  the  nervous  system,  it  does  so  to  a  far  less  ex- 
tent than  disease  of  the  ovaries.  He  reviews  a  complication  of 
symptoms  connected  with  simple  ovarian  tenderness,  and  practi- 
cally nothing  more,  which  may  be  attributed  or  not  to  inflamma- 
tion, according  to  the  view  accepted  by  the  author.  These  symp- 
toms comprise  considerable  systemic  disturbance,  and  sometimes 
great  mental  irritation  and  hysterical  manifestations.  Prolapsus 
of  the  ovaries,  from  whatever  cause,  also  produces  serious  nervous 
disturbance,  and  he  attributes  to  the  presence  of  this  complication 
the  much  greater  general  disorder  observed  in  some  cases  of  lacer- 
ation of  the  cervix  than  in  others.  The  nervous  disorders  ob- 
served with  some  cases  of  pelvic  peritonitis,  are  also  attributed  to 
involvement  of  the  ovaries  in  the  morbid  process,  and  in  two 
cases  of  mania  with  uterine  cancer,  that  came  under  his  observa- 
tion, he  was  also  led  to  suppose  that  the  ovaries  were  the  disturb- 
ing elements.  Dr.  Skene  agrees  with  Peaslee,  who  held  that  hys- 
teria was  connected  with  some  condition  of  the  ovaries  rather 
than  with  uterine  disease,  and  the  recent  developments  by  Char- 
cot and  others,  in  regard  to  the  condition  known  as  hystero- 
epilepsy,  seem  to  favor  this  view. 

The  diagnosis  of  ovarian  disease  naturally  presents  some  diffi- 
culties, the  nature  of  many  of  these  affections  and  their  clinical 
history  being  as  yet  imperfectly  understood.  This  is  less  the 
case  with  ovaritis  and  displacement,  in  regard  to  which  he  referred 
to  Dr.  Munde's  paper  in  the  fourth  volume  of  the  gynecological 
transactions.  Menstrual  derangements  and  the  graver  conditions 
of  nymphomania  and  epilepsy  are  much  more  difficult  for  diagnosis, 
and  the  varied  results  obtained  by  Battey  and  others  from  re- 
moval of  the  ovaries,  show  clearly  how  uncertain  even  the  best 
authorities  may  be  in  this  respect.  The  exact  relations,  causative 
or  secondary,  of  the  ovarian  trouble  at  the  time  must  be  carefully 
searched  out.  The  products  of  pelvic  inflammation  may  cause 
reflex  irritation,  and  the  ovaries  be  only  the  secondary  sufferers 
rather  than  the  primal  cause.  A  case  related  by  Battey  in  which 
he  was  only  able  to  break  up  old  adhesions  instead  of  removing 


392  PERISCOPE. 

the  ovaries,  is  in  point,  since  relief  was  obtained  by  merely  this 
operation. 

The  treatment  of  ovario-neuroses  is  considered  very  briefly  by 
the  author.  Both  the  nervous  system  and  the  sexual  organs 
should  be  treated,  not  one  to  the  exclusion  of  the  other.  In 
amenorrhoea,  or  irregular  or  scanty  menstruation,  local  stimulants 
and  especially  electricity  are  useful.  Marriage  is  generally  bene- 
ficial in  irritable  and  congested  conditions  of  the  ovaries,  but  is 
disastrous  in  inflammatory  affections  and  prolapsus.  In  this  lat- 
ter condition,  something  can  be  done  in  the  way  of  mechanical 
relief  by  pessaries  and  postural  treatment  ;  local  sedatives  and 
counter-irritation  are  also  sometimes  beneficial.  The  bromides 
are  sometimes  of  the  greatest  value  in  obscure  ovarian  disease, 
and  Dr.  Skene  prefers,  as  least  likely  to  disagree  with  the  stomach, 
the  bromide  of  sodium,  and  gives  large  and  frequently  repeated 
doses  till  its  characteristic  effect  is  produced.  Conium  may  be 
used  in  the  same  way.  It  is  not  advisable  to  make  prolonged  use 
of  these  drugs,  at  least  not  in  large  doses,  and  they  should  be  com- 
bined with  tonic  treatment.  The  state  of  the  bowels  ought  to  be 
carefully  looked  after,  as  constipation  aggravates  the  suffering. 
Opium,  chloral,  and  alcohol  often  give  relief,  but  their  use  should 
be  limited  and  carefully  watched,  as  these  patients  readily  acquire 
a  dependence  on  such  agents. 

The  paper  concludes  with  an  account  of  five  cases  illustrating 
the  ideas  contained  in  the  paper. 


Local  Symmetrical  Asphyxia  of  the  Extremities. — In 
the  Gaz.  des  Hopitaux,  No.  13,  Feb.  i.  M.  Hardy  gives  an  ac- 
count of  a  case  now  in  the  Hospital  La  Charite  at  Paris,  of  an 
affection  rather  rare  in  its  advanced  form  here  described,  but 
which  in  its  earlier  and  middle  stages  is  not  altogether  unfrequent. 
It  was  that  of  a  young  man  who,  after  having  been  exposed  to  a 
sudden  change  from  a  high  temperature  to  cold,  was  taken  with 
paralysis  of  both  hands  ;  sensation  of  all  kinds  being  completely 
lost,  and  motion  to  a  very  large  extent,  and  completely  as  regards 
the  hands.  There  was  also  a  slight  choreic  movement  of  the  eye- 
lids, and  a  bluing  of  vision.  This  was  the  second  time  the  patient 
had  been  thus  attacked,  the  former  attack  having  lasted  six 
months.  M.  Hardy  gives  to  the  disorder  the  name  of  local  sym- 
metrical asphyxia  of  the  extremities,  and  considers  it  only  a  degree 
of  the  disorder  described  by  M.  Maurice  Raymond  under  the 
name  of  symmetrical  gangrene  of  the  extremities,  a  condition 


PATHOLOGY.  393 

only  very  rarely  met  with  in  its  full  development.  The  much 
more  frequently  observed  "  digiti  mortui "  is  a  still  milder  and 
more  temporary  phase  of  the  same  complaint.  The  following  are 
M.  Hardy's  general  remarks  on  the  disorder  : 

"  It  affects  especially  young  persons,  from  fifteen  to  thirty  years 
old  ;  both  sexes  are  liable  to  it,  but  females  appear  to  be,  accord- 
ing to  the  observations,  more  predisposed  to  it  than  males.  The 
immediate  cause  is  exposure  to  cold.  Unfortunately  this  cause  is 
not  proven,  for  the  first  attack  of  our  present  patient  occurred 
in  the  month  of  July. 

"  The  disease  exhibits  three  different  periods  or  degrees  of 
development.  The  first  is  characterized  by  numbness  or  pallor  of 
one  or  more  fingers  or  of  the  whole  hand.  This  is  what  is  called 
'  dead  fingers,'  these  members  appearing  white  as  if  bloodless, 
the  patient  declaring  that  sensation  is  lost.  This  period  has  been 
called  by  M.  Raymond  '  local  syncope.'  I  do  not  like  this  term 
'  syncope,'  which  indicates  properly  an  arrest  of  the  cardiac  cir- 
culation, and  much  prefer  that  of  '  local  anaemia,'  which  seems 
to  me  to  better  express  the  actual  conditions. 

"  The  disorder  may  stop  at  this  point,  the  phenomenon  being, 
from  time  to  time,  reproduced,  lasting  a  few  hours  or  days,  and 
the  members  then  recovering  their  normal  appearance  and 
condition. 

"  The  second  period  or  degree  is  characterized  by  the  local 
asphyxia  of  the  extremities  described  in  the  present  case,  a  lesion 
constantly  symmetrical,  occupying  either  the  feet  or  the  hands, 
and  usually  both  at  the  same  time.  The  symptoms  are  numbness 
and  coldness  of  the  tissues,  so  that  the  temperature  is  lowered  in 
the  parts  involved  to  21°,  20°,  or  even  19°  C.(  =  7o°,  68°,  66.5°  F.). 
There  is  also  blueness,  violaceous  or  cyanosed  coloration,  disap- 
pearing under  pressure  to  slowly  return,  and  more  or  less  com- 
plete anaesthesia,  that  is,  diminution  or  abolition  of  the  tactile 
sensibility,  of  that  to  pain  and  to  temperature.  Finally,  in  almost 
all  cases  the  patients  experience  spontaneous  lancinating  pains, 
like  that  of  a  severe  burn,  so  severe  at  times  as  to  prevent  sleep 

or  rest  and  to  call  forth  loud  cries, 
**■»** 

"  The  third  period  is  that  which  really  deserves  the  name  given 
to  the  disease  by  M.  Raymond,  viz.,  symmetrical  gangrene  of  the 
extremities.  After  generally  a  rather  lengthy  period,  there  are 
found  on  the  affected  parts  phlyctenulae  containing  dark-colored, 
sometimes  even  bloody  serum,  which  breaks  after  a  while,  leaving 


394  PERISCOPE. 

an  ulceration  that  gradually  dries  up,  and  gradually  other  phlyc- 
tenulse  appear  and  act  in  the  same  way.  The  termination  may 
occur  in  one  of  two  ways  :  either  the  fingers  become  more  and 
more  tapering,  the  skin  clings  to  the  subjacent  tissues,  and  there 
is  a  veritable  sclerodermy  with  alteration  of  the  tactile  sense,  or 
the  disorder  terminates  in  a  genuine  gangrene,  dry,  black,  with 
atrophy  of  the  integuments,  with  all  the  characters  of  senile  gan- 
grene, suppuration,  sloughing  of  black  eschars  and  mortified  por- 
tions, and  the  patient  recovers  with  mutilation. 

"  The  recovery,  whatever  the  form  of  the  disease,  is  invariable, 
after  a  varying  period,  generally  protracted. 

"  In  our  patient  we  have  the  second  stage  of  the  disease,  with 
some  variations  from  the  tableau  described  by  M.  Raymond.  Thus, 
on  the  one  hand,  there  are  none  of  the  spontaneous  pains  men- 
tioned by  that  author,  and,  on  the  other,  there  is  a  muscular  par- 
alysis that  has  not  been  heretofore  observed,  or  which,  at  least, 
has  not  extended  further  than  slight  benumbing.  Finally,  our 
patient  is  now  a  second  time  affected.  Relapses  have  been  ob- 
served before  in  this  affection  by  my  colleague  at  La  Charite,  with 
this  peculiarity,  that  they  generally  are  each  time  worse  than  the 
preceding  attack. 

"  The  treatment  is  indicated  by  the  nature  of  the  disease,  which 
is  of  nervous  origin.  Thus,  long  applications  of  the  constant  cur- 
rent, irritant  frictions  with  camphorated  alcohol,  tincture  of  nux 
vomica  or  cantharides,  may  be  usefully  employed  ;  likewise  sulphur 
baths. 

"  This  local  symmetrical  asphyxia,  or  symmetrical  gangrene  of 
the  extremities,  as  we  may  choose  to  call  it,  is,  as  we  have  seen,  g, 
bizarre  affection,  offering  similarities  to  sclerodermy  and  to  the 
anaesthesia  of  lepra.  There  is  an  alteration  of  the  functions  of 
the  capillary  vessels,  characterized  by  gorging  of  the  veinules  with 
venous  blood,  and  resulting  in  a  sort  of  paralysis  of  the  vaso-motor 
nerves.  There  certainly  exists  some  disorder  of  the  central  ner- 
vous system,  of  the  spinal  cord  in  the  vicinity  of  the  medulla,  and 
I  base  this  statement  on  the  constant  symmetry  manifested  by  the 
phenomena,  and  on  the  paralysis  of  the  radial  and  the  muscles  it 
suppplies,  as  much  in  the  right  hand  as  in  the  left.  But  what  is  this 
lesion  ?  This  question  can  only  be  answered  by  further  observa- 
tions, when  we  can  have  the  light  afforded  by  an  autopsy." 


Ocular   Symptoms  in   General   Diseases. — There  are  few 
general  affections  that  do  not  more  or  less  involve  the  organ  of 


PATHOLOGY.  395 

vision,  and  the  ocular  phenomena  to  which  they  give  rise  in  cer- 
tain cases  form  a  valuable  element  for  the  diagnosis.  For  this 
reason  Dr.  Gorecki  has  endeavored  to  bring  together  in  review 
the  principal  affections  of  which  the  appearance  of  the  eye  may 
give  rise  to  a  suspicion,  or  confirm  the  existence. 

Blepharoptosis  or  droop  of  the  superior  eyelid  indicates  a  com- 
plete or  incomplete  paralysis  of  the  third  pair.  The  lids  on  both 
sides,  in  a  young  female  especially,  cause  a  suspicion  of  hysteria. 

Lagophthalmus,  or  inability  to  completely  close  the  palpebral 
opening,  is  a  sign  of  idiopathic  facial  hemiplegia,  or  is  sympto- 
matic of  a  cerebral  affection. 

Strabismus  occurring  suddenly  and  accompanied  with  diplopia 
is  generally  the  result  of  a  cerebral  affection. 

Xanthelasma  of  the  lids  appears  under  the  influence  of  certain 
alterations  of  the  liver. 

Subconjunctival  ecchymoses  are  frequent  in  whooping-cough, 
and  may  sometimes,  in  the  beginning,  serve  to  clear  up  a  dubious 
diagnosis. 

Redness  of  the  conjunctiva,  tears,  and  photophobia,  and  some- 
times even  a  little  catarrhal  secretion,  indicate  in  infants  the  im- 
minence of  an  eruptive  fever,  notably  measles.  Tears  are  an 
important  prognostic  sign  ;  good  if,  in  crying,  they  appear,  and 
bad  if  their  secretion  is  suppressed. 

Sclerotomy  or  episcleritis  is,  nine  times  out  of  ten,  a  symptom 
of  gout,  like  tophus  of  the  ear. 

Spots  on  the  cornea  are  often  indicative  of  a  strumous  di- 
athesis. 

Dilatation  of  the  pupil,  or  mydriasis,  indicates  either  excessive 
fatigue,  or  the  existence  of  intestinal  worms,  or  meningitis  in  its 
second  stage,  or  a  veritable  amaurosis. 

This  dilatation  is  frequently  connected  with  atrophy  of  the 
optic  nerve.  It  is  also  observed  during  the  epileptic  attack,  in 
the  period  of  resolution  from  chloroformization,  after  intoxication 
from  belladonna,  datura,  etc.  Unequal  dilatation  of  the  two  pupils 
is  a  sign  of  the  beginning  of  general  paralysis. 

Contraction  of  the  pupil,  on  the  other  hand,  or  myosis,  is  an 
early  sign  of  tabes  dorsalis.  It  is  met  with  also  at  the  commence-* 
ment  of  meningitis,  and  in  poisoning  by  opium  or  chloral  in  its 
early  stages. 

Deformity  of  the  pupil,  especially  after  instillations  of  atropine, 
indicates  an  old  iritis,  which,  in  nine  cases  out  of  ten,  is  of  syph- 
ilitic origin,  when  not  due  to  disease  of  neighboring  organs. 


39^  PERISCOPE. 

Cataract,  in  persons  still  young  (forty  to  fifty  years),  is  fre- 
quently of  diabetic  origin,  and  of  the  soft  variety. 
Exophthalmus  is  indicative  of  exophthalmic  goitre. 
Finally,  the  ophthalmoscope  reveals  to  us  the  so-called  albu- 
minuric retinitis  in  Bright's  disease,  in  simple  polyuria,  and  some- 
times in  pregnant  females.  Retinal  hemorrhages,  oedema  of  the 
retina,  and  embolism  of  the  central  artery,  are  met  with  in  organic 
cardiac  disease.  Optic  neuritis  and  perineuritis,  and  papillary 
atrophy  are  symptomatic  of  syphilis  and  of  tumor  near  the  cere- 
bellum and  corpora  quadrigemina.  Finally,  tubercles  of  the  cho- 
roid almost  always  accompany  tubercular  meningitis,  and  are  a 
valuable  element  of  diagnosis  between  that  affection  and  typhoid 
fever.  

Eye  Symptoms  in  Locomotor  Ataxy. — Dr.  J.  Hughlings 
Jackson  read  a  paper  before  the  Ophthalmological  Society,  Lon- 
don, Dec.  9,  1880  {Lancet,  Dec.  18,  1880),  in  which  three  well- 
marked  non-ocular  tabetic  symptoms  were  considered,  in  connec- 
tion with  certain  ocular  symptoms.  Twenty-five  cases,  in  dif- 
ferent stages,  furnished  the  materials  for  the  communication. 
Of  these  there  were  twelve  of  optic  atrophy.  In  two  there  were 
also  ocular  paralyses,  and  in  one  a  history  of  it ;  in  nine  there  was 
Westphal's  symptom.  In  one  of  the  three,  without  this  symptom 
there  had  been  no  pains  ;  gait  was  slightly  ataxic.  In  the  second 
there  had  been  double  vision  ten  years  ago  ;  there  is  now  paresis 
of  the  left  third  nerve  ;  this  patient  had  pains,  but  his  gait  was 
normal.  The  third  case  was  one  of  atrophy  of  one  disk,  with 
limitation  of  the  field  outward  and  downward  ;  this  patient  saw 
green  as  gray  and  red  as  reddish  brown  ;  he  had  pains,  but  his 
gait  was  good. 

In  one  case,  in  which  there  was  paralysis  of  those  parts  sup- 
plied by  oculo-motor  nerve  trunks,  it  was  noticed  that  the  patient 
had  no  positive  symptom  except  Westphal's  (tendon  reflex).  This 
patient's  pupils  acted  well  to  light  and  during  accommodation  ;  he 
had  no  pains  of  any  sort  anywhere.  In  one  case,  with  normal 
pupils  and  Westphal's  symptom,  there  had  been  paralysis  of  the 
third  nerve.  In  one  case  of  inactive  pupils,  with  Westphal's  symp- 
tom, there  had  been  temporary  double  vision.  In  another,  with 
inactive  pupils  and  Westphal's  symptom,  paralysis  of  one  sixth 
nerve.  That  condition  of  the  pupil,  observed  by  Hempel,  Vin- 
cent, Erb,  Hutchinson,  and  others,  called  the  Argyll-Robertson 
pupil,  is  a  double  condition,  negative  and  positive,  and  in  this  way 


PATHOLOGY.  397 

resembles  the  so-called  disorder  of  coordination  of  locomotor 
movements.  This  symptom  is  not  peculiar  to  tabes  ;  it  may  be 
found  in  general  paresis  of  alienists — at  least,  reflex  pupillary  im- 
mobility. Erb's  diagram  was  exhibited  to  the  society,  which  gave 
that  physician's  view  of  the  central  conditions  corresponding  to 
the  double  pupillary  condition,  and  the  following  case  was  cited, 
which  was  considered  a  very  rare  one  :  A  woman,  aged  twenty-six 
years,  had  sought  advice,  simply  because  her  right  pupil  was 
larger  than  the  left.  It  had  been  so  for  three  years.  The  right 
pupil  was  dilated,  and  absolutely  motionless  to  light,  and  also 
during  accommodation.  Yet  her  ciliary  accommodation  on  this 
side  was  perfect.  She  could  read  No.  i  Jaeger  from  fourteen 
inches  up  to  five,  or  by  effort  to  four.  The  field  was  perfect. 
The  fundus  was  normal,  except  that  the  veins  were  large,  and 
convoluted  at  the  disk,  probably  physiological  ;  the  media  were 
clear.  Her  sight  with  this  eye  was  perfect.  The  pupil  of  the 
left  eye  was  most  active,  and  of  normal  size  ;  the  left  disk  was 
slightly  paler  than  the  right ;  the  veins  as  on  the  right ;  macula 
normal  ;  double  slight  limitation  of  nasal  part  of  the  field.  She 
could  read  Jaeger  No.  2  with  the  left  eye,  but  the  centre  syllable 
of  a  long  word  seemed  blurred.  She  seemed  to  be  in  perfect  health, 
except  for  the  ocular  abnormalities  mentioned.  In  testing  her 
knees  not  the  smallest  trace  of  the  knee  phenomenon  could  be 
found. 

There  were  no  other  symptoms  of  tabes.  Erb  has  found  the 
pupillary  condition  in  patients  who  had  no  other  nervous  symp- 
toms, as  well  as  in  nervous  affections  which  could  not  be  classed 
as  tabes  or  as  general  paresis.  Again,  it  is  not  said  that  the 
action  of  light  may  not  be  present  in  very  well-marked  cases  of 
tabes.  Pagenstecher  has  recorded  a  case  verifying  this  fact,  and 
it  has  also  been  observed  by  Laidlaw  Purves. 

Twenty  years  ago,  Dr.  Jackson  had  observed  that  many  men 
who  had  "  white  atrophy"  of  the  optic  disks,  had  also  lightning 
pains  in  the  legs  ;  and  later,  on  making  a  distinction  as  to  the 
kind  of  atrophy,  he  concluded  that  the  pains  were  a  symptomatic 
link  between  "uncomplicated  amaurosis"  and  locomotor  ataxy. 
This  atrophy  is  now  more  particularly  described  as  gray  degener- 
ation, and  is  supposed  by  Charcot  and  others  to  be  parenchyma- 
tous. The  peculiar  limitation  of  the  field  of  vision  in  cases  of 
the  atrophy  in  tabes  is  significant  when  we  consider  that  the  de- 
veloped disease  is  in  great  part  one  of  the  locomotor  system.  The 
limitation  would  seem  to  correspond  roughly  to  certain  ocular  de- 


39^  PERISCOPE. 

viations  from  cerebellar  disease,  in  the  way  that  hemiopia  does  to 
lateral  deviation  of  the  eyes  from  cerebral  disease.  In  all  cases 
of  optic  atrophy  we  should  enquire  for  the  pains,  and  test  the 
knees,  whether  the  gait  be  abnormal  or  not.  The  pains  are  often 
bridging  symptoms  between  so-called  uncomplicated  amaurosis 
and  tabes.  Charcot  says  that,  as  far  back  as  1868,  he  pointed  out 
that  the  great  majority  of  women  admitted  into  La  Salpetriere  for 
amaurosis  have,  sooner  or  later,  manifestations  of  tabes.  He  men- 
tions one  case  in  which  the  amaurosis  preceded  the  pains  ten  years. 
Gowers  has  seen  a  case  of  tabes,  in  which  optic  atrophy  preceded 
other  ataxic  symptoms  twenty  years.  N.  Y.  Medical  Record, 
Feb.  12.  

The  Increase  of  Fibrine  of  the  Blood  in  Pericerebritis. 
— Dr.  Daniel  Bonnet,  Physician-in-Chief  of  the  asylum  at  Evreux, 
France,  publishes,  Ayin.  Me'd.  Psych.,  January,  1881,  the  results  of 
his  investigations  in  regard  to  the  fibrine  of  the  blood  in  general 
paralysis.  The  fibrine  increases,  as  is  well  known,  in  acute  inflam- 
mations, and  decreases  in  pyrexias  ;  its  normal  average  in  health 
is  .022  to  .023  per  cent.  He  commenced  the  investigation  when 
an  interne  under  Calmeil  at  Charenton,  but  had  not  been  able  to 
continue  it  steadily.  The  method  employed  was  that  of  Andral 
and  Gavarret.  The  fibrine,  extracted  from  the  clot,  washed  with 
care  and  desiccated,  was  then  weighed  ;  the  fatty  matter  still  con- 
tained naturally  increases  the  weight.  In  six  cases  of  cerebral 
hemorrhage  he  found,  like  Andral  and  Gavarret,  a  decrease  of 
fibrine,  it  ranging  from  only  .017  to  .0214  per  cent.  In  two  cases 
of  delirium  tremens  it  was  .0145  ^"^  .o\(i,  and  in  three  cases  of 
acute  mania  it  was  .0265,  .03,  and  .0314. 

In  30  cases  of  general  paralysis  the  amount  of  fibrine  varied 
between  .013  and  .059  per  cent.,  being  in  relation  with  the  inten- 
sity of  the  inflammation.  The  minima  .013  and  .0186  were  met 
with  in  two  cases  of  general  paralysis  of  the  dement  type  ;  slow  in 
progress  ;  and  the  blood  was  taken  at  the  close  of  the  second 
period  on  account  of  slight  and  temporary  symptoms  of  cerebral 
congestion. 

In  24  cases  the  weight  of  the  fibrine  varied  from  .02  to  .0332 
per  cent.,  the  average  being  .026.  Four  cases,  in  which  it  ex- 
ceeded .04  per  cent.,  are  related  in  more  or  less  detail.  The  con- 
clusions of  the  memoir  are  as  follows  : 

General  paralysis,  like  every  other  chronic  inflammation,  does 
not  produce  an  increase  of  fibrine   in  the  blood  when  it  takes  a 


PA  THOLOG  Y.  399 

slow  and  regular  course.  The  quantity  may  even  be  diminished 
in  some  cases.  An  increase  occurs  when  the  phlegmasic  phe- 
nomena become  very  intense,  exceeding  the  ordinary  acute  stage. 
The  percentage  by  weight  of  fibrine  may  then  attain  the  figure  of 
•059-  

FoLiE  A  Deux. — M.  Marandon  de  Montezel,  Ann.  Med.  Psych., 
January,  1881,  discusses  the  subject  of  folic  a  deux,  noticing  the 
previous  memoirs  of  MM.  Lasegue  and  Falret,  and  Emanuel 
Regis.  He  recognizes  the  forms  described  by  these  authors,  and 
adds  a  third  based  on  the  contagion  of  insanity  in  predisposed 
cases.  He  narrates  histories  of  four  cases  illustrating  these  forms, 
and  concludes  as  follows  : 

The  principal  ideas  on  which  this  memoir  is  based  may  be 
summed  up  in  the  following  conclusions  : 

I.     Folie  a  deux  include  three  perfectly  distinct  orders  of  cases: 

1.  Folie  impose'e.,  in  which  an  insane  person  imposes  his  insane 
conceptions  upon  another,  more  feeble  morally  and  intellectually 
than  himself,  under  certain  conditions  already  developed  in  the 
paper  of  MM.  Lasegue  and  Falret. 

2.  Folie  simultan^e,  in  which  two  hereditarily  predisposed  in- 
dividuals contract  simultaneously  the  same  type  of  insanity,  under 
certain  conditions  formulated  by  M.  Em.  Regis. 

3.  Folie  communique'e ,  in  which  an  insane  person  communicates 
his  hallucinations  and  delusions  to  another  person  hereditarily 
disposed  to  insanity. 

II.  It  seems  necessary  for  three  indispensable  conditions  to 
simultaneously  combine  to  produce  \\\&  folie  communiqu^e  : 

1.  A  well  marked  hereditary  predisposition  in  the  recipient  or 
passive  party  to  whom  the  disorder  is  communicated. 

2.  In  every  case  as  intimate  an  association  as  possible  between 
the  two  persons  who  will  share  the  insanity. 

3.  Incessant  action  on  the  part  of  the  insane  person  upon  the 
mentally-sound  person  to  cause  him  to  adopt  the  hallucinations 
and  delusions  of  the  former. 

III.  In  a  medico-legal  point  of  view  the  passive  individual  in 
the  folie  impose'e  is  more  or  less  weak-minded  or  imbecile  ;  and, 
even  when  he  cooperates  in  the  insane  acts  of  the  other  active 
party,  he  need  not  be  considered  as  an  insane  person  in  the  strict 
sense  of  the  term.  On  the  other  hand,  in  the /<?//>  simultan^e  and 
Xhe  folie  communique'e,  hoih.  parties  must  be  considered  insane. 

IV.  In  a  medico-legal  point  of  view,  in  the  folie  impose'e,  the 


400  PERISCOPE. 

appearance  of  insanity  is  a  relative  matter,  and  the  expert,  in 
order  to  draw  a  conclusion  in  regard  to  it,  should  study  to  inform 
himself  in  respect  to  the  previous  psychic  condition  of  the  passive 
receiving  individual. 

V.  Folie  siniultane'e  and  folic  communiquie  are  only  two  particu- 
lar instances  of  the  general  influence  of  surroundings  on  the  forms 
taken  on  by  mental  alienation. 

VI.  It  is  also  by  the  general  influence  of  the  environment  that 
we  have  to  explain  the  fact  that  all  the  cases  of  folie  a  deux  are 
delusions  of  persecutions  ;  it  is  the  type  of  the  nineteenth  century. 

This  last  proposition  needs  the  explanation  that  it  applies  more 
directly  to  the  folie  simuitane'e,  in  which  Regis  made  the  observa- 
tion that  all  the  cases  were  of  this  character.  We  see  no  reason 
why  it  should  necessarily,  for  any  one  of  the  types  described,  be 
exclusively  the  case,  and  doubt  the  generalization. 


Nervous  Phenomena  of  Dyspepsia. — At  the  session  of  the 
Soc.  de  Biologic,  Nov.  13th  (rep.  in  Gaz.  des  Hopitaux),  M.  Leven 
described  the  nervous  symptoms  developed  in  dyspepsia,  disor- 
ders of  sensibility  and  motility  and  of  the  cerebral  faculties,  and 
intends,  at  a  later  time,  to  mention  the  special  nervous  attacks 
confounded  hitherto  with  those  of  hysteria,  from  which  they  are 
entirely  distinct,  and  which  disappear  as  the  functions  of  the 
stomach  are  reestablished.  At  present  he  confined  himself  to  the 
disorders  of  sensibility. 

Briquet  has  described  among  the  constant  symptoms  of  hysteria, 
hypersesthesia,  in  which  he  includes  dermalgia,  myosalgia,  epigas- 
tralgia,  rachialgia,  etc. 

Hyperaesthesia  is  not  a  phenomenon  appertaining  to  hysteria, 
but  to  dyspepsia,  so  frequent  among  hysterical  subjects,  and  the 
eminent  physician  of  La  Charite  has  referred  to  this  neurosis  a 
symptom  that  does  not  belong  to  it.  M.  Leven  has  analyzed 
twenty-four  observations  of  dyspepsia,  a  sufficient  number  of  cases 
to  show  the  conditions  of  the  development  of  this  symptom. 

In  ten  cases  only,  out  of  the  twenty-four,  was  the  hyperesthesia 
lacking  ;  this  shows  the  frequency  of  the  symptom. 

If  hysteria  is  rather  frequently  met  with  in  females,  it  is,  on  the 
other  hand,  very  rare  in  males,  so  that  it  was  for  a  long  time  de- 
nied that  it  could  be  produced  in  the  masculine  sex.  But  hyper- 
aesthesia was  observed  to  be  one-half  more  abundant  in  males 
than  in  females.     Hysteria  is  a  disease  beginning  generally  at  the 


PATHOLOGY.  40I 

epoch  of  puberty,  and  decreases  generally  as  the  female  advances 
in  age  and  passes  the  thirtieth  year.  The  symptom,  hyperses- 
thesia,  has  been  observed  by  M.  Leven  only  three  times  in  fe- 
males between  twenty  and  thirty  years,  and  only  twice  in  males  ; 
it  is  most  frequent  after  the  age  of  forty,  and  is  observed  in  both 
sexes  up  to  sixty  years. 

Thus,  there  is  no  comparison  between  this  symptom  and  the  com- 
mon manifestations  of  hysteria.  Hypersesthesia  attacks,  by  prefer- 
ence, the  left  side  of  the  body,  in  its  superior  portion,  the  skin 
of  the  thorax,  the  intercostal  muscles,  the  skin  of  the  back  on  the 
left  side,  and  the  underlying  muscles.  All  of  the  back  on  the  left 
side  of  the  vertebral  column,  through  the  whole  range  of  the 
dorsal  vertebrae,  is  painful  to  pressure.  The  hyperaesthesia  ex- 
tends to  the  neck,  the  cranium,  the  region  of  the  kidneys,  and 
even  the  leg  on  the  left  side.  It  does  not  always  begin  on  the 
left  side  ;  it  is  often  met  with  on  the  right,  and  in  symmetrical 
parts  on  the  back,  thorax,  etc.  Nevertheless,  it  is  most  common 
on  the  left. 

When  the  dyspepsia  is  very  severe,  both  sides  of  the  body  are 
often  hyperaesthetic,  but  one  is  more  so  than  the  other,  and  the 
hyperaesthesia  may  generalize  itself  in  the  skin,  the  muscles,  the 
joints,  the  limbs,  etc.  Sometimes  a  surface,  of  some  centimetres 
in  extent,  of  skin  or  muscle,  may  become  the  seat  of  crises  or  at- 
tacks of  severe  pain,  which  the  patient  may  even  try  to  suppress 
by  hypodermic  injections  of  morphine.  I  have  observed  these  in 
a  woman  of  fifty-seven  years,  in  men  aged  sixty-three,  sixty-six, 
thirty-nine,  and  forty-two  years.  They  occurred  in  the  back  and 
thorax  of  the  left  side,  in  the  thorax  on  the  right,  in  the  region  of 
the  stomach,  and  behind  the  great  tuberosity. 

These  have  not  been  previously  noticed;  they  disappear  as  the 
stomach  itself  is  restored  to  health. 

M.  Leven  declares  that  the  hyperaesthesia  of  dyspepsia  is  never 
accompanied  with  anaesthesia  in  other  parts  of  the  body,  at  least 
in  an  individual  not  hysterical.  Anaesthesia  is  the  characteristic 
of  hysteria  ;  hyperaesthesia,  of  dyspepsia.  In  his  service  in  the 
Hospital  Rothschild,  he  had  a  woman,  twenty-two  years  old,  an 
invalid  for  many  months,  who  exhibited  hyperaesthesia  of  the 
right  side,  and  anaesthesia  of  the  left  (upper  member  and  thorax), 
and  had  explained  it  to  his  students  as  a  case  of  hysterical  dys- 
pepsia. It  was  sufficient  to  merely  use  pressure  over  the  ovarian 
region,  to  produce  a  hysterical  attack. 

The  symptom,  hyperaesthesia,  en  resume,  may  be,  nevertheless, 


402  PERISCOPE. 

considered  as  appertaining  to  dyspepsia,  and  not  to  hysteria.  It 
is  rather  more  common  in  men  than  in  women,  at  an  advanced 
age  rather  than  in  youth  ;  it  is  aggravated  with  the  dyspepsia,  and 
disappears  when  a  rational  treatment  is  applied  to  the  general 
condition. 


Posthemiplegic  Hemi-ataxia. — J.  Grasset  gives  {Frogres 
Medical,  1880,  No.  46)  an  account  of  a  patient  who,  after  an 
irregular  life,  with  all  kinds  of  excesses,  had  a  series  of  apoplectic 
attacks,  always  followed  by  right  hemiplegia  and  embarrassment 
of  speech,  and  came  under  his  care  after  the  fifth  of  these  attacks. 
He  was  suffering  then  from  right  hemiparesis,  some  trouble  in 
speech  (speech  slow,  and  tendency  to  use  all  verbs  in  the  infini- 
tive). The  right  hand,  in  repose,  showed  nothing  abnormal,  but 
whenever  he  attempted  to  use  it,  the  fingers  were  seized  with 
irregular  contractions,  preventing  him,  for  instance,  from  writing, 
etc.  When  he  extended  the  right  arm,  there  were  only  slight 
oscillatory  movements. 

The  patient  left  the  hospital,  and  indulged  in  new  excesses,  so 
that  that  after  two  months'  absence  he  returned  with  all  these 
symptoms  aggravated,  the  face  involved  in  the  hemiplegia,  the 
ataxic  movements  exaggerated,  and  not  affected  by  occlusion  of 
the  eyes,  and  generally  much  enfeebled.  The  patient  died  of 
generalized  pleuro-pneumonia  a  little  over  a  month  later. 

At  the  autopsy  the  principal  points  of  interest  were  the  follow- 
ing :  Nothing  abnormal  in  the  right  hemisphere,  as  shown  in 
Pitres'  cuts.  In  the  left  hemisphere  there  was  found  a  focus  of 
softening,  occupying,  in  the  pediculo-frontal  section,  the  height  of 
the  striate  body,  and,  in  the  frontal  cut,  the  caudate  nucleus,  and 
the  whole  height  of  the  optic  thalamus,  the  internal  capsule,  and 
the  lenticular  nucleus.  At  this  horizon  the  lower  portion  of  the 
internal  capsule  is  yellowish.  The  second  focus  of  softening,  of 
much  less  extent,  occupied  the  internal  (ventricular)  third  of  the 
optic  thalamus.  The  third,  which  was  extremely  minute,  was 
situated  in  the  lower  portion  of  the  thalamus,  bordering  the  in- 
ternal capsule,  which,  at  this  point,  was  intact.  The  other  sec- 
tions revealed  nothing  abnormal. 

There  were  numerous  adhesions  of  the  dura  and  arachnoid 
along  the  interhemispheric  fissure,  slight  atheroma  of  the  arteries 
at  the  base  of  the  brain,  and  evidences  of  chronic  meningitis  of 
the  convexity  of  the  left  hemisphere.  The  case  is  of  clinical 
rather  than  of  pathological  interest,   and    does   not  throw  very 


PATHOLOGY.  403 

much  light  on  the  question  of  cerebral  localizations,  except,  per- 
haps, in  a  negative  way.  The  phenomena  of  hemi-ataxia,  after 
lesions  of  the  brain,  are  not  altogether  novel ;  we  have  ourselves 
under  observation  one  case  of  the  kind,  following  an  apoplectic 
attack,  with  a  history  of  temporary  complete  right  hemiplegia  of 
the  limbs,  and  crossed  paralysis  of  the  face,  which  still  remains,  to 
some  extent.  There  is  also  disorder  of  speech.  The  symptoms 
seem  to  favor  a  lesion  of  the  pons  in  this  case,  and  that  agrees 
with  the  pathological  findings  in  somewhat  similar  cases  reported 
by  Leyden  and  Kahler. 

Idiopathic  Lateral  Sclerosis. — Dr.  John  E.  Morgan  de- 
scribes in  the  British  Med.  'your.,  January  29th,  several  cases  of 
spastic  spinal  paralysis,  one  of  which  proved  fatal.  An  autopsy 
was  made  with  microscopic  examinations  of  numerous  sections  of 
the  spinal  cord  by  Dr.  Julius  Dreschfeld.  The  lesions  found  were 
patches  of  sclerosis,  of  varying  extent,  in  the  lateral  columns,  most 
marked  in  the  dorsal  region,  but  nowhere  trespassing  on  the  an- 
terior or  posterior  horns  or  the  anterior  or  posterior  columns. 
Sections  were  sent  to  M.  Charcot,  who  found  the  lesions  very 
characteristic,  and  who  said  the  case  was  unique,  as  far  as  at  pres- 
ent observed,  in  the  exclusive  involvement  of  the  lateral  columns 
in  the  sclerosis,  without  any  participation  of  the  posterior  col- 
umns. 

Hydrophobia. — The  following  are  the  conclusions  of  a  me- 
moir by  M.  Debove  (of  Pau),  read  by  M.  Beauvais  at  the  session 
of  the  Societe  de  Medecine,  Paris,  July  19,  1880,  as  given  in  the 
L  Union  Midicale,  November  14th. 

This  memoir  may  be  summed  up  in  one  principal  conclusion, 
taking  in,  in  its  ensemble,  the  question  of  pathological  physiology 
that  we  have  studied  in  detail,  according  to  the  results  of  reason- 
ing and  experiment. 

The  producing  agent  of  hydrophobia  is  not  absorbed.  It 
propagates  itself  insensibly  along  the  nerve-fibres  that  are  affected 
by  the  virulent  liquid. 

As  regards  the  secondary  conclusions,  which  are  only  the  de- 
velopment of  that  announced,  they  are  comprised  in  the  following 
propositions  : 

1.  The  propagation  of  the  hydrophobic  virus  is  done  by  way  of 
the  axis  filaments  and  the  corresponding  nerve-cells. 

2.  The  sensory  nerve-fibres  are  probably  alone  affected,  to  the 
exclusion  of  the  motor  ones. 


404  PERISCOPE. 

3.  The  morbid  agent  progresses  slowly,  in  a  centripetal  direc- 
tion, from  the  locality  of  the  bite  to  the  medulla,  and  very  rapidly, 
in  a  centrifugal  direction,  from  this  last-named  organ  back  to  the 
sensory  nerves  from  which  it  comes. 

4.  The  symptoms  of  hydrophobia  appear  at  the  moment  when 
the  virus  reaches  the  medulla,  and  are  frequently  announced  by 
pain  radiating  only  along  the  corresponding  nerves  coming  from 
the  seat  of  the  bite. 

5.  The  period  of  incubation  is,  as  a  rule,  the  shorter,  the  less 
the  distance  of  the  wound  from  the  medulla.  Hence,  it  is 
shorter  in  infants  than  in  adults,  with  wounds  of  the  face  than 
with  those  of  the  limbs,  and,  probably,  in  persons  of  small  than  in 
those  of  large  stature. 

6.  Everything  leads  us  to  believe  that,  in  certain  cases,  the  trans- 
mission of  the  hydrophobic  virus  may  occur  by  a  recurrent  route  ; 
that  is,  after  having  begun  at  the  peripheral  end  of  torn  or  de- 
nuded nerve,  it  continues  its  course  by  way  of  the  anastomoses 
of  this  nerve  with  an  adjoining  one,  and  follows  the  latter  to  the 
mesencephalon. 

7.  The  anatomical  dispositions  that  multiply  the  flexures  of  a 
nerve,  or  the  circumstances  that  affect  its  nutrition  seem  to  in- 
crease the  duration  of  the  period  of  incubation,  and  vice  versa. 

8.  The  morbid  phenomena  which  characterize  the  period  of  in- 
vasion, affect  the  general  and  special  sensibility,  which  first  be- 
comes exquisite,  and  ends  by  being  exhausted,  in  some  cases 
finishing  with  paralysis.  Thus,  paralysis  of  the  vaso-motor  cen- 
tres in  the  medulla  causes  congestions  of  all  the  organs,  and,  con- 
secutively, asphyxia  and  considerable  elevation  of  temperature. 

9.  The  lesions  of  hydrophobia  are  of  two  kinds  :  the  ont,  prim- 
itive., visible  only  with  the  microscope,  and  consisting  in  more  or 
less  marked  opacities  of  the  nerve-cells,  and  in  a  granular  condi- 
tion of  these  cells,  and  a  certain  number  of  afferent  or  efferent 
fibres  ;  the  other,  late.,  visible  to  the  naked  eye,  and  consisting  in 
more  or  less  marked  congestions  of  various  organs. 

10.  Once  in  contact  with  the  nerve-cells  of  the  medulla  and  the 
pons,  the  virus,  in  all  probability,  is  rapidly  transported  in  all  di- 
rections, according  to  routes  of  the  fibres  from  the  nerve-centres. 

•  II.  It  is  probable  that  when  the  nerves  thus  charged  with  the 
virulent  principle  are  superficial,  under  a  very  thin  and  permeable 
mucous  membrane,  this  contagious  principle  may  traverse  the 
mucous  membrane  and  show  its  effects  on  the  epithelium  in  the 
form  of  vesicles  of  various  sizes.     From  this  may  arise  the  viru- 


PATHOLOGY.  405 

lence  of  the  buccal  secretion,  so  well  attested,  on  the  one  hand  ; 
and,  on  the  other,  the  formation  of  lyssas,  in  certain  rare  and  ex- 
ceptional cases  ;  and  still  also  the  dangers  to  be  feared  from 
suction. 

12.  The  characteristic  lesions  of  hydrophobia  maybe  unilateral, 
as  is  demonstrated  by  reason  aided  by  attentive  observation. 
Hence,  it  follows  that  the  fluids  may  become  virulent  only  on  one 
half  of  the  mouth,  and,  therefore,  only  one  half  of  the  bites  are 
effective  ;  a  view  confirmed,  in  fact,  by  the  statistics  collected  by 
Renault. 

13.  The  virulence  of  the  bronchial  form  is  dubious. 

14.  The  bites  of  wolves  are  the  more  dangerous,  as  they  are 
given  with  greater  ferocity,  and  insure  more  fully  the  mixture  of 
the  fluids  of  the  two  sides  of  the  mouth. 

15.  The  virulence  of  the  buccal  liquids  persists  twenty-four 
hours  after  death.  Hence  the  possibility  of  experimenting  vari- 
ously on  animals  with  security. 

16.  Hydrophobia  belongs  to  a  large  class  of  affections  of  periph- 
eral origin,  such  as  certain  eruptive  fevers  or  certain  neuroses, 
like  vaccinia  and  variola  from  inoculation,  and  probably  syphilis, 
also  such  as  ascending  neuritis,  epilepsy,  tetanus,  certain  forms  of 
cylindrical  neuroma  of  the  skin,  etc. 

17.  The  transmission  of  the  virus  by  the  nerves,  or  the  nervous 
theory,  is  one  of  extreme  simplicity,  that  has  already  led  an 
English  physician  of  the  last  century.  Hicks,  to  put  into  execu- 
tion one  of  the  most  striking  therapeutic  indications  of  this  dis- 
order. 

18.  On  various  accounts  we  are  led  to  substitute  this  theory  for 
the  blood-disease  theory  that  has  always  prevailed,  and  still  pre- 
vails, among  physicians. 

19.  A  complete  demonstration  of  the  nervous  theory  has  only 
become  possible  by  the  recent  progress  of  statistics  and  of  patho- 
logical histology. 

20.  This  theory  leads  us  to  very  precise  therapeutic  indications, 
while  the  blood-theory  has,  up  to  date,  apart  from  the  practice  of 
immediate  cauterization  of  the  wound,  produced  only  a  profound 
skepticism,  and  a  treatment  grossly  empirical  and  nearly  worth- 
less. 

As  regards  the  therapeutic  indications  deduced  from  the  pres- 
ent study  of  the  pathology  of  the  disease,  they  are  four  in  num- 
ber, and  are  : 

I.  To  destroy  the  virus  locally. 


406  PERISCOPE. 

2.  To»prevent  its  transmission  to  the  medulla  in  case  it  is  not 
destroyed. 

3.  To  obtund,  in  advance,  the  sensibility  of  the  medulla  dur- 
ing the  whole  period  of  incubation,  and  as  thoroughly  as  possible, 
in  case  the  two  preceding  indications  were  impossible  to  be  ful- 
filled. 

4.  To  act  also  with  quickness  and  energetically  on  this  same 
sensibility  of  the  medulla,- by  hypodermic  injections  into  the  veins  ; 
to  fight,  in  fact,  the  ordinarily  rapid  progress  of  asphyxia. 

The  above  conclusions  seem  to  us  fanciful  rather  than  other- 
wise. The  idea  of  the  virus  circulating  in  the  nerves  is  not  alto- 
gether a  physiological  one,  as  nerves  are  not  exactly  organs  of 
circulation.  It  is  possible,  however,  that  some  at  present  undis- 
covered morbid  process  may  extend  itself  by  these  routes,  and 
the  nervous  theory,  in  this  sense,  be  correct.  But  it  requires  a 
different  phraseology  from  that  adopted  by  M.  Debove. 

At  the  session  of  the  Acad,  de  Medecine,  November  2d  (rep.  in 
Gaz.  des  Hopitaux),  M.  Colin  reported  a  case  of  a  sub-officer  of 
artillery,  bitten  by  a  rabid  dog,  in  Algeria,  November  2,  1874  ;  a 
comrade,  bitten  at  the  same  time,  dying  forty  days  later  of  hydro- 
phobia. The  officer  felt  no  inconvenience  whatever  till  four  and 
a  half  years  later,  when  he  also  was  seized  with  the  disease  and 
shortly  succumbed.  The  military  authorities  requested  M.  Colin 
to  carefully  examine  the  case,  since,  the  wound  having  been  re- 
ceived when  in  the  line  of  his  duty  in  succoring  a  comrade,  the 
pension  to  his  family  depended  upon  whether  that  was  the  cause 
of  his  death  or  not.  M.  Colin  was  able  to  answer  the  query  to 
his  own  satisfaction  in  the  affirmative,  notwithstanding  the  long 
period  of  incubation.  The  circumstances  all  precluded  any  other 
disease,  such  as  alcoholism,  etc. 

He  asks:  Is  this  remarkably  lengthened  incubation  altogether  in- 
explicable ?  Hydrophobia  has  no  fixed  period  of  latency,  and  he 
compared  it  in  this  respect  to  certain  cases  of  pernicious  malarial 
fever,  in  which  the  outbreak  of  the  disease  only  occurs  long  after 
exposure. 

The  case  formed  the  subject  of  discussion  at  the  next  following 
meeting  of  the  Academy  of  Medicine.  M.  Bouley  doubted  the 
correctness  of  the  diagnosis  ;  so  long  a  period  of  incubation  was 
altogether  remarkable,  and  called  for  a  great  reservation  of  opin- 
ion in  regard  to  it.  M.  Colin  also  had  not  verified  his  diagnosis 
by  the  discovery,  at  the  post-mortem,  of  the  characteristic  lesion 
noted  especially  by  MM.  Gombault  and  Nocart,  of  foci  of  white 


PATHOLOGY.  4^7 

globules  in  the  perivascular  lymphatic  sheaths  in  the  floor  of  the 
fourth  ventricle.  Another  equally  important  diagnostic  point, 
that  of  inoculation  of  rabbits,  had  also  been  neglected  by  M. 
Colin.  The  point  that  the  patient  had  not  been  bitten  in  the  in- 
terim was  not  conclusive,  since  inoculation  might  occur  in  other 
ways,  such  as  by  the  dog  licking  the  hand,  etc. 

M.  Maurice  Raynaud  said  that  the  lesions  described  by  M. 
Bouley  were  not  alone  characteristic  of  rabies  ;  they  also  occurred 
in  fatal  chorea. 

M.  Bouillaud  supported  M.  Colin,  and  the  latter,  replying  to  M. 
Bouley,  admitted  that  he  had  not  sought  for  the  lesions  described 
by  M.  Bouley,  as  he  did  not  suspect  their  existence,  and,  more- 
over, the  facts  stated  by  M.  Raynaud  deprived  them  of  much  of 
their  importance.  He  regretted  that  he  had  not  experimented 
on  rabbits,  but  the  experiments  on  these  animals,  alluded  to  by  M. 
Bouley,  had  not  been  made  when  he  observed  his  patient,  and  he 
considered  himself  somewhat  excusable.  He  had,  moreover,  in 
his  investigations,  found  that  the  patient  had  been  very  cautious 
in  regard  to  exposing  himself  to  any  inoculation  in  any  manner. 

As  the  case  stands,  it  is  certainly  open  to  doubt,  if  any  one 
choose  to  discredit  the  diagnosis,  which  was  not  absolutely  per- 
fected and  confirmed  by  all  the  tests  now  available.  But  it  can- 
not be  positively  denied  on  any  a  priori  grounds,  and  the  long 
period  of  latency  does  not,  of  itself,  absolutely  discredit  it.  We 
do  not  know  how  long  a  time  hydrophobic  virus  may  take  to  pro- 
duce its  ultimate  effects,  and  if  six  months  or  a  year  are  not  un- 
common, we  cannot  say  that  in  altogether  exceptional  cases  it  may 
not  require  a  still  longer  period.  But  this  case  only  suggests,  does 
not  prove  this. 

While  the  above  case,  if  admitted  as  genuine,  shows  the  ex- 
treme limit,  so  far  as  reported,  of  the  incubation  of  hydro- 
phobia in  the  human  species,  a  recent  report  on  the  disease  by 
Dr.  T.  G.  Richardson,  of  the  University  of  Louisiana,  mentions 
two  cases  briefly,  that  are  remarkable  for  the  shortness  of  the 
period  between  the  bite  and  the  outbreak  of  the  disease.  In  one 
case  it  was  seven,  and  in  the  other  only  four  days  ;  both  were 
young  females,  aged  respectively  eighteen  and  fourteen  years.  The 
locality  of  the  bite,  in  both  cases,  was  the  lower  limb  (in  one  the 
ankle)  and,  taken  together  with  the  short  period  of  latency  or  in- 
cubation of  the  disease,  does  not  seem  to  favor  the  theory  above 
given  by  M.  Debove,  that  the  manifestations  of  the  hydrophobic 
symptoms  will  be  later  in  appearance  the  greater  the  distance  be- 


408  PERISCOPE. 

tween  the  point  bitten  and  the  nerve-centres.  One  of  these  two 
cases,  that  in  which  the  incubation  was  seven  days,  was  treated 
with  curare,  but  with  the  usual  result.  There  seems  to  be  as  yet 
no  satisfactorily  assured  case  of  recovery  from  undoubted  hydro- 
phobia in  the  human  species. 

At  the  session  of  the  Academie  de  Medecine,  January  i8th  (rep. 
in  La  France  M^dicale),  M.  M.  Raynaud  communicated,  for  M. 
Lannelongue  and  himself,  the  results  of  their  experiments  on  the 
transmission  of  hydrophobia.  Conveying  the  disease  from  the 
dog  to  the  rabbit,  the  period  of  incubation  is  only  fifteen  days,  a 
very  valuable  discovery,  provided  that  the  disease  is  really  hydro- 
phobia.    They  had  experimented  on  some  forty  rabbits. 

On  December  8th,  a  child  suffering  with  hydrophobia  was 
brought  to  the  Hospital  St.  Eugenie;  the  disease  first  appeared  De- 
cember 7th  ;  the  bite  occurred  November  nth  ;  the  incubation, 
therefore,  was  only  twenty-six  days.  The  first  marked  symptom 
was  dyspnoea,  and  the  child  died  four  days  after  the  onset. 

Three  series  of  experiments  were  performed.  In  the  first,  four 
rabbits  were  inoculated  with  the  saliva  of  the  child  while  still  liv- 
ing; three  of  these  quickly  succumbed,  the  fourth  recovered,  after 
having  apparently  suffered  severely.  Two  rabbits,  inoculated 
with  the  blood,  survived ;  a  fact  which  seems  to  indicate  that  the 
saliva,  rather  than  the  blood,  is  virulent. 

After  the  death  of  the  child,  a  second  series  of  experiments  was 
instituted.  Inoculation  with  bronchial  mucus  killed  the  rabbits, 
while  a  trituration  of  the  salivary  glands,  introduced  under  the 
skin,  gave  dubious  results  ;  only  one  rabbit  thus  inoculated  died. 
At  the  autopsy  of  the  child,  the  ganglia  of  the  neck,  on  the  side  of 
the  face  bitten,  were  strongly  tumefied  ;  and  the  scrapings  from 
these  ganglia  killed  one  of  two  rabbits  into  which  it  was  inocu- 
lated. The  two  roots  of  the  trigeminus,  cut  close  to  the  pons  and 
inoculated  under  the  skin  of  a  rabbit,  caused  death  at  the  end  of 
three  days  ;  hence  it  appears  that  the  nervous  system  may  serve 
as  a  vehicle  for  the  poison. 

In  a  third  series  of  experiments  the  inoculation  was  made  from 
a  dead  rabbit  to  a  living  one.  These  inoculations  caused  death, 
even  when  the  blood  was  used. 

To  sum  up,  out  of  38  inoculations  26  were  followed  by  death, 
thus  seemingly  proving  that  hydrophobia  is  transmissible  from 
man  to  the  rabbit.  The  interval  between  the  inoculation  and 
death  was  about  45  hours  ;  when  practised  from  rabbit  to  rabbit 
it  averaged  only  29  hours. 


PATHOLOGY.  4^9 

These  observations  are  very  difficult,  as  we  are  but  little  ac- 
quainted with  the  symptomatology  of  hydrophobia  in  the  rabbit ; 
in  many  cases  there  was  paraplegia,  and  convulsions  occurred  in 
eleven. 

It  cannot  be  objected  that  the  rabbit  is  an  animal  that  succumbs 
to  the  least  injury,  for  the  inoculation  with  saliva  does  not  affect 
its  health,  and  those  operated  upon  died  not  of  septicaemia,  but  of 
rabies.  A  very  conclusive  experiment  would  be  to  inoculate  the 
dog  from  the  rabbit  with  hydrophobia  ;  up  to  the  present  this  has 
not  been  done. 

In  the  discussion  of  M.  Raynaud's  communication,  MM.  Colin 
and  Dujardin-Beaumetz  doubted  whether  the  cause  of  death  in 
the  rabbits  was  rabies  ;  they  were  inclined  to  consider  it  rather 
due  to  septicaemia.  In  reply,  M.  Raynaud  recognized  the  force 
of  their  objections,  but  held  that  if  septicaemia  was  the  cause  of 
death  the  characteristic  vibrion  was  lacking,  and  he  thought  that 
M.  Lannelongue  and  himself  had  sufficiently  guarded  against  that 
complication.  It  is  true  that  what  was  seen  in  the  rabbits  did 
not  resemble  the  classic  hydrophobia. 

M.  Pasteur  then  reported  that  he  had  experimented  with  the 
oral  mucus  from  the  same  child  as  MM.  Raynaud  and  Lanne- 
longue, inoculating  two  rabbits,  both  of  which  died  36  hours  after 
the  operation.  The  saliva  of  these  rabbits,  introduced  info  others 
of  the  same  species,  also  caused  death.  In  the  first  ones  he 
found  swelling  of  the  lymphatic  ganglia,  and  in  these  and  the 
trachea  numerous  hemorrhages.  In  the  blood,  examined  imme- 
diately, he  found  a  very  peculiar  microscopic  organism  ;  a  little 
rod,  slightly  constricted  in  the  middle,  and  not  over  a  thousandth 
of  a  millimetre  in  diameter.  When  placed  in  cultivating  liquids, 
especially  veal  broth,  it  multiplied  exceedingly,  presenting  the 
same  general  shape,  but  more  pronounced,  sometimes  resembling 
the  figure  8.  The  inoculations  with  these  liquids  produced  always 
the  same  results. 

Whether  in  these  cases  the  cause  of  death  is  rabies  is  a  ques- 
tion ;  the  fact  of  non-inoculation  is  worthy  of  consideration.  It 
is  not  septicaemia,  for  the  microscopic  organism  and  symptoms  of 
septicaemia  are  lacking.  M.  Pasteur  was  of  the  opinion  that  it  is 
a  new  disease.  It  was  not  transmissible  to  guinea  pigs,  and  when 
a  dog  was  inoculated  he  died  within  three  or  four  days,  but  not  of 
hydrophobia. 

M.  Colin  objected  that  the  organism  described  by  M.  Pasteur 
was  common  in  cases  of  septicaemia.     In  reply,  M.  Pasteur  stated 


4IO  PERISCOPE. 

that  there  was  no  animal  more  susceptible  to  septicaemic  poisoning 
than  the  guinea  pig,  and  yet  he  had  failed  to  produce  the  disease 
in  them  by  inoculation. 

.M.  Bergeron  did  not  believe  that  the  rabbits  inoculated  suc- 
cumbed to  septicaemia,  and  yet  they  did  not  present  the  symptoms 
of  hydrophobia,  and  he  asked  whether  there  was  not  a  simple 
question  of  dosage. 

M.  Colin  called  attention  to  the  change  of  form  noticed  by  M. 
Pasteur  in  his  organism  from  cultivation,  and  asked  how  we  could 
be  sure  they  were  not  new  products  of  putrefaction.  During 
digestion  the  intestines  of  herbivorous  animals  contain  numerous 
organisms  like  those  of  charbon,  and  which  yet  do  not  give  rise  to 
that  disease. 

M.  Pasteur  replied  that  after  an  animal  died  of  charbon  the 
charbonous  bacteria  disappeared  in  proportion  as  putrefaction 
advanced,  and  the  organisms  that  replaced  them  did  not  produce 
charbon. 

M.  J.  Guerin  noted  the  fact  that  some  of  M.  Raynaud's  inocu- 
lated rabbits  recovered.  These  were  abortive  forms  of  disease. 
M.  Bouley  had  at  one  time  described  to  him  the  case  of  a  girl  who 
had  the  symptoms  of  hydrophobia  in  a  mild  form,  and  who  re- 
covered ;  her  case  was  perhaps  an  abortive  one  of  the  disease. 

M.  Gosselin  said  that  he  would  believe  that  M.  Raynaud  had 
inoculated  rabbits  with  hydrophobia,  only  after  the  disease  had 
been  retransmitted  to  the  dog  in  its  characteristic  form. 

At  the  session  of  January  29th,  M.  Doleris  reported  the  results 
of  his  inoculations  of  rabbits  from  the  child  already  mentioned  by 
MM.  Raynaud  and  Lannelongue.  He  observed  the  following 
phenomena  :  loss  of  appetite,  vertigo,  weakness  of  posterior  limbs, 
very  little  excitement,  sometimes  slight  convulsions,  and  terminal 
collapse.  He  thought  that  the  death  in  these  animals  was  caused 
not  by  rabies,  but  by  septicaemia,  and  that  there  are  two  kinds  of 
virus,  the  one  hydrophobic  and  the  other  septicaemic,  and  it  was 
difficult  to  determine  the  proper  conditions  for  the  production  of 
one  rather  than  the  other. 


The  following  are  the  titles  of  certain  papers  recently  published 
on  the  pathology  of  the  nervous  system  and  mind  and  patholo- 
gical anatomy. 

Mann,  Removal  of  both  Ovaries  for  Hystero-Epilepsy  without 
Controlling  the  Convulsions  ;    Rapid  Improvement  under  Central 


THERAPEUTICS.  4II 

Galvanization,  etc.  N.  Y.  Med.  Jour.,  Jan.  Benedikt,  On  the 
Question  of  the  Four  Frontal  Convolutions  Type.  Centralb.  f.  d. 
Med.  IVissensch.,  No.  46,  1880.  Mancini,  Cerebral  Localiza- 
tions and  especially  Aphasia.  Lo  Speriinentale,  Oct.  Brown- 
Sequard,  Remarks  on  some  of  the  Physiological  and  Patholog- 
ical Influences  of  the  Nervous  System  on  Nutrition.  Brit.  Med. 
'Jour.,  Dec.  11.  Hutchinson,  On  Structure  of  Peripheral 
Organs.  Nordiskt.  Med.  Arktv,  Bd.  xii,  i88c,  No.  26.  Furst, 
The  Nerves  of  the  Iris.  Nordiskt.  Med.  Arkiv,  xii,  1880,  No.  19. 
Chapman,'^  The  Brain  of  the  Orang.     Science,  Dec.  31. 


C. — THERAPEUTICS    OF    THE   NERVOUS   SYSTEM   AND   MIND. 


Arsenic  in  Tetanus. — Dr.  John  T.  Hodgen  reports  {St.  Louis 
Courier  of  Medicine,  December  9th)  a  case  of  traumatic  tetanus  fol- 
lowing a  compound  comminuted  fracture  of  the  os  calcis  and  a 
comminuted  fracture  of  the  thigh,  from  a  fall.  The  treatment 
was  commenced  with  the  hypodermic  injection  of  ten  drops, 
Fowler's  sol.,  the  use  of  chloral,  thirty  grains  of  chloral  every 
hour,  till  three  doses  had  been  given,  and  then  it  was  discontinued, 
and  the  injections  of  arsenic  alone  depended  upon,  and  given  at 
intervals  of  four  hours.  Under  this  treatment  the  tetanic  symp- 
toms disappeared,  but  the  patient  died  of  septicaemic  poisoning 
from  his  wound  three  weeks  after  the  injury. 

No  bad  effects  were  experienced  from  the  use  of  the  arsenic  or 
the  method  of  its  administration,  not  even  nausea,  and  the  injec- 
tions appeared  to  promptly  relieve  the  rigidity,  substernal  pain, 
the  difficulty  of  deglutition,  and  also  controlled  the  small,  quick, 
and  fluttering  pulse.  The  patient  asked  himself  for  their  repe- 
tition. 

Nerve-stretching. — In  addition  to  the  cases  noted  in  our 
previous  issues,  there  have  been  reported  in  the  service  of  M. 
Debove  two  new  cases  in  which  nerve-stretching  has  had  the  hap- 
piest effects  in  locomotor  ataxia.  In  the  first  case  {Pr ogres  Medi- 
cal, No.  50,  1880)  the  patient  was  entirely  relieved  by  the  opera- 
tion of  his  ataxic  pains,  and  the  gastric  attacks  and  incoordina- 
tion also  disappeared  almost  or  quite  entirely.  The  second  patient 
having  observed  these  effects  in  the  person  first  operated  upon, 
demanded  to  have  the  same  performed  on  himself.  The  fulgu- 
rant  pains  were  most  troublesome  in   the  arms,  and  therefore  the 


412  PERISCOPE. 

operation  was  performed  on  the  median  and  radial  nerves  of  the 
right  side.  The  immediate  results,  as  stated  by  M.  d'Olier  in  the 
Progris  Medical,  No.  52,  were  a  considerable  diminution  of  the 
pains  in  the  right  arm,  and  their  disappearance  in  the  left  and  in 
the  legs,  diminution  of  the  plantar  anaesthesia  on  the  left  side,  and 
marked  improvement  in  coordination,  so  that  the  patient  was  able 
to  walk  unsupported,  which  could  not  be  done  previously.  There 
■was  also  improvement  in  other  respects  ;  the  patient  regained  his 
regular,  undisturbed  sleep,  and  refused  anodynes,  after  the  opera- 
tion, as  needless. 

This  operation,  judging  from  these  and  the  other  cases  re- 
ported, seems  likely  to  make  locomotor  ataxia  a  surgical  disease, 
as  far  as  therapeutics  are  concerned,  and  they  go  far  to  give  an 
altogether  different  face  to  its  prognosis.  We  shall  await  further 
observations  and  experience  with  this  method  of  treatment  with 
the  greatest  interest. 

At  the  session  of  the  Soc.  de  Biologic,  February  5th  (rep.  in 
Le  Progres  Medical),  M.  Laborde  exhibited  two  guinea  pigs  in 
which  he  had  stretched  the  sciatic  nerve,  and  he  concluded  from 
his  experiments  that  if  the  operation  was  thoroughly  done  it 
caused  the  complete  disappearance  of  the  sensitive  current.  In 
fact,  in  these  guinea  pigs  he  pinched  the  two  external  phalanges, 
innervated,  as  is  well  known,  by  the  sciatic,  and  they  remained 
unmoved  ;  but  if  he  pinched  the  same  part  of  the  corresponding 
limb  in  which  the  nerve  had  not  been  stretched,  he  immediately 
produced  pain  and  reflex  movements,  extending  to  the  other  limb. 
The  descending  nerve-current  is  therefore  preserved  ;  and,  for  a 
further  proof,  the  two  internal  phalanges  of  the  Umb  operated  on, 
wiiich  are  innervated  by  the  crural  nerve,  preserved  their  sensi- 
bility intact.  These  results  are  permanent,  both  in  the  rabbit  and 
in  the  dog.  M.  Laborde  had  examined  at  the  Bicetre  the  patient  on 
whom  M.  Debove  had  first  operated,  and  in  whom  the  fulgurant 
pains  had  disappeared  since  the  operation.  But,  besides  this 
effect,  the  conscious  and  reflex  sensibility  in  this  patient  were  no- 
tably different  on  the  two  sides.  On  the  side  operated  upon,  the 
sensibility  and  the  reflexes  were  notably  enfeebled.  This  is  a  valu- 
able fact,  since  it  agrees  with  the  results  of  experimentation  on  the 
lower  animals.  It  appears  necessary,  therefore,  in  nerve-stretching 
to  continue  the  traction  till  the  sensibility  is  markedly  affected.. 


Purgatives    in    Tetanus. — Dr.    Alfred    Bron    {Practitioner, 
December)  protests  against  the  customary  employment  of  active 


THERA  PE  U  TICS.  4  ^  3 

purgation  in  the  treatment  of  tetanus,  and  which  is  recommended 
in  all,  or  nearly  all,  the  treatises  on  the  disease.  In  the  course  of 
a  rather  extensive  experience  with  tetanus  in  the  West  Indies,  he 
began  with  the  usual  practice  in  this  respect,  and  with  uniform  ill 
success.  In  many  cases  he  observed  that  when  a  patient  was  ap- 
parently doing  well,  the  administration  of  a  powerful  purgative 
would  be  followed  by  an  exacerbation  of  all  the  bad  symptoms, 
and  speedy  decease.  Since  then  he  has  abandoned  the  use  of 
these  agents,  and  has  had  the  satisfaction  of  seeing  a  large  pro- 
portion of  his  cases  recover. 

He  is  satisfied  that  in  a  large  proportion  of  cases  of  this  dis- 
ease the  bowels  may  be  safely  let  alone,  to  act  of  their  own  ac- 
cord, and  the  patient  be  the  better  off  for  being  spared  this  source 
of  irritation.  Only  in  those  cases  in  which  there  is  abdominal 
distress,  different  from  the  usual  epigastric  pain  of  tetanus,  and  a 
desire  to  go  to  stool  without  ability  to  pass  faeces,  does  he  advise 
the  use  of  laxatives  ;  and  in  these  cases  he  recommends  only  the 
milder  laxatives,  and  the  only  one  he  has  used  in  such  cases  and 
can  recommend  is  castor  oil,  in  drachm  doses,  at  pretty  frequent 
intervals  ;  it  acts  without  producing  abdominal  irritation,  but  it  is 
well  to  add  a  few  minims  of  tincture  of  hyoscyamus  to  each  dose. 
He  says,  in  conclusion,  that  he  has  never  had  occasion  to  regret 
not  having  purged  a  patient  in  tetanus,  but  he  more  than  once 
had  occasion  to  repent  for  having  followed  the  time-honored 
practice  of  the  text-books. 


Hot-Water  Compresses  in  Tetanus. — Dr.  C.  H.  Sporer 
{^St.  Petersb.  Med.  Wochenschr.,  Oct.  2d)  recommends  the  use  of 
hot-water  compresses  in  the  treatment  of  tetanus.  He  reports 
three  cases  :  one  traumatic,  one  connected  with  rheumatism,  and 
one  very  complicated  case  of  cerebro-spinal  meningitis,  in  all  of 
which  these  applications  produced  great  and  lasting  relief,  which 
he  is  not  inclined  to  attribute  to  any  other  of  the  measures 
employed. 

His  method  of  application  is  simple.  He  wrings  out  a  suitable 
piece  of  flannel  with  water  as  hot  as  can  be  borne  by  the  naked 
hand,  and  applies  it  along  the  whole  spine,  from  the  occiput  to 
the  sacrum.  The  temperature  of  the  water  by  the  thermometer 
should  be  from  122°  F  to  131°  F.  This  application  in  his  cases 
showed  its  effects,  in  each  case,  in  five  or  ten  minutes,  in  relieving 
the  tetanic  attacks. 


414  PERISCOPE. 

CoNiUM. — A  communication  from  M.  Bochefontaine  was  pre- 
sented to  the  Acad,  des  Sciences,  Paris,  in  October  last  (rep.  in 
Z'  Union  Me'dicale),  on  the  physiological  action  of  conium.  In 
1878,  in  connection  with  M.  Tiryakian,  he  had  communicated  to 
the  Academy  some  results  of  experiment  from  which  they  had  de- 
duced that  there  existed  in  conium  maculatum  two  active  princi- 
ples, one  of  which,  coniine  or  conicine,  had  the  action  attributed 
to  hemlock,  and  the  other,  an  action  somewhat  like  that  of  curare. 
Since  then,  in  July,  1879,  M.  Prevost  (of  Geneva)  had  published 
the  conclusions  of  a  memoir  tending  to  show  that  the  paralysis 
caused  by  bromohydrate  of  conicine  was  due  to  its  action  on  the 
motor  nerves.  Their  results  being  different,  it  appeared  necessary 
to  M.  Bochefontaine  to  seek  the  reasons  for  this  difference,  and 
he  therefore  commenced  a  new  series  of  experiments  on  the  phys- 
iological and  therapeutical  action  of  coniine.  The  following  are 
the  results  : 

Coniine  is  absorbed  by  the  mucous  membrane  of  the  digestive 
tract  in  man,  as  in  the  dog,  and  it  produces  a  general  enfeeble- 
ment  and  the  disappearance  of  severe  stomachal  pains.  A  few 
drops  of  this  alkaloid,  applied  directly  to  certain  mucous  mem- 
branes, act  directly  as  an  analgesic,  and  even  causes  sleep  for 
many  hours.     Curare  does  not  have  this  effect. 

The  experiments  from  which  the  other  differences  between  the 
alkaloid  of  hemlock  and  curare  were  shown  were  as  follows  : 

1.  Into  the  saphenous  vein  of  a  large,  healthy  dog,  after  having 
divided  the  sciatic  nerve,  he  injected  about  seven  centigrammes 
of  coniine  in  a  convenient  hydro-alcoholic  solution.  The  reflex 
activity  of  the  medullary  spinal  gray  axis  was  speedily  abolished, 
and  faradization  of  the  central  portion  of  the  divided  nerve  caused 
neither  manifestations  of  pain  nor  reflex  movements,  or,  more 
exactly,  it  did  not,  as  before  the  injection,  cause  either  move- 
ments of  the  head  or  members  or  cries,  while  excitation  of  the 
peripheral  portion  still  produced  its  usual  effects. 

May  we  not  here  also  cite  a  characteristic  difference  between 
our  alkaloid  and  curare,  noticed  by  Mm.  Jolyet  and  Pelissard, 
and  then  by  M.  Prevost  ;  the  former  paralyzing  the  vagus  before 
any  other  nerves,  thus  reversing  the  action  of  curare. 

2.  In  two  frogs  we  cut  across  the  sacrum,  and  tied  the  trunk 
in  its  lower  part,  with  the  exception  of  the  sciatic  plexus.  Then 
in  one  a  drop  of  curare  was  injected  under  the  skin  of  the  anterior 
limb,  and  in  the  other  the  same  quantity  of  a  suitable  solution  of 
coniine.     As  the   two  animals  lay  flaccid,  when  we   pinched  the 


THERAPEUTICS.  4^5 

digits  of  the  intact  fore  limb  of  each,  or  touched  the  skin  of  the 
axilla  of  one  side,  or  around  the  anus,  with  a  drop  of  acid,  the 
curarized  frog  made  the  motions  of  defence  or  flight  with  the  pos- 
terior limbs,  while  the  other  remained  immovable. 

From  these  it  follows  that  coniine  diminishes  or  destroys  the 
physiological  functions  of  the  nerve-centres  before  it  acts  like 
curare  on  the  "  nervo-muscular  connections  "  (Vulpian).  In  both 
dogs  and  frogs  it  finally  abolishes  the  nervous  motor  excitability, 
if  given  in  sufficient  amount  ;  but  then  it  is  inevitably  fatal  for 
frogs  as  well  as  mammals.  The  physiological  action  of  this  alka- 
loid is  therefore  different  from  that  of  curare. 

As  to  the  action  of  the  bromohydrate  derived  from  conium, 
the  following  are  the  results  of  experiments  with  the  products 
crystallized  in  the  same  general  form  and  prepared  by  M.  Mour- 
rut,  mainly  in  M.  Vulpian's  laboratory. 

We  may  divide  these  bromohydrates  into  two  groups  : 

a.  These  have  an  amber  color  and  resemble  samples  formerly 
used  by  M.  Tiryakian  and  myself.  These,  more  toxic  than  those 
of  the  next  group,  act  very  much  like  coniine,  they  represent  the 
principal  physiological  action  of  that  alkaloid. 

b.  The  second  group,  colorless  or  slightly  pearly,  purified  by 
many  crystallizations,  and  similar  to  that  used  by  M.  J.-L. 
Prevost,  are  shown  to  be  less  toxic  than  the  yellowish  salts,  and 
act  differently  from  them.  Frogs  paralyzed  by  from  15  to  20 
milligrammes  of  these  purified  bromohydrates  lose  their  motor 
excitability  like  curarized  frogs,  but  do  not  recover,  like  those 
benumbed  with  curare  and  otherwise  placed  in  the  same  con- 
ditions. A  little  smaller  dose,  sufficient,  nevertheless,  of  incom- 
pletely benumbing  frogs,  so  that  they  can  still  execute  some  spon- 
taneous movements,  will  yet  produce  death  after  two  or  three 
days. 

To  the  query  whether  these  alkaloids  differ  chemically  or  not, 
an  answer  cannot  yet  be  given. 

As  regards  the  comparative  action  of  hemlock  and  curare,  it 
can  be  apparently  formulated  thus  :  Hemlock  may  act  like  curare, 
but  it  causes  still  other  physiological  effects  not  observed  in  curarized 
animals. 

Action  of  Digitaline  on  the  Blood-Vessels  and  the 
Heart. — F.  Klug  {Archiv  f.  Physiologic,  1880,  p.  457),  after 
quoting  the  rather  contradictory  literature  on  the  subject,  records 
his  results.     Examining,  in  the  first  place,  the  muscles  of  the  frog, 


4l6  PERISCOPE. 

he  found  that  digitaHne  diminishes  gradually  excitability  of  the 
skeletal  muscles  until  paralysis  sets  in. 

On  the  nervous  system  it  acts  in  an  inverse  manner,  at  first 
increasing  the  irritability,  and,  after  directly  irritating,  secondary 
depression  and  ultimate  paralysis  follow. 

One  milligramme  of  digitaline  is  hardly  sufficient  to  kill  a  frog 
(Rana  esculanta).  The  agent  further  stimulates  the  muscular 
tissue  of  the  blood-vessels,  and  thus  causes  persistent  muscular 
spasm  of  peripheral  origin  ;  hence  the  blood-pressure  rises.  In 
larger  doses  it  produces  a  temporary  irritation  of  the  vagus  centre, 
without  destroying  finally  the  irritability  of  that  nerve.  The 
blood-pressure  will  at  last  sink  on  account  of  feeble  cardiac  action. 
This  is  due  to  the  direct  influence  of  the  alkaloid  upon  the  heart 
muscle,  and  cannot  be  stopped  by  irritation  of  the  vagus.  The 
heart  stops  finally  in  systole. 

The  results  on  mammals  the  author  condenses  into  the  follow- 
ing conclusions :  Digitaline  acts  less  energetically  upon  the 
blood-vessels  of  the  rabbit  than  upon  those  of  the  dog.  In  small 
doses  it  raises  the  blood-pressure.  In  larger  quantities  it  influ- 
ences the  cardiac  activity.  Large  quantities  check  the  heart  by 
irritation  of  the  vagus  centre.  This  condition  is  but  temporary. 
When  it  ceases  there  follows  no  paralysis  of  the  vagus.  The  heart 
will  finally  beat  abnormally  fast  from  increased  activity  of  the  ac- 
celerating ganglia.  Death  is  caused  by  paralysis  of  the  central 
nervous  system.  The  rise  of  blood-pressure  is  due  to  the  com- 
bined action  upon  the  vaso-motor  centre  and  the  muscular  walls 
of  the  vessels.  The  latter  influence  accounts  for  the  rise  of  blood- 
pressure  even  after  dissection  of  the  spinal  cord. 

The  Action  of  Anesthetics. — The  British  Med.  Journal  of 
December  i8th,  contains  an  elaborate  report,  by  the  Scientific 
Grants  Committee  of  the  British  Medical  Association,  on  the  ac- 
tion of  anaesthetics,  by  a  committee  consisting  of  Drs.  J.  G. 
McKendrick,  Joseph  Coats,  and  David  Newman.  The  report  is 
illustrated  by  graphic  tracings  and  cuts  of  the  apparatus,  and  con- 
tains elaborate  discussions  on  the  points  involved.  The  subjects 
of  the  experiments  were  frogs  and  rabbits,  and,  as  will  be  seen, 
the  more  special  subject  of  investigation  was  the  comparative  ac- 
tion of  chloroform,  ether,  and  ethidene  dichloride.  The  results, 
which  alone  we  have  the  space  to  give,  are  summed  up  as  follows  : 

A. — Clinical. 

I.     The  dose  (administered  on  a  towel)  is  greater  with  ethidene 


THERA  PE  UTICS.  4 1 7 

than  chloroform  ;  but  the  time  necessary  to  anaesthetize  the  pa- 
tient is  longer  with  the  latter  than  the  former  agent. 

II.  The  number  of  cases  of  sickness  and  vomiting  is  about  the 
same  with  the  two  agents,  but  the  duration  is  considerable  pro- 
tracted in  the  case  of  chloroform  ;  the  occurrence  of  these  symp- 
toms have  no  relation  to  the  length  of  time  the  patient  has  been 
under,  or  reference  to  the  quantity  of  anaesthetics  administered  in 
a  given  time. 

III.  With  both  agents,  the  pulse-respiration  ratio  is  consider- 
ably altered  in  a  certain  number  of  cases,  the  pulse  falling  as  the 
respirations  increase  in  frequency.  With  chloroform,  this  change 
is  not  only  much  more  marked,  but  its  occurrence  is  also  more 
frequent  than  with  ethidene  :  the  proportion,  in  our  experience, 
being  nine  of  the  former  to  two  of  the  latter.  There  is  also  a 
greater  tendency,  in  cases  of  chloroform,  to  retardation  of  the 
heart's  movements,  and  to  dicrotism. 

B — Physiological. 

I.  The  effect  of  anaesthesia  with  chloroform  is  to  increase  the 
amount  of  carbonic  acid  exhaled  in  a  given  time.  The  results  of 
our  investigations,  in  connection  with  the  effects  of  anaesthetics 
on  the  gases  of  the  blood,  are  not  sufficiently  reliable  to  permit  us 
to  give  results. 

II.  Both  chloroform  and  ethidene,  administered  to  animals, 
have  a  decided  effect  in  reducing  the  blood-pressure  ;  while 
ether  has  no  appreciable  effect  of  this  kind. 

III.  Chloroform  reduces  the  pressure  much  more  rapidly,  and 
to  a  greater  extent,  than  ethidene. 

IV.  Chloroform  has  sometimes  an  unexpected  and  apparently 
capricious  effect  on  the  heart's  action,  the  pressure  being  re- 
duced with  great  rapidity  almost  to  nil,  while  the  pulsations  are 
greatly  retarded,  or  even  stopped.  The  occurrence  of  these  sud- 
den and  unlooked  for  effects  on  the  heart's  action  seems  to  be  a 
source  of  serious  danger  to  life — all  the  more  that,  in  two  in- 
stances, they  occurred  more  than  a  minute  after  chloroform  had 
ceased  to  be  administered,  and  after  the  recovery  of  the  blood- 
pressure. 

V.  Ethidene  reduces  the  blood-pressure  by  regular  gradations, 
and  not.  so  far  as  observed,  by  these  sudden  and  unexpected 
depressions. 

VI.  Chloroform  may  cause  death  in  dogs  either  by  primarilv 
paralyzing  the  heart   or  the   respiration.     The  variations  in  this 


41.8  PERISCOPE. 

respect  seem  to  depend,  to  some  extent,  on  individual  peculiari- 
ties of  the  animals  :  in  some,  the  cardiac  centres  are  more  readily 
affected;  in  others,  the  respiratory.  But  peculiarities  in  the  condi- 
tion of  the  same  animal  very  probably  have  some  effect  in  deter- 
mining the  vulnerability  of  these  two  centres  respectively  ;  and 
they  may  both  fail  simultaneously. 

VII.  In  most  cases,  respiration  stops  before  the  heart's  action  ; 
but  there  was  one  instance  in  which  respiration  continued  while 
the  heart  had  stopped,  and  only  failed  a  considerable  number  of 
seconds  after  the  heart  had  resumed. 

VIII.  The  use  of  artificial  respiration  was  very  effective  in  re- 
storing animals  in  danger  of  dying  from  the  influence  of  chloro- 
form. In  one  instance,  its  prolonged  uses  produced  recovery 
even  when  the  heart  had  ceased  beating  for  a  considerable  time. 

IX.  Under  the  use  of  ethidene,  there  was,  on  no  single  occa- 
sion, an  absolute  cessation  either  of  the  heart's  action  or  of  respi- 
ration, although  they  were  sometimes  very  much  reduced.  It  can? 
therefore,  be  said,  that,  though  not  free  from  danger  on  the  side 
of  the  heart  and  respiration,  this  agent  is  in  a  high  degree  safer 
than  chloroform. 

X.  In  regard  to  the  effect  of  anaesthetics  upon  the  pulmonary 
circulation,  as  in  the  experiments  on  the  effects  of  the  anaesthet- 
ics upon  the  blood-pressure,  it  may  be  stated  that  chloroform  pro- 
duces the  most  immediate  effect,  ether  the  least,  while  ethidene 
occupies  an  intermediate  position. 

XL  The  quantity  of  air  and  the  length  of  time  required  to  re- 
store the  circulation  in  the  lung,  are  in  an  inverse  ratio  to  the 
amount  of  anaesthetic  vapor  and  the  time  necessary  to  stop  it. 

XII.  The  changes  produced  in  the  lung  are  the  same  in  all  ; 
the  only  difference  being  in  the  rapidity  of  their  occurrence. 

XIII.  The  anaesthetics  produce  the  following  changes  in  the 
lungs  :  (i)  retardation  and  ultimate  stoppage  of  the  circulation  in 
the  lung,  first  in  the  capillaries,  then  in  the  arterioles,  and  subse- 
quently in  the  larger  vessels  ;  (2)  the  epithelium  cells  of  the 
meshes  and  their  nuclei  are  no  longer  apparent  ;  (3)  the  capillaries 
contract  slightly,  and  their  walls  become  less  distinct,  or  even  dis- 
appear from  view,  and  the  enclosed  corpuscles  may  become  more 
or  less  disintegrated. 

XIV.  The  effect  of  ether  and  ethidene  upon  the  heart,  after 
artificial  respiration  for  seven  and  five  minutes  respectively,  is 
simply  to  produce  a  retardation  of  the  impulses — ethidene  having 
ihe   most  marked  effect.     Chloroform  not  only  produces  a  retar- 


THERA  PE  UTICS.  4^9 

dation  of  the  pulse,  but  the  ventricular  contractions  are  delayed 
and  slightly  separated  from  the  auricular,  and  an  auricular  con- 
traction may  immediately  follow  the  ventricular.  The  auricular 
contractions  frequently  occur  without  any  corresponding  ventric- 
ular movements. 

C. — Practical. 

The  conclusions  to  be  drawn  from  the  above  observations  are 
these  : 

I.  It  is  not  only  necessary  to  watch  the  effect  of  the  anaesthet- 
ic upon  the  pulse,  but  it  is  also  requisite  to  have  regard  to  the 
respiration.  We  must  not  only  take  into  account  the  danger  of 
sudden  stoppage  of  the  respiration,  but  must  also  remember  that 
in  the  event  of  abnormal  increase  of  respiratory  movements,  it 
may  become  essential,  for  the  safety  of  the  patient,  to  temporarily 
discontinue  the  administration. 

II.  Owing  to  the  tendency  of  chloroform  and  ethidene — par- 
ticularly chloroform — to  reduce  the  blood-pressure  suddenly,  not 
only  during  the  administration  of  these  agents,  but  also  after  they 
have  been  stopped  for  so?ne  little  time  (a  source  of  serious  danger), 
it  is  necessary  for  the  person  who  has  charge  of  the  administra- 
tion of  the  drug  to  be  on  the  lookout  for  symptoms  of  this  oc- 
currence, both  during  the  time  the  agent  is  being  given,  and  for 
some  time  after  the  patient  has  recovered  from  its  more  evident 
effects. 

III.  The  danger  of  death  from  stoppage  of  the  respiratory 
functions  must  be  borne  in  mind  in  every  case  in  which  anaesthet- 
ics are  given  ;  but  of  perhaps  greater  importance  is  the  danger 
from  interference  with  the  proper  action  of  the  heart — particu- 
larly when  it  is  remembered  that,  by  artificial  means,  we  can  com- 
bat the  former  contingency.  It  might  even  be  advisable,  in  cer- 
tain cases,  to  introduce  a  tracheal-tube  by  the  mouth,  so  as  to  en- 
able us  to  force  air  into  the  lungs  by  means  similar  to  those 
adopted  in  experiments  with  animals  ;  or,  in  circumstances  where 
such  a  procedure  was  impracticable,  tracheotomy  might  be  per- 
formed with  the  same  object  in  view.  Artificial  respiration  should 
be  continued,  even  though  all  evidence  of  cardiac  action  has 
ceased. 

IV.  As  regards  comparative  danger,  the  three  anaesthetics 
may  be  arranged  in  the  following  order  :  chloroform,  ethidene, 
ether  ;  and  the  ease  with  which  the  vital  functions  can  be  re- 
stored may  be    conversely  stated   thus  :  the  circulation  is  more 


420  PERISCOPE. 

easily  reestablished  when  the  cessation  is  due  to  ether  than  to 
ethidene  ;  and  when  the  result  of  ethidene,  than  when  chloro- 
form has  been  used.  The  advantages  which  chloroform  pos- 
sesses over  ether — in  being  more  agreeable  to  the  patient,  and 
more  rapid  in  its  action,  in  the  complete  insensibility  produced 
by  it,  and  the  absence  of  excitement  or  movements  during  the 
operation — are  more  than  counterbalanced  by  its  additional 
danger. 

V.  The  chief  dangers  are  :  (i)  sudden  stoppage  of  the  heart  ; 
(2)  reduction  of  the  blood-pressure  ;  (3)  alteration  of  the  pulse- 
respiration  ratio  ;  and  (4)  sudden  cessation  of  the  respiration. 
The  danger  with  ether  approaches  from  the  pulmonary  rather 
than  from  the  cardiac  side,  so  that,  by  establishing  artificial  respi- 
ration, we  have  a  means  of  warding  off  death.  Its  disadvantages 
are,  to  a  great  extent,  obviated  by  the  use  of  ethidene  ;  whilst 
the  dangers  of  chloroform  are  also  reduced  to  a  minimum. 

The  committee  propose,  in  case  it  is  thought  best  to  continue 
the  investigations,  the  following  lines  of  future  research  :  i.  Spe- 
cific action  of  anaesthetics  upon  the  heart  ;  to  determine  whether 
they  act  {a)  on  ganglia,  {]j)  muscular  protoplasm,  or  (r)  on  both. 
2.  The  action  of  anaesthetic  agents  on  the  medullary  centres  ;  {a) 
cardiac,  (^)  respiratory,  {c)  vaso-motor.  3.  Specification  of  anaes- 
thetics on  pulmonary  tissue. 

The  committee  now  feel  that  it  is  unnecessary  for  them  to  un- 
dertake clinical  observations,  except  in  the  way  of  taking  simul- 
taneous tracings  of  the  pulse  and  respiration  ;  and  for  this  pur- 
pose they  have  devised  a  special  apparatus.  They  suggest  that 
schedules  similar  to  one  published  in  their  report  be  distributed 
all  over  the  world  to  collect  information.  They  are  especially  de- 
sirous of  information  from  America,  as  the  statistics  of  ether- 
administration  in  England  are  not  sufficiently  numerous  for  pur- 
poses of  comparison. 

The  Value  of  Homatropine  Hydrobromate  in  opthal- 
Mic  practice. — In  a  paper  on  this  subject  in  the  January  number 
of  the  American  yournal  of  Medical  Sciences,  Dr.  S.  D.  Risley 
draws  the  following  conclusions  : 

1.  That  homatropine  hydrobromate  in  solutions  of  two,  four, 
and  six  grains  to  the  ounce  is  competent  to  paralyze  the  accom- 
modation. 

2.  That  in  from  sixteen  to  thirty  hours  this  paralysis  entirely 
disappears. 


THERA  PE  U  TICS.  4^  I 

3.  That  dilatation  of  the  pupil  accompanies  the  paralysis  and 
is  more  persistent,  the  probable  duration  being  forty-eight 
hours. 

4.  That  it  is  more  liable  to  produce  conjunctival  irritation 
than  atropia  or  duboisia. 

5.  That  it  produces  far  less  constitutional  disturbance  than 
either  of  the  old  mydriatics. 

Curare. — M.  G.  Planchon  {Journ.  de  Phartti.  et  de  Chim.)  says 
that,  so  far  as  our  present  knowledge  extends,  there  are  four 
different  sections  of  northern  South  America  where  curare  is  pre- 
pared, and  in  each  of  these  sections  a  different  kind  of  strychnos  is 
used  as  the  source  of  the  poison.  These  four  sections,  from  west 
to  east,  are  the  following  :  i.  The  region  of  the  upper  Amazon, 
the  largest  of  all,  comprising  the  rivers  Solimoeus,  Javiri,  lea,  and 
Yapura.  It  furnishes  the  curare  of  the  Ticunas,  Pebas,  Yaguas, 
Oregones.  This  is  prepared  from  Sirychfios  Castelnceana  (Wedd). 
2.  The  region  of  the  upper  Orinoco  to  the  Rio  Negro.  This  con- 
tains the  district  visited  by  Humboldt  in  1880.  It  furnishes  the 
curare  of  the  Maquiritaras  and  Piaroas,  which  is  derived  from 
Strychnos  gubleri.  3.  The  region  of  British  Guiana,  furnishing  the 
curare  of  the  Macusis,  Orecumas,  and  Wapisianas.  This  is  de- 
rived from  Strychnos  toxifera,  Schombemsk  including  Str.  Schom- 
burgkii  Kl.  and  Str.  cogens  Benth.  4.  The  region  of  upper  French 
Guiana  furnishing  the  curare  of  the  Trios  and  Rouconyennes, 
which  is  derived  from  Str.  Crevauxii. — British  Med.  J^ourn., 
Jan.  22,  1881, 

The  Action  of  Aconitia. — B.  Van  Aurep  {Archiv  f.  Physio- 
logic, supplement,  p.  161)  examined  three  varieties  of  the  alkaloid, 
the  German,  the  English,  and  Duquesnel's  crystalline  preparation. 
Between  the  German  and  English  there  exist  only  quantitative 
differences.  Doses  of  0.05  milligramme  of  the  former  variety  is 
fatal  to  the  frog,  while  0.2  milligramme  of  the  English  is  necessary 
The  striking  symptom  is  paralysis,  preceded  by  symptoms  of  irri- 
tation. There  exists  an  abnormal  secretion  of  the  skin,  followed 
by  dryness  and  a  change  in  color  toward  black.  The  pulse  is  at 
first  increased  in  frequency,  especially  with  small  doses.  This  is 
not  due  to  the  paralysis  of  the  vagus,  although  this  does  occur, 
but  the  acceleration  is  much  greater  than  can  be  produced  by 
section  of  the  vagus.  The  acceleration  is  followed  by  slacking 
and  debility  of  the  cardiac  action.  Before  the  heart  is  completely 
paralyzed  there  is  often  a  stage  of  tumultuous,  almost  tetanic, 


422  PERISCOPE. 

action,  which  may  be  called  cardiac  spasm.  The  sensory  nerves 
diminish  in  irritability  when  under  the  influence  of  aconitia, 
but  it  requires  large  doses  to  paralyze  them.  The  motor  nerves 
are  apparently  not  affected.  Early  loss  of  coordination  and 
immobility  of  the  animal  are  due  to  the  depressing  effect  upon 
the  brain. 

The  agent  causes  very  decided  dyspnoea,  in  large  doses  even 
stoppage  of  breathing.  The  effect  is  due  to  the  action  upon  the 
respiratory  centre.  Clonic  spasm  and  fibrillary  contraction  com- 
plete the  description. 

Duquesnel's  crystalline  aconitia  has  only  been  tested  by  Du- 
quesnel  and  Grehaut.  The  authors  observed  an  effect,  from  small 
doses,  resembling  curare.  Aurep  could  confirm  this  curare-like 
action,  but  found  it  feeble.  The  agent  seemed  more  poisonous 
than  the  other  varieties  of  the  alkaloid  ;  0.02  to  0.03  milligramme 
are  fatal  to  frogs.  The  symptoms  resembled  those  produced  by  the 
other  variety,  but  the  crystalline  preparation  seems  more  irritating 
locally.  It  differs  in  its  action  on  the  heart  by  not  accelerating  it 
at  first,  and  by  not  producing  spasm.  Its  paralytic  action  on  the 
heart  is  the  same  as  that  of  the  other  varieties.  No  other  striking 
differences  are  observed. 

On  mammalia  the  three  varieties  act  alike.  The  Duquesnel's 
aconitia  is  fatal  to  rabbits  in  the  dose  of  one-fourth  milligramme, 
and  to  medium-sized  dogs  at  double  that  quantity.  It  is  hence 
the  most  poisonous  of  all  known  substances.  The  other  varieties 
require  two  to  four  times  the  dose.  Death  seems  to  be  caused  by 
cardiac  paralysis,  but  the  experiments  on  mammalia  were  not 
extensive. 

Ergotine,  its  Drawbacks  and  Dangers. — Dr.  Boissarie 
(de  Sarlet),  in  a  note  read  at  a  recent  meeting  of  the  Paris  Sur- 
gical Society  {An?iales  de  Gynecol.,  June,  1880),  draws  attention  to 
the  possible  dangers  attending  the  prolonged  administration  of 
ergotine,  particularly  when  given  by  the  mouth.  After  briefly 
alluding  to  the  great  and  varied  utility  of  this  energetic  drug,  he 
refers  to  the  experience  of  M.  Debove.  This  gentleman  lately 
reported  to  the  Hospital  Medical  Society  the  case  of  a  young 
woman,  aet.  25,  suffering  from  albuminuria,  who  developed  a  gan- 
grene of  both  inferior  extremities.  This  gangrene  had  followed 
treatment  by  ergotine,  extending  over  four  weeks,  during  which 
time  a  daily  dose  of  0.02  had  been  administered.  Although 
a  month  had  elapsed  between  the  cessation  of  the  drug  and  the 


THERAPEUTICS.  423 

appearance  of  the  gangrene  (and  contrary  to  the  opinion  of  M. 
Debove),  the  writer  thought  that  the  two  events  stood  in  causal 
relation  to  each  other. 

M.  Dujardin-Beaumetz  had  also  observed  the  supervention  of 
gangrene,  in  a  case  of  typhoid  fever  subjected  to  treatment  by 
ergot  of  rye.  The  dose  in  this  case  was  i.o  daily,  continued 
one  month. 

The  author's  case  was  that  of  a  child,  aet.  13,  which,  while  in 
excellent  general  health,  began  to  suffer  from  incontinence  of 
urine.  After  having  tried  various  drugs,  without  benefit  to  the 
patient,  ergot  treatment  was  commenced.  Hypodermic  exhi- 
bition of  the  medicine  being  refused,  a  daily  dose  of  about  0.2 
(=  about  3  grains)  was  given  by  the  mouth.  At  first  the  results 
of  this  treatment  appeared  to  be  marvellous,  the  incontinence  be- 
ing completely  relieved  for  several  days.  But  soon  the  old  troub- 
les reappeared,  and  after  continuing  the  ergot  for  two  months 
more  without  apparent  benefit,  the  medicine  was  stopped.  This 
was  about  February  20th.  During  all  this  time  ill  effects  of  the 
ergot  had  never  been  observed.  On  March  2d,  however,  the 
child  began  to  complain  of  pains  in  the  left  side,  general 
malaise  was  noticed,  and  the  child  seemed  prostrated  and  was 
feverish.  On  the  following  day,  the  pulse  ranged  at  no,  the 
pains  persisted,  occasional  crepitant  rales  posteriorly.  On  the 
morning  of  March  4th,  the  expectoration  became  extremely 
fetid.  The  sputa  were  raised  with  painful  efforts,  appeared  of  a 
grayish  color,  were  thick  and  profusely  abundant.  The  condi- 
tion of  the  child  grew  worse  from  day  to  day,  the  pulmonary  gan- 
grene spread,  on  the  loth  the  sputa  showed  plentiful  sanguineous 
admixture.  Later  the  hemorrhage  became  profuse,  and  on  the 
15th  it  became  fatal.  This  abrupt  appearance  of  acute  pulmo- 
nary gangrene  is  ascribed  by  the  author  to  the  influence  of  the 
ergotine,  and  the  fact  is  pointed  out  that  in  this  case  also,  as  in 
that  of  M.  Debove,  some  time  had  elapsed  after  cessation  of  the 
drug  before  evil  symptoms  were  first  noticed.  It  seems,  there- 
fore, that  the  action  of  this  powerful  drug  is  truly  a  cumulative 
one  ;  that  it  has  the  property  of  causing,  sooner  or  later,  a  sud- 
den explosion  of  formidable  accidents,  and  that,  therefore,  new 
physiological  researches  are  needful  to  explain  the  mechanism  of 
its  action.  According  to  Dr.  Boissarie,  the  principal  conclusion 
to  be  derived  from  his  observation  is,  that  we  should  learn  to 
abandon,  more  and  more,  the  oral  exhibition  of  ergot,  and  sub- 
stitute in  its  place  hypodermic  administration  of  the  drug.     And 


424  PERISCOPE. 

also  that,  When  the  latter  method  is  inadmissible,  to  use  smaller 
doses  by  the  mouth,  and  avoid  a  protracted  course  of  the  medi- 
cine  when  so  administered. — Am.  Jour.  Obst.,  January. 


The  Action  of  Anaesthetics  on  the  Reflexes. — The  fol- 
lowing is  a  translation  of  a  short  article  in  the  Centralblatt  fiir  die 
Medicinishen  Wissenschaften,  No.  6,  by  Dr.  Eulenburg,  of  Greifs- 
wald  : 

The  narcosis  produced  in  warm-blooded  animals  (dogs,  rabbits) 
by  the  inhalation  of  the  anaesthetic  agents  is  accompanied  by  nu- 
merous different  conditions  of  the  reflex  irritability.  This  may 
be  increased  or  diminished  ;  it  may  also  be  extraordinarily  varied, 
either  quantitatively  or  qualitatively,  or  in  relation  to  their  succes- 
sion in  time  in  the  different  single  reflexes  and  reflex  groups  (re- 
spectively, the  tendon,  periosteal,  and  fascial  reflexes,  those  of  the 
skin,  cornea,  conjunctiva,  and  iris).  Besides  minor  varieties,  we 
can  determine  the  following  principal  types  of  their  effect  on  the 
reflexes  : 

1.  Certain  anaesthetics  (chloroform)  produce,  generally  in  the 
beginning  of  this  action,  a  transient  increase  of  certain  reflexes 
(patellar  reflex  in  dogs  and  rabbits),  followed  by  their  diminution 
and  disappearance.  The  patellar  reflex  is  always  lost  perceptibly 
before  the  corneal  ;  the  disappearance  of  the  latter  generally 
occurs  with  the  appearance  of  myosis  and  rigid  pupil.  Vice  versa 
the  corneal  always  reappears  perceptibly  earlier  than  the  patellar 
reflex  with  the  disappearance  of  the  narcosis.  The  same  phe- 
nomena are  regularly  observed  in  man  under  the  influence  of 
chloroform.  But  in  man  the  nasal  reflex  always  persists  still 
longer  than  the  corneal  one,  agreeing  in  this  completely  with  the 
observations  of  O.  Rosenbach  on  children  in  natural  sleep.  The 
nasal  reflex  in  both  these  conditions  disappears  when  the  hypnosis 
is  most  complete.  The  condition  of  the  patellar  reflex  is  suffi- 
cient guide  for  operative  purpose  in  chloroform  narcosis. 

2.  Other  anaesthetics  (ether,  and,  to  a  less  degree,  certain  ethyl 
combinations)  when  inhaled,  frequently  cause  an  enormous  in- 
crease of  certain  reflexes  (sinew  or  periosteal  reflexes  ;  patellar, 
tibial,  and  foot  reflexes  in  rabbits).  These  phenomena  may,  in- 
deed, continue  after  the  cessation  of  the  narcosis.  The  corneal 
reflex  is,  at  a  rather  late  stage  of  ether  narcosis,  weakened,  rarely 
entirely  suppressed. 

3.  Other  anaesthetics  (especially  the  double  chloride  combina- 
tions— ethyl-chloride,   ethylid-chloride,  methyl-chloride)  produce, 


THERA  PE  U  TICS.  425 

when  inhaled,  in  dogs  and  rabbits,  loss  of  the  reflexes  (without 
previous  exaltation),  and,  indeed,  the  corneal  here  always  disap- 
pears before  the  patellar  reflex,  and  the  latter  always  reappears 
before  the  former  on  the  recovery  from  the  narcosis.  Here  we  may 
recall  that  Liebreich  attributes  to  these  agents  a  primary  anaesthetic 
effect. upon  the  sensory  cranial  nerves,  and  also  that,  according  to 
my  own  observation,  the  corneal  reflex  disappears  in  asphyxia 
some  time  before  the  patellar  reflex,  as  a  rule. 

4.  Still  other  anaesthetics  (for  example,  bromide  of  ethyl),  when 
inhaled,  affect  the  reflexes  scarcely  at  all,  or  very  slowly  ;  the  pa- 
tellar reflex  is  gradually  diminished  without  any  previous  rise  ; 
the  corneal  reflex  becomes  weaker,  but  is  rarely  altogether  sup- 
pressed. Bromide  of  ethyl  acts  somewhat  like  ether  ;  the  differ- 
ent behavior  may  be  attributed  to  the  fact  that  ethyl  bromide  is 
decomposed  in  alkaline  blood  with  the  formation  of  soluble  bro- 
mine ;  after  inhalation  of  large  quantities,  bromine,  in  combina- 
tion with  an  alkaline  metal,  is  found  in  the  urine. 

According  to  these  experiments  the  participation  of  the  reflex 
apparatus  stands  in  no  definite  connection  or  only  in  a  sort  of 
time-relation  to  the  involvement  of  the  psychomotor  and  psycho- 
sensory centres  by  the  action  of  the  anaesthetic.  The  degree  of 
the  narcosis  and  the  extent  of  the  anaesthesia  are  not  at  all  pro- 
portional to  the  condition  of  single  reflexes  or  reflex  groups. 
The  successive  attacks  on  the  separate  cerebral. and  spinal  reflex 
centres  are  throughout  dissimilar  with  different  anaesthetics.  The 
relation  with  the  commonly  used  hypnotics  and  sedatives  is  also 
dissimilar.  Morphine,  given  hypodermically  to  the  extent  of 
0.5  (  =  7  grains)  to  rabbits  and  dogs,  has  but  little  effect  on  the 
reflexes,  and  morphine  injected  at  the  beginning  of,  or  during  the 
administration  of  the  anaesthetic  has  no  effect  on  the  action  of  the 
latter  in  this  respect.  (In  subjects  of  the  morphine  habit  who 
used  very  large  doses,  I  found  the  tendon  reflexes  perfectly  un- 
affected.) Chloral  hydrate,  given  to  the  extent  of  from  1.25  to 
1.5  (=  iS-22  grains;  to  rabbits,  hypodermically,  acted  very  sim- 
ilarly to  chloroform,  but  without  the  primary  exaltation  of  the  re- 
flexes ;  the  pateller  reflex  gradually  disappeared  while  the  cor- 
neal reflex,  in  non-fatal  cases,  was  generally  retained,  though 
diminished.  Of  the  bromides,  the  potash  salt,  given  subcutane- 
ously  to  rabbits,  in  doses  of  i.  to  2.  (=  15-30  grains),  caused  an 
initial  increase  of  the  patellar  reflex  followed  by  a  decrease. 
Bromal  hydrate  and  bromate  of  quinine  exhibited  no  definite 
effects.     The  fatally-ending  cases  are  excluded  from   considera- 


426  PERISCOPE. 

tion.  In  so  far  as  death  resulted  from  asphyxia,  the  corneal  re- 
flex disappeared,  as  a  rule,  a  little  before  the  patellar,  the  latter 
being  generally  lost  just  previous  to  the  exophthalmos,  dilatation  of 
pupils,  and  terminal  dyspnoeic  convulsions. 


Alcohol. — The  following  are  the  conclusions  of  a  paper  by  Dr. 
J.  D.  Castillo,  U.  S.  Navy  {Phila.  Med.  Times,  Oct.  23,  1880), 
based  on  some  fifty  odd  separate  experiments  on  drugs,  etc.  : 

1.  That  alcohol,  in  sm'all  doses,  causes  an  acceleration  of  the 
pulse,  with  increased  cardiac  force. 

2.  That  this  acceleration  of  the  pulse,  and  the  increase  of  the 
cardiac  force,  are  due  to  a  direct  stimulation  of  the  heart. 

3.  That  alcohol,  in  larger  doses,  causes  an  acceleration  of  the 
pulse,  with  diminished  cardiac  force,  and  that  this  is  due  to  a 
direct  depression  of  the  heart. 

4.  That  if  the  dose  be  excessive,  the  pulse-rate  is  diminished 
from  the  first,  or  the  heart  may  be  immediately  arrested,  being 
due  to  a  direct  paralysis  of  the  heart. 

5.  That  the  heart  is  always  arrested  in  diastole. 

6.  That  small  doses  cause  a  rise  of  the  arterial  pressure. 

7.  That  large  dos?s  cause  a  fall  of  the  arterial  pressure. 

8.  That  these  changes  effected  in  the  arterial  pressure  are 
due  to  the  action  of  alcohol  on  the  heart  alone  ;  in  the  former  case, 
being  one  of  stimulation,  and,  in  the  latter,  one  of  depresion. 

9.  That  alcohol  in  small  doses  is  a  cardiac  stimulant,  and,  in 
large  doses,  a  cardiac  depressant. 


Absinthism. — At  the  session  of  the  Acad,  de  Medecine,  Paris, 
Oct.  19,  1880  (rep.  in  La  France  MMcale),  M.  Lancereaux  made 
a  communication,  in  which  he  claimed  that  the  effects  of  the  use 
of  absinthe  did  not  reveal  themselves  solely  in  the  acute  and 
transient  symptoms,  such  as  convulsive  phenomena,  etc.,  following 
excess.  It  produced,  when  long  continued,  a  series  of  gradually- 
and  regularly-developing  symptoms  of  intoxication,  profoundly 
modifying  the  system,  and  often  causing  death.  These  symptoms, 
which  affect  especially  the  sensory  and  mental  faculties,  consti- 
tute what  he  calls  the  chronic  type  of  absinthism,  as  opposed  to 
the  acute  form. 

There  is  still  another  form  of  intoxication,  the  hereditary  type 
of  absinthism.  Each  of  these  forms  has  great  analogies  with  the 
pathological  condition  known  as  hysteria.     The  acute  type  recalls 


THERA  PE  U  TICS.  42  7 

the  convulsive  hysteric  attack  ;  the  second  presents,  in  the  male 
as  well  as  in  the  female,  disorders  of  sensibility,  which  it  is  impos- 
sible to  differentiate  from  those  of  hysteria.  Therefore,  he  be- 
lieves that  many  of  the  so-called  cases  of  hysteria  in  males  (in 
France),  are  really  only  cases  of  chronic  absinthism.  The  third 
of  these  forms  is  generally  confounded  with  hysteria. 


The  Treatment  of  Alcoholism. — Dr.  J.  K.  Bauduy  {St.  Louis 
Courier  of  Medicine,  Dec,  1880)  deduces  the  following  conclu- 
sions from  a  study  of  over  eight  hundred  cases  of  alcoholism  under 
his  observation  at  St.  Vincent's  Asylum,  St.  Louis  : 

1.  Acute  alcoholism  is  a  self-limiting  affection. 

2.  Acute  alcoholism  results,  not  from  sudden  withdrawal,  but 
from  excess  and  abuse  of  alcoholic  "  so-called  stimulants,"  better 
called  sedatives  and  narcotics  in  the  doses  in  which  they  are 
taken. 

3.  The  expectant  plan  of  treatment  is  the  most  successful. 

4.  Opiates  are  dangerous,  because  they  additionally  derange 
digestion,  and,  acting  as  powerful  cardiac  sedatives,  tend  to  para- 
lyze the  heart,  and,  finally,  because  they  check  elimination,  inter- 
fere with  the  normal  secretions  and  digestion. 

5.  Sleep  is  never  to  be  produced  at  risk  or  hazard  to  the 
patient,  but  is  to  be  expected  as  one  of  the  harbingers  of  a  con- 
valescence not  to  be  forced. 

6.  In  acute  alcoholism,  as  in  many  other  acute  diseases,  the 
vis  tnedicatrix  naturce  is  fully  adequate,  in  most  cases,  to  produce 
the  happiest  of  results. 


Electricity. — Dr.  Mossdorf,  in  a  paper  offered  to  the  Gesellsch. 
f.  Natur  u.  Heilkunde,  at  Dresden,  April  3,  1880  (rep.  in  Deutsche 
Med.  Wochenschr.,  Dec.  11).  recommends  strongly  the  use  of 
the  constant  current  in  those  cases  of  diphtheritic  paralysis  that 
call  for  treatment.  He  uses  the  descending  spinal  current  alone  ; 
its  effects,  he  claims,  are  remarkable,  not  only  relieving  the  par- 
alysis, but  acting  as  a  general  tonic  to  the  patient.  It  has  the  ad- 
vantage also  of  causing  no  pain  or  inconvenience,  even  to  a  child, 
in  its  application. 

Of  course,  though  he  says  nothing  as  to  the  strength  of  the 
current,  the  general  rule  of  caution  should  be  observed. 

Dr.  Roberts  Bartholow,  in  a  clinical  lecture  published  in  the 
Medical  News  and  Abstract  for  January,  says,  that  in  treatment 


428  PERISCOPE. 

with  electricity,  not  enough  attention  is  paid  to  the  durations  and 
frequency  of  the  applications.  Galvanic  applications  about  the 
head  should  be  with  moderate  currents,  should  not  last  over  five 
minutes,  and  may  be  repeated  several  times — say  three  a  day.  In 
neuralgias  the  seances  should  be  of  longer  duration,  and  should  be 
repeated  at  short  intervals.  Thus,  he  says,  much  better  results 
would  be  obtained  in  sciatica,  for  example,  than  is  usually  the 
case,  if  they  were  each  fifteen  minutes  long,  and  were  repeated 
every  three  or  four  hours.  In  the  treatment  of  muscular  paralysis, 
however,  with  faradism,  the  care  must  be  to  avoid  fatigue  of  the 
muscles,  and  the  smallest  current  that  will  cause  contractions 
may  be  used  from  five  to  fifteen  minutes  twice  a  day.  He  says 
he  has  had  experience  with  these  frequently-repeated  applications 
in  neuralgias,  etc.,  and  his  statements  are  based  upon  this  ex- 
perience.   

Among  others,  the  following  may  be  mentioned  as  recent  pub- 
lications on  the  therapeutics  of  the  nervous  system  and  mind  : 

Beard,  The  Asylums  of  Europe.  Boston  Med.  and  Surg.  Journ., 
Dec  23.  Briquet,  Metallotherapy,  and  the  Treatment  of  Dis- 
orders of  Sensibility  in  Hysterical  cases  by  Electricity.  Bull, 
gen  de  Therap.,  Nov.  30,  1880.  Walsh  am,  A  Case  of  Epilepti- 
form Neuralgia  Cured  by  Stretching  the  Infra-orbital  Nerve  :  with 
Remarks.  Brit.  Med.  J^ourn.,  Dec.  25th.  Kane,  Chloral  Hy- 
drate. N.  Y.  Med.  Rec,  Dec.  25th,  Jan.  ist,  Jan.  8th,  Jan.  15th. 
Stephen  Smith,  Partial  Intoxication  in  the  Prevention  of  Shock 
during  Operations.  N.  V.  Med.  Bee,  Dec.  25th.  Crothers, 
Clinical  Studies  of  Inebriety.  The  Treatment  of  Inebriety  Em- 
pirically. Med.  and  Surg.  Rep.,  Feb.  5th.  Kane,  Chloral  Hy- 
drate as  an  Antidote  to  Strychnia.  Ibid.,  Jan.  29th,  Poole,  Elec- 
tricity a  Paralyzing  Agent.  N.  Y.  Med.  Rec,  Jan.  29th,  Davies, 
Chemical  Restraint  and  Alcohol.  Jour.  0/ Ment.  Sci.,  ]diX\.  1881. 
Poole,  Strychnia  a  Paralyzing  Agent.  N.  Y.  Med.  Rec,  Feb. 
19th.  Engelhorn,  On  General  Faradization.  Centralbl.  f.  Ner- 
venheilk,  Jan  1st.  Hughes-Bennett,  On  the  Action  of  the 
Bromides  in  Epilepsy.     Edinburgh  Med.  Jour.,  Feb. 


BOOKS  RECEIVED.  429 

BOOKS  AND  PAMPHLETS  RECEIVED. 


Contribute  alio  Studio  delle  Malatie  Accidentali  dei  Pazzi. 
Dei  Dottori  Seppilli,  Guiseppe,  e  Riva,  Gaetano.  Milano,  Fratelli 
Rechiedei  Editori,  1879. 

Di  Alcune  Eruzioni  Cutane  Dovute  all'Azione  Patogenica  dell' 
loduro  di  Potassio  pel  Dott.  Celso  Pellizzari.  Firenze,  Tipo- 
grafia  Cenniniana,  1880. 

Rocky  Mountain  Health  Resorts,  by  Chas.  Denison,  M.D.  Bos- 
ton, Houghton,  Mifflin  &  Company,  1881. 

Aphorisms  in  Fracture,  by  R.  O.  Cowling,  A.M.,  M.D.  (Mor- 
ton's Pocket  Series,  number  2.) 

Cerebral  Anatomy  Simplified,  by  S.  V.  Clevenger,  M.D.  (Re- 
print from  Chicago  Medical  Journal  and  Examiner,  November, 
1880.) 

The  Results  of  Treatment  in  over  Eight  Hundred  Cases  of  Al- 
coholism, by  J.  K.  Bauduy,  M.D.  (Reprint  ixoxtiSt.  Louis  Courier 
of  Medicine,  December,  1880.) 

Hemiopia,  by  Wm.  Dickinson,  M.D.,  St.  Louis.     (Reprint  from 

Alienist  and  Neurologist,  J^^n'y,  1881.) 

The  Asylums  of  Europe,  by  Geo.  M.  Beard,  M.D.  (Reprint 
from  Boston  Medical  and  Surgical  Journal,  Dec.  23,  1880.) 

The  Relations  of  Goitre  to  Pregnancy  and  Derangements  of 
the  Generative  Organs  of  Women,  By  E.  W.  Jenks,  M.D.  (Re- 
print from  the  American  journal  of  Obstetrics,  January,  1881.) 

Phthisis  Pulmonalis  and  its  Treatment  with  Hypophosphites, 
by  L.  de  Bremon,  M.D.,  University  of  Paris  (France),  1880. 

Spinal  Myosis  and  Reflex  Pupillary  Immobility,  by  William 
Erb,  M.D.     (Reprint  from  Archives  of  Medicine,  October,  1880.) 

Tracheotomy  in  Croup  and  Diphtheria,  by  Drs.  E.  W.  Lee  and 
Christian  Fenger.  (Reprint  from  Chicago  Medical  y^ournal  and 
Examiner,  October,  1880.) 

Caries  of  the  Superior  Maxilla,  by  T.  W.  Brophy,  M.D., 
D.D.S.  (Reprint  from  Chicago  Medical  J^ournal  and  Examiner^ 
December,  1880.) 

Comparative  Neurology,  by  S.  V.  Clevenger,  M.D.  (Reprint 
from  American  Naturalist,  January,  1881.) 

Suggestions  for  Improvements  in  the  Management  of  the  Insane 
and  of  Hospitals  for  the  Insane  in  the  State  of  New  York,  by 
Wm.  A.  Hammond,  M.D. 

A  Contribution  to  the  Doctrine  of  Bilateral  Functions  after 
Experiences  of  Metalloscopy,  by  A.  S.  Adler,  M.D.  (Reprint 
from  San  Francisco  Western  Lancet,  Feb'y,  1881.) 


430  BOOKS  RECEIVED. 

The  Cardiac  Nerves  Tabulated,  by  Roswell  Park,  A.M.,  M.D. 
(Reprint  from  Annals  of  Anatomy  and  Surgery,  1881.) 

An  Inner  View  of  the  State  Lunatic  Asylum  at  Utica,  by 
William  L.  Trull. 

Transactions  of  the  Eleventh  Annual  Session  of  the  Medical 
Society  of  Virginia,  1880. 

Proceedings  of  the  Louisiana  State  Medical  Association.  New 
Orleans,  April,  1880. 

Thirteenth  Annual  Report  of  the  Inspector  of  Asylums, 
Prisons,  and  Public  Charities  for  the  Province  of  Ontario  for 
1880. 

Forty-Sixth  Annual  Report  of  the  Waterford  District  Lunatic 
Asylum  for  1880. 

Report  of  the  Investigation  by  the  Commissioners  on  Chari- 
table Institutions  of  the  City  of  St.  Louis,  October  26,  1880. 

The  Law  of  Commitment  to  Hospitals  for  the  Insane  in  the 
State  of  Illinois. 

Kankakee,  by  Rev.  F.  H.  Wines,  Secretary,  Illinois  State  Board 
of  Charities. 

Report  of  the  Superintendent  of  the  Nebraska  Hospital  for  the 
Insane  for  1878-80. 

Fifteenth  Report  of  the  Board  of  Trustees  of  the  Connecticut 
Hospital  for  the  Insane,  1881. 

Report  of  the  Albany  Hospital  for  two  years  ending  January 
31,  1880. 

Third  Biennial  Report  of  the  Board  of  Managers  of  State 
Lunatic  Asylum  Number  2,  of  Missouri. 

Reports  of  the  Trustees  and  Superintendent  of  the  Butler  Hos- 
pital for  the  Insane,  Providence,  R.  I.,  January,  1881. 

Annual  Report  of  the  Trustees  and  Superintendent  of  the  State 
Lunatic  Hospital  of  Pennsylvania,  1880, 

Twelfth  Annual  Report  of  the  Trustees  of  the  Willard  Asylum 
for  the  Insane  for  1880. 

Second  Biennial  Report  of  the  Illinois  Eastern  Hospital  for  the 
Insane  at  Kankakee,  October  i,  1880. 

Seventh  Annual  Report  of  the  Cincinnati  Sanitarium,  1880. 


PERIODICALS  RECEIVED,  43  I 

THE   FOLLOWING    FOREIGN     PERIODICALS   HAVE   BEEN 
RECEIVED   SINCE   OUR   LAST   ISSUE. 


Allgemeine  Zeitschrift   fuer  Psychiatric  und  Psychisch.  Gerichtl. 

Medicin. 
Annales  Medico-Psychologiques. 
Archives  de  Neurologic. 

Archives  dc  Physiologic  Normale  et  Pathologiquc. 
Archiv  fuer  Anatomie  und  Physiologic. 

Archiv  fuer  die  Gesammte  Physiologic  der  Menschen  und  Thierc. 
Archiv  fuer  Path.  Anatomie,  Physiologic,  und  fuer  Klin.  Medicin. 
Archiv  f.  Psychiatric  u.  Nervenkrankhcitcn, 
Archivio  Italiano  per  le  Malatic  Nervose. 
Brain. 

British  Medical  Journal. 
Bulletin  Generale  de  Therapcutique. 
Ccntralblatt  f.  d.  Med.  Wissenschaftcn. 
Centralblatt  f.  d.  Nervenheilk.,  Psychiatric,  etc. 
Cronica  Med.  Quirurg.  de  la  Habana. 
Deutsche  Medicinische  Wochenschrift. 
Dcutsches  Archiv  f.  Geschichte  der  Medicin. 
Dublin  Journal  of  Medical  Science, 
Edinburgh  Medical  Journal. 
Gazetta  degli  Ospitali. 
Gazetta  del  Frenocomio  di  Reggio. 
Gazetta  Medica  di  Roma. 
Gazette  des  Hopitaux. 
Gazette  Medicale  de  Strasbourg. 
Hospitals-Tidendc. 
Hygeia. 

Jahrbiicher  fiir  Psychiatric. 
Journal  de  Medecinc  de  Bordeaux. 
Journal  de  Medecinc  ct  dc  Chirurgic  Pratiques. 
Journal  of  Mental  Science. 
Journal  of  Physiology. 
La  France  Medicale. 
Le  Progres  Medical. 
Lo  Spcrimcntale. 
L'Union  Medicale. 
Mind. 

Nordiskt  Medicinskt  Arkiv. 
Norsk  Magazin  for  Lagensvidenskabens. 
Practitioner. 
Revue  Dc  Medecinc. 
Rivista  Clinica  di  Bologna. 

Rivista  Spcrimcntale  di  Freniatria  c  di  Medicina  Legale. 
Schmidt's  Jahrbiicher  der    In-    und    Auslandischen    Gesammten 
Medicin. 


432 


PERIODICALS  RECEIVED. 


St.  Petersburger  Med.  Wochenschrift. 
Upsala  Lakarefornings  Forhandlinger. 


THE   FOLLOWING   DOMESTIC   EXCHANGES    HAVE   BEEN 
RECEIVED. 


Alienist  and  Neurologist. 
American  Journal  of  Insanity. 
American    Journal   of    Medical 

Sciences. 
American  Journal  of  Obstetrics. 
American  Journal  of  Pharmacy. 
American  Medical  Journal. 
American  Practitioner. 
Annals  of  Anatomy  and  Surgery. 
Archives    of   Comp.    Med.   and 

Surgery. 
Archives  of  Dermatology. 
Archives  of  Medicine. 
Atlanta    Medical    and    Surgical 

Journal. 
Boston    Medical    and    Surgical 

Journal. 
Buffalo  Medical  Journal. 
Bulletin     National     Board     of 

Health. 
Canada    Medical    and    Surgical 

Journal. 
Canada  Medical  Record. 
Canadian    Journal    of    Medical 

Sciences. 
Chicago    Medical    Journal    and 

Examiner. 
Chicago  Medical  Review. 
Chicago  Medical  Times. 
Cincinnati  Lancet  and  Clinic. 
Clinical  News. 

College  and  Clinical  Record. 
Country  Practitioner. 
Detroit  Lancet. 
Dial. 

Gaillard's  Medical  Journal. 
Independent  Practitioner. 
Index  Medicus. 
Indiana  Medical  Reporter. 
Maryland  Medical  Journal. 
Medical  and  Surgical  Reporter. 
Medical  Annals, 


Medical  Brief. 

Medical  Herald. 

Medical  News  and  Abstract. 

Medical  Record. 

Michigan  Medical  News. 

Monthly  Review. 

Nashville  Journal  of  Medicine. 

Neurological  Contributions. 

New  Orleans  Medical  and  Sur- 
gical Journal. 

New  Remedies. 

New  York  Medical  Journal. 

Pacific  Medical  and  Surgical 
Journal. 

Philadelphia  Medical  Times. 

Physician  and  Bulletin  of  the 
Medico-Legal  Society. 

Physician  and  Surgeon. 

Proceedings  of  the  Medical  So- 
ciety of  the  County  of  Kings. 

Quarterly  Epitome  of  Braith- 
waite's  Retrospect. 

Quarterly  Journal  of  Inebriety. 

Rocky  Mountain  Medical  Re- 
view. 

Sanitarian. 

Science. 

Southern  Clinic. 

Southern  Practitioner. 

Specialist  and  Intelligencer. 

St.  Joseph  Medical  and  Surgical 
Reporter. 

St.  Louis  Clinical  Record. 

St.  Louis  Courier  of  Medicine. 

St.  Louis  Medical  and  Surgical 
Journal. 

Therapeutic  Gazette. 

Toledo  Medical  and  Surgical 
Journal. 

Veterinary  Gazette. 

Virginia  Medical  Monthly. 

Walsh's  Retrospect. 


VOL.  VIII.  JULY,    1881.  No.  3. 

THE 

Journal 

OF 

Nervous  and  Mental  Disease. 


C^x:i0ltta^  ^xticlts. 


ON  SOME  POINTS  IN  REGARD   TO  COLOR- 
BLINDNESS. 

By  B.  joy  JEFFRIES,  M.D., 

BOSTON,  MASS. 

IN  No.  I,  vol.  viii,  of  this  JOURNAL  is  an  article  by  Dr. 
Bannister,  with  the  above  heading,  which  I  feel  called 
upon  to  answer  or  criticizfe  in  some  points. 

The  author  says  :  "  If  color-blindness  of  certain  kinds 
and  degrees  does  not  disqualify  the  individual  from  correct- 
ly distinguishing  signals,  as  is  claimed  by  Mr.  Wm.  Pole, 
then  the  practical  importance  of  the  defect  is  greatly  dimin- 
ished, if  not  altogether  destroyed,  as  regards  these  occupa- 
tions." 

Even  if  we  refuse  to  accept  any  of  the  testimony  from 
the  experts  on  the  other  side  of  the  water,  we  have  a  per- 
fect answer  to  this  from  the  examinations  made  in  this 
country.  From  the  report  of  the  Board  of  Health  of  Con- 
necticut, it  will  be  seen  that  all  persons  shown  to  be  color- 
blind by  the  worsted  test  failed  in  the  examination  with 
flags  and  lanterns,  even  at  the  distance  the  railroad  em- 
ployes and  their  counsel  claimed  was  fair.  I  am  conversant 
with  Mr.  Pole's  case,  both  from  the  published  description 

433 


434  B.   JO  Y  JEFFRIES. 

and  personal  correspondence,  and  am  certain    he  would  fail 
to  distinguish  colored  railroad  and    sea   signals  at  distances 
at  which  they  must  be  distinguished   to  render  traffic  on 
land  and  sea  safe.     I  would  here  refer  to  the  reports  of  the 
marine  hospital  surgeons  in   the  last  annual  report  of  the 
Sup.  Surg.  Genl.     My  own  experience   perfectly  coincides 
with  what  Holmgren,  Bonders,  and  others  have  said  on  this 
point.     Bonders'  apparatus  for  transmitted   light  gives  us 
just  the  condition  of  colored  signals,  without  extraneous  cir- 
cumstances to  help  the  color-blind   to   guess  by.     By   it  I 
have  never  failed  to  show  how  dangerous  a  color-blind  was, 
no  matter  how  little  defective  he  was.     The  point  is  just 
this.      There    are    many    so    color-blind    that    they    cannot 
tell  red  from  green  signals  close  to,  others  can  distinguish 
them  a  little  further  off,  and   so   on,  up  to  the  normal  eye's 
power.     A  color-blind   pilot    could  not  tell  which  light    I 
held  up  in  my  offtce  when  not  ten  feet  from  it.     It  was  said 
he  had   never  met  with  accidents.      He   himself  honestly 
believed   he   could  see  the  signals  as  we  did,  and  would 
never  fail.     He  was  perfectly  unaware  of  all  the  extrane- 
ous circumstances  which  helped  him  to  guess  which  light 
was  before  him.    In  reference  to  these  surroundings,  I  must, 
for  truth's  sake,  refer  to  my  manual,  and  to  the   Sup.  Surg. 
Genl.   Report  above    mentioned.     But  all  these  helps  may 
fail.     A  pilot  sees  one  light  and  has  no  chance  to  compare 
the  two,  which  he  might  distinguish   if  they  were  seen  to- 
gether.    The  pilot  of  the  tug  Lumberman  failed  once,  mis- 
taking red  for  green,  and   it   cost  ten   lives  and  much  prop- 
erty.    The  cause  of  how  many  more  accidents  will  thus  be 
cleared  up,  provided  the  author,  as  in  the  case  of  the  Nor- 
walk  accident  in  Connecticut  and   the  Revere  accident  in 
Massachusetts,  are  not  beyond   the   reach   of  expert   test- 
ing!    This  last  winter,  Prof.  Camalt,  of  Yale,  and  myself, 
spent  several  hours  at  Washington  in  proving  to  the  Super- 


SOME  POINTS  IN  REGARD  TO  COLOR-BLINDNESS.      435 

vising  Inspectors  of  steam-vessels  that  lanterns  were  no  tests 
for  color-blindness,  and  that  any  degree  of  chromatic  defect 
was  dangerous,  in  spite  of  the  reports  of  the  local  inspec- 
tors and  their  examinations.  A  handsome  vote  of  thanks 
from  the  Board  proved  that  our  arguments  were  convincing. 
When  now  it  is  said  that  those  "  who  may  be  scientifically 
color-blind  "  can  see  colored  signals  as  well  as  the  normal- 
eyed,  it  simply  is  not  true,  and  EXPERT  testing,  even  with 
lanterns,  will,  as  in  Connecticut  and  elsewhere,  prove  it  to 
hasty  and  even  recalcitrant  officials.  Mr.  Pole's  remarks 
were  quoted  last  summer  in  Connecticut,  versus  examina- 
tions of  railroad  employes.  And  so  were  Mr.  Herbert 
Page's.  But  since  the  latter  has  gone  to  work  in  England, 
with  Holmgren's  method,  he  is  quite  convinced  of  all  I 
would  claim,  and  has  so  written  me,  asking  me  also  to  make 
any  use  of  his  letter  which  may  assist  the  cause  of  control  in 
this  country.  The  physical  impossibility  of  the  color-blind 
seeing  as  we  do,  and  therefore  believing  as  we  do,  has  natu- 
rally led  them  to  make  many  assertions  which  thorough  in- 
vestigation would  contradict,  and  these  have  done  great 
harm.  I  cite  Mr.  Pole,  Prof.  Delboeuf  as  to  supposed  cure 
by  fuchsine,  and  I  must  add  Dr.  Bannister,  for  although  he 
prefixes  his  sentences  above  quoted  with  if,  yet  he  must  re- 
member that  all  interested  pecuniarily  or  otherwise  in 
opposing  laws  of  control  on  land  or  water,  will  omit  this  if 
in  arguing  before  committees  or  officials. 

That  all  this  is  a  pretty  practical  issue  will  be  admitted, 
when  it  is  seen  that  by  the  rolling  up  of  such  apparent  evi- 
dence the  opposers  of  control  can  go  so  far  as  to  say,  as 
does  the  Chicago  Inter  Ocean  of  December  17,  1880:  "All 
this  being  true,  the  originator  of  the  yarn  system  ought  to 
be  put  in  jail,  and  pilots  who  have  suffered  ought  to  bring 
suit  against  the  government  for  damages.  We  say  this  in 
all  seriousness,  and  good  lawyers  inform  us  that  they  think 
damages  can  be  recovered,"  etc.,  etc. 


436  B.  yO  Y  JEFFRIES. 

The  writer  says :  "  Again,  if  this  infirmity  is  curable  by  ex- 
ercise or  education,  as  is  held  to  be  the  case  by  Dr.  Favre, 
who  was  himself  one  of  the  first  to  call  attention  to  the 
practical  points  involved,  then  the  whole  subject  is  deserv- 
ing of  far  less  importance  than  is  nowadays  attributed 
to  it." 

Here  is  another  if,  which  "  good  lawyers"  will  omit  when 
arguing  for  the  consignment  to  jail  of  the  author  of  the 
"yarn  system."  If  the  JOURNAL  readers  will  take  the 
trouble,  they  can  find  in  my  manual,  by  Holmgren,  in  the 
Brit.  Med.  and  Surg.  Journ.,  March  28,  1878,  and  in  the 
monographs  and  journal  articles  from  all  over  Europe,  over- 
whelming testimony  to  the  absurdity  of  the  mistake  of  Dr. 
Favre  in  classing  as  color-blind  all  boys  and  girls  who 
failed  to  name  colors  correctly,  and  as  cured,  all  of  those 
who  could  be  taught  to  call  them  rightly.  I  confess  to  a 
little  surprise,  to  say  the  least,  at  the  author  thus  introduc- 
ing Favre's  ideas,  so  long  ago  entirely  exploded.  I  do  not 
think  it  necessary  to  say  more  on  this  point. 

Dr.  Bannister  says:  "  If  either  of  these  views  is  correct, 
it  is  a  reasonable  presumption  that  a  person  in  constant 
exercise  of  his  perceptive  powers  in  the  distinction  of 
colored  signals,  would  be  able  to  overcome  or  compensate 
for  this  particular  defect,  so  far  as  all  practical  purposes 
are  concerned,  while  still,  it  may  be,  exhibiting  it  in  the 
plainest  manner  to  the  usual  tests.  Some  facts  point  very 
strongly  in  this  direction  ;  the  recent  examinations  of  pilots 
and  engineers  have  revealed  cases  of  color-blindness  where 
it  was  utterly  unsuspected,  and  in  persons  who  had  accep- 
tably filled  positions  for  many  years  that  required  daily, 
and  almost  hourly,  exercise  and  test  of  their  ability  to 
correctly  distinguish  colored  signals." 

This  is  precisely  what  makes  these  men  so  dangerous, 
namely,  that  like   the   color-blind   in    other  avocations  of 


SOME  POINTS  IN  REGARD  TO  COLOR-BLINDNESS.      43 7 

every-day  life,  they  escape  detection.  Now,  we  have  means 
of  readily  exhibiting  their  defect,  and  of  showing  how  they 
have  caused  accidents,  the  reason  of  which  has  hitherto 
been  unexplainable. 

It  is  not  any  change  in  the  color-blinds'  chromatic  sense 
which  has  enabled  them  to  get  along  as  well  as  they  have, 
but  simply  the  various  means  necessity  has  taught  them  to 
supplement  their  want  by.  As  to  just  what  these  means 
are,  I  must  refer  again  to  my  manual.  They  are  now  quite 
well  understood,  and  recognized  by  all  examiners.  Dal- 
ton's  color-sense  did  not  alter  through  life.  Many  a  scien- 
tific color-blind,  as  chemists,  etc.,  have  told  me  how  hard 
they  have  tried  to  learn  to  see  colors  correctly,  but  that 
they  were  still  the  same  in  advanced  life.  The  color-blind 
cannot  see,  and,  therefore,  cannot  believe  this.  In  corre- 
spondence with  the  author,  I  have  said  that  it  would,  I 
thought,  be  possible  for  a  partially  color-blind  to  become 
educated  within  his  range,  as  the  normal  eye  becomes  edu- 
cated. Precisely  how  much  this  would  help  him,  is  very 
hard  to  decide,  as  it  is  difficult  to  separate  this  possible 
cultivation  of  his  color-sense  from  the  other  extraneous 
helps  outside  of  this  sense,  which  he  uses  quite  unawares  to 
himself.  My  experience  with  highly  educated  color-blind, 
who  needed  the  chromatic  sense  for  their  special  studies, 
and  who,  therefore,  in  course  of  years,  would  have  culti- 
vated the  eye  all  possible,  has  been  that  they  wholly  failed 
when  all  the  extraneous  helps  were  removed,  and  they  had 
to  decide  by  the  color-perception  alone,  just  as  the  color- 
blind pilots  reported,  failed  when  all  that  enabled  them  to 
guess,  was  removed.  I  have  never  seen  any  one,  even 
officials,  ready  to  trust  their  lives,  or  others,  to  the  color- 
blind after  their  defect  was  perfectly  demonstrated  to  them. 
It  can  be  readily  shown  that  such  a  color-blind  as  Dr. 
Bannister  would  be  a  dangerous  pilot  or  engineer,  since  he 


438  B.  JOY  JEFFRIES. 

could  not  see  colored  signals  quickly  enough,  or  far  enough 
off.  In  describing  his  defect,  Dr.  Bannister  says:  "The 
lithium  line  is  a  very  beautiful  and  typical  red."  *  *  ■» 
"  I  recognize  all  the  spectral  colors  as  distinct  in  tint,  ex- 
cept, perhaps,  indigo,  which  seems  only  a  variety  of  blue." 
The  casual  reader  might  be  misled  by  this.  It  must  be 
remembered  that  the  color-blind  in  any  degree  cannot,  of 
course,  see  red  and  green  as  the  normal-eyed.  This  is  now 
perfectly  proved  by  the  reports  of  cases  of  monocular  color- 
blindness. Their  use  of  the  same  terms  or  expressions  for 
colors  as  we  do,  is  no  proof  of  having  the  same  sensations 
we  do.  This  can  very  readily  be  shown  by  Maxwell's  discs. 
Dr.  Bannister  cannot  see  red  with  the  brilliancy  we  do. 

The  author  says  :  "  It  may  easily  be,  and,  indeed,  it  appears 
highly  probable,  that  a  deficient  early  training,  and  a  lack 
of  special  observations  of  colors  in  early  life,  when  the  cere- 
bral centres  are  receiving  those  first  impressions  that  most 
strongly  influence  their  organization,  may  have,  as  their 
result  in  adult  life,  a  defect  of  color-sensibility,  varying  in 
degree  from  scarcely  perceptible  enfeeblement  to  pro- 
nounced partial  color-blindness,  or  to  dyschromatopsia,  as 
in  my  own  case.  It  may  even  be  that  to  this,  combined  with 
heredity,  is  due  the  relatively  greater  frequency  of  the  de- 
fect in  the  male  sex." 

We  were  all,  I  think,  at  first  inclining  to  adopt  this  rea- 
soning, but  facts  do  not  support  it.  Children  as  young  as 
between  three  and  four  years  can  be  readily  tested,  and 
their  color-blindness  detected  with  certainty.  In  the  case 
of  girls,  their  education  and  surroundings  would  especially 
tend  to  develop  the  color-sense,  yet  it  does  not.  Mothers 
have  told  me  how  they  have  worked  over  their  color-blind 
boys  in  vain,  in  endeavoring  to  teach  them  to  see  differ- 
ently. Others,  of  course,  like  Dr.  Favre,  have  made  the 
mistake  of  supposing  that  because  the  color-blind  could  be 


SOME  POINTS  IN  REGARD  TO  COLOR-BLINDNESS.      439 

taught  to  remember  the  color  names  of  objects,  that  the 
color-sense  was  altered.  I  do  not  here  refer  to  the  20  or  30 
per  cent,  of  boys  whom  he  called  color-blind,  because  they 
did  not  know  color-names,  and  whom  he  supposed  he  cured 
of  color-blindness  by  teaching  them  these  color-names. 

Dr.  Bannister  refers  to  the  mention  in  my  manual  "  of 
dulness  of  color-perception,  or  rather  a  peculiar  slowness 
in  the  colors  taking  effect."  I  do  not  mean  by  this  the  retar- 
dation of  color-perception,  "  which  he  describes  in  his  own 
case,  but  the  slowness  to  catch  colors,  which  would  be 
helped  in  the  normal  eyes  by  brightening  them.  For  in- 
stance, in  a  poor  light  or  on  a  dull  day,  both  the  girls  and 
boys  went  through  the  test  less  quickly.  I  had  even  to 
take  this  into  consideration  in  calculating  my  time  at  the 
schools,  etc. 

The  author  seems  to  have  misunderstood  as  to  the  blind 
children  whom  I  asked  to  name  the  colors  of  objects.  Six 
were  blind  from  birth,  totally  so,  and  only  knew  by  ear  the 
color-names  of  objects.  The  seventh  I  said  could  see 
somewhat,  tell  light  from  dark.  This  I  intended  to  show 
by  quoting  his  expression  that  it  was  "  hard  for  him  to  get 
hold  of  colors,"  meaning  that  he  got  hold  of  colors  through 
the  eye  with  difficulty,  because  he  could  see  so  poorly  ;  he 
was,  therefore,  not  to  be  classed  with  the  six  totally  blind 
from  birth. 

I  must  criticize  the  deductions  Dr.  Bannister  has  made 
from  his  supposed  peculiar  chromatic  sense  or  condition, 
viz.  :  that  by  "  mental  effort"  he  can  see  colors  sooner  or 
later.  He  says:  "  The  usual  test  employed  in  this  country 
for  the  examination  of  railway  employes  and  pilots — that 
of  Holmgren — makes,  however,  no  allowance  for  this  variety 
of  color-defect."  Dr.  Jeffries,  the  principal  authority  on  this 
subject  in  this  country,  says,  in  his  directions  for  the  use  of 
this  test,  referring  to  the  colored  plate  accompanying  it :  "  If 


440  B.   JO  Y  JEFFRIES. 

the  person  examined  takes  any  of  the  confusion  colors 
(X5)  to  put  with  the  green,  he  proves  himself  color-blind  ; 
or  even  if  he  seems  to  want  to  put  them  together.  This 
rules  out  all  hesitation,  and  condemns  at  once  as  defective 
any  one  who  exhibits  any  uncertainty,  requiring  mental 
effort  or  comparison."  These  directions  and  explanations 
are  Prof.  Holmgren's,  and  are,  of  course,  to  be  taken  in 
connection  with  the  very  careful  and  minute  description  of 
the  tests  which  he  has  given,  and  which  I  have  translated  in 
full  in  my  manual.  One  great  difficulty  about  the  worsted 
test  is  that  it  can  only  be  best  learned  de  situ,  and  when  so 
learned,  these  directions  are  quite  plain.  This  same  direc- 
tion was  quoted  by  the  Mass.  Railroad  Commissioners  in 
arguing  before  the  Railroad  Committee  of  the  Legislature 
last  year,  versus  my  position  of  the  need  of  expert  exam- 
iners. It,  of  course,  gave  me  a  very  good  opportunity  of 
making  a  strong  point  in  my  favor.  The  hesitation  such 
a  color-blind  as  Dr.  Bannister  would  exhibit,  the  expert 
recognizes  as  due  to  color-blindness,  and  this  is  the  hesita- 
tion Holmgren  means,  as  a  study  of  all  he  says,  and  some 
personal  familiarity  with  the  test  will  show.  There  is 
great  difficulty  in  so  describing  the  test  and  its  applica- 
tion as  to  be  properly  understood.  He  states  most  dis- 
tinctly that  it  can  best  be  learned  de  situ.  This  is  very  ex- 
pensive, as  proved  by  the  medical  officers  of  the  U.  S. 
government  who  have  studied  the  use  of  the  test  by  work- 
ing with  me  in  our  schools,  etc. 

Dr.  Bannister  says  :  "  Holmgren's  test  has  the  advan- 
tage of  detecting  very  slight  abnormalities  of  color-vision, 
but  it  also  has  the  defect  of  exaggerating  them."  The  first 
part  of  this  is  true,  and  hence  the  very  great  value  of  the 
test.  The  second  part  is  not  the  case  when  it  is  properly 
applied,  and  this  is  not  such  a  simple  thing  as  it  at  first 
seems.      Recent    letters  from   Prof.   Holmgren  admit  and 


SOME  POINTS  IM  REGARD  TO  COLOR-BLINDNESS.      44^ 

confirm  this  fully.  The  worsted  test  quickly  shows  such 
defect  as  Dr.  Bannister  reports  that  he  has,  and  all  other 
tests,  as  with  lanterns,  etc.,  when  properly  applied,  will  show 
the  danger  of  this  amount  of  chromatic  loss.  These  so- 
called  "  practical  tests,"  which  are  difficult,  consume  time, 
require  special  apparatus,  and  open  wide  the  door  for  col- 
lusion and  cheating,  will  only  finally,  as  Surgeon  Hutton  of 
the  Marine  Hospital  Service  says,  "confirm  what  was  de- 
cided, wiJthin  five  minutes  after  commencing  the  first  exam- 
ination," with  the  worsteds. 

What  Dr.  Bannister  say^  about  the  greens  and  blues  in 
relation  to  Holmgren's  test,  would  lead  me  to  think  that  he 
had  not  seen  it  carried  out  always  as  it  should  be.  An 
expert  takes  no  account  of  the  lack  of  appreciation,  from 
want  of  training  or  education,  between  greens  and  blues, 
and  also  will  understand  when  any  such  confusion  means 
violet-blindness  to  be  decided  by  test  H  with  purple.  Prof. 
Holmgren  or  his  adherents  can  not  be  responsible  for  gross 
mistakes  in  testing,  any  more  than  for  the  mistake  of  using 
the  colored  plate  to  examine  for  color-blindness  by,  as  has 
been  done. 

Dr.  Bannister  says  very  properly:  "When  we  consider 
that  a  man's  whole  livelihood  may  depend  on  the  result  of 
the  examination,  the  advisability  of  avoiding  unnecessary 
mistakes  is  sufficiently  obvious." 

As  in  this  country  the  community  is  always  sacrificed  to 
the  individual,  we  must  remember  that  the  slightest  source 
of  danger  from  color-blindness  ought  to  be  eliminated,  and 
the  lives  of  a  whole  steamer  or  train-load  of  passengers 
not  be  jeopardized  for  the  benefit  of  a  partially  color-blind 
pilot  or  engineer,  who  may  guess  right  or  may  guess 
wrong. 

Again,  he  says  :  "  Holmgren's  should  be  always  carefully 
supplemented  with  some  other  that  approaches  more  nearly 


442  B.   JO  V  JEFFRIES. 

the  practical  conditions  that  the  color-sense  must  meet,  in 
cases  of  incomplete  color-blindness.  Bonders'  test  with 
lights  seen  through  colored  media  in  apertures  of  various 
sizes,  appears  to  me  much  more  satisfactory  for  practical 
purposes  than  the  generally  employed  one  of  Holmgren." 

This  test  of  Bonders'  is  not  to  find  out  whether  a  person 
is  color-blind, — that  Bonders'  has  by  Holmgren's  or  his  modi- 
fication of  it, — but  to  ascertain  the  degree  of  color-blindness. 
The  great  dif^culty  is  that  it  is  not  a  comparison  test;  we 
have  to  ask  the  examined  what  he  sees,  and  he  has  to  Jiame 
colors,  2.  source  of  great  danger  in  testing.  Moreover,  it  will 
be  found  that  wherever  proper  laws  have  been  made  for 
testing  thoroughly,  control  tests,  so-called,  are  always  used 
besides  the  worsteds.  But  time  and  absolute  experience 
among  large  numbers  of  railroad  employes  have  shown  the 
very  great  value  and  accuracy  of  this  test  of  Holmgren's, 
because  wherever  a  man  has  been  by  proper  examiners 
shown  to  be  color-blind  by  it,  all  the  additional  or  control 
tests  have  but  confirmed  this  decision.  And,  moreover, 
wherever  a  man  has  by  proper  examiners  been  shown  by 
Holmgren's  test  to  be  in  any  degree  color-blind,  he  has 
equally  well  been  shown  to  be  dangerous,  in  that  he  could 
not  distinguish  quickly  and  readily,  as  can  the  normal-eyed, 
the  necessary  colored  signals. 

Br.  Bannister  says,  further :  "  I  might  discuss  here  at 
length  the  vision  of  the  color-blind,  and  examine  the  claim 
made  by  Mr.  Pole  that  the  red-blind  individual,  seeing  red 
light  as  a  dark  saturated  yellow,  could  yet  distinguish  it 
from  the  green,  especially  if  the  blue-green,  the  complemen- 
tary color  to  red,  and  the  tint  advised  by  M.  Redard  in  a 
recent  report  to  the  French  government,  is  used  instead  of 
the  manifold  tints  now  employed." 

An  engineer  or  pilot  sees  one  light,  not  two,  and  has  no 
opportunity  for  comparison,  and  no  time  to  stop  and  timik 


SOME  POINTS  IN  REGARD  TO  COLOR-BLINDNESS.      443 

which  is  before  him.  The  flash  of  color  to  the  normal-eyed 
is  instantaneous,  and  hence  the  value  of  color  for  signals, 
and  safety  in  having  only  normal-eyed  in  positions  where  so 
much  depends  on  their  being  felt  "  like  a  slap  in  the  face," 
as  my  friend,  Prof.  Camalt,  said  in  arguing  before  the  Mas- 
sachusetts Railroad  Legislature  Committee. 

As  to  Redard's  wholly  theoretical  suggestion  of  the  use  of 
bluish-green  as  opposed  to  red,  experience  has  shown  that  it 
is  precisely  the  bluish-green  glass  which  must  be  discarded, 
because  all  the  blue  in  it  breaks  down  the  light  to  such  an 
extent  that,  in  consequence,  two  distinct  starboard  lights  are 
sold  on  the  ships.  One  of  them  is  deep  bluish-green,  and 
it  reduces  the  amount  of  light  so  much  that  the  purchaser 
is  pretty  sure  to  return  and  want  it  changed.  The  dealer 
then  replaces  it  with  a  pale  yellowish-green.  This  the 
buyer  brings  back  and  says  it  is  mistaken  for  an  ordinary 
white  light,  when  the  change  is  made  again  back  to  the 
dark  bluish-green.  After  a  presentation  of  these  facts,  and 
an  exhibition  of  the  several  signal  glasses  before  the  Board 
of  Supervising  Inspectors  of  Steamboats  at  Washington, 
they  requested  the  Secretary  of  the  Treasury  to  put  in  the 
hands  of  local  inspectors  standard  red,  green,  and  white 
glass,  to  which  all  lights  on  steamers  must  conform.  These 
standard  glasses  are  now  being  made,  and  bluish-green  will 
be  particularly  avoided.  All  this  applies  equally  well  to 
the  glass  for  railroad  signals.  Officials  of  all  kinds  have 
there  made  the  mistake  of  supposing  that  a  man  reported 
by  expert  examiners  color-blind  by  the  worsted  test,  was 
not  so  or  was  not  dangerous  because  he  could  distinguish 
these  bluish-green  glasses  from  the  red.  The  red-  or  green- 
blind,  of  course,  see  blue  and  yellow  as  we  do.  Now  a  large 
glass  company  have  lately,  of  their  own  accord,  thrown  aside 
all  these  bluish-green  glasses,  and  manufacture  at  present 
only  pure  green,  so  convinced  were  they  of  the  danger  from 


444  S-   70  Y  JEFFRIES. 

the  want  of  brightness  of  this  dark  bluish-green  glass.  Sig- 
nal glass  for  railroads  and  the  ocean  should  be  adapted  to 
the  96  per  cent,  with  normal  color-sense,  and  not  to  the  four 
per  cent,  who  are  more  or  less  color-blind. 

The  political  office-seekers  in  Connecticut  have  just  re- 
pealed the  laws  controlling  color-blindness  and  visual 
defects  among  railroad  employes.  Massachusetts  has  just 
enacted  a  law  of  control.  Mr.  Wm,  Pole  or  Mr.  Herbert 
Page  had  no  idea  that  their  articles  could  or  would  be  used 
by  Connecticut  office-seekers  versus  proper  laws  of  control 
urged  by  the  railroad  commissioners  and  passed  by  the  Leg 
islature,  and  found  to  be  very  necessary  when  carried  out. 
Dr.  Bannister's  article  would  have  been  equally  well  used^ 
though,  no  doubt  so,  opposed  to  the  author's  intention.  It 
becomes  the  duty,  not  always  pleasant,  of  those  trying  to 
obtain  legislation,  to  explain  the  mistakes  or  misunderstand- 
ings which  color-blind  writers  especially  fall  into. 


CONTRIBUTIONS  TO  PSYCHIATRY. 

By  JAS.  G.  KIERNAN,  M.  D., 
chicago,  ill. 

VI. PSYCHOSES    FROM    TRAUMATISM. 

TRAUMATISM  is  a  very  frequently-cited  cause  of  the 
psychoses,  but  many  of  these  are  cases  in  which 
traumatism  complicates  rather  than  produces  the  psychosis. 
Skae*  ranges  this  form  and  that  produced  by  heat  under 
the  same  heading,  and  in  a  preceding  article  I  have  cited 
his  conclusions,  and  so  need  scarcely  repeat  them  here. 
Voisin^  claims  that  traumatism  sometimes  produces  pro- 
gressive paresis,  which  assumes  the  paralytic  dementia  type. 
Marc^'  says,  concerning  the  psychoses  produced  by  trauma- 
tism :  "  In  the  greater  number  of  these  patients  the  mental 
disease  assumes  an  illy-defined  form,  offering  irregular  alter- 
nations of  stupor,  agitation,  and  imperfect  lucidity,  with- 
out systematized  delirious  ideas,  but  recovery  is  never  com- 
plete, and  the  patient  becomes  progressively  demented." 
Calmeil*  and  Las^gue'  cite  cases  of  patients  being  seized 
by  epilepsy  at  puberty,  after  having  sustained  injuries  to 
the  skull  in  childhood,  and  becoming  victims  of  progressive 
paresis  at  the  age  of  50. 

KrafTt  Ebing'  "  classifies  insanity  from  traumatism  as  it  is  : 
First,  the  direct  consequence  of  an  accident ;  second,  mani- 
fested later,  the  prodromus  of  disordered  motor  and  sensory 

445 


446 


J  AS.   G.  KIERNAN. 


phenomena  and  change  of  character;  third,  preceded  by  a 
latent  susceptibility  (the  result  of  the  accident),  which  may 
be  called  an  acquired  predisposition,  and  which  only  re- 
quires an  exciting  cause  to   develop  into  actual  insanity." 

Crichton  Brown'  gives  the  following  cases  of  psychoses 
preceded  by  traumatism  : 


PSYCHOSIS. 

CASES 

Amentia i 

Mania,  acute 

I 

"       puerperal 

I 

"       general 

2 

"       recurrent 

I 

"       a  potu 

3 

Dementia 

9 

"           with  epilepsy 

5 

"           senile 

a 

"           with  general  paralysis 

3 

Melancholia,  hypochondriacal 

3 

This  table  scarcely  needs  a  comment,  and  it  speaks  very 
strongly  as  to  the  knowledge  of  clinical  psychiatry,  of  any 
one,  that  they  are  capable  of  charging  cranial  injuries  with 
producing  senile  dementia,  puerperal  mania,  and  mania  a 
potu.  Bucknill  and  Tuke®  cite  a  case  where  a  "fall  on  the 
back  of  the  head  "  led  to  irritability,  violence,  and,  finally, 
general  paresis,  and  one  case  where  a  patient  became  emo- 
tional, irritable,  and  depressed,  after  a  fall,  and  finally  pre- 
sented all  the  physical  symptoms  of  progressive  paresis,  his 
memory  remaining  good.  Schlager,*  in  a  very  valuable 
article  on  this  subject,  gives  the  following  statistics  and 
opinions :  Of  five  hundred  cases  of  insanity,  he  found 
forty-nine  resulting  from  injuries  to  the  skull.  In  twenty- 
one  of  these  the  injury  was  followed  by  immediate  loss  of 
consciousness,  in  sixteen  by  simple  mental  confusion  and 
wandering  of  the  thoughts,  in  sixteen  by  dull  pain  in 
the  head.     In  nineteen  cases  the  disease,    insanity,    com- 


CONTRIBUTIONS  TO  PSYCHIATRY.  447 

menced  within  one  year  after  the  accident ;  the  other 
cases  after  an  interval  of  from  four  to  ten  years  after 
the  accident.  Generally  the  patients  manifested  from  the 
time  of  the  injury  a  tendency  to  cerebral  congestion,  after 
the  ingestion  of  even  a  small  amount  of  spirits,  or,  mental 
excitement.  In  several  cases  ocular  hyperaesthesia  and  even 
amblyopia  made  its  appearance.  In  fifteen  cases  there  ap- 
peared, shortly  before  and  during  the  existence  of  the  cere- 
bral disorder,  scotomic  dots,  which  exerted  a  deciding  influ- 
ence on  the  character  of  the  delirium.  The  patient  often 
experienced  ringing  and  noises  in  the  ears.  In  eighteen  cases 
there  was  dulness  of  hearing  ;  in  three,  abnormal  subjective 
perceptions  of  smell,  and  changes  in  the  pupils.  Frequently 
the  character  and  disposition  changed.  In  twenty  cases 
great  irascibility  and  an  angry,  passionate  manner,  even  to 
the  most  violent  outbursts  of  temper,  was  remarked.  Some- 
times, but  far  less  frequently,  there  occurred  over-estimation 
of  self,  prodigality,  restlessness,  and  disquietude.  In  foQr- 
teen  cases  there  were  attempts  at  suicide,  and  frequent  loss 
of  memory  and  confusion.  The  prognosis  in  all  was  un- 
favorable ;  seven  became  progressively  paretic. 

Esquirol^  °  and  Rush^  ^  both  cite  cases  of  mania  produced 
by  an  injury.  Azam's  ^^  article  on  the  subject  scarcely  de- 
serves notice.  From  the  majority  of  these  authorities, 
therefore,  it  would  appear  as  if  traumatism  produced  not 
only  the  form  of  insanity  ascribed  to  it  by  Skae,  but  also 
other  forms  widely  different  from  this. 

My  own  cases,  forty-five  in  number  out  of  a  gross  total 
of  twenty-two  hundred  cases  of  insanity,  a  smaller  percent- 
age than  that  of  Schlager,  range  themselves  as  follows : 

NUMBER. 

1.  Epileptic  dementia,        ......         lo 

2.  Epileptic  mania  ending  in  paresis,  ...         12 

3.  Mania  chronic  with  depressing  delusions,       .         .  8 


448  JAS.  G.  KIERNAN. 

4.  Mania  chronic  with  depressing  delusions  ending  in 

progressive  paresis,         .....  10 

5.  Acute  mania,  ultimate  history  not  known,      .         .  2 

6.  Acute  mania  ending  in  paresis,      ....  2 

7.  Melancholia  attonita,     ......  i 

The  epileptic  dements  from  traumatism  did  not  vary  any 
from  the  ordinary  epileptic  dement,  and  therefore  scarcely 
need  extended  notice.  As  a  rule,  this  class  of  patients  had 
sustained  the  injury  between  the  ages  of  ten  and  twenty- 
five.  Those  of  the  second  class  had  usually  sustained  the 
injury  between  the  ages  of  twenty  and  thirty-five,  and  of 
these  varieties  the  following  cases  are  a  fair  example. 

Case  i. — E.  A.,  English,  moderate  drinker,  common  school 
education,  was  admitted  to  the  asylum  during  the  year  1873. 
Two  years  and  a  half  previous  had  been  struck  on  the  head  by  a 
cake  of  ice,  causing  loss  of  consciousness  for  a  time.  A  week 
after  he  had  convulsions  which  recurred  every  twenty-four 
hours  for  one  month  and  then  ceased  for  three  months,  then 
returned  at  intervals  of  from  one,  two,  to  three  months.  The 
patient  was  at  times  violent  and  excitable,  but  on  admission 
denies  all  knowledge  of  the  periods  of  excitability  that  led  to  his 
arrest.  He  had  a  very  vague  aura  preceding  his  convulsions  and 
was  slightly  hesitant  in  speech.  ,  He  continued  in  much  the  same 
condition  for  three  months,  being  considered  a  case  of  epileptic 
mania  passing  into  dementia.  Eight  months  after  this  he  had 
hallucinations  which  soon  disappeared,  he  becoming  alternately 
stupid  and  excited,  and  finally  completely  demented,  remaining 
in  this  condition  for  ■  eight  months.  He  then  began  to  exhibit 
delusions  about  making  money  by  millions  in  the  ice  business, 
pilfered  from  his  neighbors,  and  exhibited  considerable  motor  and 
emotional  disturbance.  He  soon  exhibited  all  the  usual  mental 
and  physical  symptoms  of  progressive  paresis,  and  died  exhausted 
in  the  course  of  a  year  from  several  convulsions. 

In  this  connection  I  may  observe  that  the  psychoses  due  to 
traumatism  seem  to  be  divisible  into  two  great  classes,  those  due 
to  slight  traumatism  and  those  originating  in  traumatic  injuries  of 
a  grave  character.  To  the  former  class  belong  the  cases  of  mania 
chronic 'with  depressing  delusions,  while  to  the  latter  belong  the 
other  types  of  insanity. 


CONTRIBUTIONS  TO  PSYCHIATRY.  449 

Case  2. — D.  P.,  Irish,  admitted  to  the  New  York  City  Asylum 
during  1873,  was  then  in  a  condition  of  chronic  mania  with  de- 
pressing delusions,  and  his  friends  gave  the  following  history  :  In 
the  spring  of  187 1  was  struck  on  back  of  the  head  with  a  slung- 
shot  during  a  street  fight,  after  which  the  patient  who  had  hitherto 
been  good-humored  became  irascible,  and  at  length  had  fully  de- 
veloped delusions  of  persecution  which  were  well  marked  and 
systematized.  He  had  hallucinations  of  hearing  and  marked  in- 
sanity of  manner.  His  delusions  were  built  up  on  sundry  slight 
circumstances  and  relatively  logical.  The  patient  had,  on  admis- 
siop,  a  hard,  dry,  constrained  manner,  talked  very  suspiciously, 
recognized  clearly  that  he  had  been  committed  to  an  asylum  for 
the  insane,  but  took  this  fact  with  relative  calmness.  He  was  in- 
duced, after  some  persuasion,  to  engage  in  some  labor  in  the  ward. 
The  hallucinations  were  very  vivid;  the  patient,  however,  regarded 
them  as  schemes  of  his  enemies,  and  they  caused  him  less  annoy- 
ance than  is  usual  with  hallucinations.  He  was  very  careful  of 
his  dress  and  rather  dignified  in  manner.  He  treated  the  physi- 
cians with  relative  politeness  with  the  exception  of  the  superin- 
tendent, who  at  one  time  acted  dictatorially  to  him,  and  whom  he 
in  consequence  regarded  as  one  of  his  enemies.  He  died  five 
years  after  admission,  retaining  to  the  last  all  his  delusions. 

Case  3. — This  patient  was  admitted  in  1872  ;  was  then  a  clear 
case  of  chronic  mania,  with  depressing  delusions.  The  patient, 
previous  to  receiving  a  pistol-shot  wound,  of  slight  character,  of 
the  skull,  was  a  cheerful,  good-humored  companion,  but  after 
recovery  from  this  wound,  became  irritable,  suspicious,  and  quer- 
ulent.  The  patient  remained  about  six  months  in  the  asylum, 
and  was  then  taken  out  by  his  friends,  but,  becoming  unmanage- 
able, was  returned  early  in  1873,  having  then  well-marked  delu- 
sions about  his  brother  attempting  to  poison  him,  together  with  hal- 
lucinations about  being  denounced  as  an  enemy  of  mankind.  He 
was  again  taken  out  by  his  relatives,  but  returned  in  1875,  ^^^ 
was  then  a  well-marked  case  of  general  paresis,  of  which  he  died 
in  1877. 

These  three  cases  are  typical  ones  of  certain  phases  of  in- 
sanity, as  produced  by  traumatism,  coming  under  observa- 
tion. As  already  remarked,  slight  traumatism  seemed  to 
produce  different  effects  from  grave  traumatism,  and  these 
and  other  points  connected  with  the  question  can  best  be 
shown  in  tabular  form : 


450 


JAS.   G.  KIERNAN. 


TABLE  I. 


SLIGHT 

GRAVE 

TOTAL, 

TRAUMATISM. 

TRAUMATISM. 

Epileptic  dementia. 

2 

8 

lO 

Epileptic  mania,  ending  in  progressive 
paresis, 

Acute    mania ;    ultimate    history   un- 
known. 

4 
2 

8 

12 

2 

Acute   mania,  ending    in   progressive 

paresis. 

Melancholia  attonita, 

Chronic    mania,    vi^ith   depressing   de- 
lusions, 

2 

I 

6 

2 

2 

I 

8 

Chronic  mania,  ending  in  progressive 
paresis, 

8 

2 

TO 

25 

20 

45 

From  this  table  it  would  appear  as  if  the  majority  of 
cases  had  resulted  from  slight  traumatism. 


TABLE  IL 


HEREDITARY 

NO    HEREDITARY 

TAINT. 

TAINT. 

Slight 
Traumatism. 

Grave 

Traumatism. 

Slight 
Traumatism. 

Grave 
Traumatism. 

TOTAL. 

Epileptic  dementia, 

I 

6 

I 

2 

lO 

Epileptic  mania,  end- 

mg    m    progressive 
paresis. 

3 

6 

I 

2 

12 

Acute  mania;  ultimate 

history  unknown, 

2 

2 

Acute   mania;  ending 

in   progressive  par- 
esis, 

I 

I 

2 

Melancholia  attonita. 

I 

I 

Chronic  mania  of  de- 

pressing type, 
Chronic  mania,  ending 

2 

2 

4 

8 

in    progressive  par- 
esis. 

2 

2 

6 

ID 

12 

i6 

13 

4 

45 

CONTRIBUTIONS  TO  PSYCHIATRY. 


451 


TABLE 

III. 

Ages- 

20-25, 

25- 

■40, 

4(^50. 

SLIGHT. 

GRAVE. 

SLIGHT, 

GRAVE. 

SLIGHT. 

GRAVE. 

TOTAL. 

Epileptic  dementia, 

Epileptic  mania,  ending  in 
progressive  paresis, 

Acute  mania;  ultimate  his- 
tory unknown, 

Acute    mania,    ending    in 

2 
2 

7 
I 

2 

I 

I 

6 

I 

I 

10 

12 

2 

progressive  paresis. 
Melancholia  attonita. 
Mania    chronic,   with    de- 
pressing delusions. 
Mania  chronic,  ending  in 
paresis. 

I 
2 
2 

I 

I 

I 

4 
3 

I 

I 

2 

I 
I 

2 

I 

8 
10 

Total, 

9 

10 

II 

8 

4 

3 

45 

From  these  cases  it  would  seem  to  me  that  the  following 
conclusions  follow : 

First,  that  traumatism  produces  certain  psychoses. 

Second,  that  the  majority  of  these  are  unaccompanied  by 
epilepsy. 

Third,  that  the  majority  have  a  tendency  to  end  in  pro- 
gressive paresis. 

Fourth,  that  a  large  proportion  are  accompanied  by  de- 
pressing delusions. 

Fifth,  that  the  majority  of  these  latter  do  not  exhibit 
any  hereditary  taint. 

Sixth,  that,  with  certain  modifications,  Krafft-Ebing's  con- 
clusions respecting  the  traumatic  psychoses  are  correct. 

Seventh,  that  injuries  received  before  the  age  of  forty  are 
probably  of  more  effect  in  producing  insanity  than  those 
received  subsequently. 

Eighth,  that  slight  injuries,  from  the  insidious  nature  of 
the  changes  they  set  up,  are  as  much  to  be  dreaded,  if  not 
more,  than  the  grave  injuries. 

Ninth,  that  traumatic  causes  did  not  have  as  much  influ- 


452  JAS.   G.  KIERNAM. 

ence  in  the  production  of  insanity  as  intimated  by  Schlager, 
he  finding  that  over  eight  per  cent,  of  the  cases  were  caused 
by  traumatism,  while  at  the  New  York  City  Asylum  for  the 
Insane  but  two  per  cent,  were  so  caused. 

Tenth,  that  certain  cases  of  insanity  caused  by  trauma- 
tism have  well-marked  systematized  delusions. 

Eleventh,  that  in  all  cases  of  insanity  caused  by  trauma- 
tism a  guarded  prognosis  should  be  given. 

VII.      PSYCHOSES    PRODUCED    BY    QUININE. 

That  quinine  should  exceptionally  produce  psychoses, 
will  scarcely  appear  surprising  when  its  tendency  to  produce 
cerebral  hyperaemia  is  recollected.  I  am  unacquainted  with 
any  literature  on  the  subject,  and,  therefore,  report  only  the 
cases  which  have  come  under  my  observation. 

Case  i. — T.  P.,  American,  single;  grandfather,  uncle,  and 
brother  died  insane.  Patient  had,  however,  been  in  very  good 
health  up  to  about  three  months  before  admission,  which  occurred 
during  the  year  1874,  when  he  was  attacked  by  headache,  for 
which,  on  the  supposition  of  its  being  malarial,  three  grains  of 
quinine  were  prescribed  three  times  a  day  ;  after  taking  three 
doses  of  this  the  patient  was  seized  by  a  violent  attack  of  acute 
mania,  with  marked  hallucinations  of  hearing  of  a  depressing  type, 
and  considerable  dimness  of  vision.  These  phenomena  persisted 
for  three  months  as  the  quinine  was  continued,  and  the  patient 
treated  with  morphia  subcutaneously.  On  admission  to  the  asy- 
lum, which  was  at  length  rendered  necessary,  the  patient  was  in 
the  condition  already  described,  and  was  placed  under  chloral  and 
hyoscyamus  as  a  hypnotic,  and  conium  to  quiet  motor  excitement. 
Under  this  treatment  the  patient  was  in  fit  condition  to  be  dis- 
charged within  six  weeks  after  admission.  He  manifested,  a  day 
previous  to  discharge,  some  slight  evidences  of  malaria,  where- 
upon quinine  was  administered,  which  had  the  effect  of  bringing 
on  a  fresh  attack  of  acute  mania,  with  the  same  symptoms  as  pre- 
viously. The  quinine  was  stopped,  and  the  same  treatment  as 
before  resorted  to,  when  the  symptoms  of  acute  mania  disappeared. 
The  patient  was  discharged,  fully  recovered,  four  months  after 
admission,  but  returned  within  a  year  in  the  same  mental  condition, 


CONTRIBUTIONS  TO  PSYCHIATRY.  453 

under  precisely  the  same  circumstances,  to  recover  and  to  have  a 
relapse  under  much  the  same  circumstances  as  on  the  first  occa- 
sion. 

Case  2. — P.  J.,  Irish,  aet.  30,  married,  brother  insane,  sister  epi- 
leptic, uncle  afflicted  with  shaking  palsy,  was  admitted  to  the  New 
York  City  Asylum  in  a  condition  of  extreme  dementia,  being  able 
to  utter  but  few  words,  and  being  very  neglectful  about  himself 
and  his  surroundings.  He  had  been  in  relatively  good  health  up 
to  about  three  weeks  prior  to  admission,  when  he  was  attacked  by 
a  slight  chill,  for  which  he  was  given  ten  grains  of  quinine  ;  in 
three  hours  after  he  sank  into  the  condition  in  which  he  was  on 
admission,  but  from  which  he  recovered  after  three  months'  treat- 
ment in  the  asylum.  In  1875  he  was  admitted  in  precisely  the 
same  mental  condition  from  the  same  cause  ;  was  treated  much 
the  same,  and  had  apparently  fully  recovered,  when,  manifesting 
some  evidences  of  malarial  infection,  an  assistant  physician,  who 
was  ignorant  of  his  history,  ordered  him  five  grains  of  quinine, 
which  had  the  effect  of  producing  a  relapse,  the  patient  returning 
to  much  the  same  mental  condition  as  he  was  on  admission.  He, 
however,  at  length  fully  recovered. 

These  cases  are  the  only  ones  I  have  seen  in  an  asylum 
experience  covering  over  two  thousand  cases,  and  although 
exceedingly  few  in  number,  are,  I  think,  of  sufficient  value 
to  serve  as  the  basis  of  the  following  conclusions  : 

First,  that  in  hereditarily  predisposed  individuals,  quinine 
may  give  rise  to  psychoses. 

Second,  that  these  psychoses  may  present  themselves  in 
two  groups :  one  of  which  is  a  form  of  acute  mania,  with 
aural  hallucinations,  probably  not  entirely  independent  of 
the  physiological  effects  of  the  quinine ;  and  the  other,  that 
of  extreme  dementia. 

Third,  that  quinine  can  exert  this  aetiological  influence 
but  rarely. 

Fourth,  that  a  favorable  prognosis,  like  the  prognosis  in 
regard  to  the  individual  attacks  of  all  acute  cases  of  insanity 
occurring  in  hereditarily  predisposed  individuals,  can  be 
given. 


454  7-45.  G.  KIERNAN. 

VIII. — PSYCHOSES   PRODUCED    BY    LEAD. 

While  lead  appears  to  be  a  not  infrequent  cause  of  gen- 
eral neuroses,  opinions  vary  widely  as  to  the  extent  of  its 
etiological  power  in  the  production  of  insanity.  Exact 
figures  are  wanting,  however,  though  details  of  well-reported 
cases  are  by  no  means  uncommon.  Among  the  earliest  to 
describe  cases  of  this  kind  was  Tanquerel  des  Planches,^  ^ 
whose  description  is  one  fully  covering  many  points  of  value 
even  now.  He  found  that  lead  produced  both  an  acute 
and  a  chronic  form  of  insanity,  the  acute  form  being  a  spe- 
cies of  melancholic  frenzy  with  great  incoherence.  Lange,i^ 
Closs,^*  and  Boettger^^  describe  cases  of  a  similar  type. 
Moreaui''  (de  Tours),  Bottentuit,^^  and  Guislain^'  narrate 
cases  of  melancholia  attonita  due  to  this  cause.  Leisdes- 
dorf,2o  Popp,3i  Brochin,2  2  and  Hirt^s  report  cases  of  what 
they  call  mania  transitoria  due  to  this  cause,  the  mania 
having  a  decidedly  melancholic  type.  Bartens,^*  in  a  re- 
cent interesting  article,  deals  with  this  subject  very  fully, 
and  finds  that  the  psychoses  produced  by  lead  are  both  of 
a  chronic  and  acute  variety  ;  that  the  acute  form  is  a  species 
of  mania  transitoria  of  short  duration,  depressing  type, 
great  incoherence,  and  very  vivid  hallucinations  of  sight 
and  hearing.  Lead  poisoning  has,  according  to  Falke,^^ 
produced  very  similar  phenomena  in  cattle.  In  some  cases 
melancholia  attonita  is  present.  The  chronic  type  pre- 
sents hallucinations  of  taste,  touch,  sight,  and  hearing  ;  the 
patients  are  suspicious,  and  have  delusions  of  persecution. 
Some  present  the  physical  phenomena  of  progressive  pare- 
sis. The  prognosis  in  the  acute  type,  according  to  Bartens, 
is  by  no  means  unfavorable  ;  two-thirds  of  his  cases  recov- 
ered. Paralytic  and  choreic  complications  are  not  rare,  and 
the  maniacal  furor  is  at  times  not  unlikely  to  lead  to  death 
from  exhaustion.     The  prognosis  of  the  chronic  type,  as 


CON  TRIE  UTIONS  TO  PS  YCHIA  TRY.  455 

regards  recovery,  is,  of  course,  unfavorable.  The  great 
tendency  of  these  latter  cases  to  the  development  of  apo- 
plectiform attacks  renders  the  prognosis,  as  regards  life,  a 
very  grave  one. 

Maccabe^e  reports  a  case  of  what  he  calls  monomania 
with  depressing  delusions  and  hallucinations,  clearly  trace- 
able to  the  use  of  lead.  I  have,  in  all,  seen  thirty  cases  of 
insanity  due  to  lead  poisoning,  about  one  and  a  half  per 
cent,  of  all  cases  of  insanity  coming  under  observation. 
There  were  in  the  great  majority  of  these  cases  a  strong 
hereditary  taint.  The  cases  presented  themselves  in  three 
great  groups,  one,  in  which  there  was  a  marked  melancholic 
furor  of  relatively  short  duration,  subsiding  under  anti- 
saturnine  treatment,  or  on  the  appearance  of  wrist-drop  or 
lead  colic.  Of  this  type,  the  following  three  cases  may 
serve  as  examples : 

Case  i, — J.  P.,  aet.  30,  Canadian,  painter.  Mother  died  during 
an  epileptic  attack,  as  also  did  the  maternal  grandfather.  The' 
patient,  who  is  very  regular  in  habits,  was  in  good  health  up  to 
about  a  week  before  admission,  when,  after  working  at  his  trade 
for  about  a  month,  he  was  noticed  to  become  delirious,  after  hav- 
ing complained  for  some  days  previously  of  his  head.  On  admis- 
sion the  patient  had  very  vivid  hallucinations  of  sight  and  hear- 
ing ;  complained  that  the  Fenians,  clad  in  deep  green,  were  in 
search  of  him  to  shoot  him,  and  that  he  both  saw  the  men  and 
heard  their  guns  go  off.  He  was  much  emaciated,  and  had  not 
slept  during  the  week  prior  to  his  admission.  On  examination,  a 
deep  blue  line  was  found  on  his  gums.  He  was  placed,  in  conse- 
quence, on  iodide  of  potassium,  chloral,  and  conium.  He  slept 
very  well  during  the  first  quarter  of  the  night,  but  was  noisy  and 
boisterous  during  the  remainder.  It  was  ascertained  on  the 
morning  of  the  following  day,  that  the  patient  complained  of  his 
food  being  poisoned.  He  was  given  sulphuric  acid  lemonade,  as 
he  complained  of  great  thirst.  This  treatment  was  continued  for 
three  days,  when  the  patient  grew  somewhat  quieter,  his  hallucina- 
tions becoming  less  vivid,  and  his  agitation,  which  had  been  very 
great,  markedly  diminishing.  Two  weeks  after  admission,  the  pa- 
tient was  discharged,  fully  recovered. 


45 6  JAS.   G.  KIERNAN. 

This  case  presents  many  analogies  to  the  acute  form  de- 
scribed by  Bartens.  Against  the  term  transitory  mania,  as 
used  by  him,  Falcke,  and  others,  there  are  strong  and  vaHd 
objections.  The  type  of  insanity  is  not  a  mania  but  a 
melanchoHa  with  frenzy  ;  the  disease  lasts  longer  than  any 
case  of  transitory  mania,  and  in  no  respect  presents  the 
psychical  features  of  that  disease.  The  treatment  adopted 
in  this  case  was  purely  symptomatic,  the  saturnism  being 
dealt  with  as  a  complication  and  treated  specially.  The 
second  case  is  as  follows : 

T.  P.  Irish,  set.  29,  was  brought  to  the  asylum  in  a  condition  of 
melancholia  with  frenzy,  rushing  excitedly  around  the  room  with 
his  eyes  covered  by  his  hands  and  shouting  "  mercy  !  mercy  !  " 
The  patient  was  much  run  down  physically,  but  at  the  first  ex- 
amination no  details  concerning  his  history  could  be  gleaned  from 
him.  He  was  sent  to  a  room  and  ordered  cannabis  Indica,  co- 
nium,  and  laudanum,  which  seemed  to  have  but  little  effect.  He 
would  not  eat  any  thing  next  day,  and  while  feeding  him  by  force 
a  blue  line  was  noticed  on  his  gums.  Acting  on  this  therapeutic 
hint  iodide  of  potassium  in  large  doses  was  given  him  during  the 
following  day  ;  he  slept  quietly  during  the  early  part  of  that  night, 
but  grew  very  noisy  toward  morning,  the  previous  treatment  being 
continued.  This  treatment  was  kept  up  for  about  a  week,  when, 
the  patient  having  fully  regained  his  strength  and  resting  well,  the 
sedative  mixture  was  stopped,  the  iodide  being  kept  up,  and 
an  occasional  enemad  given.  The  patient  was  discharged,  one 
month  after  admission,  fully  recovered,  and  gave,  on  leaving  the 
asylum,  the  following  history  :  His  family  history  was  very  un- 
favorable. The  father  died  of  apoplexy,  a  paternal  uncle  was  an 
epileptic,  and  two  sisters  are  insane.  The  patient  himself,  who  is 
a  painter  by  trade,  was  in  relatively  good  health  until  about  three 
weeks  before  admission,  when  he  was  taken  by  frequent  attacks 
of  vertigo,  at  one  time  amounting  to  almost  complete  unconscious- 
ness. During  one  of  these  attacks  he  stepped  down  from  the 
ladder  on  which  he  was  standing  while  painting,  and  recollected 
no  more  until  he  found  himself  in  the  asylum.  He  had  remained 
in  good  health  for  about  two  years  after  his  discharge  from  the 
asylum,  at  which  time  he  passed  from  under  observation. 

The  third  case  differs  in  some  respects  from  the  other  two. 


CON  TRIE  U  TIONS  TO  PS  YCHIA  TRY.  457 

J.  R.,  aet.  31,  American  ;  father  an  inmate  of  the  asylum, 
mother  had  died  an  inmate  of  the  female  asylum.  The  patient 
has  been  in  very  good  health  up  to  six  weeks  before  admission, 
at  which  time  he  began  to  feel  "  dizzy,"  staggered  at  times  with- 
out apparent  cause,  and  complained  of  a  blur  before  his  eyes. 
The  patient  made  bird-cages,  and  lived  in  a  close-confined  room 
in  the  rear  of  his  shop  which,  itself,  is  not  well  ventilated.  He 
had  been  working  hard  for  some  time  previous  to  admission, 
scarcely  stopping  for  his  meals.  On  admission  the  patient  was 
markedly  agitated,  complained  of  being  played  upon  from  a  hose 
filled  with  hot  water,  closed  his  eyes  and  stopped  his  ears,  declar- 
ing what  he  saw  and  heard  were  too  frightful  for  utterance.  He 
was  treated  for  three  weeks  with  sedatives,  in  which  opium  pre- 
dominated, without  apparent  effect.  One  day  he  was  found  in  a 
condition  of  slight  confusion,  his  hallucinations  and  agitation 
having  disappeared,  but  both  wrists  presented  the  characteristic 
phenomena  of  lead-poisoning.  His  gums  showed  the  pathogno- 
monic blue  lines.  The  patient  on  being  placed  under  iodide  of 
potassium  and  the  usual  anti-saturnine  treatment  made  a  rapid 
recovery. 

This  case  is  not  without  a  parallel  among  those  recorded 
by  Bartens  and  others,  for  he  cites,  as  a  common  phenom- 
enon, the  disappearance  or  amelioration  of  the  psychic 
symptoms  on  the  full  evolution  of  "  drop-wrist "  and 
other  physical  symptoms  of  lead  poisoning.  The  suspi- 
cion of  lead  poisoning  would  readily  arise  in  the  first  two 
cases  on  account  of  the  patient's  occupation,  but  not  so 
readily  in  the  third.  The  second  group  in  which  lead  ex- 
erted an  etiological  influence  is  well  exemplified  by  the 
following  cases. 

Case  i. — R.  McG.,  aet.  29,  painter  ;  strong  hereditary  taint,  in- 
temperate ;  was  admitted  to  the  asylum  once  before  about  a  year 
previous  ;  then  in  a  condition  of  melancholia  attonita,  coming  on 
after  an  attack  of  lead  colic,  and  recovering  under  anti-saturnine 
treatment.  He  has  had  another  attack  of  lead  colic,  subsequent 
to  which  the  following  psychical  phenomena,  now  present,  were 
observed.  He  has  a  markedly  suspicious  manner,  unsystematized 
delusions  of  persecution,  very  vivid  hallucinations  of  sight,  taste. 


45 8  7 AS.   G.  KIERNAN. 

touch,  and  hearing.  These  phenomena  after  three  months  of 
anti-saturnine  treatment  disappeared,  and  he  engaged  again  in  his 
trade  ;  was  attacked  once  more  by  same  symptoms,  became  and 
remained  an  inmate  of  the  asylum  for  two  years,  being  then  taken 
out  by  his  friends  in  much  the  same  condition  as  he  was  upon  his 
third  admission.  He  died  six  months  after  discharge,  from  apo- 
plexy, having  sunk  into  slight  dementia  for  three  months  previous 
to  this. 

Case  2.  — Jno.  R.,  painter,  ast.  30,  unmarried,  intemperate. 
Father  died  of  apoplexy,  twt)  brothers  and  a  paternal  cousin  are 
insane.  The  patient  was  in  very  good  health  up  to  about  three 
weeks  before  admission,  when  he  began  to  complain  of  being  fol- 
lowed about,  when  returning  home  from  work,  by  men  having  evil 
designs  on  him.  He  was  restless  and  uneasy  at  night,  and  fre- 
quently searched  his  rooms  to  ascertain  if  any  person  were  hidden 
in  them.  This  patient  on  admission  had  a  hard  suspicious  manner, 
refused  to  enter  into  a  lengthy  conversation,  and  had  evidently 
hallucination  of  hearing.  On  examination  a  blue  line  was  dis- 
covered on  his  gum,  whereupon  he  was  placed  under  treatment 
for  lead  poisoning.  He  recovered  after  two  months'  treatment, 
and  was  discharged.  Six  months  after  he  was  again  admitted, 
was  much  in  the  same  mental  condition  as  on  his  first  admission, 
except  that  he  now  displayed  unsystematized  delusions  of  perse- 
cution. He  had  had  an  attack  of  wrist-drop  some  weeks  pre- 
vious to  the  present  admission,  but,  disregarding  these  ominous 
symptoms,  continued  to  work  at  his  trade,  but  began  at  length  to 
display  such  active  symptoms  of  insanity,  that  his  friends  re- 
garded asylum  treatment  as  necessary.  He  was  again  placed  un- 
der anti-saturnine  treatment,  but  although  the  vividness  of  his  hal- 
lucinations grew  less,  he  still  retained  his  insanity  of  manner, 
and  was  somewhat  feeble  in  memory.  Three  months  after  ad- 
mission, epileptoid  attacks  developed  themselves,  and  in  one 
of  these  the  patient  died. 

There  vi^as,  it  is  obvious,  in  these  tvi^o  cases,  a  progres- 
sive mental  enfeeblement  from  the  time  of  the  second 
attack.  The  cases  belonged  to  a  large  group,  which  hovers 
between  monomania  and  dementia,  with  unsystematized 
delusions  of  persecution.  The  third  group  is  well  exem- 
plified in  the  following  cases  : 


CONTRIB  UTIONS  TO  PS  YCHIA  TR  V.  459 

Case  i. — J.  G.,  German,  aet  41,  painter  ;  was  admitted  to  the 
asylum  with  the  history  of  having  suffered  at  various  times  from 
attacks  of  insanity  on  several  occasions,  all  of  which  preceded 
by  one  week  an  attack  of  lead  colic,  and  were  evidently  refera- 
ble to  the  same  cause.  Four  months  before  his  admission  he  was 
attacked  by  lead  colic,  which  was  preceded  as  before  by  insanity. 
This,  hoAvever,  did  not  subside  as  before  on  recovery  from  the 
lead  colic,  but  continued,  and  the  patient  was  transferred  to  the 
asylum.  On  admission  he  presented  the  following  symptoms  : 
His  pupils  were  markedly  unequal,  both  responding  feebly  to 
light.  The  facial  folds  were  also  unequal,  and  his  tongue  was 
tremulous.  His  speech  was  hesitant  ;  he  was  markedly  emo- 
tional, and  he  had  delusions,  both  equally  ilnsystematized,  of 
grandeur  and  persecution.  These  symptoms  improved  for  a 
time  under  ergot  and  iodide  of  potassium,  but  the  patient's  men- 
tal condition  was  that  of  intellectual  enfeeblement.  He  had 
from  time  to  time  rather  stupid  delusions  about  poisoning.  After 
about  two  years'  treatment,  the  patient  died  from  a  paretic  con- 
vulsion. 

The  next  case  has  been  elsewhere  quoted^''  in  illustration, 
however,  of  something  other  than  its  etiology. 

Case  2. — J.  H.,  Scotch,  set.  36.  Three  months  before  admis- 
sion, early  in  1876,  had  lead-colic,  succeeded  by  an  attack  of  drop- 
wrist,  which  in  turn  was  followed  by  hemiplegia  and  aphasia. 
The  patient  recovered  from  this  under  anti-saturnine  treatment, 
but  slight  spots  of  his  skin  began  to  change  color,  followed  by 
similar  changes  in  his  hair.  On  admission  the  patient  presented 
the  usual  mental  and  physical  symptoms  of  progressive  paresis. 
Four  months  after  admission  he  complained  of  band-like  sensa- 
tions about  the  fifth  lumbar  vertebrae,  with  electric-like  pains  down 
his  thighs.  He  was  at  length  confined  to  bed,  dying  within  three 
months  from  a  paretic  convulsion. 

Before  contrasting  these  results  with  those  obtained  by 
Bartens  and  others,  it  would  be  well  to  enquire  what  pecu- 
liar forms  of  insanity  lead  has  given  rise  to.  Of  these  thirty 
cases  eight  were  cases  of  melancholia,  of  greater  or  lesser 
duration  ;  three,  cases  of  acute  mania,  of  short  duration  ; 
five  were  cases  of  the  second  group ;  nine  were  cases  of  ter- 


460  JAS.  G.  KIERNAN. 

minal  dementia  ;  and  five  were  cases  of  progressive  paresis. 
In  contrast  with  these  results  it  may  be  said  that  the  cases 
reported  by  Bartens  have  been  principally  mania  transitoria, 
at  he  puts  it,  properly  melancholia  with  frenzy,  and  a  form 
of  what  he  calls  insanity  with  apathy,  really  melancholia 
attonita.  The  chronic  types  given  by  him  were  principally 
dementia.  While  it  cannot  be  said  that  these  cases  denote 
that  lead  produces  peculiar  psychoses,  it  certainly  gives  a  de- 
pressing tinge  to  any  psychoses  it  produces.  Like  Bartens 
I  have  found  that  the  acute  psychoses  produced  by  lead 
have  a  favorable  prognosis  ;  all  of  my  cases  recovered,  but 
the  chronic  forms  all  died  insane,  or  still  continued  to  be  in- 
sane long  after  my  leaving  the  asylum.  From  these  cases  I 
feel  warranted  in  concluding  : 

First,  that  lead  poisoning  produces  certain  psychical 
manifestations. 

Second,  that  these  manifestations  may  be  of  an  acute 
or  chronic  type. 

Third,  that  in  any  case  the  psychosis  always  preserves 
an  element  of  depression. 

Fourth,  that  the  acute  forms  usually  resemble  melan- 
cholia with  frenzy. 

Fifth,  that  the  chronic  forms  vary  from  a  condition  re- 
sembling monomania,  but  with  a  strong  element  of  demen- 
tia, to  progressive  paresis. 

Sixth,  that  the  prognosis  in  the  acute  types  is  favorable. 

Seventh,  that  anti-saturnine  remedies  are  of  great  yalue  in 
treatment. 

Eighth,  that  the  prognosis  of  the  chronic  types  is,  as 
might  be  expected,  bad. 

Ninth,  that  heredity,  as  in  all  other  psychoses,  is  an  im- 
portant element  in  the  production  of  these. 


CON  TRIE  UTIONS  TO  PS  YCHIA  TR  Y.  46 1 

IX, STEALING     AS    A     PREMONITORY     SYMPTOM     OF      PROGRESSIVE 

PARESIS. 

L61ut,"  Baillarger,'»  Parot,'"  Billod,"  Brierre  de  Bois- 
mont,"  A.  Sauze,"  Maudsley,^^  Burman,"  Fafore,"  Darde/' 
Mickle/*  Voisin/'  and  others,  have  reported  various  cases 
in  which  paretics  have  committed  thefts  and  other  viola- 
tions of  morality.  My  experience  in  this  matter  has  been, 
by  no  means,  an  unusual  one.  I  have  observed  many 
cases  in  which  phenomena  of  this  kind  were  the  first  ob- 
vious evidence  of  the  patient's  insanity,  but  which  was  not 
recognized  until  the  patient  had  been  tried  and  condemned 
to  the  penitentiary.  The  following  case  fully  illustrates  this: 

Case  i. — R.  C,  Irish,  stone-mason,  had  been  an  honest,  hard- 
working man  up  to  a  month  prior  to  admission,  when  he  deliber- 
ately entered  a  variety  store,  and  in  plain  view  of  every  one  took 
four  shirts.  Despite  the  peculiar  stupid  character  of  the  act  the 
man  was  tried  and,  as  the  store  had  been  much  victimized  by 
shoplifting  before  his  attempt,  received  a  sentence  of  six  months 
in  the  penitentiary.  About  a  week  after  his  arrival  there  he  was 
noticed  to  be  very  uncleanly  in  habits,  and  was  several  times  pun- 
ished without  effect,  when  it  was  suggested  that  the  patient  might 
be  insane.  On  an  examination  of  his  mental  condition  being 
made  he  was  found  to  have  very  expansive  delusions.  The  pa- 
tient was  in  consequence  transferred  to  the  asylum,  and  on  ad- 
mission presented  the  usual  symptoms,  mental  and  physical,  of 
progressive  paresis,  from  which  disease  he  died  a  year  and  a  half 
later. 

Certainly  it  was  a  great  injustice  that  condemned  this 
man  to  the  penitentiary  and  to  the  punishment  inflicted  on 
him  there.  It  strongly  hints  at  the  propriety  of  submitting 
every  case  of  theft,  where  the  exact  motive  is  inexplicable, 
to  medical  examination.  The  psychological  basis  of  these 
thefts  is  easily  explained.  The  patient  claiming  to  be 
wealthy  regards  himself  as  taking  things  on  credit  to  be 
subsequently  paid  for. 


4^2  JAS.  G.  KIERNAN. 

This  propensity  for  stealing  of  the  paretics  led  me  to 
watch  for  a  year  a  case  of  monomania  in  whom  it  appeared 
suddenly,  and  who,  a  year  after,  developed  marked  symp- 
toms of  paresis.  These  cases,  clear  as  they  may  be  at  times, 
should  lead  to  a  little  caution  in  the  condemnation  of  all 
criminals  whose  crimes  are  a  little  inexplicable  on  the 
grounds  of  stupidity. 

BIBLIOGRAPHY. 

1.  Journal  of  Nervous  and  Mental  Disease,  April,  1881,  p.  243. 

2.  Paralysie  Gdnirale  des  Alidnis. 

3.  Maladies  Mentales. 

4.  La  Paralysie  chez  les  Aliinds,  p.  250. 

5.  Cited  by  Voisin,  op.  cit. 

6.  Lehrbuch  der  Psychiatrie. 

7.  West  Riding  Lunatic  Asylum  Reports,  vol.  ii. 

8.  Psychological  Medicine. 

9.  Zeitschrift  der  K.  K.  gesellschaft  der  Aerzte  zu  IVien,  xiii,  1857,  p.  454. 

10.  Maladies  Mentales. 

11.  Disease  of  the  Mind. 

12.  Archives  Generales  de  Medecine,  February  and  March,  1881. 

13.  Maladies  de  Plomb,   Paris,  1839. 

14.  Beobachtungen  am  Krankenbett,  Konigsburg,  1850. 

15.  Bleitollheit.  Wiiriemberger  Medicinisches  Correspondenz-blatt,  1852, 
No.  51. 

16.  Allgemeine  Zeitschrift  fUr  Psychiatrie,  Band  xxvi. 

17.  Annates  Midico-Psychologiques,  1855. 

18.  V  Union  MMicale,  151,  1873.  Wiirtembergischen  Correspondenz-blatt, 
xliii,  1873. 

19.  Sur  les  Phrenopathies. 

20.  Lehrbuch  der  Psychischen  Krankheiten. 

21.  Bayerisches  Arztliches  intelligenz-blatt,  p.  357,  1874. 

22.  Gazette  des  Hdpitaux,  24,  1875. 

23.  Krankheiten  der  Arbeiter. 

24.  your?ml  of  Mental  Science,  ]vly,  1872. 

25.  Zeitschrift  fiir  Psychiatrie,  Band  xxxvii.  Heft  I,  p.  9. 

26.  Bericht  Uber  Thierarzneikunde. 

27.  .  Trophic  Disturbances  of  the  Insane.  Journal  of  Nervous  and 
Mental  Disease,  April,  1878. 


CONTRIBUTIONS  TO  PSYCHIATRY.  463 

28.  Annates  Me'dico-Psychologiques,  tome  i. 

29.  Annates  Medico-Psychologiqiies,  tome  v,  p.  479. 

30.  Annates  Medico-Psychologiques,  tome  v,  page  481. 

31.  Annates  Mddico-Psychotogiques,  tome  ii,  page  626. 

32.  Annates  d'  Hygiene  Pubtiqiie,  i860,  p.  409. 

33.  Annates  Jiledico-Psyckotogiques,  1861,  p.  54. 

34.  Responsibility  in  Mental  Disease.     Lancet,  1875,  p.  693. 

35.  youmat  Alentat  Science,  1873,  p.  536. 

36.  Annates  Medico-Psychotogiques,  1874,  p.  198. 

37.  Du  Detire  des  Acts  dans  ta  Paratysie  Ginirate,  pp.   24,  25,  et.  seq. 

38.  J ournat  Mental  Science,  1872,  page  19S. 

39.  Paralysie  General  des  Alienes. 


SPASM    OF    THE    CILIARY    MUSCLES    OF    CEN- 
TRAL ORIGIN* 

By  Dr.  H.   GRADLE. 

THE  case  upon  which  this  paper  is  based  presents  the 
rare  occurrence  of  a  contracture  of  the  ciHary  muscles 
apparently  in  consequence  of  brain  disease.  Ciliary  spasm 
is  a  common  complaint  in  ophthalmic  practice,  but  in  the  in- 
stances ordinarily  observed  the  spasm  arises  from  some  con- 
dition in  the  eye.  The  exaggeration  of  a  true  myopia  and 
the  simulation  of  shortsightedness  in  a  really  hypermetro- 
pic or  astigmatic  eye  by  reason  of  such  spasm,  are  every- 
day occurrences.  But  in  these  instances  we  cannot  usually 
speak  of  a  contracture  of  the  ciliary  muscle,  for  the  spasm 
persists  only  while  the  eye  is  adjusted  for  some  visual  ob- 
ject. When  the  patient  is  examined  ophthalmoscopically 
in  a  dark  room,  it  is  easy  to  measure  the  true  refraction. 
The  ciliary  muscle  relaxes  nearly  completely  under  these 
circumstances,  and  the  refraction  thus  determined  is  found 
nearly  the  same  as  after  paralysis  of  accommodation  by  means 
of  atropia.  I  add  the  word  nearly,  because  a  slight  normal 
tonus  of  the  non-atropinized  muscle  is  undeniable.  In- 
stances of  ciliary  spasm  so  persistent  as  to  stimulate  myopia 
even  on  ophthalmoscopic  examination  are  much  less  com- 
mon. In  fact,  such  an  occurrence  as  a  complication  in  the 
ordinary  anomalies  of  refraction  is  wholly  denied  by  some 

*  Read  before  the  American  Neurological  Society. 

464 


SPASM  OF  THE  CILIARY  MUSCLES.  4^5 

authors  of  experience.  I  have  likewise  never  seen  an  in- 
stance of  it.  A  true  and  persistent  spasm  of  the  ciliary 
muscle  from  other  causes  has  only  been  reported  a  few 
times.  It  was  generally  due  to  some  trauma,  abrasion  of 
the  cornea,  or  contusion  of  the  eyeball.  A  few  cases  are  re- 
ported as  accompanying  facial  neuralgia  and  blepharospasm. 
Most  instances  of  which  I  could  find  mention  in  ophthalmic 
literature  were  confined  to  one  eye.  But  as  far  as  I  have 
been  able  to  learn  no  instance  of  apparent  myopia  suddenly 
beginning  in  consequence  of  a  brain  lesion  has  yet  been  re- 
ported. The  patient  in  whom  I  observed  this  unique  state 
of  affairs  is  a  lady  23  years  of  age,  who  was  referred  to  me, 
through  the  kindness  of  Dr.  Jewell,  for  the  ophthalmic  feat- 
ures of  the  case. 

The  patient,  previously  in  good  health,  had  a  very  pro- 
tracted labor  during  five  days  in  March,  1880.  Two  days 
before  the  birth  of  a  healthy  child  she  was  attacked  with 
left  hemiplegia  while  sitting  in  her  chair.  She  had  had  no 
premonitory  symptoms  ;  she  did  not  lose  consciousness  and 
did  not  complain  of  headache,  but  was  simply  faint  and 
confused  in  her  mind.  Her  speech  was  heavy  for  some 
days.  The  paralysis  extended  to  the  entire  left  side,  but 
the  face  soon  recovered  from  it,  while  the  limbs  improved 
in  power  more  slowly.  At  no  time  was  there  any  involve- 
ment of  sensory  nerves.  The  only  interference  with  any  of 
the  involuntaiy  functions  consisted  in  transitory  paralysis 
of  the  bladder,  necessitating  the  temporary  use  of  the 
catheter.  In  the  following  October,  when  she  was  exam- 
ined by  Dr.  Jewell  and  later  by  myself,  there  remained  only 
a  paresis  of  the  left  arm,  with  complete  paralysis  of  the 
extensor  muscles.  The  hand  was  flexed  but  no  contracture 
existed.  According  to  Dr.  Jewell's  notes  the  patellar  ten- 
don-reflex was  considerably  exaggerated  on  the  left  side 
and  rather  energetic  in  the  right  knee.     The  patient  was, 


466  H.   CRADLE. 

moreover,  neurasthenic.  The  treatment  consisted  in  the 
use  of  the  induced  current  with  massage  of  the  paretic  Hmb. 
Strychnia  was  given  and  attention  paid  to  the  neurasthenic 
complaints.  There  has  been,  however,  but  little  improve- 
ment in  the  control  of  the  muscles  involved.  The  exten- 
sors are  still  wholly  paralyzed. 

This  history  points  clearly  to  hemorrhage  in  the  region 
of  the  right  internal  capsule.  The  actual  destruction  of 
nerve  tissue  was  probably  quite  limited,  and  the  involve- 
ment of  the  entire  half  of  the  body  due  to  compression  of 
the  surrounding  strands,  or  inhibition.  But  this  anatomical 
diagnosis  fails  to  explain  the  peculiar  ophthalmic  symptoms 
observed. 

The  patient  claims  to  have  always  enjoyed  perfect  vision. 
In  the  fall  previous  to  the  accident  she  suffered  of  occipital 
headache  for  a  few  weeks,  during  which  time  her  pupils 
were  unusually  wide,  but  there  was  no  disturbance  of  sight. 
After  the  occurrence  of  the  apoplexy  she  noticed  a  decided 
blurring  of  sight,  especially  on  looking  at  a  distant  clock. 
She  cannot  now  state  exactly  how  soon  her  attention  was 
directed  to  it  after  the  apoplexy.  This  haziness  of  sight 
had  not  changed  when  I  first  saw  her  in  October.  At  first 
she  could  not  read  at  all,  later  on  only  with  difficulty.  At 
the  examination  I  found  her  sight  about  one-tenth  of  the 
normal  acuity.  She  accepted  a  concave  glass  of  1.75  diop- 
trics for  the  right  eye,  and  2.25  for  the  left  eye.  On  account 
of  the  late  hour  and  the  approaching  darkness,  the  examina- 
tion was  not  quite  satisfactory.  She  read  the  finest  print, 
but  only  at  a  distance  of  5'  to  7",  and  with  the  above  con- 
cave glasses  at  8"  to  12".  Objectively  the  eyes  presented  no 
evidence  of  disease.  The  pupils  were  of  normal  size  and 
mobility.  The  ophthalmoscope  showed  a  normal  fundus,  a 
deep  central  excavation  of  the  papillae,  which  were  well 
reddened,  but  not  abnormally  so.    In  the  left  eye  the  edges 


SPASM  OF  THE  CILIARY  MUSCLES.  467 

of  the  disc  were  not  sharp,  while  in  the  right  eye  there  ex- 
isted a  small  conus.  Ophthalmoscopically,  the  myopia  was 
measured  to  be  1.5  dioptrics  in  each  eye. 

The  history  caused  me  to  suspect  the  spasmodic  origin  of 
the  myopia,  but  the  patient,  when  assured  that  there  was  no 
immediate  danger,  was  anxious  to  return  home  to  a  distant 
city.  Hence,  a  further  examination  was  postponed  until 
the  middle  of  November. 

On  her  return,  at  this  date,  the  following  notes  were 
taken  : 

R.  E.     V=|f  with  -1.5  D-V=2o. 

L.  E.     V=^  with  -1.5  D-V=§^. 

Her  near-point  is  5"  from  the  eye,  but  Sn  1.25  is  not  read 
any  further  off  than  12".  There  exists  no  anomaly  of  the 
ocular  muscles.  Tested  with  prisms,  they  are  found  to  be 
of  full  strength.  Examination  of  the  visual  field  and  color- 
perception  showed  no  anomaly.  Ophthalmoscopically,  no 
change  was  noted;  it  still  required  a  correcting-glass  of  1.5 
D  concave  to  see  the  disc  and  central  part  of  the  retina 
clearly. 

That  the  myopia  was  not  an  anomaly  of  refraction,  but 
one  of  accommodation,  was  distinctly  suggested  by  the  ina- 
bility to  read  at  a  proper  distance.  A  myope,  requiring  a 
glass  of  24"  focus  and  possessing  a  nearly  normal  visual 
acuity,  can  read  not  too  fine  a  type  at  a  distance  of  24 
inches.  This  patient,  however,  evidently  exerted  her  accom- 
modation unduly  when  converging  for  an  object  at  that  dis- 
tance. It  was  one  of  those  rare  cases  in  which  the  accom- 
modative apparatus  did  not  act  in  harmony  with  the  inter- 
nal recti  muscles.  Every  thing  beyond  12"  distance  was  seen 
indistinctly,  although  with  parallel  visual  axes  the  apparent 
myopia  was  corrected  by  a  glass  of  24"  focus.  I  could  trace 
the  inability  to  read  beyond  12"  distance  to  such  an  accom- 
modative effort,  greater  than  proportionate  to  the  converg- 


468  H.  CRADLE. 

ence,  in  two  ways.  With  concave  glasses,  correcting  the 
myopia,  apparent  when  the  visual  axes  were  parallel,  she 
could  not  read  at  a  much  greater  distance  than  without 
them,  while  I  could  increase  her  reading  distance  up  to  16' 
by  means  of  weak  prisms,  with  the  bases  turned  inward  so 
as  to  diminish  the  contraction  of  the  internal  recti  muscles. 
Such  abducting  prisms,  however,  did  not  diminish  her 
myopia  for  the  distance. 

The  nature  of  the  shortsightedness  was  at  once  revealed 
by  a  thorough  application  of  atropia.  She  returned  to 
the  ofifice  delighted  with  her  normal  sight.  On  testing  I 
found  V=f  g  without  glasses,  while  the  addition  of  a  convex 
glass  of  0.5.  D,  in  front  of  the  right  eye,  gave  her  about  the 
full  sight  possible  to  a  strongly  atropinized  normal  eye. 
The  left  eye  was  perfectly  emmetropic. 

The  entire  trouble,  hence,  consisted  in  a  symmetrical, 
tonic,  uninterrupted  contraction  of  the  ciliary  muscle,  in- 
creasing the  refraction  of  the  eye  by  1.5  dioptrics.  On  con- 
verging for  near  objects  this  spasm  evidently  increased, 
until  at  a  distance  of  12"  the  accommodative  and  converg- 
ing efforts  became  about  proportionate.  The  strength  of 
the  ciliary  muscle  had  not  suffered,  since  the  patient's  near- 
point  (5')  corresponded  to  the  usual  figure  of  emmetropic 
eye  at  that  age.  This  permanent  contracture  had  not  given 
rise  to  any  unpleasant  sensations.  Since  no  other  cause 
could  be  accused,  and  the  spasm  occurred  suddenly  within 
a  very  short  time  after  the  apoplectic  attack,  it  is  fair  to  con- 
sider it  a  consequence  of  the  latter.  In  what  manner, 
however,  a  lesion  in  or  near  the  internal  capsule  can  keep 
up  a  tonic  but  feeble  activity  of  the  ciliary  branches  of  the 
motor  oculi,  cannot  be  decided.  It  is  certainly  noteworthy 
that  notwithstanding  the  close  anatomical  relationship  of 
the  nerves  of  the  iris  and  of  the  ciliary  body  there  existed 
no  pupillary  anomaly. 


SPASM  OF  THE  CILIA  FY  MUSCLES.  469 

As  soon  as  the  effect  of  atropia  ceased,  the  former 
trouble  returned.  I  advised  her  by  letter  to  continue  the 
application  in  a  more  dilute  form.  By  trial  she  learned  that 
a  solution  of  one  part  of  atropia  in  3,500  parts  of  water  re- 
moved the  spasm  completely,  without  enfeebling  the  ac- 
commodation sufficiently  to  interfere  with  reading.  With 
this  application  she  saw  well,  both  in  the  distance  and  near 
by,  while  the  inconvenience  occasioned  by  the  dilated  pu- 
pils could  be  avoided  by  the  use  of  smoked  glasses.  One 
drop  of  this  solution  every  three  days  sufficed  to  keep  her 
eyes  in  a  satisfactory  condition.  She  returned  in  March, 
at  which  date  I  found  the  former  trouble  unchanged,  since 
she  had  not  used  the  atropia  for  some  weeks.  At  that  time 
she  called  my  attention  to  a  peculiarity  she  had  lately  dis- 
covered. Her  vision  increased  at  once  in  distinctness  on 
turning  the  head  sideways,  while  retaining  the  eyes  in 
their  original  direction.  By  trial  with  glasses  I  could  not 
well  decide,  whether  the  myopia  really  diminished  on  exert- 
ing thus  the  external  rectus  of  one,  and  the  internal  rectus 
of  the  other  eye.  At  any  rate,  her  visual  acuity  rose  by 
this  manoeuvre  from  f^  to  ||^  as  tested  with  Snellen's 
plates.  Since  she  was  anxious  to  return  home,  I  was  lim- 
ited in  the  choice  of  my  remedies.  Explaining  to  the  hus- 
band the  questionable  efificacy,  I  have  still  had  him  make 
a  number  of  metallo-therapeutic  attempts,  by  applying  va- 
rious metallic  discs  to  the  temples  as  well  as  magnets  to 
the  nape  of  the  neck.  The  intelligent  patient  tested  her- 
self carefully  during  these  experiments  with  type  at  differ- 
ent distances  and  found  no  influence  whatever.  She  has 
now  returned  to  the  use  of  the  dilute  atropia  solution. 
The  only  remedial  procedure  of  which  I  could  find  a  prom- 
ising record  in  ophthalmic  literature  is  the  hypodermic  in- 
jection of  strychnia,  with  which  Nagel  has  succeeded  ad- 
mirably in  a  case  of  one-sided  ciliary  spasm. 


TUMOR  OF  THE   PONS  VAROLII,  WITH  CONJU- 
GATE DEVIATION  OF  THE  EYES  AND 
ROTATION  OF  THE  HEAD.* 

By  CHARLES    K.  MILLS,   M.D.  , 

NEUROLOGIST    TO   THE    PHILADELPHIA    HOSPITAL. 

R.  C,  aet.  32,  single,  groom,  had  for  several  years  been  intem- 
perate, and  had  a  history  of  syphilis.  About  five  years  before 
coming  under  observation  he  had  twice  been  thrown  from  a  horse 
and  kicked  on  the  head.  After  the  occurrence  of  these  accidents 
he  began  frequently  to  suffer  from  severe  headache  which  always 
came  on  at  night.  He  also  had  at  times  spells  of  dizziness.  Four 
weeks  before  coming  for  treatment  he  fell  on  the  ice,  striking  his 
head.  At  the  time  he  noticed  no  ill  effects  from  the  fall,  but  a 
week  later,  while  grooming  a  horse,  he  became  dizzy  and  fell  to 
the  ground,  but  did  not  lose  consciousness.  A  few  days  later  his 
eyes  began  to  trouble  him,  and  he  also  noticed  a  slight  loss  of 
power  in  his  right  arm  and  leg.  Such  was  the  history  obtained 
from  the  patient,  whose  memory  was  defective,  but  I  think  it 
probable  that  his  ocular  and  paretic  symptoms  were  of  longer 
standing  than  a  few  weeks. 

On  admission  to  the  Philadelphia  Hospital  he  was  able  to  walk 
about  the  wards  and  even  go  out  of  doors,  but  he  was  weak,  anae- 
mic, and  apathetic.  The  right  side  of  the  forehead  wrinkled  more 
promptly  than  the  left.  The  lower  part  of  the  right  side  of  the 
face,  and  the  right  arm  and  leg  were  paretic,  but  decided  paraly- 
sis and  contractures  were  not  present.  Sensation  was  diminished 
in  the  left  side  of  the  face  and  in  the  right  limbs,  but  owing  to 
the  patient's  mental  condition,  his  answers  with  reference  to  sen- 
sation were  somewhat  confusing  and  conflicting.  Hearing,  smell, 
and  taste  were  preserved. 

Both  eyes  were  kept  constantly  directed  to  the  right.     The  pa- 

*Read  before  the  American  Neurological  Association,  June,  1881. 


TUMOR  OF  THE  PONS  VAROLII.  47 1 

tient  could  not  by  the  utmost  effort  bring  them  even  to  the  me- 
dian line.  They  had  a  fixed,  staring  expression.  The  pupils, 
however,  were  not  dilated  ;  they  were  at  this  time  equal  and 
about  normal  in  size.  Dr.  E  O  Shakespeare,  ophthalmologist  to 
the  Philadelphia  Hospital,  examined  the  eyes  for  me,  and  the  fol- 
lowing notes  were  made  by  him  :  "  The  corneas  and  other  media 
were  transparent.  There  was  a  conjugate  deviation  of  the  optic 
axes  to  the  right.  The  power  of  accommodation  was  not  greatly 
impaired,  and  in  the  act  of  accommodation  there  was  an  associa- 
ted convergence  of  the  optic  axes  and  the  usual  contraction  of  the 
pupils.  In  attempted  movements  of  the  eyes  to  the  left,  the  right 
eye  turned  slightly,  the  left  eye  scarcely  at  all.  The  right  lid 
showed  a  slight  tendency  to  ptosis.  This  was  most  noticeable  in 
attempts  to  raise  the  eyes  above  the  horizontal  meridian.  Oph- 
thalmoscopic examination  of  the  left  eye  gave  the  following  re- 
sults :  Fundus  seen  with  a  -\-  -^-^  glass.  It  was  of  a  pale  reddish- 
yellow  color.  The  outline  of  the  disc  was  distinct,  but  not  as 
marked,  or  as  regular,  as  normal.  It  was  more  or  less  opaque 
and  slightly  hyperaemic.  The  arteries  were  scarcely  distinguish- 
able from  the  veins  by  their  color.  The  former  were  a  little  con- 
tracted, but  were  regular  in  their  course.  The  view  of  the  whole 
fundus  was,  however,  slightly  veiled.  In  consequence  of  the  ex- 
treme deviation  of  the  eyes  to  the  right,  the  right  eye  could  not 
be  satisfactorily  examined  by  the  ophthalmoscope." 

On  cutting  the  patient's  hair  close  to  the  head,  a  scar  about  one 
inch  and  a  half  in  length  was  found  in  the  scalp  of  the  left  side  of 
the  head.  Its  direction  was  from  behind  forward,  and  from 
above  downward,  at  a  slight  angle,  its  posterior  end  being  three 
and  a  quarter  inches  in  almost  a  direct  line  above  the  external 
auditory  meatus.  It  corresponded  to  the  middle  region  of  the 
squamous  portion  of  the  temporal  bone.  The  bone  beneath  the 
scar  appeared  to  have  in  it  a  cleft.  Two  slight  scars  were  found 
in  the  scalp  of  the  parietal  region  of  the  right  side. 

The  patient  was  placed  upon  potassium  iodide,  tonics,  and 
nourishment.  He  got  weaker  from  day  to  day,  however,  his  ocu- 
lar and  paretic  symptoms  remaining  about  the  same.  He  was 
compelled  because  of  weakness  and  dizziness  to  stay  in  bed.  His 
nose  began  to  bleed,  the  blood  sometimes  escaping  from  one  nos- 
tril and  sometimes  from  the  other.  In  spite  of  local  and  interna!" 
remedies,  such  as  ice,  alum,  iron,  ergot,  erigeron,  gallic  acid,  etc., 
the  epistaxis  persisted  until  the  death  of  the  patient,  the  bleeding 
sometimes  stopping  for  an  hour  or  two,  apparently  without  refer- 


472  CHARLES  K.  MILLS. 

ence  to  treatment.  He  became  extremely  anaemic,  and  died  of 
general  exhaustion.  A  few  notes  were  made  on  his  condition  the 
day  before  his  death.  The  limbs  of  both  sides  appeared  to  be 
about  equally  helpless.  The  mouth  was  now  drawn  very  slightly 
to  the  right.  Little  could  be  made  out  certainly  with  reference 
to  sensation.  He  still  appeared,  however,  to  be  less  sensitive  to 
impressions  on  the  left  side  of  the  face  and  in  the  limbs  of  the 
right  side.  Both  pupils  were  small,  the  left  a  little  smaller  than 
the  right.  The  eyes  still  looked  to  the  right  ;  the  deviation,  how- 
ever, was  not  quite  as  great  as  when  he  was  first  admitted.  The 
conjunctiva  of  the  right  eye,  from  the  cornea  to  the  internal  can- 
thus,  was  much  injected. 

Autopsy. — The  scalp  was  found  adherent  to  the  skull  in 
the  line  of  the  scar  in  the  left  squamoso-temporal  region. 
A  narrow  fissure  was  present  in  the  skull  beneath  the 
scar.  The  internal  table  of  the  skull  was  fissured  for  the 
distance  of  half  an  inch,  the  fracture  corresponding  to  a 
portion  of  the  external  cleft.  The  fracture  was  a  simple 
crack  or  break,  no  bone  being  depressed  or  displaced.  The 
dura  mater  was  slightly  adherent  along  the  internal  fissure, 
and  exactly  beneath  the  point  of  adhesion,  on  the  inner 
surface  of  the  dura  mater,  was  a  hard,  yellowish  tumor, 
no  larger  than  a  pea.  It  was  attached  below  to  the  pia 
mater,  and  caused  a  slight  depression  in  the  first  tem- 
poral convolution,  about  the  junction  of  its  middle  and 
posterior  thirds,  and  half  way  between  the  parallel  fissure 
and  the  horizontal  branch  of  the  Sylvian  fissure.  No  other 
lesion  of  the  surface  of  the  brain,  or  of  the  ganglia,  centrum 
ovale,  or  cranial  nerves,  was  discovered.  The  pia  mater  of 
the  middle  region  of  the  base  was  hyperaemic  and  not  quite 
transparent.  On  exposing  the  floor  of  the  fourth  ventricle 
a  distinct  bulging  of  its  left  upper  portion  was  observed. 
This  proved  to  be  due  to  a  tumor  about  half  an  inch  in 
diameter.  It  was  situated  in  the  body  of  the  pons,  both 
the  anterior  and  posterior  surfaces  of  the  latter  retaining 
their  integrity.     It  was  distinctly  limited  to  the  left  upper 


TUMOR  OF  THE  PONS  VAROLII.  473 

quarter  of  the  pons,  coming  close  to,  but  not  crossing,  the 
median  line.  It  was  found  on  section  to  be  of  firm  con- 
sistence and  of  a  greenish-gray  color. 

Tubercular  deposits  were  found  at  the  apex  of  the  left 
lung.  The  heart  walls  were  a  little  softened.  The  liver  was 
intensely  cirrhotic,  and  a  small  whitish  tumor  was  em- 
bedded in  the  upper  surface  of  its  left  lobe.  The  spleen 
was  soft  and  about  twice  the  norma)  size.  Both  kidneys 
were  fatty. 

The  tumor  of  the  pons  was  examined  microscopically  by 
Drs.  J.  H,  C.  Simes  and  H.  Formad,  who  concluded  that  it 
was  a  gumma. 

Both  eyeballs  and  the  optic  nerves  were  carefully  removed 
and  placed  in  the  hands  of  Dr.  E.  O.  Shakespeare,  who 
furnished  me  with  the  following  report  upon  the  micro- 
scopical examination  of  the  optic  nerves: 

"  After  proper  hardening,  thin  sections  of  the  anterior 
third  of  the  optic  nerve,  including  its  entrance  into  the  eye, 
were  made  so  that  the  sections  were  longitudinal  to  the 
course  of  the  nerve.  In  one  of  the  eyes  the  optic  disc  was 
slightly  more  prominent  than  normal.  The  walls,  both  of 
the  arteries  and  veins,  of  the  optic  papilla  were  somewhat 
sclerosed.  Their  lining  endothelium  was  slightly  irritated. 
The  connective  tissue  between  the  nerve  bundles  of  the 
papilla  was  in  a  state  of  considerable  cellular  hyperplasia. 
Their  corresponding  capillary  blood-vessels  were  apparently 
more  numerous  than  usual,  while  their  walls  were  sur- 
rounded by  numerous  leucocytes.  As  the  position  of  the 
lamina  cribrosa  was  approached,  the  cellular  hyperplasia  was 
found  to  increase,  and  large  numbers  of  nuclei  were  present 
upon  the  fibres  of  the  lamina  cribrosa  itself.  This  cellular 
multiplication  extended  far  back  of  the  nerve  entrance  into 
the  eyeball.  The  subvaginal  and  subdural  spaces  of  the 
sheath  of  the  optic  nerve  were   considerably  enlarged,  and 


474  CHARLES  K.  MILLS. 

in  the  anterior  portion,  adjacent  to  the  eyeball,  the  walls  and 
the  enclosed  fibrous  trabeculae  were  in  a  state  of  inflamma- 
tory irritation.  The  nerve  from  the  other  eye  was  in 
practically  the  same  condition.  From  the  examination,  it 
would  appear  that  there  was  present  a  descending  neuritis 
of  subacute  character." 

Remarks. — The  peculiar  ocular  symptoms  present  in  this 
case  were  doubtless  due  to  the  tumor  of  the  pons  Varolii. 
Conjugate  deviation  of  the  eyes,  with  rotation  of  the  head, 
is  a  condition  often  present  in  the  early  stages  of  apoplectic 
attacks.  The  patient  is  found  with  both  eyes  turned  to  one 
side  and  slightly  upward,  as  if  looking  over  one  or  the  other 
shoulder,  the  head  and  neck  being  usually  rotated  in  the 
same  direction.  Sometimes  the  deviation  is  slight,  some- 
times it  is  marked.  Frequently  the  muscles  of  the  neck  on 
one  side  are  rigid.  The  eyes  are  commonly  motionless,  but 
occasionally  exhibit  oscillations.  This  sign,  well  known  to 
neurologists,  usually  disappears  in  a  few  hours  or  days, 
although  it  occasionally  persists  for  a  long  time. 

Vulpian  was  probably  the  first  to  study  thoroughly  con- 
jugate deviation.  The  sign,  when  associated  with  disease 
of  the  pons,  was  supposed  by  him  and  by  others  to  be 
connected  in  some  way  with  the  rotatory  manifestations 
exhibited  by  animals  after  certain  injuries  to  the  pons. 
Transverse  section  across  the  longitudinal  fibres  of  the 
anterior  portions  of  the  pons  produces,  according  to  Schiff, 
deviation  of  the  anterior  limbs  (as  in  section  of  a  cerebral 
peduncle),  with  extreme  flexion  of  the  body  in  a  horizontal 
plane  toward  the  opposite  side,  and  very  imperfect  move- 
ments of  the  posterior  limbs  on  the  other  side.  Rotation 
in  a  very  small  circle  develops  in  consequence  of  this 
paralysis  (Rosenthal's  "  Diseases  of  the  Nervous  System," 
vol.  i,  p.  125).  The  movements  of  partial  rotation  are 
caused,  according  to  Schiff,  by  a  partial  lesion  of  the  most 


TUMOR  OF  THE  PONS  VAROLII.  475 

posterior  of  the  transverse  fibres  of  the  pons,  which  is  fol- 
lowed in  animals  by  rotation  of  the  cervical  vertebrae  (with 
the  lateral  part  of  the  head  directed  downward,  the  snout 
directed  obliquely  upward  and  to  the  side). 

This  lateral  deviation,  both  of  head  and  eyes,  occurs, 
however,  not  only  from  lesions  of  the  pons  and  cerebellar 
peduncles,  but  also  from  disease  or  injury  of  various  parts 
of  the  cerebrum — of  the  cortex,  centrum  ovale,  ganglia,  cap- 
sules, and  cerebral  peduncles.  It  is  always  a  matter  of 
interest,  and  sometimes  of  importance,  with  reference 
especially  to  prognosis,  to  determine  what  is  the  probable 
seat  of  lesion  as  indicated  by  the  deviation  and  rotation. 

Lockhart  Clarke,  Prevost,  Brown-Sequard,  and  Bastian, 
among  others,  have  devoted  considerable  attention  to  this 
subject.  To  Prevost  we  owe  an  interesting  memoir.  Bas- 
tian, in  his  work  on  ''  Paralysis  from  Brain  Disease,"  sum- 
marizes the  subject  up  to  the  date  of  publication  (1875). 
Ferrier,  Priestly  Smith,  and  Hughlings  Jackson  have  inves- 
tigated the  relations  which  cortical  lesions  bear  to  the 
deviation  of  the  eyes  and  head. 

It  has  been  pointed  out  by  several  of  the  observers  al- 
luded to  that  when  the  lesion  is  of  the  cerebrum  the  devia- 
tion is  usually  toward  the  side  of  the  brain  affected,  and 
therefore  away  from  the  side  of  the  body  which  is  para- 
lyzed. In  a  case  of  ordinary  left  hemiplegia,  it  is  toward 
the  right ;  in  one  of  right  hemiplegia,  toward  the  left.  In 
several  cases  of  limited  disease  of  the  pons,  however,  it  has 
been  observed  that  the  deviation  has  been  away  from  the 
side  of  the  lesion.  In  the  case  here  recorded,  the  conjugate 
deviation  was  to  the  right,  while  the  tumor  was  entirely  to 
the  left  of  the  median  line,  thus  carrying  out  what  appears 
to  be  the  usual  rule  with  reference  to  lesions  of  the  pons. 

During  the  life  of  the  patient,  it  was  a  question  whether 
the  case  was  not   one  of  oculomotor  monoplegia  or  mono- 


47^  CHARLES  K.  MILLS. 

spasm  from  lesion  of  cortical  centres.  I  believe,  with 
Hughlings  Jackson,  that  ocular,  and,  indeed,  all  other  move- 
ments, are  in  some  way  represented  in  the  cerebral  convo- 
lutions. In  the  British  Medical  jfournal  for  June  2,  1877, 
Jackson  discusses  the  subject  of  disorders  of  ocular  move- 
ments from  disease  of  nerve  centres.  The  right  corpus  stri- 
atum is  damaged,  left  hemiplegia  results,  and  the  eyes  and 
head  often  turn  to  the  right  for  some  hours  or  days.  The 
healthy  nervous  arrangement  for  this  lateral  movement  has 
been  likened  by  Foville  to  the  arrangement  of  reins  for 
driving  two  horses.  What  occurs  in  lateral  deviation  is 
analogous  to  dropping  one  rein  ;  the  other  pulls  the  heads 
of  both  horses  to  one  side.  The  lateral  deviation  shows, 
according  to  Jackson,  that  after  the  nerve  fibres  of  the 
ocular  nerve-trunks  have  entered  the  central  nervous  system, 
they  are  probably  redistributed  into  several  centres.  The 
nerve  fibres  of  the  ocular  muscles  are  rearranged  in  each 
cerebral  hemisphere  in  complete  ways  for  particular  move- 
ments of  both  eyeballs.  There  is  no  such  thing  as  paralysis 
of  the  muscles  supplied  by  the  third  nerve  or  sixth  nerve 
from  disease  above  the  crus  cerebri,  but  the  movement 
for  turning  the  two  eyes  is  represented  still  higher  than 
the  corpus  striatum. 

Ferrier  found  that  irritation  of  a  certain  limited  area  of 
the  surface  of  the  brain  of  the  monkey,  corresponding  to  a 
region  in  the  brain  of  man  at  the  base  of  the  first  frontal, 
and  extending  partly  into  the  second  frontal,  convolution, 
caused  elevation  of  the  eyelids,  dilatation  of  the  pupils, 
conjugate  deviation  of  the  eyes,  and  turning  of  the  head  to 
the  opposite  side. 

Priestly  Smith  {pphthabnological  Hospital  Reports,  vol. 
ix,  p.  428)  concludes  that  the  chief  coordinations  in  the 
brain  of  ocular  movements  are  of  four  kinds:  i.  Move- 
ments of  both   eyes  to   the  right.      2.   Movements  of  both 


TUMOR  OF  THE  PONS   VAROLII.  477 

eyes  to  the  left.  3.  Movements  of  both  eyes  downward 
and  inward,  narrowing  of  the  pupils,  and  contraction  of  the 
ciliary  muscles,  producing  increased  convergence  and  ac- 
commodation. 4.  Movements  of  both  eyes  upward  and 
outward,  producing  diminished  convergence,  and  accom- 
panied by,  though  not  actively  producing,  widening  of  the 
pupils  and  relaxation  of  accommodation.  These  several 
forms  of  compound  movements  are  produced  by  the  action 
of  distinct  brain  centres,  and  disease  may  destroy  or  irritate 
one  or  other  of  the  four,  and  leave  the  others  intact. 

A  few  cases  are  on  record  in  which  conjugate  deviation  of 
the  eyes  alone  has  occurred,  constituting,  according  to  Fer- 
rier,  what  may  be  regarded  either  as  unilateral  oculomotor 
monoplegia  or  monospasm.  Five  such  cases,  or,  rather, 
supposed  cases,  for  an  autopsy  was  held  in  only  one  in- 
stance, have  been  collected  by  Ferrier  ("  The  Localization 
of  Cerebral  Disease,"  New  York,  G.  P.  Putnam's  Sons, 
1879).  Three  of  these  were  reported  by  Priestly  Smith, 
whom  I  have  just  quoted.  In  the  first  case,  after  an  attack 
of  pain  in  the  head,  giddiness,  and  vomiting,  the  eyes  be- 
came persistently  turned  to  the  right,  with  complete  in- 
ability to  turn  them  to  the  left.  The  right  side  of  the 
forehead  was  marked  with  wrinkles;  the  left  eyelids  were 
more  open  than  the  right ;  there  was  frequent  winking  of 
the  eyelids,  and  synchronous  but  imperfect  action  of  the 
left.  Gradually  the  right  eye  recovered  its  mobility  to  the 
left,  while  the  outward  motion  of  the  left  eye  still  continued 
very  imperfect,  and  caused  double  vision.  Three  months 
after  the  first  appearance  of  the  symptoms  the  patient  be- 
came affected  with  left  hemiplegia.  A  fortnight  later  the 
right  side  became  paretic.  In  a  second  case,  the  symptoms 
noticeable  were  deviation  of  the  eyes  to  the  right,  facial 
paralysis  on  the  left,  and  some  paralysis  in  the  left  limbs. 
In  a  third  case,  severe  pain  in  the  right  side  of  the  head 


4/8  CHARLES  K.  MILLS. 

and  face  had  been  followed  by  "  squinting  of  both  eyes  to 
the  right."  When  first  seen,  twelve  months  after  the  at- 
tack, the  left  external  rectus  appeared  to  be  paralyzed.  It 
is  suggested,  however,  that  as  both  eyes  had  at  first  been 
turned  to  the  right,  the  eye  symptoms  are  explicable,  as  in 
the  two  preceding  cases,  by  the  recovery  of  the  right  eye, 
while  the  outward  movement  of  the  left  remains  para- 
lyzed. 

Dr.  Carroll,  of  Staten  Island,  furnished  Dr.  Ferrier  with 
the  particulars  of  another  case.  A  child,  aged  five  months, 
fell  six  feet,  and  was  stunned  for  a  few  minutes.  No 
paralysis  occurred,  but  conjugate  deviation  of  the  eyes  and 
rotation  of  the  head  to  the  right,  with,  at  first,  dilatation  of 
the  pupils,  were  noticed,  A  linear  fracture  was  detected  in 
the  right  parietal  bone,  about  midway  between  the  squa- 
mous and  sagittal  sutures,  and  intersecting  a  vertical  line 
drawn  upward  from  the  auditory  meatus.  Pressure  at  the 
seat  of  injury  caused  a  distinct  increase  of  the  deviation. 
Ferrier  supposed  the  symptoms  to  be  accounted  for  by 
unantagonized  action  of  the  left  centre,  from  hemorrhagic 
lesion  of  the  right. 

Chouppe,  quoted  by  Landouzy,  relates  the  case  of  a  lad, 
aged  19,  who  showed  symptoms  of  tubercular  meningitis, 
in  which,  in  addition  to  pain,  vomiting,  etc.,  the  most  re- 
markable symptom  was  a  rotation  of  the  head  and  eyes  to 
the  right.  After  death  a  patch  of  disease,  free  from  granu- 
lation, and  quite  superficial,  of  the  size  of  a  franc  piece,  was 
found  in  the  "  superior  part  of  the  middle  frontal  convolu- 
tion" of  the  left  hemisphere.  Ferrier  thinks  that  the  seat 
of  the  lesion  probably  corresponded  with  the  oculomotor 
centre  in  the  brain  of  the  monkey. 

I  have  taken  the  liberty  to  quote  a  condensed  account  of 
these  cases  in  order  to  fully  bring  forward  the  subject,  the 
literature  of  which  is  as  yet  scanty.     A  similarity  will  be 


TUMOR  OF  THE  PONS  VAROLII.  4/9 

observed  between  the  symptoms  presented  by  my  case  and 
those  exhibited  by  some  of  the  cases  collected  by  Ferrier. 
In  the  first  case,  reported  by  Priestly  Smith,  the  symptoms 
are  strikingly  similar  to  those  shown  by  my  patient — con- 
jugate deviation  of  the  eyes  to  the  right,  with  complete 
inability  to  turn  them  to  the  left ;  more  marked  wrinkling 
of  the  right  side  of  the  forehead  than  of  the  left ;  hemi- 
plegic  or  hemiparetic  symptoms  first  of  one  side  and  then 
of  the  other.  In  the  absence  of  an  autopsy  on  the  case  of 
Priestly  Smith,  and  in  the  light  of  the  post-mortem  examina- 
tion here  reported,  it  may,  indeed,  be  considered  doubtful 
whether  his  patient  suffered  from  a  cortical  lesion. 

It  does  not  seem  probable  that  the  fissured  skull,  and  the 
small  meningeal  tumor  in  connection  with  it,  had  any  thing 
to  do  with  the  production  of  the  ocular  symptoms.  The 
lesion  was  comparatively  remote  from  the  oculomotor  cen- 
tres of  Ferrier,  at  the  bases  of  the  first  and  second  frontal 
convolutions.  It  is  true  that  efforts  have  been  made  to 
localize  a  centre  for  the  levator  palpebrae  superioris  muscle 
in  the  angular  gyrus,  and  if  such  could  be  made  out  to  exist 
in  this  region,  it  is  probable  that  centres  for  other  ocular 
movements  would  be  in  proximity.  The  weight  of  evi- 
dence, both  physiological  and  pathological,  is,  however, 
against  this  localization.  The  meningeal  tumor  was,  in 
addition,  very  small,  and  was  a  little  too  far  forward  for  the 
angular  gyrus  proper.  Both  the  ocular  and  other  phe- 
nomena of  the  case  are,  I  think,  well  accounted  for  by  the 
pontine  lesion. 

Cases  like  that  reported  in  the  present  paper  are  far  from 
discouraging  with  reference  to  the  local  diagnosis  of  brain 
lesions.  They  serve  simply  to  give  additional  zest  to  close 
investigation.  I  conclude,  from  a  study  of  this  case,  that 
tumors  limited  to  one-half  of  the  upper  portion  of  the  body 
of  the  pons  will  cause  conjugate  deviation  of  the  eyes  and 


480  CHARLES  K.  MILLS. 

rotation  of  the  head  away  from  the  side  of  the  lesion.  It 
is  quite  likely  that  if  the  lesion  is  sufficiently  limited  the 
ocular  deviation  may  stand  alone.  In  the  vast  majority  of 
cases,  however,  owing  to  the  narrow  limits  of  the  pons  and 
its  position  with  reference  to  connecting  tracts  both  from 
the  cerebrum  and  cerebellum,  other  symptoms  will  be 
present.  In  this  last  fact  we  have  the  clue  to  the  differ- 
ential diagnosis  of  the  pontine  lesions  from  disease  of  the 
oculomotor  centres  of  the  convolutions. 

The  paralysis  or  spasm  of  face  or  limbs,  that  may  be 
associated  with  the  ocular  symptoms,  is  more  likely  in  cases 
of  cortical  disease  to  be  unilateral  than  in  lesions  of  the 
pons.  The  oculomotor  centres  of  the  cortex  are  near  to 
the  crural,  brachial,  and  facial  centres,  and  these  may  be  in- 
volved in  the  same  lesion,  or  may  become  involved  by  ex- 
tension, and  thus  arise  paralytic  or  spasmodic  symptoms 
in  face  or  limbs,  or  both,  on  the  opposite  side  of  the  body. 
Both  sides  of  the  body  would  present  symptoms  only  after 
extension  of  the  lesion  to  both  hemispheres,  which  is  not 
likely  to  occur.  Even  when  a  lesion  is  strictly  limited  to 
one-half  of  the  pons,  the  nuclei  and  tracts  for  both  sides 
are  so  close  together  that  in  the  case  of  tumors  and  hemor- 
rhages the  uninjured  side  will  be  more  or  less  involved  by 
pressure.  In  the  patient  whose  history  I  have  just  given, 
the  paresis  was  first  noticed  upon  the  right  side,  but  both 
sides  showed  signs  of  paralysis  before  his  death.  Disturb- 
ances of  sensation  are  more  likely  to  be  present  in  pontine 
lesions  than  in  cases  of  cortical  oculomotor  disease.  Such 
sensory  disorders,  according  to  Ladame,  are  to  be  found  in 
about  one-third  of  the  cases  of  tumor  of  the  pons.  Accord, 
ing  to  Rosenthal,  with  whom  I  entirely  agree,  careful  ex- 
amination will  show  them  to  be  even  more  frequent.  Sup- 
posing the  bases  of  the  first  and  second  frontal  convolutions 
to  cover  the  true  oculomotor  centres,  these  are  compara- 


TUMOR  OF  THE  PONS  VAROLII.  481 

tively  remote  from  the  sensory  zone,  which  is  in  the 
parieto-temporal  and  occipital  regions.  Some  changes  of 
sensibility  were  present  in  the  case  here  recorded.  Con- 
traction of  the  pupils,  varying  in  degree  for  the  two  eyes, 
pointed  also  to  disease  of  the  pons.  Depressed  farado- 
contractility  and  peculiarities  of  temperature  would  have 
helped  to  confirm  the  diagnosis  of  tumors  of  the  pons,  but 
these,  by  an  unfortunate  omission,  in  the  present  instance 
were  not  studied. 


CASES     OF     POLIOMYELITIS     ANTERIOR     IN 

WHICH  THE   ABDOMINAL    MUSCLES 

WERE  AFFECTED.* 

By  W.  R.  BIRDSALL,  M.D., 

ASSISTANT   PHYSICIAN   TO   THE   MANHATTAN   HOSPITAL.    NEW   YORK. 

HAVING  had  within  a  year  two  cases  of  infantile 
spinal  paralysis  (poliomyelitis  anterior)  in  which 
the  abdominal  muscles  of  one  side  were  involved,  a  condi- 
tion I  had  not  observed  before,  I  determined  to  report  them, 
together  with  a  review  of  the  similar  cases  to  be  found  on 
record  in  the  literature  of  the  disease,  in  its  infantile  and 
adult  forms,  at  my  command.  While  in  the  great  majority 
of  cases  of  this  disease  the  paralysis  is  limited  to  one  or 
more  of  the  extremities,  still,  cases  have  been  observed, 
either  in  the  infant  or  adult,  in  which  were  affected  the 
facial,  ocular,  and  laryngeal  muscles,  the  muscles  of  degluti- 
tion, and  those  of  the  neck,  the  thoracic  muscles  of  respira- 
tion, and  those  of  the  back,  as  well  as  the  voluntary  mus- 
cles of  the  rectum  and  the  bladder  ;  some  of  them  very  rare- 
ly, but  others  quite  frequently.  Involvement  of  the  abdomi- 
nal muscles,  however,  is  one  of  the  rarest  events  of  this 
disease. 

In  reviewing  the  literature  of  this  subject,  out  of  125 
references  to  articles  by  120  authors  which  I  have  collected, 
I  was  able  to  consult  100,  which  contain  reports  of  over  600 


*  Read  before  the  New  York  Neurological  Society,  March  i,  i88l. 

482 


CASES  OF  POLIOMYELITIS  ANTERIOR.  A^l 

cases  of  infantile,  and  over  50  of  the  adult  form.  Out  of 
this  number  I  found  but  2  cases  in  which  involvement  of 
the  abdominal  muscles  was  reported  in  the  former,  and  not 
more  than  7  in  the  latter  group.  In  addition  to  this  an 
analysis  of  50  cases  of  the  infantile  form,  from  the  record 
of  the  Department  for  Nervous  Diseases  at  Manhattan  Eye 
and  Ear  Hospital,  a  portion  of  them  having  been  under  my 
own  care,  the  majority,  however,  under  Dr.  E.  C.  Seguin's, 
include  the  two  cases  of  my  own  which  I  now  report.  Over 
50  cases  of  the  infantile  form,  recorded  at  Dr.  E.  C.  Seguin's 
clinic  for  nervous  diseases  at  the  College  of  Physicians  and 
Surgeons,  fail  to  exhibit  any  additional  cases  of  this 
character.  Dr.  Gibney  informs  me  that  he  has  never  seen 
such  a  case  at  the  Hospital  for  the  Relief  of  the  Ruptured 
and  Crippled,  although  they  have  had  over  one  thousand 
cases  of  paralysis  in  children,  the  majority  belonging  to  the 
variety  in  question.  My  friend,  Dr.  E.  C.  Seguin,  had  ob- 
served but  one  such  case  in  the  infant,  which  is  one  of  two 
cases  on  record.  It  is  to  be  found  in  Dr.  Newton  M.  Shaf- 
fer's monograph  on  Pott's  disease.  Dr.  Shaffer  has  seen  but 
one  other  case,  to  which  he  has  kindly  permitted  me  to  re- 
fer, although  many  hundred  cases  of  infantile  spinal  paraly- 
sis  have  been  under  his  observation  at  the  New  York 
Orthopaedic  Hospital.  Out  of  this  large  number  of  cases 
of  infantile  myelitis  of  the  anterior  horns  (from  1,500  to 
2,000  cases)  I  have  found  but  five  cases  in  which  the  ab- 
dominal muscles  were  affected,  making  it  an  extremely  rare 
condition.  It  may  be  borne  in  mind,  however,  that  in  many 
it  may  have  been  overlooked,  or,  if  observed,  perhaps  not 
recorded. 

It  is  frequent  to  find  reference  to  cases  in  which,  during 
the  first  days  of  the  disease,  the  child  appeared  to  have 
lost  all  voluntary  power,  but  this  condition  soon  passes  oflf, 
and  it  is  indeed  difificult  to  say  whether  it  be  due  to  a  true 


484  «^.  ^.  BIRDS  ALL. 

paralysis  or  to  general  asthenia.  It  is  rare  to  find  any  ref- 
erence to  the  abdominal  muscles  even  in  general  works  on 
the  subject.  Heine  speaks  of  general  distention  of  the  ab- 
domen due  to  spinal  deformity,  but  not  of  paralysis  of  the 
abdominal  muscles.  Leyden  is  one  of  the  few  who  mentions 
the  subject.  He  states  that  "the  muscles  of  the  trunk, 
notably  those  of  the  back,  and  also  those  of  the  abdomen, 
may  be  involved  ; "  he  cites  no  cases  however. 

Case.  i. — Duchenne  (fils).  Atrophic  paralysis  of  the  trunk; 
right,  and  of  both  inferior  extremities. 

In  the  beginning  of  1862,  M.  Bouvier  reported  to  M.  le  Dr. 
Duchenne  (de  Boulogne)  an  infant  of  ten  months,  who,  at  four 
months,  was  attacked  with  generalized  atrophic  paralysis  after  a 
fever  of  48  hours'  duration.  Movements  were  preserved  in  the 
superior  extremities  only.  In  the  lower  extremities  the  majority 
of  the  muscles  gave  no  sign  of  existence,  neither  by  electrical  ex- 
ploration nor  by  voluntary  efforts.  On  the  right  side  a  great  many 
of  the  muscles  of  the  trunk  and  of  the  abdomen  were  atrophied. 
This  produced  a  considerable  lateral  inclination  of  the  spine  with 
a  right  dorsal  convexity  ;  the  abdominal  walls  being  thinned  on 
this  side  electrical  excitation  failed  to  produce  muscular  contrac- 
tion, and  the  abdominal  viscera  presented  the  appearance  of  a 
hernia,  the  abdomen  being  depressed  on  the  left  side  only,  during 
the  cries  of  the  infant,  while  on  the  right,  the  intestines  presented 
in  relief,  the  hernia  being  considerably  augmented.  The  child 
was  not  seen  again.  (Translated  from  Arch,  general,  vol.,  2,  p.  45^ 
1864.) 

Case  2. — I  am  indebted  to  Drs.  Seguin  and  Schaffer  for  this 
case.  I  quote  from  Dr.  Schaffer's  monograph  on  Pott's  disease  : 
"  The  patient  was  six  years  old,  and  was  placed  under  my  care  by 
Drs.  W.  H.  Draper  and  E.  C.  Seguin.  The  original  lesion  was  a 
poliomyelitis.  Dr.  Seguin  furnished  me  with  a  memorandum  of 
the  muscles  primarily  affected.  Those  partially  paralyzed  (which 
recovered  wholly  under  Dr.  Seguin's  treatment)  were  the  muscles 
of  the  neck,  arm,  and  thigh  (left  side).  Those  wholly  paralyzed, 
and  which  did  not  recover,  were  the  left  serratus  magnus,  the  left 
transversalis,  and  obliquus  externus  and  the  supra-  and  infra- 
spinati  of  the  same  side.  The  vertebral  column  presented  an  in- 
flexible dorsal  curvature  toward  the  paralyzed  side  with  the  usual 


CASES  OF  POLIOMYELITJS  ANTERIOR.  4^5 

compensatory  (?)  curve  in  the  lumbar  region.  The  patient  walks 
well  and  has  no  loss  of  power  in  the  superior  members.  There 
was  marked  contraction  of  the  unparalyzed  antagonists  of  the 
opposite  (right)  side." 

Case  3. — Referred  to  by  Dr.  Schaffer's  permission,  being  a  case 
he  has  already  presented  at  a  clinical  lecture.  E.  H.  G.,  a  female, 
was  affected  with  paralysis  of  the  lower  extremities,  and  of  the 
back  and  abdomen  of  one  side.  (Photographs  showing  the  extent 
of  the  atrophy  were  exhibited.) 

Now  follow  my  own  cases  : 

Case  4. — Male,  aet.  3.  In  July,  1879,  at  the  age  of  20  months, 
had  a  severe  attack  of  measles.  A  month  later  his  mother  ob- 
served, one  morning,  after  he  had  passed  a  restless  night,  that  he 
could  not  walk  ;  she  took  him  in  her  arms,  when  he  became  un- 
conscious, in  which  state  he  remained  from  9  a.m.  until  5  p.m. 
The  following  day  (Sunday)  he  had  slight  epileptiform  attacks, 
the  eyes  turning  to  one  side,  the  hands  being  firmly  clinched.  On 
Monday  he  was  still  unable  to  walk,  nor  could  he  talk,  although 
before  the  attack  he  could  say  "  papa,"  "mamma,"  and  a  few 
other  words.  His  mother  noticed  that  the  abdomen  was  distended, 
and  after  a  few  days  that  the  left  side  was  more  distended  than 
the  right,  and  that  both  legs  were  paralyzed,  the  right  being  more 
completely  so  than  the  left.  He  could  not  sit  upright.  The  arms 
were  not  affected,  nor  the  muscles  of  the  head,  neck,  or  thorax. 
There  was  no  bladder  trouble,  but  constipation  was  marked  for 
several  days  ;  speech  did  not  return,  though  he  appeared  as  intel- 
ligent as  ever.  There  was  no  affection  of  sensation,  either  general 
or  special.  The  lower  extremities  began  to  show  signs  of  wasting 
very  early.  On  Aug.  30,  1879,  he  was  referred  to  me  for  electrical 
treatment,  at  Manhattan  Hospital,  from  Dr.  E.  C.  Seguin's  clinic 
at  the  College  of  Physicians  and  Surgeons.  He  was  unable  to  sit 
or  walk.  There  was  absence  of  voluntary  movements  in  both 
lower  extremities  ;  the  tissues  were  cold  and  flabby,  the  right 
more  than  the  left ;  the  reflexes  were  absent  ;  sensibility  pre- 
served. The  abdomen  was  distended  to  a  marked  degree  on  the 
left  side,  a  decided  bulging  appearing  over  the  muscular  portion 
of  the  transversalis  as  large  as  one's  fist.  The  muscles  of  the 
back  on  the  corresponding  side  appeared  softer  and  weaker  than 
on  the  opposite  side.  The  remaining  muscles  of  the  body  were 
unaffected.     The  electrical  examination  revealed  the  presence  of 


486  W.  R.  BIRDSALL. 

the  "  degeneration  reaction  "  in  the  lower  extremities  ;  namely, 
absence  of  farado-muscular  contractility  on  muscle  and  nerve, 
absence  of  galvano-muscular  contractility  on  the  nerve,  but  ex- 
altation of  the  same  on  the  muscles,  with  qualitative  changes  con- 
sisting of  a  reversal  of  the  formula  of  contraction,  the  anodal 
closing  contraction  being  greater  than  the  kathodal  closing  con- 
traction (An.  C.OKa.  C.C.),  the  contractions  being  slower  than 
in  a  healthy  muscle.  This  difference  was  most  marked  on  the 
right  side,  and  particularly  in  the  anterior  tibial  group  of  muscles. 
The  reactions  of  the  individual  muscles,  and  the  variations  from 
time  to  lime  as  they  appear  on  the  records,  are  omitted. 

It  is  next  to  an  impossibility  to  test  accurately,  with  electricity, 
the  abdominal  muscles  of  a  crying  child.  I  never  succeeded  in 
making  a  satisfactory  examination  of  them  in  this  case.  There 
was  no  reaction  to  the  faradic  current  on  the  affected  side  in  the 
transversalis  and  oblique  muscles  ;  it  was  present,  but  diminished 
in  the  rectus  ;  with  galvanism,  however,  the  results  were  too 
uncertain  to  determine  whether  the  degeneration  reaction  was 
present  or  not.  After  a  few  days  the  abdomen,  which  was  dis- 
tended by  gaseous  accumulations,  diminished  in  size  ;  and  when 
the  child  was  lying  upon  his  back  nothing  abnormal  was  observed; 
but  during  the  execution  of  other  movements,  which  required  the 
use  of  the  abdominal  muscles,  the  whole  left  side  of  the  abdomen 
became  more  prominent,  and  even  the  rectus  failed  to  contract  as 
powerfully  as  on  the  healthy  side.  He  was  treated  by  an  ascend- 
ing spinal  galvanic  current — the  "movable  stabile"  method  of  Erb 
— and  by  local  applications  of  the  interrupted  galvanic  current, 
sufficiently  strong  to  produce  contractions.  In  consequence  of 
the  paretic  muscles  of  the  abdomen  being  put  upon  the  stretch 
by  the  accumulation  of  gases,  and  by  violent  respiratory  move- 
ments, the  protrusion  became  more  and  more  marked  as  the  mus- 
cular atrophic  changes  continued.  It  became  necessary,  therefore, 
to  devise  some  support  to  prevent  this.  A  corslet  or  band,  knit 
of  cotton,  and  which  would  yield  to  a  slight  degree  only,  was  made 
by  the  mother,  and  answered  an  excellent  purpose,  as  it  allowed  a 
certain  freedom  of  movement  to  the  muscles,  but  not  sufficient  to 
produce  stretching  to  an  unnatural  degree.  This,  I  believe,  to  be 
an  important  point,  too  frequently  forgotten  in  the  treatment  by 
supporting  apparatus  of  deformities  from  paralysis.  Absolute  rest 
from  the  immobilization  of  a  part  can  only  tend  to  hasten  atrophic 
changes,  while  movements  within  certain  limits,  besides  inducing 
improvement  in  the  general  nutrition  of  the  part,  permits  that  ex- 


CASES  OF  POLIOMYELITIS  ANTERIOR.  487 

ercise  of  functions  so  necessary  to  the  continued  repair  and  growth 
of  muscular  tissue  in  the  muscles  antagonistic  to  those  paralyzed, 
and  also  in  those  muscular  fibres  which  have  not  lost  their  func- 
tion entirely  through  degeneration  changes  in  the  fibres  them- 
selves or  from  interruption  of  their  neural  connections.  I 
objected,  therefore,  to  the  use  of  plaster  of  Paris  and  other  un- 
yielding corslets  which  had  been  recommended,  and  continued  to 
use  the  knit  band  with  satisfactory  results.  The  condition,  which 
was  growing  worse  before  treatment,  improved  quite  rapidly  under 
the  use  of  the  bandage  and  galvanism. 

Oct.  7th. — There  is  reaction  to  the  faradic  current  in  the  mus- 
cles of  the  left  inferior  extremity,  even  in  the  anterior  tibial 
group,  but  none  on  the  right  side.  There  is  considerable  volun- 
tary power  on  the  left  but  none  on  the  right  side. 

Oct.  15th. — Is  able  to  sit  up  alone. 

Nov,  i2th. — He  walks  for  the  first  time.  Some  voluntary 
movement  has  returned  in  all  the  muscles,  except  the  right  an- 
terior tibial  group. 

On  two  occasions  treatment  was  discontinued  for  a  week  or  two, 
and  each  time  he  became  worse  ;  he  recovered,  however,  when 
treatment  was  resumed. 

Jan.  8,  1 88 1. — Slight  voluntary  movements  are  to  be  seen  in  the 
toes  of  the  right  foot. 

In  his  present  condition  the  left  lower  extremity  appears  well 
developed  and  of  normal  temperature  and  color  ;  there  is  a  slight 
tendency  to  talipes  (valgus),  which  is  being  antagonized  by  an 
elastic  support  from  the  inner  side  of  the  foot  to  the  knee.  The 
circumference  of  the  right  leg  is  20  cm.,  of  the  left  leg,  22  cm., 
of  the  right  thigh,  29  cm.,  of  the  left  thigh,  29  cm.  The  right  ex- 
tremity is  cold  and  somewhat  flabby.  The  muscles  of  the  an- 
terior group  are  the  only  ones  which  do  not  exhibit  more  or  less 
voluntary  power.  Tendon  reflexes  absent.  The  paretic  abdomi- 
nal muscles  have  become  stronger,  but  the  bulging  over  the  trans- 
versalis  muscle  is  still  present  when  he  cries,  though  very  much 
diminished  from  its  previous  condition.  The  muscles  of  the  back 
in  the  lumbar  region  are  not  as  firm  as  upon  the  healthy  side. 
There  is  a  slight  tendency  to  lordosis,  and  a  slight  rotation  ;  no 
scoliosis.  The  hemi-circumference  around  the  abdomen  on  the 
paretic  side  measures  3  cm.  more  than  on  the  normal  side.  The 
electrical  examination  reveals  upon  the  left  side,  to  faradism, 
moderate  reaction  in  all  muscles  ;  to  galvanism,  Ka.  C.  C.  slightly 
>   An.  C.  C.  in  muscles   of  the  thigh.     In  muscles    of   the  leg, 


488  W.  R.  BIRDS  ALL. 

Ka.  C.  C.  =  An.  C.  C.  Upon  the  right  side,  to  faradism,  no  re- 
action except  with  a  powerful  current  on  the  thigh  muscles  ;  to 
galvanism,  Ka.  C.  C.  =  An.  C.  C.  In  anterior  and  posterior 
tibial  groups  An.  C.  C.  >  Ka.  C.  C.  In  abdominal  muscles  of 
paretic  (left)  side,  to  faradism.  diminished  reaction  in  rectus,  still 
greater  diminution  in  oblique  muscles,  and  in  transversalis  proba- 
bly absent;  to  galvanism,  Ka.  C.  C.  >  An.  C.  C.  in  rectus,  in 
other  muscles,  doubtful  respecting  the  formula  of  contraction. 

Case  5. — Male,  zet.  4.  July  7,  1880,  he  fell  from  a  third-story 
window  (54  feet),  striking  on  a  two-wheeled  hand-cart,  which 
tipped,  lessening  the  force  of  the  fall,  and  throwing  him  to  the 
ground.  He  was  not  unconscious,  but  called  at  once  "  Mama." 
Bruises  were  found  on  the  legs  only  ;  no  fractures  or  dislocations. 
He  was  feverish  and  two  weak  to  walk,  but  was  bright  and  talka- 
tive. In  a  week  he  could  sit  up.  At  the  beginning  of  the  third 
week  after  the  accident  he  had  a  fever  and  was  restless  at  night  ; 
the  next  morning  the  fever  had  disappeared,  but  he  could  not  sit 
up,  and  was  unable  to  move  the  right  leg.  He  was  referred  to  me 
by  Dr.  Richard  Wiener,  Aug.  6th.  Examination  revealed  an  ab- 
sence of  voluntary  power  in  the  right  lower  extremity  in  both 
thigh  and  leg  muscles  ;  no  abnormality  of  sensation  ;  absence  of 
the  tendon  reflex.  The  left  leg  was  normal,  and  at  this  time  no 
involvement  of  other  muscles  was  observed.  There  was  no  blad- 
der trouble.  Electrical  examination  showed  the  "  degeneration 
reaction  "  in  all  muscles  of  the  right  thigh  and  leg.  Normal  reac- 
tion to  faradism  and  galvanism  in  opposite  side  and  in  the  upper 
extremities.  After  two  weeks'  treatment,  as  in  the  preceding  case, 
he  was  able  to  sit  alone  ;  about  this  time  distension  of  the  left 
side  of  the  abdomen  was  first  observed,  which  increased  until  it 
was  almost  the  counterpart  of  the  first  case.  The  muscles  of  the 
back  in  the  lumbar  regions  were  not  as  strong  as  on  the  opposite 
side.  The  same  form  of  support  and  treatment  was  ordered,  and 
after  two  or  three  weeks  improvement  began.  A  few  fasciculi  of 
the  right  internal  oblique  just  above  Poupart's  ligament  became 
weak,  giving  rise  to  a  slight  protrusion.  The  electrical  reactions 
in  the  abdominal  muscles  were  as  follows  :  to  faradism,  diminished 
in  the  left  rectus  as  compared  with  the  right  ;  slight  reaction  in 
oblique  muscles,  but  none  in  transversalis.  To  galvanism,  left 
side,  in  rectus,  Ka.  C.  C.  >  An.  C.  C.  —  24  cells  ;  in  oblique 
and  transversalis.  An.  C.  C.  >  or  =  Ka.  C.  C.  Right  side,  nor- 
mal reaction.  Very  little  improvement  has  taken  place  in  the 
paralyzed  extremity. 


CASES  OF  POLIOMYELITIS  ANTERIOR.  489 

Jan.  15,  1881. — He  commenced  to  move  the  toes,  but  voluntary- 
power  has  not  returned  in  the  other  muscles.  The  nutrition  of 
the  feet  has  improved.  The  measurements  are  :  Right  calf,  18 
cm.  ;  left,  20  cm.  ;  right  thigh,  21  cm.  ;  left,  27  cm.  An  obliquity 
of  the  pelvis  and  a  slight  compensatory  scoliosis  is  observed 
when  standing,  but  in  the  prone  position  the  spinal  column  pre- 
sents no  lateral  curvature.  At  times  there  is  slight  rotation.  Vol- 
untary power  has  returned  in  the  oblique  muscles  and  rectus  to  a 
considerable  degree. 

The  fact  that  in  both  these  cases  the  abdominal  protru- 
sion was  at  first  scarcely  noticeable,  but  gradually  increased, 
is  probably  due  to  the  fact  that  when  degeneration  took 
place  in  the  muscles,  the  remaining  tissues,  deprived  of  this 
important  means  of  support,  became  stretched  by  the  ab- 
dominal viscera  in  violent  respiratory  movements.  There 
is  reason  to  hope,  after  the  improvement  which  has  taken 
place  and  is  still  going  on,  that  great  deformity,  consequent 
upon  the  inequality  of  muscular  power  on  the  two  sides  of 
the  spinal  column,  will  be  avoided.  In  the  second  case  the 
condition  of  the  right  lower  extremity  rendered  the  prog- 
nosis far  from  hopeful. 

Of  cases  of  poliomyelitis  anterior  adultorum  in  which  the 
abdominal  muscles  were  affected,  I  found  several  cases  re- 
ported, to  which  I  shall  refer  very  briefly. 

Gumming  reports  a  case  {Dublin  Quart.  Jour.,  1869,  vol. 
i,  p.  471)  in  which  he  states  that  all  voluntary  motion  was 
absent  below  the  neck,  except  slight  movement  of  the  right 
shoulder;  this  was  during  the  first  days  of  the  disease  ;  no 
direct  mention  of  the  abdominal  muscles  is  made ;  it  is, 
therefore,  uncertain  whether  this  case  should  be  included  or 
not. 

Goldammer  reports  a  case  in  a  male,  ?et.  32  {Berlin  Klin. 
Wochen.,  No.  25,  1866),  in  which  the  muscles  of  the  extremi- 
ties, back,  and  abdomen,  were  paretic,  but  it  is  doubtful 
whether  atrophy  followed  and  the  electro-muscular  contrac- 


490  fV.  Ji.  BIRDSALL. 

tility  was  preserved,  making  the  diagnosis  of  the  case 
doubtful. 

Lanceraux  made  an  autopsy  upon  a  young  man  who 
was  first  affected  with  poliomyelitis  at  the  age  of  i6. 
No  reference  is  made  to  the  presence  of  paralysis  of  the 
abdominal  muscles  in  the  history,  but  atrophic  changes  were 
found  in  the  abdominal  muscles  of  the  right  side  as  well  as 
in  those  of  the  left  superior  and  right  inferior  extremities. 
This  case  is  cited  by  Petit,  fils  (1873). 

In  one  of  Charcot's  cases  (No.  10  of  Seguin's  collection, 
in  his  "  Myelitis  of  the  Ant.  Horns ")  there  remained 
atrophy  of  the  left  nates,  leg,  and  foot,  of  the  anterior 
part  of  the  right  thigh,  and  of  the  left  lower  abdominal 
muscles,  in  which  electro-muscular  contractility  was  lost. 

Dr.  F.  T.  Miles  reported  a  case  of  acute  spinal  paralysis 
before  the  American  Neurological  Society  in  1S75,  in  which 
the  abdominal  muscles  were  involved. 

Dr.  Bull  reports  {London  Lancet,  1880,  voi.  1,  p.  563)  a  case 
of  acute  spinal  paralysis  in  an  adult  in  which,  at  first,  there 
was  complete  loss  of  voluntary  motion  in  upper  and  lower 
limbs,  back,  neck,  and  abdomen. 

Kahler  and  Pick  report  {Vierteljahrs  &  pract.  H.  K., 
Prag,  1879,)  ^  case  of  subacute  poliomyelitis  in  an  adult  in 
which  the  "  degeneration  reaction "  was  present  in  the 
abdominal  muscles  of  one  side. 

These  are  the  only  cases  which  I  have  been  able  to  find, 
and  some  of  them  are  doubtful. 

Adamkiewicz  reported  two  cases  in  the  CJiarite  Annalen, 
Berlin,  1879 — ^"^  ^^  poliomyelitis  and  one  of  lead  paraly- 
sis. In  the  latter  the  abdominal  muscles  were  involved  and 
furnished  the  "degeneration  reaction,"  while  in  the  former 
this  was  not  the  case.  He  makes  a  plea  for  the  identity  of 
the  two  affections  from  a  pathologico-anatomical  standpoint, 
a  view  maintained,  and  with  good  reason,  by  many  eminent 
authorities. 


HOW  TO  USE  THE  BROMIDES* 

By  GEORGE  M.  BEARD,  A.M.,  M.D., 

MEMBER  OF  THE   AMERICAN   NEUROLOGICAL   ASSOCIATION,    ETC. 

THE  bromides  are  among  the  few  great  and  sure 
remedies  that  medicine  has  at  its  command.  They 
take  rank  with  opium,  quinine,  and  electricity,  as  forces 
that  we  can,  in  a  good  degree,  depend  upon  to  obtain  posi- 
tive results  ;  and  the  introduction  of  them  into  medicine 
has  made  an  era  in  the  treatment  of  diseases  of  the  nervous 
system. 

Without  the  bromides  we  should  be — in  the  treatment  of 
functional  nervous  diseases — as  much  disarmed  as  one  would 
be  in  the  treatment  of  malaria  without  quinine.  To  a  very 
considerable  extent  the  bromides  have  taken  the  place  of 
opium,  which  was  formerly  borne  much  better  than  now. 
Very  many  nervous  patients,  indeed,  are  so  sensitive  to 
opium — being  kept  awake  instead  of  being  put  to  sleep 
by  it — that,  without  the  bromides,  we  should  be,  in  many 
cases,  almost  helpless  ;  particularly  where  immediate  seda- 
tive effects  are  required. 

It  is  because  the  bromides  are  remedies  of  such  enormous 
efficiency  and  of  such  certainty  in  their  action  that  they 
have  been  over-used,  just  as  the  other  great  remedies, 
opium,  quinine,  iron,  and  calomel,  have  been  over-used  ; 
and  hence  there  has  been  reaction  against  their  use  ;  a  dis- 

*  Read  before  the  American  Neurological  Association,  June,  1881. 

491 


492  GEORGE  M.  BEARD. 

position  to  reproach  them  as  enemies,  rather  than  praise 
them  as  friends  of  the  nervous. 

The  suggestions  that  I  am  here  to  give  in  regard  to  the 
use  of  the  bromides  may  be  put  in  these  propositions. 
These  propositions  apply  especially  to  other  functional 
nervous  diseases  than  epilepsy,  since  the  use  of  the  bromides 
in  epilepsy  and  epileptoidal  states  has  been  more  studied 
and  is  more  generally  understood.  It  is  not  generally 
known  that  the  bromides  are  of  far  greater  value  in 
many  other  nervous  diseases  than  in  epilepsy. 

First,  The  object  of  using  the  bromides  is  usually  to 
produce  a  definite  effect  of  brotnization  in  a  greater  or  less 
degree. 

Bromization  is  an  abnormal  state  ;  is,  in  a  certain  sense, 
disease  artificially  produced ;  but  it  is  one  of  the  canons  of 
therapeutics  that  we  can  cure  disease  by  disease  ;  one 
set  of  symptoms  being  used  as  scourges  to  drive  out  an- 
other set  of  symptoms. 

Bromization  is  a  condition  of  degrees,  ranging  from  very 
mild  sleepiness  or  general  sedation  to  profound  stupor 
and  unconsciousness,  insanity  through  the  bromic  breath, 
bromic  acne,  profound  muscular  debility,  difificulty  of 
articulation,  and  lowering  of  all  the  functions.  Drowsi- 
ness in  the  daytime  is  not  always  the  first  symptom  of 
bromization,  although  it  usually  is.  In  some  cases  aching 
of  the  limbs,  perfectly  simulating  a  common  cold,  is  first 
noticed.  Debility  sometimes  precedes  drowsiness.  All 
these,  and  the  severer  symptoms,  may  persist  for  several 
days  after  ceasing  to  take  the  drug ;  therefore  passengers 
wishing  to  avoid  sea-sickness,  and  who  go  on  board  of 
the  steamer  well  bromized,  may  not  need  to  take  any 
more  of  the  medicine  during  the  entire  voyage  to  Europe, 
unless  the  weather  should  be  rough. 

In  [therapeutics   the  severest  effects  of   bromization,  or 


HOW  TO   USE   THE  BROMIDES.  493 

bordering  on  the  severest  (for  the  very  severest  mean  death 
— since  we  can  kill  one  with  the  bromides,  just  as  surely  as 
we  can  with  the  pistol,  if  we  but  give  them  freely  enough  and 
long  enough — ),  are  never  needed  ;  the  medium  effects  may 
be  required  in  certain  diseases — as  in  epilepsy — for  certain 
emergencies  or  crises,  in  hysteria  or  neurasthenia,  and  also 
as  preventives  or  curatives  in  sea-sickness  ;  but  the  mild 
and  incipient  symptoms  are  all  we  need  to  the  majority  of 
cases  where  the  bromides  are  to  be  given. 

It  is  possible,  it  is  even  probable,  that  good  effects  come 
from  the  bromides  without  any  real  symptoms  of  positive 
bromization ;  but,  usually,  little  demonstrable  good  comes 
from  their  use  unless  bromization  is  produced  ;  for  sleep,  by 
night  or  day,  is  itself  in  a  mild  phase,  one  of  the  symptoms 
of  bromization. 

Last  year  a  druggist  in  Liverpool  told  me  that  he  was 
putting  up  bromide  of  sodium  in  doses  of  ten  grains  for 
those  who  were  going  to  sea  and  who  supposed  that  they 
were  taking  the  treatment  recommended  in  my  work  on  sea- 
sickness. Those  who  take  the  bromides  in  that  way  will  be 
likely  to  fail  in  their  attempt  to  cure  or  prevent  sea- 
sickness, and  they  will  also  fail  in  the  treatment  of  very 
many  other  nervous  diseases. 

Secondly.  To  rapidly  induce  bromization  it  is  usually  an 
advantage — if  not  absolutely  necessary — to  give  immense 
doses  ;  all  the  way  from  thirty  to  one  hundred  grains,  more 
or  less. 

Placing  aside  idiosyncrasies — for  some  persons  are  un- 
duly susceptible  to  the  bromides,  as  some  are  unduly  sus- 
ceptible to  opium  or  quinine — placing  aside  these  idiosyn- 
crasies, it  is  not  of  much  use  to  give  bromides,  for  any  pur- 
pose whatsoever,  in  doses  of  less  than  twenty  or  thirty 
grains ;  it  is  better  to  give — except  in  initial  doses,  where 
we  wish  to  test  the  temperament  of  the  patient — as  much 


494  GEORGE  M.  BEARD. 

as  half  a  drachm,  if  not  more.  I  rarely  prescribe  so  small  a 
dose  as  twenty  grains,  and  often  prescribe  as  high  as  a 
drachm,  or  more.  It  seems  to  be  pretty  clear  that  it  is 
possible  to  give  the  bromides  in  small  doses,  say  fifteen  or 
twenty  grains,  two  or  three  times  a  day,  for  a  long  period, 
without  getting  any  effect,  good  or  bad  ;  whereas,  if  the 
same  patients  take  the  same  remedy  in  doses  of  thirty  or 
sixty  grains,  for  a  few  days  only,  they  become  more  or 
less  bromized,  and  with  all  the  good  effects  that  bromiza- 
tion  can  produce. 

In  epilepsy,  the  necessity  of  giving  doses  of  considerable 
size  is  recognized  more  and  more;  but  it  is  not  generally 
allowed,  even  by  neurologists,  that  in  neurasthenia  or  hys- 
teria doses  of  even  greater  size  are  admissible,  proper,  and 
necessary,  if  we  would  get  the  results  we  seek. 

In  many  cases  a  single  large  dose  of  bromide,  say  one 
hundred  or  one  hundred  and  twenty  grains,  or  even  a  larger 
amount,  given  in  a  tumbler  of  water,  may  be  sufficient 
of  itself,  without  any  repetition,  in  any  quantity,  to 
break  up  an  attack  of  hysteria  or  sick  headache  or  sea- 
sickness ;  whereas,  the  same  case  in  the  same  condition, 
treated  by  divided  doses  of  the  same  remedy,  might  not  be 
affected  at  all. 

It  sometimes  seems  to  be  necessary  to  overwhelm  the 
nervous  system  with  the  sedative  effects  of  the  bromide, 
in  order  to  get  bromization. 

The  book  doses  are  poor  guides  for  those  who  wish  to  get 
the  therapeutic  effect  of  the  bromides. 

Thirdly.  The  bromides  should  be  given  in  these  im- 
mense doses  for  a  short  time  only,  save  in  epilepsy  and 
epileptoidal  conditions.  The  evil  effects  of  the  bromides, 
of  which  we  hear  so  much,  do  not  appear,  as  a  rule,  except 
when  the  dose  is  very  large,  from  taking  them  a  short 
time,  say  a  few  days  or  a  week,  more  or  less,  but   from 


HOW  TO   USE   THE  BROMIDES.  49S 

keeping  them  up  weeks  or  months,  without  any  inter- 
mission, or  without  the  counteracting  effects  of  tonics,  or 
without  the  close  and  careful  study  of  the  idiosyncrasy, 
which  is  so  important  in  the  use  of  this,  as  well  as  in  the 
use  of  all  other  powerful  remedies. 

Indeed,  it  is  not  safe  or  wise  to  give  these  large  doses  of 
bromide  to  any  patient  with  whose  constitution  we  are  not 
familiar,  without  keeping  him  under  our  eye,  and  watching 
the  effects  closely.  The  bromides  are  powerful  remedies, 
and  they  may  be  dangerous  as  well  as  powerful,  but  if  we 
use  them  wisely,  we  can  obtain  and  utilize  their  full  power 
without  the  danger. 

In  some  cases  bromization  appears  very  rapidly  indeed  ; 
in  less  than  twenty-four  hours  after  beginning  treatment 
with  these  large  doses.  Sometimes  a  single  large  dose  of 
one  hundred  grains  or  more  is  enough  without  any  more 
(small  quantity  or  large)  to  bromize  a  person.  Other  per- 
sons may  take  these  large  doses  for  three  or  four  days,  or 
even  longer,  without  getting  any  easily  demonstrable  effects 
of  bromization  ;  they  do  not  feel  especially  sleepy  by  day 
— which  is  one  of  the  important  symptoms — and  the  fauces 
have  not  lost  their  sensitiveness  enough  to  prevent  gagging, 
when  irritated  by  the  finger;  and  there  is  no  special  weak- 
ness ;  but  if  these  same  cases  go  on,  perhaps  for  a  day  or 
two  more,  bromization  may  spring  upon  them  in  full  force, 
without  any  warning,  all,  or  many  of  the  symptoms  at  once  ; 
and  this  is  one  of  the  risks  we  run  in  using  the  bromides. 

A  case  very  remarkable  indeed,  illustrative  of  this,  has 
come  under  my  notice  lately.  A  lady,  who  had  taken 
bromides  as  preventives  of  sea-sickness,  felt  no  influence 
from  the  remedy,  except  that  she  was  not  sea-sick,  as  she 
had  always  been  in  her  previous  trips  across  the  ocean. 
She  took  her  meals  as  usual,  and  kept  on  with  the  large 
doses,  which  was  both   unnecessary  and   unwise,  under  the 


49^  GEORGE  M.  BEARD. 

circumstances,  as  there  was  no  severe  storm.  After  three 
or  four  days,  however,  she  became  very  sleepy,  and  for 
three  days  slept  almost  continuously.  When  rallied,  she 
was  dull  and  stupid  ;  her  friends  got  her  out  on  deck,  but 
she  could  not  continue  her  conversation,  and  preferred  to 
go  below,  where  she  could  sleep.  She  took  no  more  of  the 
bromide,  but  the  effects  remained,  even  after  she  landed 
and  went  to  London,  but  gradually  she  returned  to  her 
normal  condition.  All  this  could  have  been  avoided,  should 
have  been  avoided,  and  would  have  been  avoided,  if  the 
directions  which  I  have  given  for  the  use  of  the  bromides 
in  sea-sickness  had  been  carried  out. 

In  the  party  to  which  this  lady  belonged  there  were  two 
others  who  took  the  bromides  as  she  did,  for  a  few  days, 
but  they  stopped  before  she  did  ;  a  few  doses  absolutely  pre- 
vented sea-sickness,  although  in  all  previous  voyages  one  of 
them  had  suffered  severely  from  dock  to  dock ;  and  on  land- 
ing they  thought  only  of  their  voyage  as  a  very  delightful 
experience. 

EARLY    BROMIZATION. 

This  late  appearing  of  the  effect  of  the  bromides,  it  is  im- 
portant to  recognize,  and  for  want  of  recognition  of  this, 
many  fail  of  obtaining  sleep  by  the  use  of  this  remedy. 
They  order  a  dose  of  perhaps  fifteen  or  twenty  grains,  or 
possibly  even  larger,  to  be  taken  at  night,  and  wonder  that 
they  get  no  sleep  therefrom.  There  are  some  who  are 
bromized  so  quickly  as  to  get  benefit  from  taking  it 
this  way;  but,  as  a  law,  it  is  far  better,  if  we  are  to  give  but 
one  dose,  to  give  it  earlier  in  the  day ;  better  still  to  give 
two  doses,  one  in  the  morning,  and  the  other  at  night. 
Failures  beyond  number  in  the  use  of  the  bromides  would 
be  prevented  if  this  last  fact  were  known.  No  one  who 
knows  how  to  use  the  bromides  will  question  their  hypnotic 
power. 


HOJV  TO  USE  THE  BROMIDES.  497 

LATE    BROMIZATION. 

On  the  other  hand,  very  interesting  indeed  are  the  in- 
stances where  bromization  is  rapidly  produced.  In  my  own 
office  a  lady  to  whom  I  gave  a  large  dose  of  bromide  of 
potassium  (lOO  grains)  was  bromized  in  less  than  twenty 
minutes,  and  in  half  an  hour  was  unconscious,  almost 
moribund  ;  the  feet  and  hands  were  cold,  the  pulse  thready 
and  rapid,  and  for  two  hours  it  was,  or  seemed  to  be,  a 
fight  for  life,  as  though  she  were  battling  with  the  effects 
of  some  terrible  poison,  and  for  several  days  she  was  con- 
fined to  her  bed  ;  but  even  in  this  case  there  were  ho  per- 
manently bad  results. 

When  I  was  studying  the  Maine  Jumpers, ^  last  year,  I 
tried  the  experiment  of  thoroughly  bromizing  one  of  the 
subjects,  in  order  to  see  if  it  would  have  any  effect  over  the 
phenomena.  I  poured  the  drug  down  him  in  large  and  re- 
peated doses,  in  order  to  get  him  rapidly  under  its  influence. 
I  knew  that  I  was  dealing  with  a  strong,  healthy  man,  one 
who  probably  would  not  be  susceptible  to  large  doses,  and 
I  did  not  know  how  much  I  gave  him,  but  this  I  do  know, 
that  I  would  never  give  the  same  quantity  to  anyone  again, 
under  any  circumstances.  He  went  rapidly  under  its  influ- 
ence, had  difficulties  both  of  speech  and  walking,  was 
obliged  to  go  to  bed,  and  was  kept  in  bed  for  a  number  of 
days,  and  at  one  time  was  thought  by  those  who  took  care 
of  him  to  be  dying,  or  in  danger  of  dying.  He  recovered, 
however,  and  was  not  at  all  benefited,  as  far  as  the  jumping 
was  concerned,  either  temporarily  or  permanently ;  a  very 
interesting  confirmation  of  the  conclusion  I  then  reached, 
that  the  phenomena  of  jumping  were  psychological  (tran- 
coidal)  rather  than  physiological. 

In   another   case   where    the    bromides    were   taken    for 

'  Popular  SciiTue  Monthly,  Dec,  1 880. 


49^  GEORGE  M.  BEARD. 

sea-sickness,  temporary  helplessness  and  blindness  were 
produced.  Dr.  Reed,  a  young  physician,  of  Hartford, 
Conn.,  is  reported  to  have  jumped  overboard  during  an 
attack  of  insanity,  which  was  apparently  induced  by  tak- 
ing eleven  ounces  of  bromide  of  sodium.  It  is  quite 
probable  that  this  report  is  correct;  I  have  seen  many 
of  the  physical  symptoms  of  general  paresis  produced  by 
bromization.  There  is  no  question  that  cases  of  bromiz- 
ation  are,  now  and  then,  mistaken  for  cases  of  insanity. 
It  is  both  interesting  and  consoling  to  know  that  the 
recovery  even  from  these  severe  symptoms  of  bromization 
is  complete  and  satisfactory.  Knowing  this  fact,  I  have 
in  extreme  cases  of  opium-eating  bromized  the  patient 
profoundly  for  a  few  days. 

It  is  almost  inevitable  that  we  ask  how  it  is  that  the 
bromides  produce  such  remarkable  sedative  effects  on 
the  nervous  system.  Attention  was  first  directed  to  the 
bromides — as  every  one  knows — by  their  action  on  the  re- 
productive system  ;  but  a  wider  study  and  fuller  experience 
in  their  use  show  us  that  they  have  the  same  action  on 
the  entire  nervous  system — from  head  to  foot,  on  the  gen- 
eral and  special  functions, — the  brain  is  bromized,  the  spine 
is  bromized,  and  all  the  nerves  that  proceed  from  them  are 
bromized  ;  there  is  no  evidence  of  any  selective  or  partial 
action  of  these  remedies  on  any  organ,  or  any  limited  area 
of  the  body ;  the  molecular  movements  that  are  correlated 
to  the  evolution  and  transmission  of  nerve  force  are  lowered 
by  this  drug.  Just  as  magnets  have  their  magnetic  power 
reduced  by  heat,  just  as  metals  when  heated  also  become 
poorer  conductors  of  electricity,  just  so  the  nerves  when 
bromized  become  poorer  transmitters  of  nerve  force,  and  of 
any  other  irritation  from  outside.  This  I  take  to  be  the 
philosophy  of  the  fact  that  the  bromides  are  the  most 
popular  remedies  in  the  entire  pharmacopoeia,  in  all  nervous 


HOW  TO  USE  THE  BROMIDES.  499 

diseases  among  nervous  Americans — the  class  of  all  others 
who  most  need  to  have  their  nervous  activity  lowered  in- 
stead of  increased.  This  I  take  to  be  the  philosophy  of  the 
fact  that  bromization  is  to  sea-sickness  what  vaccination  is 
to  small-pox;  preventing  it  almost  absolutely,  when  it  is 
thoroughly  done  and  properly  repeated.  The  study  of  sea- 
sickness, I  may  add,  has  been  of  great  service  in  the  study 
of  bromization  and  its  antidotes ;  but  as  long  ago  as  the 
first  edition  of  my  work  on  "  Sea-sickness,"  I  spoke  in 
detail  of  these  unpleasant  effects  of  bromization. 

Fourthly.  The  bromides,  if  used  long  or  frequently  on  any 
patient,  should  be  used  in  alternation  or  combination  with 
tonics  of  some  kind.  In  epilepsy  this  has  been  understood 
for  some  time,  but  it  has  not  been  understood  that  in  the 
functional  nerve  diseases  the  same  principle  applies.  Last 
year,  in  our  discussion  of  this  subject,  it  was  denied  that 
benefit  could  come  from  combining  bromides  and  tonics. 
This  injunction  I  regard  as  of  very  great  importance. 
My  own  custom  is  to  give  bromides  one  week,  and  tonics 
the  next,  or  to  give  the  tonics  during  the  day  and  bromides 
at  night.  Sometimes  I  include  a  tonic,  as  nux  vomica, 
in  the  bromide  prescription,  and  also  ingluvin  and  arsenic 
in  very  small  doses  to  act  on  the  stomach.  Bromization 
can  be  held,  when  once  started,  on  land  or  sea,  by  simply 
one  dose  at  night  or  every  other  night ;  meanwhile,  before 
meals,  tonics — as  strychnine  or  quinine — can  be  given.  I  am 
fully  persuaded  we  should  not  hear  so  much  of  the  evil 
effects  of  bromides  if  these  customs  were  pursued  among 
physicians.  There  is  no  inconsistency  in  using  a  sedative 
and  a  tonic  at  the  same  time ;  and  Dr.  Gray,  in  his  paper 
on  this  subject  last  year,  was,  so  far  as  I  understood  him,, 
right  and  verifiable  all  through.  My  claim  is,  then,  on  this 
point,  of  a  two-fold  character :  first,  that  we  get  better  thera- 
peutic   effects  by  combining  or  alternating  bromides  and 


5C)0  GEORGE  M.  BEARD. 

tonics ;  and,  secondly,  that  we  avoid  the  evil  effects,  that 
are  almost  sure  to  come,  by  following  this  plan.  Even  in 
epilepsy  I  adopt  this  plan  with  satisfaction.  The  bromides, 
used  in  the  method  I  have  described,  make  it  possible 
to  give  the  nervous  system  a  vacation,  which,  perhaps,  it 
may  not  have  had  before  for  years ;  a  rest  far  superior  to 
the  rest  in  bed,  even  with  all  the  adjuncts  of  electricity 
and  massage  ;  but  if  this  vacation  be  continued,  unbroken 
by  tonics,  the  efTect  is  the  same  as  in  keeping  the  muscles 
long  disused ;  there  is  a  long  debility  from  which  it  may  be 
hard  to  recover  ;  and  thus  may  come  those  effects  which 
are  constant  advertisements  of  the  evil  effects  of  doctor- 
ing. 

One  of  the  best  remedies  to  use  against  bromization — 
that  is,  to  cut  it  short  when  it  is  going  on  to  unpleasant 
symptoms — is  powdered  citrate  of  caffeine,  in  doses  of 
three  to  five  grains.  I  provide  those  who  go  to  sea  with 
this,  to  be  used  in  case  of  bromization  that  may  have  been 
carried  too  far.  This  is  not,  I  believe,  generally  known. 
In  the  hands  of  a  physician  strychnine  is  one  of  the  best 
antidotes  to  bromization  ;  but  quinine  is  safer  for  the  pa- 
tient's home  use.  Dr.  McBride  tells  me  that  he  has  used 
strychnine  hypodermically  for  this  purpose  with  satisfac- 
tion. 

Fifthly.  It  is  an  advantage  to  use  a  number  of  the  bro- 
mides in  combination. 

The  following  bromides  are  those  which  are  most  famil- 
iar, and  which  I  use  in  combination  : 

Bromide  of  potassium,  which  contains  68  per  cent,  of 
bromine. 

Bromide  of  calcium,  which  contains  80  per  cent,  of 
bromine. 

Bromide  of  sodium,  which  contains  80  per  cent,  of 
bromine. 


HO  IV  TO  USE  THE  BROMIDES.  50^ 

Bromide  of  ammonium,  which  contains  8i  per  cent,  of 
bromine. 

Bromide  of  lithium,  which  contains  92  per  cent,  of 
bromine. 

To  these  may  be  added  bromide  of  manganese,  which 
contains  75  per  cent,  of  bromine.  I  had  some  bromide  of 
manganese  manufactured  for  me  by  Messrs.  Caswell, 
Hazard  &  Co.,  of  this  city,  and  used  it  for  a  time.  I 
suggested  its  use  on  the  theory  suggested  by  Prof.  Haines, 
of  Chicago,  that  manganese  might  be  somewhat  of  a  tonic ; 
whereas,  the  calcium  and  sodium  and  potassium  and 
ammonium  and  lithium  have  a  somewhat  debilitating  effect, 
when  used  in  excess.  I  find,  however,  two  objections  to 
bromide  of  manganese  :  first,  it  causes  a  headache,  even  in 
quite  small  doses  of  a  few  grains.  Secondly,  its  taste  is 
somewhat  bitter,  so  that,  when  added  to  a  bromide  com- 
bination, it  gives  a  bitter  taste  to  the  whole,  which  is  more 
or  less  unpleasant.  I  have  not  been  able  to  satisfy  myself, 
therefore,  that  it  has,  practically,  any  advantage  over  the 
other  bromides  of  the  class  to  which  it  belongs.  All  the 
other  bromides  I  use  in  combination,  and,  as  it  seems  to 
me,  with  advantage  ;  that  is,  we  seem  to  get  better  effects 
in  some  cases  from  this  combination  than  from  any  one 
used  alone.  I  admit  that  it  is  very  difficult  to  prove  this; 
I  cannot  prove  it  to  any  one  who  denies  it  or  doubts  it. 
But  I  form  this  judgment  from  observation  of  many 
persons  who  have  used  one  of  the  bromides  alone,  and 
have  not  obtained  the  effects  which  they  have  from  very 
much  the  same  dose  of  this  combination. 

It  will  be  observed  that  the  bromide  of  potassium  con- 
tains a  smaller  quantity  of  bromine  than  any  other  of  the 
bromides  ;  and  this  is  the  one  that  is  most  used  ;  whereas, 
the  bromide  of  sodium  contains  80  percent.,  ammonium  81, 
while  lithium  has  the  largest  proportion  of  all,  92  per  cent. 


502  GEORGE  M.  BEARD. 

For  sensitive,  delicate  stomachs,  and  for  sea-sickness, 
generally,  bromide  of  sodium  has  these  advantages,  namely: 
that  it  is  easier  on  the  stomach,  less  irritating,  and  its 
taste  is  less  disagreeable  than  the  other  bromides,  and  cer- 
tainly less  disagreeable  than  the  bromide  of  potassium. 

I  always  give  these  bromides  largely  diluted  with  water, 
one  or  two  tumblers  full,  if  the  patient  will  take  them. 
This  dilution  has  a  double  advantage  ;  first,  it  prevents  the 
local  irritating  effect  of  the  salt  on  the  stomach  ;  and, 
secondly,  it  helps  to  flush  the  system  with  water,  a  very 
desirable  thing  in  v-ery  many  of  our  nervous  patients,  who 
have,  as  one  of  the  symptoms  of  their  nervousness,  thirst- 
lessness,  or  lack  of  desire  for  fluids,  and  difficulty  in  re- 
ceiving and  assimilating  them.  For  these  same  reasons,  I 
like  to  give  all,  or  many,  of  my  remedies  freely  diluted. 

In  regard  to  the  other  bromides, — bromide  of  camphor, 
bromohydric  acid,  bromide  of  quinine,  bromide  of  zinc,  and 
bromide  of  iron, — I  may  say  that  I  use  all  of  them,  more 
or  less,  and  like  them  all.  In  treating  persons  who  have 
been  injured  by  the  ordinary  bromides,  or  who  think 
they  have,  or  who  have  taken  them  too  long,  or  who 
are  in  danger  of  taking  them  too  long,  I  find  it  an  advan- 
tage— not  only  in  epilepsy,  but  in  epileptoidal  states 
and  neurasthenic  states — to  make  a  change  in  the  form  of 
bromide  used,  to  substitute  the  bromide  of  zinc,  a  favorite 
remedy  with  me,  either  alone  or  in  combination  with 
other  zincs,  or  with  nux  vomica,  or  the  bromide  of  cam- 
phor, or  bromohydric  acid,  in  some  cases,  in  pretty  large 
doses.  I  have  not  made  much  use  of  the  bromide  of 
quinine,  or  the  bromide  of  iron,  for  the  reason  given  above, 
namely,  that  I  use  tonics  in  connection  with  the  bromides, 
and  so  do  not  need  these  preparations.  So  far  as  I  can 
see,  large  doses  of  many  of  the  chief  bromides  will  prevent 
unpleasant  action  of  quinine  on  the  head,  nearly  as  well 


NOW  TO   USE  THE  BROMIDES.  $03 

as  the  bromohydric  acid,  of  which  so  much  has  been  written. 
If,  for  example,  a  patient  takes  a  large  dose — say  60 
grains — at  night,  or  every  other  night,  and  takes  quinine 
during  the  day,  he  will  not  be  near  as  likely  to  have  the 
unpleasant  head  symptoms  of  quinine,  as  he  would  be, 
were  the  bromide  not  taken.  I  have  seen  some  cases 
where  the  bromide  of  camphor,  in  small  doses,  had  a  very 
delightful  action,  and  have  seen  many  others  where  large 
doses  could  be  taken  without  getting  very  much  effect. 

Sixthly.  Some  nervous  patients  who  are  not  epileptic  or 
even  epileptoidal  yet  need  to  use  the  bromides  frequently 
if  not  regularly,  for  a  time,  just  as  though  they  had 
epilepsy. 

The  bromides  are  to  be  used  in  such  cases  subject  to  the 
precautions  above  given. 

There  is  such  a  thing  as  the  habit  of  taking  bromides. 

The  bromides  are  not  narcotics,  and  there  is  not,  usually, 
any  great  danger  of  acquiring  the  habit  of  taking  them,  as 
the  habit  of  taking  alcohol  or  opium  is  acquired.  They, 
however,  who  get  pleasant  effects  from  them  may  take 
them  too  frequently,  or  too  much  of  them,  as  they  take  too 
much  of  quinine,  or  may  take  them  when  it  is  not  neces- 
sary, when  they  could  just  as  well  do  without  them.  But 
the  effect  in  these  cases  is  not  like  that  of  chloral,  or 
opium,  or  alcohol.  There  does  not  appear  to  be,  in  any 
cases  that  I  have  seen,  that  craving  for  the  remedy,  and 
certainly  not  an  irresistible  craving.  It  cannot  be,  how- 
ever, too  often  repeated,  or  too  widely  known,  that  the  bro- 
mides are  sedatives  rather  than  tonics,  and  that,  over-used, 
they  tend  to  depress  rather  than  to  strengthen  ;  and  that 
nervous  persons,  whatever  special  variety  the  nervousness 
may  assume,  who  depend  habitually  upon  taking  the  bro- 
mides, will  be  in  time  injured  thereby,  and  will  be  likely  to 
reach  a  point  where  they  may  be  seriously  harmed.     The 


504  GEORGE  M.  BEARD. 

great  secret  of  taking  the  bromides,  just  as  in  taking  other 
remedies  of  power,  is  to  know  just  when  to  stop  taking  them. 
And  there  is  no  arithmetical  rule  to  guide  us.  Each  case  is 
its  own  study.  I  am,  however,  convinced  that  there  are 
quite  a  number  of  persons  who  are  not  exactly  epileptic, 
and  who  do  not  have  even  epileptoid  or  epileptiform  symp- 
toms, but  who  may  be  said  to  be  half  way  between  neuras- 
thenia and  epilepsy,  who  need  to  be  treated  persistently,  at 
intervals  at  least,  with  bromides,  very  much  as  epileptics 
must  be  treated,  and  with  whom  it  will  not  answer  to  let 
up  permanently,  or  for  a  very  long  time.  The  tonics,  how- 
ever, should  be  used  in  alternation  or  combination.  In  all 
such  cases  the  effort  must  be  to  wean  the  patient  from  the 
bromides  as  soon  as  possible.  This  can  be  done  not  only 
by  the  use  of  tonics,  but  by  the  use  of  other  sedatives,  as 
hyoscyamus,  hyoscyamia,  Scutellaria,  conium  electricity,  and 
warm  baths. 

Considerable  has  been  said,  here  and  there,  of  the  relation 
of  the  bromides  to  hyperaemias  and  anaemias.  It  has  been 
said  that  they  are  good,  when  there  is  an  excess  of  blood 
in  the  nerve  centres,  and  bad,  when  there  is  a  deficiency  in 
the  nerve  centres.  My  own  views  in  regard  to  this  whole 
subject  of  congestions  and  anaemias  of  the  brain  and  ner- 
vous system  have  been  expressed  so  often,  in  my  writings 
on  neurasthenia'  and  elsewhere,  that  there  is  no  occasion  to 
repeat  them  here.  It  is  sufficient  to  say  that  I  look  upon 
the  nervous  system  as  the  primary  factor  in  the  philosophy 
of  functional  nervous  diseases,  of  which  neurasthenia  is  a 
type,  and  that  disturbances  in  circulation  are  secondary. 
In  other  words,  innervation  precedes  circulation,  and  attacks 
of  local  passive  congestion  in  all  parts  of  the  body  are  fre- 
quent results. 

I  have  no  doubt  that  these  attacks  of  passive  congestion 


*  Neurasthenia  (Nervous  Exhaustion) :    Its  nature,  symptonis,  and  treatment. 
American  Nervousness  :  Its  causes  and  consequences. 


NOPV  TO  USE   THE  BROMIDES.  505 

may  take  place  even  in  persons  who  are  very  anaemic  gen- 
erally, and  in  whose  bodies  there  is  too  little  blood,  or  the 
blood  is  unevenly  distributed  ;  too  much  in  the  nerve 
centres  and  two  little  in  the  limbs.  The  bromides,  by  their 
action  on  the  nerves,  relieve  these  passive  congestions ; 
and  this  is  one  factor  in  explaining  their  action. 

Hence  is  explained  the  fact,  that  even  in  general  anaemia 
the  bromides  may  be  used,  for  a  short  time  at  least,  with 
all  the  good  effects  that  are  obtained  in  hyperaemia. 

One  practical  inference  from  the  above  analysis  is  clear, 
namely,  that  the  bromides  are  not  to  be  tossed  off  care- 
lessly as  a  prescription  to  be  taken  any  time,  and  for  any 
time,  and  by  any  body  ;  but  are  to  be  watched  over  at  the 
outset  of  their  use  especially  ;  and  the  physician  should,  if 
possible,  have  his  hand  on  the  helm  all  through  the  voyage. 
In  all  cases  where  it  is  practicable,  I  insist  on  seeing  my 
patients  or  hearing  from  them  when  they  take  bromides. 


A  CASE  OF  ACUTE  CHOREA. 

By  FRANCIS  P.  KINNICUTT, 

PHYSICIAN   TO    ST.    LUKE's   HOSPITAL.    NEW   YORK. 

THE  following  case,  which  has  recently  been  under  my 
care,  in  my  service  at  St.  Luke's  Hospital,  pre- 
sents sufficiently  interesting  features  to  be  worthy  of 
record. 

Herman  Lutz,  set.  14,  was  admitted  to  the  hospital  on  May  21st. 
Family  history  excellent.  The  patient  has  never  had  rheuma- 
tism ;  has  enjoyed  exceptionally  good  health  during  his  life  until 
six  weeks  ago,  when  he  had  a  well-marked  attack  of  intermittent 
fever,  of  the  quotidian  type.  The  paroxysms  only  finally  ceased 
toward  the  end  of  the  third  week  from  the  beginning  of  his  ill- 
ness. With  their  cessation  the  patient  first  noticed  slight  invol- 
untary movements  of  his  right  foot  ;  gradually  his  right  hand, 
the  upper  and  lower  extremities  of  the  left  side,  became  similarly 
affected.  The  patient  was,  however,  able  to  feed  himself  and 
perform  other  voluntary  acts  until  five  days  before  admission, 
when  the  choreic  movements  became  general  and  of  such  violence 
that  all  voluntary  movements  were  rendered  impossible.  The 
disorderly  muscular  action  continued  to  increase  in  intensity  up 
to  the  time  of  admission  to  the  hospital. 

On  admission,  May  21st,  the  expression  of  the  patient's  face 
was  one  of  extreme  distress;  the  choreic  movements  were  of  great 
violence,  involving  every  visible  voluntary  muscle  ;  articulation  was 
abolished  ;  the  urine  and  faeces  were  passed  in  the  bed,  apparently 
from  the  inability  of  the  patient  to  make  his  wants  known  ;  temp, 
in  axilla,  104^°;  pulse,  120,  regular.  Conversation  addressed  to 
him  was  evidently  in  a  measure  understood.  A  physical  examina- 
tion of  the  chest  was  made  with  much  difficulty,  on   account  of 

506 


A  CASE  OF  ACUTE  CHOREA.  50/ 

the  constant  and  extremely  violent  jactitations  of  the  whole 
body  ;  a  loud  systolic  murmur  at  the  point  of  impulse  of  the 
heart  was  detected,  the  true  nature  of  which  was  a  matter  of 
doubt,  on  account  of  the  impossibility  of  a  thorough  examina- 
tion. Further  examination  failed  to  reveal  the  existence  of  any 
visceral  affection  in  explanation  of  the  high  temperature.  Mat- 
tresses were  placed  on  the  floor  of  an  alcove,  with  others  against 
the  walls,  and  within  this  enclosure  the  patient  was  confined  with 
suitable  attendants.  Nourishment  was  given  with  much  diffi- 
culty, two  nurses  restraining  by  force  the  contortions  of  the  body, 
while  a  third  introduced  the  fluid  into  the  mouth. 

May  2 2d.  The  patient  obtained  four  hours'  sleep  at  different 
intervals  during  the  night,  under  the  influence  of  3  j  of  the 
bromide  of  sodium  combined  with  3  ss  of  chloral  hydrate. 

During  sleep  the  choreic  movements  ceased.  The  patient's  con- 
dition shows  no  improvement.  Temp,  (axilla),  104^°;  pulse,  128, 
regular.  Exm.  of  urine  shows  the  absence  of  albumen,  sugar,  casts. 
Ord.  Fowler's  sol.  in  TTlvi  doses  /.  /'.  d.,  to  be  rapidly  pushed  to  the 
point  of  tolerance. 

May  23d.  Patient  slept  in  all  four  hours  during  the  night, 
under  the  influence  of  3  iss  of  the  bromide  of  sodium  and  3  ss 
of  chloral  hydrate.  His  condition  remains  unchanged;  the  choreic 
movements  are  ceaseless  and  of  great  violence.  Is  taking  TUvii 
of  Fowler's  sol.  /.  /.  d.  Ord.  hyoscyamia  gr.  -^  (Merck's  crystal- 
line preparation)  by  the  mouth,  to  be  repeated  in  six  hours. 

May  24th.  Pt.  had  only  one  hour's  sleep  during  the  night. 
The  house  physician  reports  that  the  muscular  disturbance  in- 
creased so  markedly  that  he  did  not  venture  to  repeat  the  dose  of 
hyoscyamia,  but  substituted  the  chloral  and  bromide  mixture. 
Temp,  (axilla),  104°;  pulse,  104,  regular;  resps.,  36.  The  patient 
has  been  able  during  the  past  24  hours  to  make  his  wants  known 
by  signs  sufficiently  to  avoid  soiling  the  bed.  Ord.  a  cold  pack, 
which  had  little  or  no  effect  in  even  temporarily  reducing  the 
temperature. 

May  25th.  Patient's  condition  worse,  the  choreic  movements, 
if  possible,  more  violent  than  at  any  previous  time.  Temp, 
(axilla),  105 -J^°;  pulse,  134,  regular.  Is  taking  Tllx  of  Fowler's  sol. 
/.  /'.  d.  Ord.  the  bromide  of  sodium  to  be  discontinued  ;  gr.  xxx 
of  chloral  hydrate  to  be  given  at  intervals  of  two  hours,  until 
sleep  produced. 

May  26th.  Patient  obtained  six  and  a  half  hours  of  quiet  sleep 
after  the  administration  of  3iv  of  chloral.     There  is  a  decided 


5o8  FRANCIS  P.  KINNICUTT. 

improvement  in  his  condition  in  every  respect ;  the  intensity  of 
the  muscular  disturbance  has  markedly  diminished,  imperfect 
articulation  is  possible.  Temperature  (axilla),  ioi|°.  Pulse,  loo, 
regular.     Is  taking  TTlxii  of  Fowler's  solution  /.  /.  d. 

May  27th.  Continued  improvement.  Temperature,  ioif°  ; 
pulse,  114,  regular.  From  this  date,  for  several  days,  iv-vi  scruples 
of  chloral  hydrate  were  given  daily,  with  the  effect  of  producing 
from  six  to  nine  hours  of  quiet  sleep  in  the  twenty-four  hours  ; 
there  was  accompanying  continuous  and  rapid  improvement  in  the 
patient's  condition.  Pari  passu  with  the  subsidence  of  the  mus- 
cular contractions,  the  temperature  fell,  until,  on  June  ist,  com- 
paratively slight  choreic  movements  being  present,  the  thermome- 
ter in  the  axilla  registered  98^° 

During  the  past  week  the  chloral  has  been  gradually  reduced  in 
amount,  until  at  the  present  time  only  a  single  dose  of  grs.  xv  is 
administered  at  night.  Twelve  minims  of  Fowler's  solution  are 
still  given  /,  i.  d. 

On  examination  of  the  patient  on  June  i6th,  the  following  notes 
were  taken  :  Patient  anaemic,  marked  dryness,  with  slight  general 
furfuraceous  desquamation  of  the  skin  ;  no  oedema  ;  no  gastric 
disturbance.  Examination  of  the  urine  shows  an  absence  of  al- 
bumen, sugar,  casts.  The  articulation  is  perfect,  the  patient 
cheerful  and  intelligent  for  his  age.  There  was  an  entire  absence 
of  choreic  movements  during  the  time  consumed  in  the  examina- 
tion. Examination  of  the  heart  reveals  a  very  faint  systolic  mur- 
mur at  the  apex,  which  is  confined  to  this  situation.  Area  of  dul- 
ness  normal. 

Remarks. — The  points  of  especial  interest  in  the  case 
which  has  been  recorded  are :  ia)  the  high  temperatures, 
which  form  a  curve  coinciding  very  exactly  with  each  rise 
and  fall  in  the  intensity  of  the  muscular  disturbance  ;  {b) 
the  immediate  and  rapid  improvement  following  the  admin- 
istration of  very  large  doses  of  chloral ;  {c)  the  influence  of 
the  affection  in  producing  a  functional  mitral  murmur, 

A  correct  explanation  of  the  high  temperatures  observed 
is,  perhaps,  impossible.  Ordinary  chorea  is  a  feverless  affec- 
tion, yet  the  occurrence  of  marked  pyrexia  in  the  graver 
forms  (we  do  not  refer  to  the  disease  known  as  true  chorea 


A   CASE  OF  ACUTE  CHOREA.  509 

major  or  Germanorum,  which  would  seem  to  be  an  essential- 
ly different  affection)  is  mentioned  by  numerous  authorities. 
In  the  present  case  the  influence  of  a  malarial  factor  in 
the  production  of  the  pyrexia  may  be  doubted,  in  view  of 
the  very  irregular  temperature  curve  and  the  course  of  the 
disease.  The  presence  of  a  visceral  lesion,  acting  as  a  cause, 
would  seem  improbable  from  the  complete  absence  of  phys- 
ical signs.  We  are  therefore  compelled  to  regard  the 
marked  rise  in  temperature  as  dependent  either  upon  the 
ceaseless  and  very  violent  muscular  contractions,  or  upon  an 
unknown  lesion  of  the  nervous  system,  exciting  at  once  the 
choreic  movements  and  the  pyrexia. 

The  effect  of  large  doses  of  chloral  in  controlling  the 
acute  form  of  the  disease  would  seem  to  be  demonstrated 
in  the  present  instance.  The  improvement  following  its 
administration  in  large  doses  was  immediate  and  most 
marked.  Similar  results  have  been  recorded  by  Gaidner, 
Bouchut,  Frerichs,  Verdalle,  and  others. 

The  method  pursued  in  the  above  case,  and  which  was 
shown  to  be  the  most  efificient,  consisted  in  the  administra- 
tion of  the  first  dose  toward  evening,  repeating  it  at  inter- 
vals of  two  hours  until  sleep  was  produced.  In  this  way  a 
number  of  hours  of  continuous  quiet  rest  was  procured, 
from  which  the  patient  awoke  invariably  refreshed  and 
quieter.  The  influence  of  the  arsenic  in  controlling  the 
symptoms  may  be  doubted,  inasmuch  as  extended  clinical 
experience  has  shown  that  its  effect  in  chorea  is  only  slowly 
obtained. 

The  pathogenesis  of  the  functional  disturbance  of  the 
mitral  valve  is  as  obscure  as  in  cases  of  anaemia,  chlorosis, 
etc.  An  affection  of  the  papillary  muscles  has  been  theo- 
retically suggested  in  explanation  of  the  phenomenon,  and, 
a  priori,  would  seem  more  probable  in  chorea  than  in  other 
affections. 


A  SECOND  CONTRIBUTION  TO  THE   STUDY  OF 
LOCALIZED  CEREBRAL  LESIONS  * 

By  E.  C.  SEGUIN.  M.  D. 

IN  1877  I  reported  to  the  American  Neurological  Asso- 
ciation' a  number  of  cases  with  accurate  post-mortem 
examinations,  illustrating  the  doctrine  of  localization  of 
functions  in  the  brain.  Since  that  time  I  have  made 
several  similar  observations,  some  of  which  have  been  pub- 
lished as  isolated  cases.  In  the  past  year  two  remarkable 
cases  of  cerebral  tumor  bearing  upon  the  Ferrier  hypothesis 
have  been  added  to  my  records,  and  I  think  that  the  time 
has  come  to  offer  a  second  instalment  of  facts  in  this  de- 
partment of  medicine  to  the  medical  public.  I  shall  first 
relate  my  last  unpublished  cases,  and  point  out  their  signifi- 
cance, then  reproduce  in  brief  the  isolated  observations, 
positive  and  negative,  which  I  have  separately  published. 

I  would  only  claim,  in  offering  this  second  paper,  to  be 
adding  a  few  data,  trustworthy  data,  I  believe,  to  a  mass  of 
observations  which  tend  to  support  the  theory  of  cerebral 
localization.  This  theory  or  hypothesis  can  be  established 
as  true  only  by  great  numbers  of  pathological  facts  cor- 
roborating the  results  of  experimental  physiology  and  of 
anatomy. 

*  Read  by  title  at  the  seventh  annual  meeting  of  the  American  Neurological 
Association,  June  17,  1881. 

'  Contribution  to  the  study  of  localized  cerebral  lesions.  Transactions  of  the 
American  Neurological  Association,  vol.  ii,  1877. 

510 


LOCALIZED  CEREBRAL  LESIONS.  5  1 1 

Case  i. — Mrs.  I.  D.,  aged  58  years,  seen  Oct.  3d,  1880. 

A  strong,  intellectual  woman,  who  has  enjoyed  good  health. 
In  early  spring  was  overworked  and  anxious  about  the  outfit  of  a 
daughter  who  wai  to  be  married. 

In  May  began  to  have  a  peculiar  general  headache  (different 
from  any  she  had  had  before),  most  marked  in  the  occipital  re- 
gion, and  always  worst  at  night.  She  often  complained  of  a 
sore,  stiff  feeling  in  the  neck  on  rising  in  the  morning.  At 
times,  in  connection  with  headache,  has  had  nausea  and  vomiting. 
This  headache  has  been  a  prominent  symptom  ever  since,  amount- 
ing at  times  to  agony. 

Later  in  the  month  of  May,  or  in  the  early  part  of  June,  there 
was  noticed  a  trembling  of  the  left  hand  ;  this  increased,  and  was 
accompanied  by  evident  loss  of  power.  Relatives  of  the  patient 
describe  two  sorts  of  movements  of  the  left  arm  :  first,  a  slight 
and  nearly  constant  fine  tremor  ;  and,  second,  attacks  of  consid- 
erable jerking,  so  that  the  patient  was  obliged  to  hold  the  affected 
left  hand  with  the  right.  Each  day  there  were  several  such  at- 
tacks, some  lasting  an  hour. 

Has  grown  steadily  worse  ;  more  headache,  marked  paresis  of 
the  left  arm,  with  some  contracture,  slight  weakness  of  the  left 
leg.  Sight  not  so  good  as  formerly,  but  there  has  been  no 
diplopia,  hemiopia,  etc. 

Last  night  the  pain  was  intense  through  the  mastoid  regions, 
and  in  the  whole  of  the  head.  Was  given  -J-  grain  sulphate  of 
morphia  occasionally,  and  by  10  a.  m.  to-day  had  taken  \  grain  ; 
is  semi-comatose,  but  still  groaning  from  pain  ;  the  left  hand  and 
arm  are  semi-flexed  and  stiff. 

Examination  at  5  p.  m.  Patient  is  profoundly  asleep,  yet  can 
be  roused  ;  respiration  is  slow  and  very  irregular,  but  not  of  the 
Cheyne-Stokes  type.  When  spoken  to  loudly,  points  (with  right 
hand)  to  the  sides  of  the  head  as  the  seat  of  chief  pain  ;  is  able 
to  swallow.  The  pupils  are  small  and  fixed,  the  right  larger. 
The  right  internal  rectus  is  weak.  The  left  lower  face  is  paretic. 
The  left  arm  and  hand  are  strongly  adducted  and  semi-flexed  on 
the  thorax,  and  passive  extension  is  difficult  and  painful.  Legs  ex- 
tended, not  stiff ;  both  show  good  reflexes  at  the  knees.  Left  hand 
and  leg  are  less  sensitive  than  the  right.  The  pulse  beats  about 
72  per  minute,  and  is  weak  ;  the  axillary  temperature  is  37.4°  C. 
(99.3°  F.).  After  the  use  of  atropia,  I  was  able  to  observe  typical 
neuro-retinitis  (choked  disks)  in  both  eyes  ;  no  hemorrhages. 
Urine  contains  a  trace  of  albumen. 


512  E.   C.    SEGUIN. 

My  diagnosis  was  tumor  in  the  right  cerebral  hemisphere,  com- 
plicated by  morphia  narcosis.  I  considered  that  very  probably 
the  tumor  was  in  the  median  region  of  the  hemisphere,  in  the  so- 
called  centres  for  the  arm  and  leg,  according  to  Ferrier's  experi- 
ments and  to  rtcent  post-mortem  facts. 

A  great  many  notes  were  made  during  the  progress  of  the  case, 
but  they  only  show  the  extraordinary  variations  in  the  state  of  the 
patient,  which  I,  and  others,  have  observed  in  cases  of  cerebral 
tumor.  Some  days  Mrs.  D.  would  be  sitting  up  and  very  bright, 
and  the  next  day  might  appear  moribund. 

On  October  5th  is  up  on  a  lounge,  is  bright  and  cheerful, 
though  mind  wanders  at  times  ;  headache  has  returned  about  the 
vortex.  Can  converge  eyes  well.  Exhibits  common  left  hemi- 
paresis,  with  contracture,  most  marked  in  arm  and  hand. 
Ordered  solid  food,  and  iodide  of  potassium. 

Oct.  loth.  Growing  steadily  worse.  Attacks  of  pain  in  the 
head,  at  times  very  severe,  controlled  by  morphia  and  chloral. 
The  arm  is  now  completely  paralyzed,  with  painful  contracture  of 
elbow  and  shoulder.  No  voluntary  motion  in  left  arm  for  forty- 
eight  hours  ;  the  left  leg,  which  four  days  ago  could  be  drawn  up 
fairly  well,  is  now  nearly  motionless.  Left  face  is  paretic,  but 
tongue  points  straight.  Answers  questions,  but  wanders  ;  wants 
to  be  dressed,  to  go  out,  etc.  Wets  the  bed.  Optic  nerves  choked 
as  before. 

Oct.  13th.  State  of  paralyzed  limbs  has  varied  from  partial  to 
complete  paralysis.     Extreme  sensibility  to  narcotics. 

Oct.  15th.  Sulphate  of  quinia  produced  delirium  the  other 
evening,  and  she  is  easily  plunged  into  dangerous  narcosis  by 
morphia.      Morphia  .002  -f-  and  chloral  .15  have  some  effect. 

[On  Oct.  9  it  is  noted  that  left  arm  is  completely  relaxed  and 
the  tongue  is  straight.] 

Nov.  ist.  Divergent  strabismus  and  slight  drooping  of  right 
upper  lid.  Speech  very  indistinct.  Left  hemiplegia  as  above. 
Delirious  and  semi-comatose  at  different  times.  Incontinence  of 
urine  and  faeces. 

Nov.  4th.  Greater  coma  and  first  appearance  of  fever.  7.30 
A.M.:  Pulse,  162  ;  respiration,  52.  At  4.30  p.m.,  pulse,  136;  axil- 
lary temperature,  39.2°  C.  (102.5°  ^■)  '■>  breathing,  moribund  t.  e., 
inspiration  and  expiration  equal.  Left  arm  in  semi-flexion  on  chest, 
elbow  and  wrist  limber,  fingers  slightly  but  decidedly  contractured. 
At  10  P.M.,  respiration,  56  ;  pulse,  160  ;  axillary  temperature  (six 
minutes),  39.8°  C.  (103.75°  F.).      Right  eye  is  in  slight  external 


LOCALIZED  CEREBRAL  LESIONS. 


513 


strabismus  and  motionless  ;  the  left  is  in  continual  lateral  motion  ; 
pupils  medium-sized,  equal. 

Nov.  5th,  I  A.M.  Respiration,  56  ;  pulse,  176  ;  axillary  temper- 
ature, 40.15°  C.  (104.25°  F.)  ;  jaws  firmly  closed.  Death  occurred 
before  daylight,  and  the  temperature  finally  rose  to  40,6°  C. 
(105°  F.). 

'^o  post-mortem  measurements  could  be  made. 

The  autopsy  was  made  about  ten  hours  after  death  by 
Dr.  R.  W.  Amidon  under  my  direction.  Drs.  W.  R. 
Birdsall  and  C.  Adam  were  also  present. 


Lateral  view  of  the  right  cerebral  hemisphere,  after  Ecker.  Shaded  spot 
represents  the  location  of  the  tumor.  Superficially  it  involved  only  the  ascend- 
ing frontal  gyrus. 

Very  little  blood  escaped  on  removing  the  calvarium. 
The  pia  mater  was  found  excessively  dry  and  sticky  and 
without  gloss.  There  was  a  marked  prominence  of  the  right 
parietal  portion  of  the  brain,  causing  the  whole  hemisphere 


514 


E.   C.  SEGUIN. 


to  appear  much  larger  than  the  left.  The  convolutions  about 
the  upper  end  of  the  fissure  of  Rolando  on  the  right  side 
were  very  much  flattened. 

A  vertical  transverse  section  passing   through  the  mid- 
dle of  the  motor  zone  revealed    a  consistent,   grayish-red 


Transverse  vertical  section  through  the  right  hemisphere,  anterior  view  ;  after 
photo.  No.  5  of  Bitot.  The  gray  shaded  mass  in  the  upper  part  of  the  figure 
represents  the  tumor. 


tumor  lying  chiefly  in  the  right  ascending  frontal  convolu- 
tion, wholly  under  the  pia,  and  in  the  angle  formed  by 
the  ascending  frontal  convolution  and  the  paracentral 
lobule  at  the  top  of  the  brain.     See  fig.  i. 

The  tumor  was  about  the  size  of  a  small  English  walnut, 


LOCALIZED  CEREBRAL  LESIONS.  5  1 5 

well  defined  from  the  brain  substance,  vascular,  and  at 
points  almost  gelatinous  in  structure. 

The  right  third  nerve  was  grayish.  Right  eye  removed, 
showed  an  elevated  papilla. 

The  brain  and  eye  were  placed  in  bichromate  of  potassium 
solution  for  hardening. 

The  following  is  a  study  of  the  topography  of  the  lesion 
made  upon  the  hardened  specimens  : 

The  tumor,  ovoid  in  shape,  lies  in  the  upper  part  of  the 
ascending  frontal  convolution  and  in  its  subjacent  white 
matter.  It  measures  upon  the  vertical  transverse  section  of 
the  brain,  transversely,  15  mm.  at  its  pia  mater  attachment, 
20  mm.  in  its  middle,  and,  vertically,  from  its  deepest  point 
to  the  pia  28  mm.     See  fig.  2. 

It  extended  well  across  the  bottom  of  the  fissure  of  Ro- 
lando, so  as  to  slightly  impinge  upon  the  ascending  parietal 
gyrus.  The  distance  from  the  surface  of  the  brain  in  the 
longitudinal  fissure  to  the  internal  edge  of  the  tumor  is  25 
mm.,  thus  leaving  the  paracentral  lobule  and  its  attached 
white  matter  intact. 

The  tumor  is  spongy  in  texture,  well  defined  from  the 
surrounding  cerebral  substance,  and  seems  firmly  united  to 
the  pia.  The  microscope  shows  it  to  be  an  alveolar  carci- 
noma. 

It  probably  caused  a  great  deal  of  pressure  in  spite  of  its 
small  size. 

Case  2 — L.  K.,  an  upholsterer,  aged  34  years,  came  to  the 
Manhattan  Eye  and  Ear  Hospital,  department  for  nervous  dis- 
eases, Oct.  6,  1879.  He  was  a  strong  and  healthy-looking  Ger- 
man.    The  following  is  a  transcript  of  my  notes  : 

Has  had  attacks  of  right-sided  epilepsy.  First  seizure  was 
about  two  years  ago  (1877),  and  the  attacks  have  occurred  at  the 
rate  of  one  every  four  or  six  weeks.  In  the  last  few  months  has 
had  attacks  every  week,  and  even  several  times  a  week.  The 
phenomena  have  always  been  the  same  in  these  numerous  attacks  ; 


5l6  E.   C.  SEGUIN. 

the  spasms  being  wholly  restricted  to  the  right  arm  and  leg ;  the 
slightest  attacks  are  only  momentary  shocks  on  the  right  side  of 
the  body — no  spasm  in  the  face.  Even  in  the  severe  attacks  the 
spasm  is  wholly  clonic,  and  he  never  loses  consciousness.  An  ex- 
ception to  this  occurred  on  August  5,  1879,  when  he  had  a  severe 
seizure  with  loss  of  consciousness. 

The  attacks  last  from  a  few  seconds  to  a  few  minutes  ;  they  are 
preceded  by  a  sensation  of  something  rising  from  below  upward 
to  the  throat,  and  there  causing  choking.  He  never  foams  at  the 
mouth,  or  bites  tongue,  or  micturates  in  attacks,  and  during  them 
he  is  often  able  to  speak  a  few  words  in  a  jerky  manner. 

In  intervals  between  attacks  has  good  use  of  his  right  hand  and 
leg  ;  he  is  now  working  at  his  trade.     Mind  clear  and  calm. 

Very  lately  has  noticed  a  slight  weakness  in  the  right  limbs,  and 
the  right  leg  has  been  the  seat  of  an  indefinite  numbness.  Com- 
plains of  diffused  headache,  mostly  frontal.  No  vertigo  or  petit- 
mal. 

Denies  injury  to  head  and  any  venereal  disease. 

Examination. — Manner,  appearance,  and  speech  normal.  No 
facial  palsy  ;  tongue  straight ;  pupils  equal.  Right  hand  grasps 
45°  and  48°,  and  the  left  45°  and  45°  on  Mathieu's  dynamometer. 
No  anaesthesia  to  careful  testings.  Patellar  tendon  reflex  absent 
on  the  left  side,  and  strong  on  the  right  (never  sharp  pains  in 
legs).  The  walk  is  rather  of  heraiplegic  type  on  the  right  side  ; 
the  right  foot  is  held  slightly  in  equino-varus  position.  Complains 
of  sight  of  right  eye,  and  states  that  when  a  soldier  he  was 
obliged  to  aim  with  the  left  eye.  Examination  of  eyes  by  Dr.  J. 
O.  Tansley  shows  myopia  of  right  eye,  but  optic  nerves  normal. 

The  diagnosis  was  a  cortical  lesion  (tumor  ?)  in  the  left  hemi- 
sphere, involving  the  upper  part  of  the  motor  area. 

The  following  mixture  was  ordered:  ^.  potassii  iodidi,  15.; 
potassii  bromidi,  30.;  aquae,  200.;  S.:  one  teaspoonful  before  each 
meal,  and  two  at  bedtime,  in  plenty  of  water. 

Oct.  loth.  No  spasm  since  beginning  of  the  treatment,  but  the 
paralytic  phenomena  have  increased  ;  the  walk  is  distinctly  hemi- 
plegic  on  the  right  side.  Still  works.  Ordered  to  continue  treat- 
ment, with  addition  of  4.  ext.  ergotae  fld.  with  the  evening  dose  of 
bromide. 

Oct.  13th.  No  attack.  Speech  normal  ;  tongue  deviates  slight- 
ly to  the  right. 

Oct.  17th.  Slight  spasm  in  the  arm  (right)  yesterday  ;  increas- 
ing paresis.     Right  hand  squeezes  44°  and  45°  ;  the  left,  50°  and 


LOCALIZED  CEREBRAL  LESIONS.  $17 

45°.  Ordered  only  three  teaspoonfuls  of  bromide  mixture  at  bed- 
time. To  take  besides  20  drops  of  a  saturated  solution  of  iodide 
of  potassium  three  times  a  day  in  water. 

Nov.  loth.  No  spasm  ;  paresis  of  right  leg  more  marked  ;  walk 
distinctly  hemiplegic. 

Nov.  20th.  Dr.  Amidon  was  summoned  to  see  the  patient 
at  his  house.  Has  violent  headache,  more  to  the  left  of  the 
median  line  at  the  vertex ;  photophobia,  nausea,  and  almost 
constant  vomiting.  There  is  complete  paralysis  of  the  right 
arm  and  leg,  and  these  parts  are  oedematous.  Partial  relief  by 
hypodermic  injection  of  .02  sulphate  of  morphia  thrice  during 
the  day. 

Nov.  2 2d.  The  pain  has  continued  intense.  Has  asked  to  be 
killed.  No  aphasia.  Eyes,  examined  by  ophthalmoscope,  show 
myopia  yV  in  each  eye  ;  fundus  normal  ;  sleep  induced  by  hypo- 
dermic injection  of  chloral. 

Nov.  30th.  Headache  has  continued  intense,  requiring  chloral 
and  morphia.  Has  also  had  bromide  and  iodide  of  potassium  as 
above.     Some  motion  in  fingers  and  right  foot  (lost  on  31st), 

Nov.  14th.  Less  headache,  but  continued  right  hemiplegia. 
Bed-sore  beginning  over  sacrum.  Some  hesitancy  of  speech.  At 
no  time  any  aphasic  defect. 

Nov.  19th.  Eyes  again  examined  (without  atropine)  ;  right 
fundus  well  seen,  and  found  normal. 

Nov.  2 1  St.  First  signs  of  paresis  in  face;  right  cheek  looks 
weak,  and  tongue  points  a  little  to  the  right  side.  Still  has  very 
severe  headache. 

Nov.  30th.  Involuntary  escape  of  urine.  Scarcely  able  to 
speak  from  difficulty  of  articulation.     At  times  silly. 

Dec.  4th.  Cannot  be  understood.  Some  contracture  at  right 
elbow,  and  the  muscles  of  right  arm  and  leg  show  some  atrophy. 

Dec.  19th.     Paralysis  now  very  marked  about  right  cheek. 

Dec.  31st.  Quite  a  large  bed-sore  has  formed  on  the  right  side 
of  the  sacrum.  Marked  atrophy  of  right  arm  and  leg  ;  elbow  very 
stiff.  Is  semi-comatose.  Pupils  moderately  small.  Understands 
what  is  said  to  him,  and  tries  to  protrude  his  tongue  when  asked. 
Profuse  sweating. 

Jan.  2,  1880.  Much  brighter  ;  speech  can  be  understood.  Of 
late  has  had  no  treatment  except  chloral  occasionally. 

Jan.  4th.  Beginning  of  terminal  stage.  Fever  and  rapid  res- 
piration. A.M.,  axilla  temperature,  38.8°  C.  (101.80°  F.).  At  5 
P.M.,  asleep  and  sweating  profusely.     Pulse,  126  ;  respiration,  26  ; 


5l8  E.   C.  SEGUIN. 

temperature,  39.2°   C.   (102.5°  F-)  iri   axilla  ;  in  the  rectum   the 
thermometer  indicates  40.1°  C.  (104.12°  F.). 

Jan.  5th.  Fever  and  rapid  respiration  all  night.  At  11  a.m., 
pulse,  126  ;  respiration,  56  (shallow)  ;  rectal  temperature,  41.25° 
C.  (106.2°  F.).  At  2  P.M.,  comatose  without  stertor;  skin  moist. 
Eyes  in  conjugate  deviation  to  the  right  side  ;  head  straight. 
Pulse,  145;  respiration,  50  ;  rectal  temperature,  41.6°  C.  (106.8°  F.). 
At  4  P.M.,  died. 

The  autopsy  was  made  by  Drs.  R.  W.  Amidon  and  W.  R. 
Birdsall  24  hours  after  death.  The  calvarium  was  found 
very  thin ;  translucent  in  spots.  Dura  mater  normal.  No 
subarachnoid  fluid.  There  were  many  large  superficial 
cerebral  veins.  The  left  motor  area  gave  a  sense  of  fluctu- 
ation ;  the  convolutions  of  this  part  seemed  normal,  but 
were  flat.  On  attempting  to  remove  the  falx  cerebri  in  the 
usual  manner,  it  was  found  adherent  to  the  inner  surface  of 
the  left  hemisphere,  pretty  well  back  toward  the  tentorium. 
The  cortex  was  ruptured  in  this  location,  and  a  gelatinous, 
bloody  mass  escaped.  The  rest  of  the  encephalon  seemed 
normal  to  external  inspection. 

A  vertical  transverse  section  was  made  through  both 
hemispheres  in  the  motor  area,  passing  through  the  ascend- 
ing frontal  gyri.  Occupying  the  centrum  ovale  underneath 
the  left  cortical  motor  area,  and  completely  undermining  it 
was  a  large  cavity  capable  of  holding  100  cc.  (?),  very  much 
resembling  a  distended  lateral  ventricle,  which  contained  a 
large  amount  of  coffee-red  serum,  and  also  a  mass  (tumor) 
lying  on  its  inner  side,  near  the  paracentral  lobule.  The 
tumor  was  gelatinous  and  grayish-red.  The  walls  of  the  sac 
were  vascular  and  grayish,  and  appeared  covered  by  an 
ependyma-like  membrane,  which,  under  the  microscope,  was 
found  to  consist  of  capillaries  and  portions  of  blood  pig- 
ment. 

The  tumor  itself  had  formed  a  connection  with  the  falx 
cerebri  posteriorly,  in  the  region  of  the  paracentral  lobule, 


LOCALIZED  CEREBRAL  LESIONS. 


519 


and  this  region  of  the  cortex  was  thinned  ;  it  bulged  across 
the  median  line  and  indented  the  opposite  hemisphere. 

On  the  left  side  the  corpus  callosum  was  pressed  down- 
ward, and  the  optic  thalamus  was  also  depressed  and  flat- 
tened. The  left  lateral  ventricle  was  displaced  downward 
and  closed  by  pressure ;  on  opening  it,  it  was  found  free  from 
disease.  These  appearances  were  sketched  from  the  fresh 
surface  of  section  by  Dr.  Amidon,  and  are  shown  in  fig.  3. 

Sections  made  through  the  hardened  brain  confirmed  the 
above  notions  of  the  seat  of  the  tumor.     It  lay  wholly  be- 


FIG.   3. 

Transverse  vertical  section  of  the  brain,  Case  2,  viewed  from  behind.  R, 
normal  right  hemisphere  ;  L,  diseased  left  hemisphere  ;  /,  distorted  lateral  ven- 
tricles ;  //,  depressed  corpus  callosum  ;  ///,  thalami  optici,  depressed  on  left 
side  ;  IV,  the  tumor  ;    V,  the  cavity  formed  by  the  hemorrhage. 

neath  the  externally  visible  convolutions  of  the  left  hemi- 
sphere, springing  from  and  destroying  that  part  of  the  first 
frontal  gyrus  which  lies  within  the  longitudinal  fissure, 
above  the  corpus  callosum  and  the  paracentral  lobule,  forc- 
ing downward  the  gyrus  fornicatus,  extending  outward  into 
the  white  substance  of  the  hemisphere,  causing  great  com- 
pression of  the  surrounding  parts,  including  the  upper  ex- 
tremities of  the  first  and  second  frontal  gyri,  the  upper  half 
of  the  ascending  frontal  and  parietal  gyri,  and,  to  a  less  ex- 
tent, of  the  upper  parietal  lobule. 


520 


E.   C.  SEGUIN. 


A  part  of  this  pressure  was  due  to  the  cyst  lying  outside 
of  the  tumor,  near  the  convexity  convolutions,  which  is 
more  especially  shown  in  the  sketch  made  by  Dr.  Amidon 
from  the  fresh  specimens. 

The  situation  and  dimensions  of  the  lesion  in  this  second 
case  were  therefore  very  different  from  those  in  the  first 
case.  In  Case  2  the  destructive  effects  of  the  tumor  were 
expended  upon  the  gray  and   white  substances  lying  next 


FIG.    4. 

View  of  inner  surface  of  the  left  hemisphere,  after  Schwalbe.     Shaded  spot 
indicates  the  superficial  location  of  the  tumor. 


the  longitudinal  fissure,  and  the  rest  of  the  hemisphere  suf- 
fered only  compression  effects.  The  posterior  extremity 
of  the  intra-fissural  part  of  the  first  frontal  convolution  and 
the  paracentral  lobule  suffered  the  most  destructive  effects. 
The  tumor  and  cyst  were  of  very  irregular  shape  and  I 
can  only  give  approximate  measurements.  In  the  longitu- 
dinal fissure  and  near  it  in  the  brain  the  tumor  was  about 
60  mm.  in  length  (antero-posterior  dimension) ;  on  a  verti- 


LOCALIZED  CEREBRAL  LESIONS. 


521 


cal  transverse  section  of  the  hemisphere,  as  in  fig.  5,  it 
measured  30  mm.  transversely,  and  from  30  to  35  mm.  ver- 
tically. These  figures  include  the  cyst,  which  was  more 
developed  in  the  frontal  lobe,  extending  forward  as  far  as 
the  posterior  part  of  the  second  frontal  gyrus  (wholly  un- 
der it).     The  other  (posterior)  extremity  of  the  lesion,  the 


Transverse  vertical  section  of  left  hemisphere,  anterior  view ;  after  photo. 
No.  4  of  Bitot.  Shaded  spot  in  upper  part  of  drawing  shows  the  location  of  the 
solid  tumor. 


solid  growth,  could  be  traced,  on  the  median  surface  of  the 
hemisphere,  well  into  the  surface  of  the  precuneus. 

A  microscopical  examination  of  the  tumor  showed  it  to 
be  a  common  small-celled  sarcoma. 

Remarks. — There  are  many   interesting  features   in   the 


522  E.   C.   SEGUIN. 

semeiology  of  these  two  cases,  but  I  shall  dwell  only  upon 
those  symptoms  which  are  concerned  in  the  questions  of 
cerebral  localization. 

In  both  cases  the  first  motor  symptoms  were  epileptiform, 
and  in  Case  2  the  spasm  was  the  first  and  only  symptom  for 
many  months.  In  Case  i  it  was  preceded  by  severe  pain  in 
the  occipital  region.  In  Case  i  attacks  of  jerking  of  the 
left  arm,  as  well  as  trembling  of  that  member,  were  observed 
by  the  patient  some  weeks  before  the  weakness  became 
apparent.  There  was  no  jerking  of  the  cheek  or  leg.  It 
was  a  brachial  monospasm.  It  is  remarkable  and  most  in- 
structive to  note  how  quickly  paresis  and  paralysis  followed, 
these  phenomena  being  for  a  long  time  limited  to  the  arm ; 
a  brachial  monoplegia  succeeding  the  brachial  monospasm. 
Contracture  of  the  arm  and  hand  also  showed  itself,  but  at 
what  time  is  not  definitely  stated. 

Late  in  the  disease,  when  she  came  under  observation, 
the  left  lower  face  and  left  third  nerve  were  somewhat  pa- 
retic, the  sensibility  was  somewhat  impaired  on  the  left 
side  of  the  body. 

If  it  be  permissible  to  formulate  the  chief  symptoms  ob- 
served during  life  in  correlation  with  the  lesion  found  post 
mortem,  then  this  (Case  i)  was  a  remarkable  instance  of  irri- 
tating and  destructive  lesion  of  the  upper  part  of  the  right 
ascending  frontal  gyrus,  causing  brachial  monospasm  and 
brachial  monoplegia  on  the  left  side  (with  other  phenomena 
of  secondary  logical  value). 

In  Case  2  the  course  of  the  motor  phenomena  was  quite 
different.  There  was  a  period  of  two  years  previous  to  the 
patient  being  seen  by  me,  in  which  the  only  symptom  was 
right  hemi-epilepsy.  That  is  to  say,  from  time  to  time 
clonic  epileptoid  spasms  occurred  in  the  right  arm  and  leg 
for  a  few  moments.  The  face  was  never  affected,  the  pa- 
tient could  usually  talk  in   the  paroxysm,  and  he  only  once 


LOCALIZED  CEREBRAL  LESIONS.  523 

lost  his  consciousness.     He  was  unable  to  say  whether  the 
spasm  appeared  first  in  the  arm  or  in  the  leg. 

At  the  time  when  the  patient  presented  himself  at  the 
hospital  the  paralytic  phenomena  were  just  developing. 
He  was  still  working  all  day  at  his  trade,  and  was  not  con- 
scious of  the  partial  hemiplegia.  This  was,  and  remained 
until  the  apoplectic  attack,  more  marked  in  the  lower  than 
in  the  upper  extremity.  At  the  time  of  first  examination 
the  right  hand  (affected  side)  was  still  stronger  than  the 
left  hand,  but  the  walk  was  slightly  hemiplegic,  the  right 
foot  being  held  in  a  slight  equino-varus  position.  There 
was  then  no  facial  paresis  and  no  aphasia. 

Later  the  epileptiform  attacks  were  controlled  by  bro- 
mide of  potassium,  but  the  hemiplegia  progressed,  still 
greater  paresis  being  noted  in  the  lower  extremity. 

About  six  weeks  after  first  calling  at  the  hospital,  the 
patient  was  stricken  down  by  an  apoplectic  attack,  which 
rendered  the  right  hemiplegia  complete  in  the  arm  and 
leg,  with  marked  paresis  of  cheek,  but  never  aphasia. 
This  attack  obscured  the  symptoms  which  we  may  rea- 
sonably assume  had  been  caused  by  the  tumor.  At  no 
time  was  there  marked  anaesthesia  on  the  paralyzed  side. 

Headache  was  remarkably  slight  prior  to  the  occur- 
rence of  the  apoplectic  attack. 

The  post-mortem  findings  explain  all  these  symptoms 
very  well  I  think.  The  cyst  outside  of  the  tumor  proper, 
found  in  the  white  substance  of  the  hemisphere,  was  the 
remains  of  a  hemorrhage  which  took  place  at  the  mo- 
ment of  the  apoplectic  attack,  which  was  characterized  by 
intense  pain  in  the  head,  vomiting,  collapse,  and  complete 
right  hemiplegia.  Dr.  Amidon  states  that  in  removing 
the  brain  a  small  laceration  occurred,  and  "a  gelatinous 
bloody  mass  escaped,"  probably  the  contents  of  the  cyst, 
about  seven  weeks  old. 


524  E.   C.   SEGUIN. 

The  long  stage  of  hemi-epilepsy  without  paresis,  two 
years,  is  accounted  for  by  the  fact  that  the  morbid  growth 
began  upon  the  median  surface  of  the  hemisphere,  springing 
from  the  pia  covering  the  inner  winding  of  the  first  frontal 
gyrus,  and  perhaps  the  paracentral  lobule  ;  at  any  rate,  for  a 
long  time  it  was  an  irritating  lesion  causing  discharges,  and 
only  gradually  exercised  enough  pressure  to  destroy  the 
irritability  of  the  neighboring  gyri.  The  parts  of  the  hemi- 
sphere which  must  have  suffered  first  in  a  destructive  manner 
were  the  paracentral  lobule  and  adjacent  parts  (posterior  ex- 
tremity of  first  frontal  gyrus  on  median  surface),  and  in  con- 
nection with  this  should  be  noted  the  fact  that  paresis  of  the 
leg  preceded  and  preponderated  over  that  of  the  arm,  until 
the  apoplectic  attack  occurred.  The  absence  of  aphasia 
throughout,  and  of  facial  paresis  previous  to  the  hemor- 
rhage, are  likewise  of  interest. 

If  I  may  venture  to  formulate  this  case,  I  should  de- 
fine it  as  one  of  irritating  and  destructive  lesion  of  the  left 
paracentral  lobule  (and  adjacent  parts),  causing  crural  and 
brachial  monospasm  and  monoplegia,  with  greater  develop- 
ment of  symptoms  in  the  leg. 

It  will  be  seen  by  a  reference  to  the  now  numerous 
recorded  cases  of  localized  cerebral  lesions  that  the  two 
cases  which  I  report  are  in  sufficient  harmony  with  the  re- 
sults reached,  by  many  observers,  thus  far,  viz.,  that  the 
"  centres  "  for  the  hand  and  arm  are  in  or  about  the  ascend- 
ing frontal  gyrus  in  its  middle  region,  while  the  "  centres  " 
for  movements  of  the  lower  extremity  are  further  backward 
in  the  posterior  extremity  of  the  ascending  frontal  and 
ascending  parietal  gyrus,  and  their  prolongation  upon  the 
median  surface  of  the  hemisphere,  known  as  the  paracen- 
tral lobule. 

The  many  other  interesting  features  of  these  two  cases  of 
cerebral  tumor,  I  purpose  considering  in  a  future  article 
upon  the  semeiology  of  cerebral  tumors  in  general. 


LOCALIZED  CEREBRAL  LESIONS.  S^S 

Before  closing  this  contribution,  it  may  perhaps  be  well  if 
I  present  a  brief  resume  of  the  other  cases  of  localized 
cerebral  lesion  which  I  have  thoroughly  studied  {i.  e.,  while 
alive  and  post  mortem)  since  the  publication  of  my  first  paper 
on  localization.  Most  of  these  cases  have  been  published 
in  medical  journals. 

Case  3. — Hemiplegia  with  first  symptoms  in  foot,  and  a  limited 
cortical  lesion. 

In  November,  1878,  I  saw,  in  consultation  with  Dr.  Gran- 
niss  of  Saybrook,  Ct.,  a  gentleman  aged  54  years,  who  was  hemi- 
plegic  on  the  left  side,  and  almost  unconscious.  The  following 
account  of  his  illness  was  furnished  : 

In  December,  1877,  after  having  enjoyed  good  health,  he  awoke 
one  night  with  clonic  convulsions  of  the  left  toes,  foot  and  leg 
only.  There  was  no  impairment  of  consciousness,  no  spasm  in 
any  other  part.  He  watched  the  spasm  some  time,  and  made  com- 
ments on  it.  Since,  there  has  gradually  developed  a  left-sided 
hemiplegia.  For  months  only  the  foot  and  leg  were  paretic  ;  in 
the  last  few  weeks  the  left  arm  has  become  weak,  and  now  the  left 
cheek  is  paretic,  though  the  relatives  have  not  noticed  it.  In 
January,  1878,  vision  became  impaired,  but  an  examination  by  Dr. 
Noyes  revealed  no  cause.  In  the  last  few  weeks  patient  has  seen 
double  at  times,  and  sight  has  gradually  failed.  Severe  headache 
has  existed  from  the  first ;  frontal,  bilateral  pain,  most  marked  on 
the  right  side.  The  pain  has  been  worst  about  daylight.  In  the 
past  month  pain  decidedly  nocturnal.  On  a  number  of  occasions 
"  lost  himself"  while  out  of  doors,  not  remembering  where  he  had 
been  (petit-mal?).  A  business  associate  thinks  that  patient  has 
committed  errors  in  judgment.  No  extravagance  in  design  or  in 
deed.     Lately  has  become  stupid  and  semi-comatose. 

Since  January,  1878,  a  tumor-like  swelling  has  appeared  over 
the  right  parietal  region.  No  albuminuria,  but  has  had  several 
attacks  of  gout.  After  severe  cross-examination,  patient  admits 
having  had  a  chancre  fifteen  years  ago,  treated  with  mercury  ;  de- 
nies secondary  and  tertiary  symptoms. 

Examination  showed  a  typical  left  hemiplegia,  face  and  limbs. 
No  diplopia,  pupils  small  and  equal  ;  after  atropia  there  is  found 
a  well-marked  double  neuro-retinitis.  Sensibility  preserved  on  the 
paralyzed  side.  Articulation  indistinct,  no  aphasia.  Stupor  is 
peculiar,  like  that  of  drunken  sleep.     Patient  can  be  roused  by 


526 


E.   C.   SEGUIN. 


loud  talking  and  shaking,  and  then  answers  correctly  (showing  fair 
memory)  and  clearly.  The  swelling  upon  the  head,  raised  per- 
haps half  an  inch,  is  just  above  the  right  parietal  eminence,  extend- 
ing inward  to  the  median  line,  and  forward  almost  to  the  vertical 
line  from  the  meatus  auditorius  to  the  bregma.  This  tumor  over- 
lies Ferrier's  centres  for  the  leg. 

Diagnosis  :  External  and  internal  nodes  involving  dura  mater 
and  the  subjacent  gyri  of  the  right  hemisphere. 


FIG.   6. 
Lateral  view  of  right  cerebral  hemisphere,  with  lesion. 

A  few  days  later  the  patient  died  comatose,  and  after  much 
trouble  Dr.  Granniss  secured  a  partial  autopsy.  He  was  not  al- 
lowed to  raise  the  brain  from  the  skull  or  to  incise  it.  He  simply 
removed  the  calvarium  and  noted  the  lesions  at  the  vertex.  He 
found  that  there  was  an  internal  as  well  as  an  external  osteitis, 
forming  quite  a  tumor  which  had,  after  adhering  to  the  dura,  ex- 
erted great  pressure  upon  the  subjacent  convolutions  of  the  right 
hemisphere.  Dr.  Granniss  marked  the  location  of  the  cortical 
lesion  upon  an  Ecker's  diagram,  and  the  annexed  wood-cut  is  a 
copy  of  his  sketch. 

It  is  of  course  very  much  to  be  regretted  that  a  thorough  ex- 
amination of  the  brain  was  not  permitted,  but  in  view  of  numer- 
ous recent  cases,  it  is  impossible  not  to  admit  a  causal  relation 
between  the  lesion  causing  pressure  upon  the  inner  end  of  the 
right  ascending  frontal  and  parietal  convolutions  and  the  symp- 
toms in  the  left  foot  and  leg— spasm  and  paralysis. ^ 

1  Archives  of  Medicine,  vol.  ii,  p.  105.  (A  remarkable  case  of  hemorrhage 
under  the  paracentral  lobe,  with  paralysis  of  the  opposite  leg,  is  recorded  by  Dr. 
Miles,  of  Baltimore,  in  the  same  journal,  p.  103.) 


LOCALIZED  CEREBRAL  LESIONS.  S^7 

Case  4. — Aphasia  with  word-deafness  ;  no  permanent  paral- 
ysis ;  lesion  in  the  parietal  region.' 

The  main  facts  of  the  last  illness  of  the  late  Dr.  C.  M.  A.,  of 
New  York,  are  already  well  known  to  his  numerous  friends  in  the 
medical  profession,  who  watched  the  progress  of  his  disease  w'th 
painful  interest.  Throughout  his  illness  he  was  attended  by  his 
partner,  Dr.  A.  Dubois,  and  myself.  He  was  also  seen  in  consul- 
tation by  Profs.  Austin  Flint,  Sr.,  John  T.  Metcalfe,  H.  D.  Noyes, 
and  Dr.  Allan  McLane  Hamilton  ;  and  for  several  months  was 
under  the  professional  care  of  Prof.  E.  C.  Seguin. 

Dr.  A.  was  born  in  1827,  and  was  therefore  fifty-two  years  of 
age  at  the  time  of  his  aphasic  attack.  At  the  age  of  eleven  years 
he  had  a  long  illness,  which  was  called  "  brain  fever."  Whatever 
may  have  been  its  real  nature  the  illness  was  sufficiently  severe  to 
seriously  endanger  life,  and  for  several  years  retarded  his  growth. 
At  about  the  age  of  thirty  years  he  had  an  attack  of  inflammatory 
rheumatism  affecting  the  larger  joints.  This  was  followed  by 
three  or  four  other  attacks  within  the  next  few  years,  but  none  of 
them  lasted  longer  than  from  three  days  to  a  week,  or  was  attended, 
so  far  as  we  can  learn,  by  any  cardiac  complication.  Twelve 
years  ago  he  had  a  well-marked  attack  of  gout,  and  since  then 
from  three  or  four  other  paroxysms,  the  most  severe  one  five  years 
ago,  after  a  violent  quinzy,  when  both  great  toes  were  affected. 
For  several  years  before  his  aphasic  attack,  he  was  subject  to 
flatulent  dyspepsia,  and  had  occasional  outbreaks  of  eczema.  It 
should  be  noted  here  that  neither  gout  nor  rheumatism  were 
hereditary  in  his  family,  and  that  the  most  frequent  cause  of  gout 
— over-indulgence  at  the  table — was  notably  absent  in  his  case,  as 
he  was  usually  very  abstemious  both  in  eating  and  drinking.  In 
November,  1877,  he  had  a  severe  attack  of  renal  colic.  The  con- 
cretion was  arrested  in  the  ureter,  and  not  discharged  until  the 
end  of  ten  days,  after  repeated  paroxysms  of  colic.  The  stone, 
on  analysis,  was  found  to  be  composed  of  uric  acid.  On  February 
I,  1879,  h^  attended  a  concert  in  evening  dress,  and  on  his  way 
home  became  thoroughly  chilled.  During  the  night  he  was 
awakened  by  pain  and  oppression  in  the  chest,  these  symptoms 
continuing  during  the  following  day.  As  there  was  no  evidence 
of  pulmonary  lesion,  but  merely  tenderness  over  the  middle  por- 
tions of  the  chest  anteriorly,  on  both  sides,  with  pain  in  these  sit- 
uations on  movement  of  the  pectoral  muscles,  the  symptoms  were 

'Dr.  A.  B.  Ball.  A  contribution  to  the  study  of  aphasia,  etc.  Archives  of 
Medicine,  vol.  v.  No.  2,  April,  1881. 


528  E.  C.   SEGUIN. 

referred  to  muscular  rheumatism.  Within  a  few  days  he  was  able 
to  return  to  business,  but  was  still  so  far  from  well  that  some  more 
serious  disturbance  was  apprehended  by  his  medical  attendants. 

On  February  nth,  the  date  of  his  aphasic  attack,  he  was  in 
much  better  spirits.  At  half-past  eight  in  the  evening  he  was  seen 
in  his  office  writing  a  letter.  A  few  minutes  before  ten  o'clock  he 
rang  his  bell  violently,  and  was  found  by  his  servant  lying  on  the 
lounge  talking  unintelligibly.  I  saw  him  not  more  than  five  minutes 
afterward.  He  was  conscious,  but  unable  to  answer  questions  ex- 
cept by  a  confused  muttering.  The  face  was  slightly  flushed  : 
pulse  soft,  easily  compressible,  about  90  per  minute  ;  the  first 
heart  sound  feeble,  and  no  murmur  audible.  Incomplete  right 
hemiplegia  and  right  hemi-anaesthesia.  Was  apparently  aware  of 
the  nature  of  his  attack  as  he  pointed  to  his  right  arm  and 
left  frontal  region.  By  gestures  he  finally  succeeded  in  direct- 
ing my  attention  to  important  cases  in  his  note-book,  re- 
quiring attention  on  the  following  day.  At  eleven  o'clock  he  was 
seen  by  his  partner,  Dr.  Dubois,  and  with  slight  assistance  walked 
up  two  flights  of  stairs  to  his  bedroom.  On  the  following  morn- 
ing he  complained  of  paroxysms  of  pain  in  the  left  frontal  region. 
This  symptom,  which  yielded  to  local  applications  of  hot  water, 
annoyed  him  frequently  for  several  weeks,  and  recurred  at  inter- 
vals during  the  whole  course  of  his  illness.  Repeated  examina- 
tions of  the  heart  failed  to  disclose  any  morbid  condition  except 
feeble  action  and  moderate  hypertrophy.  No  albumen  or  casts  in 
the  urine.  Absence  of  fever,  except  on  the  evening  of  the  third 
day,  when  there  was  a  slight  rise  of  temperature  which  lasted  only 
a  few  hours.  From  this  time  his  physical  condition  steadily  im- 
proved, and  by  the  end  of  six  weeks  his  general  health  was  fairly 
restored.  Beyond  slight  paresis  of  motility  and  sensation  on  the 
right  side  the  only  marked  change  was  the  aphasic  condition  to 
be  presently  described.  During  the  summer  and  autumn  of  1879 
his  physical  condition  remained  fairly  good.  The  kidneys  per- 
formed their  work  well,  although  it  was  evident  from  the  occas- 
ional appearance  of  traces  of  albumen  and  casts  in  the  urine,  and 
from  the  enlargement  of  the  left  ventricle  without  valvular  mur- 
murs, that  the  kidneys  had  probably  undergone  cirrhotic  changes. 
At  no  time  was  any  increased  arterial  tension  noticed  in  the 
sphygmographic  tracings,  but  this  absence  was  ascribed  to  muscu- 
lar degeneration  of  the  cardiac  muscle,  as  feeble  action  of  the 
heart  was  a  constant  symptom  throughout  his  illness. 

In  March,  1880,  he  had  another  attack  which  was  supposed  to 


LOCALIZED  CEREBRAL  LESIONS.  S^9 

be  due  to  a  small  cerebral  hemorrhage.  At  dinner,  while  talking 
with  a  friend,  he  suddenly  turned  his  head  to  the  right,  and  began 
muttering  incoherently.  With  assistance,  he  immediately  left  the 
apartment  and  walked  to  his  bedroom,  muttering  all  the  way  with 
his  head  turned  to  the  right.  At  my  visit,  half  an  hour  later, 
when  his  consciousness  was  fully  restored,  he  said  that  the 
attack  began  with  an  explosive  noise  in  the  head  like  a 
pistol-shot.  Immediately  he  heard  some  one  talking  to  him  over 
his  right  shoulder,  and  turned  to  see  who  was  addressing  him. 
Every  word  uttered  by  himself,  he  said,  was  mockingly  repeated 
by  this  imaginary  individual,  and  the  mutterings  his  friends  had 
heard  were  his  indignant  protests  against  the  insult.  On  examina- 
tion there  was  found  slight  paralysis,  with  numbness  and  anaesthesia 
on  the  ie/t  %\dt.  These  symptoms  disappeared  after  a  few  days, 
his  mental  condition  remaining  without  apparent  change.  Shortly 
after  this  attack  it  was  evident  that  his  heart  was  failing  in  power. 
He  frequently  complained  of  breathlessness  on  exertion,  and  the 
heart  sounds  were  feeble,  with  occasional  intermittence  of  beat. 
Toward  the  end  of  May  he  was  seized  with  what  proved  to  be  his 
final  attack.  The  symptoms  were  slight  fever  for  several  days  ; 
oppression  in  the  chest  with  shortness  of  breath  ;  slight  cough, 
generally  dry  but  occasionally  accompanied  by  expectoration  tinged 
with  blood  ;  and  marked  tenderness  over  the  region  of  the  heart. 
At  a  few  examinations  a  faint  aortic  obstructive  murmur  was  heard, 
or  rather  a  soft  blowing  sound  over  the  base  of  the  heart  near  the 
aortic  valves,  with  the  first  sound.  Urine  nearly  normal  in  amount ; 
specific  gravity  varying  from  1012  to  1018  ;  no  albumen  and  no 
casts  except  a  few  hyaline  cylinders  found  at  one  examination. 
These  symptoms  were  hardly  sufficient  to  warrant  a  positive  diag- 
nosis, but  they  seemed  to  point  to  endocarditis  with  possibly  myo- 
carditis, and  this  view  was  confirmed,  or  at  least  considered  plausible, 
by  Prof.  J.  T.  Metcalfe,  who  saw  him  in  consultation.  The  urgent 
symptoms  subsided  by  the  end  of  a  week,  but  he  was  still  much 
prostrated,  and  complained  of  giddiness  and  mental  confusion. 
On  one  occasion  he  exhibited  in  a  marked  form  the  so-called  ro- 
tatory phenomenon,  turning  over  rapidly  to  the  right,  and  would 
have  rolled  out  of  bed  had  he  not  been  prevented.  On  June  19th, 
about  3  P.M.,  he  suddenly  became  totally  blind.  Dr.  Dubois,  who 
saw  him  shortly  afterward,  found  him  still  partially  blind,  but 
gradually  regaining  his  vision.  At  my  visit,  two  hours  later,  he 
was  perfectly  conscious,  with  his  sight  fully  restored.  Half  an 
hour  afterward    he    fell   into   a    quiet    slumber,    from    which  he 


530  E.   C.  SEGUIN. 

suddenly  awakened  at   7  o'clock,   exclaimed   "  Oh  !  "   and   died 
instantly. 

In  considering  the  aphasic  symptoms  which,  constituted 
the  most  striking  and  interesting  feature  of  his  case,  a  few 
preliminary  remarks  on  the  essential  nature  of  aphasia  may- 
be permitted  before  analyzing  the  symptoms  in  detail. 

The  interchange  of  thought  between  members  of  the 
human  family  is  carried  on  by  means  of  various  symbols, 
that  is,  by  signs  which  stand  for  the  ideas  they  represent ; 
for  example:  articulate  sounds,  written  language,  gestures, 
facial  expression,  mathematical,  musical,  and  other  signs. 
In  aphasia  this  symbolic  function,  or  capacity  to  interpret 
and  express  thought  in  a  symbolic  form — the  facultas  signa- 
trix  of  Kant — is  more  or  less  seriously  impaired.  In  some 
cases  the  chief  difificulty  is  in  the  direction  of  symbol-expres- 
sion (ataxic  aphasia),  the  concept  being  present,  but  failing 
to  enunciate  itself  on  account  of  some  lesion  in  the  motor 
track  concerned  in  the  expression  of  symbols.  In  other 
instances  the  concept  is  present  in  the  mind,  but  the  appro- 
priate symbol  for  it  is  forgotten  (amnesic  aphasia).  In  a 
third  class  of  cases  there  is  also  a  defect  in  the  capacity  for 
compreJiendiug  s3''mbols.  Certain  auditory  and  visual  im- 
pressions, especially  those  of  word  symbols,  fail  to  recall 
into  consciousness  their  corresponding  concepts,  although 
the  capacity  for  forming  such  concepts  under  the  influence 
of  other  stimuli  may  still  be  retained.  When  concepts  can 
no  longer  be  formed,  the  lesion  involves  the  fundamental 
processes  of  thought,  and  extends  beyond  the  sphere  of 
simple  aphasia.  The  latter  term  fails,  however,  to  recog- 
nize the  impaired  capacity  to  understand  symbols,  and  as 
most  cases  of  aphasia  present  some  degree  o.  this  derange- 
ment, Fnkelburg*  has  proposed  to  substitute  the  word 
"  asymbolia  "  as  a  generic  term   for  all  the  phenomena  of 

^  Berl.  Klin.   Wochenschiift,  1870,  Nos.  37,  38. 


LOCALIZED  CEREBRAL  LESIONS.  531 

aphasia.  Kussmaul'  prefers  the  term  asentia,  suggested  by 
Steinthal,  as  being  still  more  comprehensive  ;  "  symbol "  rep- 
resents an  idea  behind  it,  whereas  "  sign  "  often  represents 
merely  an  emotion.  In  the  following  description  of  the 
aphasia  symptoms  in  Dr.  A.'s  case,  we  shall  use  the  word 
"  symbol  "  in  preference  to  "  sign,"  as  there  was  no  diffi- 
culty in  comprehending  or  expressing  emotions.  Our 
classification  is  based  upon  that  of  Spamer." 

1. — EXPRESSION    OF    SYMBOLS. 

a.  Disturbances  of  speech.  On  the  morning  following 
the  first  paralytic  seizure,  by  which  time  the  general  shock 
to  the  brain  had  abated,  it  was  evident  that  the  cerebral 
disturbance  was  limited  chiefly  to  the  verbal  expression  of 
ideas.  His  general  intelligence  was  fairly  well  preserved, 
and  he  understood  much  that  was  said  to  him,  but  there 
was  a  marked  defect  in  verbal  expression.  His  principal 
difficulty  was  with  proper  names  and  common  nouns. 
When  a  glass  of  milk  was  held  before  him  he  said  :  "  That 
is  something  to  drink,"  recognizing  at  once  its  several  attri- 
butes, its  color,  uses,  etc.,  but  the  word  which  combined 
these  qualities  into  a  single  concrete  expression,  or  symbol, 
he  could  not  utter,  even  when  the  word  was  repeated  to 
him.  He  had  less  difficulty  with  adjectives,  verbs,  and 
adverbs,  that  is,  with  words  of  less  concrete  symbolic  char- 
acter. His  vocabulary  of  proper  and  common  nouns  very 
soon  began  to  increase.  Within  the  first  few  days  we  suc- 
ceeded in  teaching  him  a  number  of  such  words  by  direct- 
ing his  attention  to  the  movements  of  the  lips  and  tongue 
in  pronunciation.  My  own  name,  being  short  and  easily 
pronounced,  he  learned  in  one  day,  and  rarely  afterward  for- 
got it.     Long  names  of  individuals,  or  long  words  which  he 

^  Ziemssen's  Cyclopcedia  of  Medicine.     American  edition,  vol.  xiv,  p.  609. 
'C.  Spamer.     Archiv  fUr  Fsychiatrie,  Bd.  vi,  p.  526. 


532  E.  C.   SEGUIN. 

rarely  had  occasion  to  use,  he  seldom  mastered  completely 
at  any  period  of  his  illness.  During  the  summer  and  au- 
tumn of  1879,  ^^s  vocabulary  increased  so  as  to  include  a 
considerable  number  of  words  used  in  ordinary  conversa- 
tion. With  these  he  generally  succeeded  in  expressing  his 
ideas  fairly  well,  but  an  attempt  to  leave  the  beaten  track 
resulted  in  mental  confusion  and  inability  to  proceed  with 
the  conversation.  In  rare  instances  his  conversational  pow- 
ers astonished  his  friends,  and  gave  him  delusive  hopes 
of  ultimate  recovery.  On  one  occasion  he  conversed  with 
fluency  on  various  topics  for  nearly  an  hour,  with  a  friend 
who  had  not  met  him  for  several  years  and  was  unaware 
of  his  illness.  His  friend  noticed  no  aphasic  disturbance 
during  the  interview,  and  was  greatly  surprised  afterward 
on  learning  the  facts  of  the  case.  Such  flashes  were,  how- 
ever, only  intermittent,  and  it  became  more  and  more 
evident  that  any  thing  like  perfect  recovery  was  hopeless. 

In  conversation,  true  paraphasia,  that  is,  the  substitution 
of  wrong  words,  was  rarely  noticed.  Almost  invariably  the 
word  uttered  bore  some  resemblance  to  the  correct  one, 
and  differed  from  it  in  only  some  of  its  letters.  Thus  the 
first  letters  were  usually  correct.  This  fact  was  of  great 
assistance  to  him  in  conversation,  as  it  enabled  him,  when 
he  knew  the  first  letter,  to  find  the  correct  word  in  a  dic- 
tionary or  work  of  reference,  where  he  at  once  recognized 
it  as  soon  as  he  saw  it,  showing  that  the  concept  was  pres- 
ent in  his  mind  in  a  latent  form,  and  needed  only  the  right 
stimulus  to  recall  it  into  consciousness.  His  Medical  Reg- 
ister was  frequently  consulted  for  physicians'  names  he  was 
unable  to  pronounce,  as  he  retained,  to  a  marked  degree, 
his  interest  in  news  affecting  the  medical  profession. 

In  the  expression  of  musical  and  other  non-verbal  sounds, 
as  in  singing,  whistling,  and  imitation  of  various  significant 
sounds,  there  was  no  observable  deficiency. 


LOCALIZED  CEREBRAL  LESIONS.  533 

As  regards  the  alphabet  and  numerals  the  same  cannot  be 
said.  At  the  outset  of  his  illness  he  was  able  to  pronounce 
only  a  few  letters,  and  could  not  count  above  four.  With 
training,  however,  he  in  time  learned  most  of  the  alphabet, 
but  never  succeeded  in  spelling  any  but  short  and  simple 
words.  Counting  he  reacquired  quite  perfectly,  and  was 
able  to  solve  simple  sums  in  arithmetic,  that  is,  to  express 
their  answers  verbally.  Even  when  unable  to  do  this  he 
could  often  write  the  answers  correctly.  When  both  these 
efforts  failed  him  he  was  frequently  able  to  recognize  the 
correct  answers  if  shown  to  him  in  writing.  During  the  lat- 
ter part  of  his  illness  he  supervised  his  business  accounts, 
and  rarely  failed  to  notice  mistakes  in  them  made  by 
others.  Jhis  circumstance  belongs,  however,  rather  under 
the  head  of  s>yvciho\-comprehension  than  under  that  of  symbol- 
expression. 

b.  Defects  in  writing.  At  the  outset  of  his  illness  there 
was  complete  agraphia.  When  asked  to  write  the  word 
"  cat,"  he  took  the  pencil  in  his  left  hand,  and  drew  three 
perpendicular  lines,  naming  them  one,  two,  three.  As  we 
shall  see  in  a  later  illustration,  this  substitution  of  numerals 
for  letters  and  words  was  at  first  very  noticeable.  He  knew 
the  number  of  letters  required  for  the  word  "  cat,"  but  there 
was  no  attempt  at  the  formation  of  letter  symbols,  although 
he  was  perfectly  aware  that  his  straight  lines  were  not  let- 
ters. Under  training  he  gradually  learned  to  form  letters 
with  his  right  hand,  and  after  several  months  could  copy 
simple  sentences  correctly,  sign  his  name  in  his  usual  clear 
and  elegant  handwriting,  and  even  write  short  sentences  of 
his  own  composition,  but  more  than  this  he  never  succeeded 
in  accomplishing. 

c.  Gesture  language.  The  capacity  for  expressing  ideas 
by  gestures  seemed  to  be  unimpaired.  He  retained  much 
of  his  natural  vivacity  of  manner,  more  in  fact  than  could 


534  E.  C.  SEGU/N. 

have  been  expected  in  a  person  of  his  keen  sensibility, 
when  he  found  himself  cut  off  from  the  ordinary  modes  of 
social  intercourse.  His  gesture  language  had  always  been 
a  prominent  characteristic,  and  now  became  an  important 
aid  in  the  expression  of  ideas.  Names  of  individuals  and 
objects,  which  he  was  unable  to  remember  or  to  pronounce, 
he  frequently  succeeded  in  recalling  to  others  by  gestural 
description,  and  this  was  very  noticeable  even  early  in  his 
aphasic  attack. 

II. — COMPREHENSION    OF    SYMBOLS. 

Before  entering  upon  this  branch  of  our  subject  it  should 
be  noted  that  the  senses  of  sight  and  hearing  in  the  present 
case  were  perfect,  so  far  as  could  be  determined  by  the 
usual  tests.  With  respect  to  vision,  the  only  exceptions  to 
this  statement  were  a  transient  attack  of  total  blindness 
a  few  hours  before  death,  and  occasional  attacks  of  hemi- 
opia.  Prof.  H.  D.  Noyes,  who  made  an  ophthalmoscopic 
examination  of  his  eyes  in  the  autumn  of  1879,  reports  that 
"he  found  no  remarkable  change  in  the  optic  nerves  or 
retinae.  The  arteries  of  the  nerves  were  rather  small,  and, 
with  this  exception,  nothing  abnormal  was  noted." 

A. — Comprehension  of  Auditory  Symbols. 

a.  Spoken  words.  Early  in  his  illness,  on  my  remarking  to 
him  one  day,  "  Dr.  Peters  called  to  .see  you,"  he  replied,  "  I 
don't  know  him."  The  name  was  repeated  several  times, 
but  he  failed  to  recognize  it,  although  it  was  the  name  of 
an  intimate  friend.  The  written  name  was  then  shown  him. 
•'  What  a  fool  1  am,"  he  exclaimed,  "  of  course  I  know 
him."  This  was  the  first  instance  in  which  my  attention 
was  drawn  to  the  fact  that  certain  auditory  impressions 
failed  to  be  converted  into  concepts,  although  the  concep- 
tive  faculty  remained  intact.  Not  long  afterward  he  noticed 


LOCALIZED  CEREBRAL  LESIONS.  535 

this  peculiarity  himself,  as  was  shown  by  his  remarking  to 
me:  "The  words  I  can't  pronounce  are  the  words  I  can't 
hear."  This  observation,  the  general  correctness  of  which 
was  verified  by  repeated  experiments,  points  to  a  very  in- 
teresting peculiarity  in  his  case.  The  words  over  which  he 
stumbled  in  conversation  were  words  which  made  no  intel- 
ligible impression  on  his  mind  when  repeated  to  him,  and, 
conversely,  the  words  he  failed  to  understand  in  conversa- 
tion were  words  he  had  great  difificulty  in  pronouncing 
spontaneously.  The  concepts  represented  by  these  word 
symbols  we  were  generally  able  to  recall  to  his  conscious- 
ness by  other  means,  such  as  writing,  gestures,  etc.,  but 
even  then  he  was  unable  to  express  them,  except  after  a 
certain  amount  of  training.  This  "  word-deafness,"  except 
when  it  was  possible  to  stimulate  the  conceptual  centres  by 
visual  or  other  impressions,  made  it  extremely  difficult  to 
determine  how  much  of  his  aphasia  was  due  to  the  ataxic 
and  how  much  to  the  amnesic  element. 

b.  Musical  and  other  sounds.  His  appreciation  of  music 
was  fortunately  well  preserved,  and  was  a  source  of  much 
pleasure  to  him.  In  attending  concerts  and  operas  he 
exhibited  his  usual  good  critical  taste.  The  significance 
of  other  sounds,  such  as  the  tone  of  a  bell,  the  striking 
of  a  clock,  etc.,  was  perfectly  understood. 

B. — Comprehension  of  Visual  Symbols. 

On  the  third  day  of  his  aphasic  attack  a  scroll  of  Scripture 
texts  was  held  before  him,  and  he  was  asked  to  read  the  fol- 
lowing sentence  :  "  We  love  Him  because  He  first  loved  us. 
While  we  were  yet  sinners  Christ  died  for  us."  He  read 
aloud  as  follows  :  "  We  he  have  two  three  that  I  have  to 
have  the  same.  I  have  two  three."  The  substitution  of 
numerals  for  words  is  here  again  noticed  as  in  a  previous  il- 
lustration.    The  words  "  the  same  "   probably  refer  to  the 


53^  E.   C.   SEGUIN. 

repetition  of  "love"  in  the  first  sentence.  He  was  aware 
that  this  rendering  of  the  text  was  incorrect ;  in  fact  he  al- 
most always  knew  when  he  read  aloud  incorrectly,  and  ex- 
pressed impatience  thereat.  Later  in  his  illness  when  he 
was  able  to  read  sufficiently  well  to  gather  from  the  news- 
paper the  main  points  of  news,  he  remarked  to  me  that  there 
were  always  words  in  every  long  sentence  which  conveyed 
no  impression  to  his  mind,  and  that  he  was  compelled  to 
form  his  idea  of  the  meaning  of  such  a  sentence  from  the 
other  words  whose  meaning  he  understood.  The  signifi- 
cance of  many  of  these  uncomprehended  words  could  be 
conveyed  to  him  in  other  ways,  showing  that  his  failure  to 
recognize  the  written  symbols  was  not  always  due  to  a  de- 
fect in  the  conceptual  centre,  but  rather  to  a  lesion  in  the 
channel  of  transmission  from  the  optical  centre  for  word 
symbols  to  their  ideational  centres. 

The  same  difficulty  extended  at  first  also  to  the  compre- 
hension of  written  numerals  and  their  combinations,  but,  as 
we  have  already  seen,  he  reacquired,  to  a  certain-extent,  this 
capacity  under  training.  Gesture  language  he  understood 
perfectly  from  the  start. 

The  degree  of  impairment  in  intelligence,  otherwise  than 
in  the  comprehension  and  expression  of  symbols,  it  was  ex. 
tremely  difficult  to  determine,  for  reasons  already  given. 
His  intimate  friends  were  satisfied  that  there  was  much  less 
general  mental  deterioration  than  those  who  met  him  casu- 
ally would  infer.  His  memory  of  incidents  in  his  own  life, 
of  the  past  illness  of  his  patients,  and  of  numerous  other 
details  was  strictly  accurate,  so  that  we  could  rely  upon  his 
statements  upon  such  points  in  every  particular.  In  busi- 
ness matters  he  always  manifested  his  usual  tact  and  good 
judgment.  During  the  last  few  months  of  his  life  he  was  a 
constant  attendant  at  the  surgical  operations  of  the  New 
York  Hospital,  of  which  he  was  an  attending  surgeon,  and 


LOCALIZED  CEREBRAL  LESIONS.  537 

his  criticisms  showed  that  he  retained  not  merely  a  general 
interest,  but  also  his  special  knowledge  in  surgery.  On 
several  occasions  he  assisted  me  in  minor  surgical  operations 
and  dressings,  with  his  usual  deftness  and  attention  to  de- 
tails. At  whist,  euchre,  and  all  games  with  which  he  had 
been  familiar,  he  was  as  expert  as  ever.  During  the  winter 
of  1879-80  he  consulted  numerous  medical  works  on  the 
subject  of  aphasia.  Since  his  death  I  have  seen  a  sheet  of 
paper  containing  his  notes  of  reference  to  articles  on  this 
subject  in  English  and  French  works  and  journals.  The 
titles,  dates,  etc.,  are  strictly  correct,  and  are  written  in  his 
usual  clear  and  elegant  handwriting.  His  memory  of  loca- 
tion was  particularly  well  preserved.  He  could  always  turn 
without  hesitation  to  the  right  place  in  books  he  wished  to 
consult,  remembered  the  houses  of  friends — that  is,  their 
relative  positions  in  this  city, — and  in  numerous  other  ways 
showed  that  he  perfectly  understood  the  spatial  relations  of 
objects.  The  only  exception  to  this  fact  was  a  singular 
symptom  which  annoyed  him  for  several  months,  viz. :  a 
tendency  to  reverse  the  natural  position  of  objects  which 
he  handled,  such  as  table-knives,  spoons,  pencils,  canes,  etc. 
He  immediately  recognized  his  mistake,  however,  and  cor- 
rected it,  but  always  spoke  of  the  inclination  as  irresistible. 

As  an  aid  to  the  interpretation  of  the  aphasic  symptoms 
in  the  present  case,  we  reproduce,  below,  Spamer's  diagram 
representing  the  several  tracts  between  the  reception  of  im- 
pressions, the  comprehension  of  these  impressions,  and  their 
expression. 

It  will  be  noticed  in  the  above  diagram  that  the  tract 
from  P  to  -5  is  represented  by  a  straight  line,  while  the  tract 
from  P '  to  B  pursues  a  circuitous  route.  By  this  distinc- 
tion Spamer  attempts  a  rough  explanation  of  the  difference 
observed  in  most  cases  of  aphasia  between  the  compre- 
hension of  auditory  word  symbols  and  the  comprehension 


538 


E.   C.   SEGUIN. 


of  visual  word  symbols.  Cases  of  marked  word-deafness 
without  ordinary  deafness,  seem  to  be  extremely  rare ;  at 
least  there  are  very  few  instances  of  this  kind  on  record. 
The  tracts  for  ^//auditory  impressions,  he  supposes,  lie  in 
close   connection,   and    may   be    represented    by   a    single 


wmriNG  WORDS 


gAR     £_re 


FIG.    7. 

The  circle  in  the  middle  of  the  diagram,  V,  represents  the  ideational  tracts. 
From  the  right  the  excitations  of  the  sensory  nerves  pass  into  the  brain. 

n.  a.=auditory  nerve,     n.  £'.=optic  nerve. 

P  and  /"  represent  the  places  where  the  auditory  (A')and  the  optical  {G)  im- 
pressions are  perceived.  When  the  impressions  reach  these  points  we  have 
merely  sense-perceptions  without  associated  conceptions.  The  association  with 
definite  corresponding  conceptions  takes  place  only  when  the  excitation  travels 
onward  to  B,  the  conception.  From  this  point  the  excitation  may  proceed  to 
C,  C'  and  C,  thp  centres  of  coordination  for  movements  in  speech,  writing  and 
gestures. 

TV,  //'  and  N'  are  the  motor  nerves  concerned  in  symbol  expression  (speech, 
writing,  gestures).  At  their  terminali&n  these  nerves  are  broken  up  into  fibres 
distributed  to  individual  muscles. 

The  diagram  represents  the  reception  and  tracts  of  'word  symbols  through  the 
eye  and  ear.  The  tracts  of  other  auditory  and  ocular  impressions  are  not 
designated. 


straight  line.  With  visual  impressions  the  case  is  different. 
Aphasic  patients  very  generally  recognize  material  objects, 
but  exhibit  a  marked  defect  in  understanding  written  and 
printed  words,  as  well  as  in  expressing  the  concepts  in 
speech  and  writing.     The  tract  for  visual  word  symbols  is 


LOCALIZED  CEREBRAL  LESIONS.  539 

therefore  more  or  less  widely  separated  from  the  tract  for 
other  visual  impressions,  and  lies  in  some  parts  of  its  course 
near  the  centres  of  coordination  for  speech  and  writing,  or 
near  the  tract  from  B  to  the  latter.  This  explanation  is  in- 
genious, but  hardly  satisfactory.  If  the  tract  from  P '  io  B 
should  be  represented  by  a  circuitous  route,  that  from  Pto 
B  could  scarcely  have  been  direct  in  Dr.  A.'s  case,  be- 
cause the  word-deafness  was  even  more  marked  than  the 
word-blindness,  although  both  auditory  and  visual  impres- 
sions, with  the  exception  of  word  symbols,  were  interpreted 
with  equal  acuteness.  Indeed,  our  main  reliance,  when  the 
word  symbol  failed  to  be  recognized  by  him  in  conversation, 
was  to  present  the  word  to  him  in  writing.  The  reverse 
process,  that  is,  the  presentation  of  the  auditory,  in  place 
of  the  visual,  word  symbol  rarely  succeeded.  In  other 
words,  he  seldom  understood  the  spoken  words  when  he 
failed  to  comprehend  the  written  form. 

DR.   SEGUIN'S   report   OF  THE  AUTOPSY. 

The  autopsy  was  made  twenty  hours  after  death,  on 
June  20th.     The  body  was  well  preserved  in  ice. 

Head. — The  dura  mater  is  abnormally  adherent  to  the 
calvarium,  on  both  sides  equally;  no  thickening  of  dura. 
Pacchionian  bodies  small.  Marked  subarachnoid  effusion, 
which  has  gravitated  to  posterior  regions.  Dura  of  base 
normal.  The  basilar  artery  is  really  a  continuation  of  the 
right  vertebral  artery ;  the  left  being  only  i  mm.  thick. 
The  right  vertebral  and  the  basilar  arteries  are  the  seat  of 
patches  of  arteritis,  separated  by  regions  of  healthy  tissue, 
but  nowhere  obstructing  the  flow  of  blood.  Circle  of  Willis 
is  complete  and  patent.  The  carotids,  just  below  the  circle 
of  Willis,  are  extraordinarily  thickened,  quite  rigid,  but  not 
calcareous ;  their  wall  is  nearly  i  mm.  thick.  The  same  al- 
terations in  patches  can  be  traced  in  the  accessible  branches 


540  E-   C.   SEGUIN. 

of  the  middle  cerebral  arteries ;  the  anterior  cerebrals  are 
only  slightly  affected.  Nerves  at  the  base  normal.  The  left 
hemisphere  is  the  seat  of  a  large  depression  caused  by  the 
destruction  of  several  convolutions,  viz. :  the  whole  of  the 
inferior  parietal  lobule,  with  the  first  tier  of  temporal 
gyri.  The  posterior  extremity  of  the  angular  gyrus,  and 
the  whole  of  the  ascending  parietal,  are  preserved.  This 
lesion  is  a  yellow  patch  lying  in  the  region  supplied  by 
the   terminal   branches  of  the  left  middle  cerebral  artery. 


FIG.   8. 

Lateral  view  of  left  cerebral  hemisphere,  after  Henle.     Shaded  spot  shows 
the  superficial  location  of  the  yellow  patch. 

To  external  examination,  the  remaining  convolutions  are 
normal,  more  especially  the  third  frontal,  the  ascending 
frontal,  and  the  anterior  gyri  of  the  island  of  Reil.  The 
first  branch  of  the  middle  cerebral  artery  on  the  left  side  is 
pervious,  though  there  are  a  few  patches  of  arteritis  near 
its  origin.  The  main  trunk  of  the  artery,  in  the  fissure  of 
Sylvius,  and  its  two  terminal  branches  are  pervious  to  the 
confines  of  the  patch,  and  in  the  pia  covering  the  patch. 
The  patch  was  probably  caused  by  blockade  of  smaller  ar- 
teries which  cannot  be  traced.  The  right  hemisphere  pre- 
sents a  healthy  surface.  On  opening  the  fissure  of  Sylvius, 
the  middle  cerebral  artery  is  found  patent  but  bearing  a 
few  patches  of  thickening. 


LOCALIZED  CEREBRAL  LESIONS. 


541 


The  brain  is  sliced  in  transverse  vertical  sections. 

Section  No.  i,  about  37  mm.  (one  and  a  half  inch)  from 
apex  of  frontal  lobes,  presents  no  lesion. 

Section  No.  2,  at  a  distance  of  25  mm.  behind  No.  i, 
passing  through  the  posterior  extremity  of  the  third  frontal 
convolution  and  cutting  off  the  apex  of  the  temporal  lobe, 
is  free  from  lesion. 


FIG.  9. 

Digram  of  transverse  vertical  section  through  left  hemisphere,  showing  the 
extension  inward  of  the  patch.  This  view  corresponds  to  section  No.  4,  de- 
scribed in  the  text. 


Numerous  fine  slices  made  in  the  speech  tract  in  this  region 
{left  side)  reveal  no  alterations  of  structure. 

Section  No.  3,  25  mm.  further  back,  showing  the  lenticu- 
lar ganglion  and  the  thalamus,  no  lesion. 

Section  No.  4,  made  at    25  mm.  behind  No.  3,  passing 


542  E.   C.   SEGUIN. 

through  the  anterior  limit  of  the  yellow  patch  above  de- 
scribed, and  cutting  through  the  posterior  extremity  of  the 
thalami.  There  is  no  lesion  to  be  seen  except  the  yellow 
patch  in  the  left  hemisphere,  and  its  full  extent  is  well 
shown  ;  besides  destroying  the  convolutions  it  extends  deep 
into  the  white  substance  of  the  hemisphere  to  the  roof  of 
the  lateral  ventricle. 

Section  No.  5,  made  at  a  distance  of  25  mm.  posterior 
to  No.  4,  reveals  the  penetration  of  the  yellow  patch  as 
just  described. 

Section  No.  6  shows  no  lesion. 

The  brain  was  afterward  finely  sliced  up  without  any 
other  lesion  being  discovered. 

Sections  made  at  different  points  in  the  pons  Varolii  and 
medulla  oblongata  seem  normal. 

Cerebellum  normal. 

CONCLUDING   OBSERVATIONS   BY   DR.   SEGUIN. 

Dr.  A's  paraesthesiae  and  perversions  of  muscular  sense 
were  very  curious.  He  referred  his  sensations  of  numbness 
on  the  right  side  to  homologous  regions  in  the  hand  and 
foot,  viz. :  the  distribution  of  the  ulnar  nerve  and  that  of  the 
musculo-cutaneous  in  the  leg  and  foot.  In  the  right  side, 
generally,  the  paraesthesiae  were  of  drawing  up,  or  tighten- 
ing, and  as  if  a  strong  rotatory  movement  were  going  on  in 
each  limb  around  its  longitudinal  axis,  the  hand  in  prona- 
tion, the  foot  in  inversion.  The  patient's  account  of  these 
subjective  movements  never  varied,  and  he  would  often 
illustrate  them  by  moving  his  hand  and  forearm  in  extreme 
pronation  and  rotation. 

The  impairment  of  muscular  sense  of  which  he  com- 
plained was  something  which  I  had  never  met  with  before. 
If  he  did  not  use  his  eyes  in  prehending  objects  with  his 
right  hand,  he  would  find  that  he  had  seized  them  by  the 


LOCALIZED  CEREBRAL  LESIONS.  543 

wrong  end.  He  sometimes  found  himself  standing  with  the 
head  of  his  cane  on  the  ground  and  its  point  in  his  hand. 
Frequently,  in  my  presence,  he  essayed  to  grasp  a  pen  or 
pencil  with  his  head  turned  away,  and  repeatedly  he  found 
himself  holding  the  object  by  the  wrong  end,  and  this  after 
turning  it  over  three  or  four  times  to  get  its  outlines. 

Yet  with  these  perversions  of  sensibility  there  was  no 
common  anaesthesia,  either  to  pricking,  to  cold,  or  to 
aesthesiometer  points. 

Dr.  A's  aphasia  was  complex,  but  the  striking  feature 
in  it,  during  my  six  months'  observation,  was  the  word-deaf- 
ness. 

He  could  express  himself  fairly  well  in  short  sentences, 
and  might  for  a  little  while  carry  on  a  commonplace  conver- 
sation with  a  non-expert  without  betraying  his  defect ;  but 
he  frequently  failed  to  find  the  right  word,  and  often  found 
it  only  after  struggling  a  good  deal. 

In  attempting  to  speak  he  would  often,  after  failing  to 
get  the  proper  noun,  use  a  corresponding  verb  or  employ 
synonyms,  showing  that  his  idea  or  concept  was  always  cor- 
rect, but  that  his  vocabulary  was  faulty.  He  could  copy 
written  or  printed  characters  quite  readily,  but  experienced 
great  difficulty  in  writing  spontaneously. 

All  the  auditory  relations  of  language  were  much  im- 
paired. He  used  to  say  that  going  to  church  and  listening 
to  a  sermon  was  to  him  all  a  mixed-up,  meaningless  jargon, 
like  "  drub-arub-drub."  He  could  catch  very  few  words.  In 
ordinary  conversation,  familiar  short  sentences  were  appre- 
hended readily  ;  equally  simple  sentences,  containing  other 
than  the  most  commonplace  words,  had  to  be  repeated 
again  and  again.  Reading  from  a  book  was  jargon  to  him. 
Writing  from  dictation  was  impossible,  and  even  the  alpha- 
bet was  poorly  executed  in  this  way.  The  sound  of  the 
letter  c  seemed  the  one  for  which  he  was  most  deaf. 


544  E-   C.   SEGUIN. 

Yet  his  hearing  was  not  impaired  (I  never  tested  it  care- 
fully), and  he  understood  and  appreciated  music.  While  a 
lecture  or  a  sermon  was  unintelligible,  he  enjoyed  a  concert 
and  claimed  to  appreciate  it.  He  whistled  and  hummed 
airs  correctly — much  better  than  he  spoke. 

I  often  questioned  about  and  tested  him  for  hemiopia, 
with  negative  results.  Occasionally  he  had  attacks  of  mov- 
ing fortification  lines  in  the  left  fields  of  vision,  but  these 
were  evidently  phenomena  of  the  migraine  type. 

The  pathology  of  the  case  is  obscure  in  many  respects. 

The  arteritis  (see  Dr.  Peabody's  description)  is  not  of  the 
senile  type,  and  the  patient's  statement,  that  he  had  never 
had  syphilis,  was  positive,  and,  we  believe,  perfectly  trust- 
worthy. This  would,  therefore,  be  one  of  the  best  authen- 
ticated instances  of  non-specific  endarteritis  deformans, 
leading  to  obliteration  of  the  calibre  of  small  arteries, 
ischaemia  of  a  cerebral  territory,  and  softening.* 

The  location  of  the  lesion  is  peculiar,  and  some  years 
ago  would  have  been  considered  as  destructive  of  the  mod- 
ern theory  of  aphasia.  In  view  of  the  experiments  of 
Ferrier,  Munk,  ^  and  others,  however,  it  seems  clear  that  the 
lesion  occupied  a  portion  of  the  brain  which  is  concerned 
in  the  reception  of  sensory  impressions  from  various 
sources,  more  especially  the  eye  and  ear. 

So  long  as  aphasia  was  looked  upon  as  sometimes  a  form 
of  motor  disorder,  a  difficulty  in  the  emission  of  language, 
and  in  other  cases  as  dependent  upon  verbal  amnesia,  it 
was  impossible  to  explain  its  production  by  a  lesion  of  the 
parietal  or  sphenoidal  lobes.  In  the  last  two  or  three  years 
the  elements  of  imperfect  perception  of  the  written  signs 
and  spoken  sounds  of  language — word-blindness  and  word- 

^  It  is  very  much  to  be  regretted  that  the  cerebral  arteries  and  the  brain  it- 
self were  not  examined  microscopically  ;  but  the  autopsy  was  allowed  only  on 
condition  that  the  brain  be  not  retained  for  examination. 

*  Consult :  Ferrier,  The  Functions  of  the  Brain,  New  York,  1876  ;  Munk, 
Ueber  die  Functionen  der  Grosshirnrinde,   Berlin,   1881. 


LOCALIZED  CEREBRAL  LESIONS.  545 

deafness  respectively — have  received  some  recognition,  and 
these  phenomena  are  perfectly  explicable  by  lesions  placed 
in  the  sensory  or  perceptive  regions  of  the  cortex  and  in- 
ternal capsule. 

In  such  cases  the  aphasia  is  indirect,  not  due  to  any  inter- 
ference with  the  channel  for  the  emission  of  sound-forming 
impulses,  but  to  a  break  in  the  other  part  of  the  circuit, 
viz.,  the  receptive  organ. 

Dr.  A.  B.  Ball,  of  New  York,  is  the  author  of  the  article 
from  which  the  foregoing  large  extract  is  made,  and  my 
small  share  in  it  is  the  description  of  the  lesion  found  in 
the  brain,  and  some  general  remarks  upon  the  pathology  of 
aphasia.  In  this  connection  I  quote  from  the  article  be- 
cause the  lesion  seems  to  indicate  the  postero-inferior  limit 
of  the  motor  area  of  the  hemisphere.  Although  a  large 
part  of  the  inferior  parietal  lobule,  and  the  first  tier  of  tem- 
poral gyri,  together  with  the  associated  white  matter,  were 
necrosed,  there  was  no  permanent  hemiplegia.  At  the  be- 
ginning of  the  illness,  for  a  while  after  the  attack,  "  slight 
paresis  of  motility"  was  noted.  Whatever  value  this  case 
may  have  for  the  study  of  indirect  aphasia,  it  certainly  will 
rank  high  as  a  negative  case  in  the  question  of  cortical  mo- 
tor localizations. 

Case  5. — Abscess  of  the  left  frontal  lobe  of  the  cerebrum, 
•without  motor  phenomena.* 

On  April  11,  1880,  I  was  asked  by  Dr.  J.  Lewis  Smith  to  see  a 
case  in  consultation  with  himself  and  Dr.  J.  R.  Leaming.  The 
patient  was  a  young  married  woman,  aged  about  28  years,  who 
had  formerly  enjoyed  good  health  and  had  borne  several  chil- 
dren. During  the  month  of  February  one  of  these  children 
had  died  after  a  severe  illness,  and  she  had  undergone  consid- 
erable fatigue.  She  seemed  depressed,  weak,  and  anaemic  after- 
ward. 

About  four  weeks  before  the  date  of  consultation  she  com- 
plained of  pain  over  the  left  eye.     This  was   soon   accompanied 

^Archives  of  Medicine,  vol.  v.  No.  I,  Feb.,  1881,  p.  107. 


54^  E.   C.  SEGUIN. 

by  swelling  and  exophthalmus,  and  on  March  24th  Dr.  Knapp 
was  called  in  and  diagnosticated  orbital  (sub-periosteal)  abscess. 
This  was  opened  on  March  26th  by  Dr.  Knapp. 

It  was  remarked  that  the  pus  was  under  great  tension,  and 
that  it  spurted  out  a  considerable  distance  when  released.  Pain 
ceased  at  once,  the  exophthalmus  disappeared,  and  the  wound 
quickly  healed.  During  the  first  few  days  of  April  all  seemed 
going  on  well  ;  the  wound  was  healed  ;  the  patient  was  free  from 
pain  ;  she  was  taking  tonics,  and  on  the  3d  made  a  call  on  a  near 
neighbor. 

During  the  night  of  April  3d  and  4th,  one  week  before  my  ex- 
amination, she  awoke  with  severe  headache  and  vomiting  ;  ever 
since  she  has  lain  abed,  presenting  the  following  symptoms  : 
headache,  chiefly  mastoid  and  through  the  base  of  the  skull  ; 
occasional  vomiting  ;  irregular  respiration  ;  irregular  and  very 
slow  pulse,  varying  from  60  to  50  beats  per  minute  ;  stupor  and 
general  feebleness.  As  negative  points  there  were  no  symptoms 
about  the  eyes,  objective  or  subjective,  except  a  partial  ptosis 
of  the  left  upper  lid  (which  had  been  incised)  ;  no  fever,  chills, 
convulsions,  paralysis,  aphasia  ;  at  no  time  had  there  been  coma. 
The  urine  was  free  from  albumen. 

Examination. — Patient  was  soporose,  but  could  be  roused  by 
loud  speaking ;  she  answered  questions  as  if  half  asleep,  but  in 
such  a  way  as  to  leave  no  doubt  as  to  the  preservation  of  lan- 
guage. She  put  up  both  hands  to  the  mastoid  regions  when  indi- 
cating the  seat  of  pain.  A  minute  inspection  showed  no  paralysis 
except  about  the  left  eye,  whose  upper  lid  drooped  and  whose 
internal  rectus  was  inert.  The  pupil  on  the  left  side  was  not 
fully  dilated,  but  it  was  a  little  wider  than  the  right.  The  optic 
nerves  appeared  somewhat  congested,  and  were  dim  at  their  pe- 
riphery, but  there  was  no  actual  choking.  Patient  appeared  to 
feel  pinching  well  everywhere.  The  thermometer  showed  no 
fever.  The  pulse  varied  from  53  to  66  beats  per  minute,  and  it 
was  a  reluctant,  delusively  full  pulse,  with  no  real  strength.  The 
breathing  was  easy  and  regular,  but  friends  of  the  patient  de- 
scribed quite  well  a  Cheyne-Stokes  breathing  which  they  had 
observed.  There  was  neither  redness  nor  tenderness  about  the 
site  of  the  orbital  abscess. 

I  diagnosticated  an  abscess  of  the  brain  probably  in  the  left 
frontal  lobe,  and  expressed  the  opinion  that  the  patient  was  in 
imminent  danger.  She  died  the  next  day  in  a  comatose  state  ; 
no  new  symptoms  having  been  observed. 


LOCALIZED  CEREBRAL  LESIONS.  S47 

It  was  then  learned  that  for  two  years  Mrs.  F.  had  suf- 
fered from  frequent  attacks  of  headache,  lasting  several 
hours.  The  pain  was  frontal,  and  sometimes  extended 
along  the  nose  and  into  the  left  temple.  There  had  never 
been  symptoms  of  chronic  nasal  catarrh. 

The  autopsy  was  made  by  me  on  April  13th,  about  thirty 
hours  post  mortem,  in  the  presence  of  Drs.  Knapp,  J.  R. 
Leaming,  J.  Lewis  Smith  (the  attending  physician),  and 
Richard  Wiener,     We  found  a  large  abscess,  the  size  of  an 


FIG.  10. 
Apparent  location  of  the  abscess,  drawn  on  an  Ecker's  diagram  of  the  brain. 

English  walnut,  in  the  left  frontal  lobe.  It  seemed  to  lie 
wholly  under  the  cortex  cerebri,  in  the  convolutions  of 
the  orbital  lobule,  and  in  the  second  frontal  convolution. 
Viewing  the  hemisphere  from  the  side,  the  apparent  pos- 
terior limit  of  the  abscess  was  the  anterior  border  of  the 
lower  part  of  the  third  frontal  gyrus.  Fig.  10  indicates  the 
seat  of  the  soft,  fluctuating,  bulging  abscess.  Its  size  and 
penetration  were  not  then  determined,  as  it  was  thought 
best  to  harden  the  brain  as  a  whole,  before  making  sections. 


548  E.   C.   SEGUIN. 

The  external  connections  and  origin  of  the  abscess  were 
most  interesting.  There  was  only  one  point  of  adherence 
between  the  diseased  frontal  lobe  and  the  dura  mater,  and 
that  was  over  the  orbital  plate  of  the  frontal  bone  immedi- 
ately under  the  swollen  frontal  lobe.  There  the  dura  mater 
was  thickened  and  adherent  to  the  pia  mater  and  cortex 
cerebri,  forming  the  inferior  wall  of  the  abscess,  over  a 
space  as  large  as  a  ten-cent  piece  (about  15  mm.).  Under 
this  patch  of  pachymeningitis  the  orbital  plate  of  the  fron- 
tal bone  was  necrosed  and  perforated  ;  a  probe  was  easily 
passed  into  the  orbit. 

In  the  orbit,  under  its  periosteum,  pus  was  found,  and  a 
part  of  the  roof  and  the  inner  wall  of  the  orbit  were  cari- 
ous. Careful  dissection  by  Dr.  H.  Knapp  showed  disease 
of  a  similar  kind  in  the  ethmoidal  cells  and  frontal  sinus. 
I  need  say  nothing  more  of  the  conditions  of  these  parts 
and  of  the  pathology  of  the  orbital  abscess,  as  the  case  has 
been  fully  reported  from  this  point  of  view  by  Dr.  Knapp.' 

The  appearance  of  the  necrosed  orbital  plate  and  of  the 
thickened,  adherent  dura  mater,  was  precisely  similar  to 
what  I  have  several  times  seen  in  cases  of  suppurative  dis- 
ease of  the  internal  ear  with  cerebral  abscess  by  contiguity. 
The  genesis  of  the  abscesses  must  have  been  alike  in  the 
two  situations. 

In  December,  the  brain  having  been  sufficiently  hardened 
in  bichromate  of  potash  solution,  I  embedded  it  in  Gud- 
den's  microtome,  and  made  several  horizontal  sections 
through  the  whole  brain  with  the  view  of  demonstrating 
the  relations  of  the  abscess.  These  cuts  showed  that  the 
abscess  was  of  quite  as  large  a  size  as  at  first  supposed, 
almost  perfectly  globular  in  shape,  measuring  about  38 
mm.  in  diameter.  It  contained  ordinary  pus,  and  was  lined 
by   a   distinct    membrane    1-2  mm.    thick.     The   anterior, 

^Archives  of  Ophthalmology,  vol  ix,  p.  185. 


LOCALIZED  CEREBRAL  LESIONS.  549 

inferior,  and  external  limits  of  the  abscess  were  thinned 
cortex  and  pia  mater ;  superiorly,  posteriorly,  and  inter- 
nally, it  was  bounded  by  apparently  normal  white  sub- 
stance. The  whole  of  the  white  centre  of  the  frontal  lobe, 
except  a  portion  near  the  convexity  of  the  hemisphere, 
was  destroyed  to  within  lo  mm.  of  the  folds  of  the  island 
of  Reil,  and  about  8  mm.  of  the  head  of  the  nucleus  cau- 
datus.  The  mass  of  white  substance  connecting  the  infe- 
rior and  posterior  part  of  the  third  frontal  convolution  and 


Relations  of  the  abscess  as  shown  in  a  horizontal  section  of  the  brain  made 
at  the  level  of  Broca's  speech-centre.  Drawn  from  a  photograph  of  the  speci- 
men.    Occipital  lobes  cut  off. 

the  anterior  gyri  of  the  island  of  Reil  with  the  internal 
capsule,  was  uninjured. 

This  fact  is  of  capital  importance  in  estimating  the  bear- 
ing of  this  case  upon  the  current  notions  of  cerebral  locali- 
zation. 

The  above  description  of  the  topography  of  the  lesion, 
especially  its  posterior  limitation,  is  made  from  the  surface 
exposed  by  the  lowest  cut  made,  viz.,  one  passing  through 
the    speech-centre    of    Broca,    about     lo   mm.    above    the 


550  E.   C.  SEGUIN. 

apparent  commencement  of  the  fissure  of  Sylvius  (pia  still 
adherent).  Fig.  1 1  is  faithfully  drawn  from  a  photograph 
taken  of  this  section-surface.  The  rest  of  the  brain  was 
healthy  to  the  naked  eye. 

This  remarkable  case  seems  to  me  of  much  importance 
as  a  negative  contribution  to  cerebral  localization.  It  is  in 
exact  accord  with  recent  experimental  data,  and  with  the 
post-mortem  findings  of  the  last  ten  years,  that  an  abscess 
placed  like  this  one  should  give  rise  to  no  motor  symptoms, 
and  should  not  cause  aphasia.  It  is  wholly  within  what 
are  now  called  the  inexcitable  districts  of  the  brain.  The 
only  symptoms  present  were  the  partial  paralysis  of  the 
left  third  nerve  (more  immediately  caused  by  the  orbital 
abscess  ?)  and  signs  of  intracranial  pressure.  Yet  it  is 
important  to  note  that  in  spite  of  the  enormous  pressure 
which  must  have  existed  there  was  no  actual  neuro-retinitis. 

I  have  elsewhere  reported  another  case  of  (smaller) 
abscess  in  precisely  the  same  location  (left  frontal  lobe)  in 
which  no  symptoms  referable  to  this  lesion  were  present.' 

On  the  other  hand  numerous  autopsies  are  on  record  in 
which  a  smaller  lesion  (softening,  hemorrhage,  etc.),  placed 
a  centimetre  further  back  in  the  left  frontal  lobe,  involv- 
ing the  posterior  part  of  the  third  frontal  gyrus  or  the 
band  of  white  substance  between  it  and  the  nucleus  cau- 
datus,  has  given  rise  to  severe  symptoms,  hemiplegia  or 
aphasia,  singly  or  combined. 

In  the  paper  just  quoted  I  have  described  such  cases. 

This  case  has  the  same  negative  importance  as  Case  4 : 
serving  to  indicate  the  anterior  limit  of  motor  activities  in 
the  hemisphere.  It  shows  that  the  lower  part  of  the  first 
and  second  frontal,  and  the  orbital  lobule  of  the  frontal 
lobe,  have    no    direct   motor  connections  with    peripheral 

'  A  contribution  to  the  study  of  localized  cerebral  lesions.  Case  6.  Transac- 
tions of  the  American  Neurological  Association,  vol.  ii,  pp.  122-4,  N.  Y.,  1877. 


LOCALIZED  CEREBRAL  LESIONS.  55  ^ 

parts    of  the   body ;    and,  also,  that  these  regions   of   the 
brain  are  non-excitable. 

CONCLUSIONS. 

The  following  conclusions  may  be  legitimately  drawn 
from  the  cases  of  localized  cerebral  disease  (twelve  in  num- 
ber) which  I  have  published  in  the  last  four  years : 

1.  The  motor  area  of  the  cerebral  cortex  and  allied  white 
substance  extends  anteriorly  as  far  as  the  lower  half  of  the 
second  and  first  frontal  gyri,  and  posteriorly  as  far  as  the 
anterior  part  of  the  interparietal  fissure.  This  statement 
is  justified  by  Case  7  of  my  first  paper  (lesion  of  the 
left  frontal  lobe),  and  Cases  4  and  5  of  the  present  paper. 

2.  The  region  lying  between  the  limits  indicated  above, 
the  middle  regions  of  the  hemisphere,  on  its  convexity  and 
(to  a  certain  extent)  on  its  median  surface,  including  the 
posterior  parts  of  the  first  and  second,  the  whole  of  the 
third,  frontal  gyri,  the  whole  of  the  ascending  frontal  and 
ascending  parietal  gyri,  with  their  terminations  in  the 
longitudinal  fissure  known  as  the  paracentral  lobule,  with 
probably  the  upper  parietal  lobe, — all  these  cortical  parts, 
with  their  associated  segments  or  fasciculi  of  white  matter, 
have  strong  motor  functions,  being  in  direct  relation  with 
the  muscles  of  the  face,  tongue,  arm,  and  leg.  This  general 
statement  is  supported  by  the  remaining  nine  cases  in  the 
two  essays,  in  which  destructive  lesions  of  this  area  gave 
rise  to  spasm  or  paralysis  on  the  opposite  side  of  the  body. 

A  further  and  more  elaborate  induction  is  permissible 
from  these  nine  positive  cases  : 

a.  The  lower  part  of  the  third  frontal  gyrus  is  intimately 
connected  with  the  organs  of  speech  (and  the  function  of 
language). — Cases  i,  2,  3,  and  4  of  former  essay. 

b.  The  middle  parts  of  the  ascending  frontal  and  ascend- 
ing parietal  gyri  are  directly  connected  with  the  arm  of  the 


552  E.   C.   SEGUIN. 

opposite  side. — Case  5  of  first  essay,  and  Case  i  of  present 
paper. 

c.  The  upper  or  posterior  part  of  the  ascending  frontal 
and  ascending  parietal  gyri,  and  the  paracentral  lobule  (also 
the  upper  parietal  lobule?),  are  directly  connected  with 
the  lower  and  upper  extremities  of  the  opposite  side, 
and  perhaps  more  closely  with  the  leg. — Case  6  of  first 
essay.  Cases  2  and  3  of  present  paper. 

I  can  not  offer  any  case  bearing  on  the  questions  of  the 
location  of  the  facial  and  ocular  centres  ;  though  I  now 
have  under  study  a  living  case  of  exquisite  epileptiform 
facial  monospasm,  which  has  been  controlled  by  a  strict 
bromide  treatment. 


ELONGATION    OF    THE    SCIATIC  NERVE  IN 
LOCOMOTOR    ATAXIA. 

By    WILLIAM    A.    HAMMOND,    M.  D. 

THE  history  of  the  whole  subject  of  nerve-stretching 
for  the  relief  of  various  diseases  of  the  nervous 
system  has  been  so  thoroughly  given  quite  recently  by 
Drs.  Fenger  and  Lee,i  that  it  would  be  a  work  of  superero- 
gation for  me  to  go  over  the  ground  they  have  so  fully 
covered.  I  will  only  say,  therefore,  that  it  appears  that  for 
the  relief  of  locomotor  ataxia  nerves  have  up  to  this  time 
been  stretched  as  follows : 

1.  By  Langenbuch,  of  Berlin,  in  1879,  Sept.  13.  Patient 
had  for  several  months  suffered  with  the  ordinary  symptoms 
of  locomotor  ataxia.  Left  sciatic  was  first  stretched,  and 
twelve  days  afterward  the  right  sciatic,  and  both  crural 
nerves  were  subjected  to  like  treatment.  All  ataxic 
symptoms  disappeared  in  the  lower  limbs,  as  did  also 
the  electric-like  pains.  Pains,  however,  appeared  in  the 
upper  extremities,  and  it  was  determined  to  stretch  the 
nerves  of  these  parts.  But  the  patient  died  while  being 
anaesthetized  with  chloroform.  The  post-mortem  examina- 
tion, made  by  Prof.  Westphal,  showed  that  the  spinal 
cord  was  healthy. 

2.  Esmarch,  in  1880,  stretched  the  nerves  in  the  axilla 
for  a  supposed  but  doubtful  case  of  locomotor  ataxia.    The 

^  Nerve-stretching.     This  Journal,  April,  i88i,  p.  263. 

553 


554  WILL  I  A  M  A.  HA  MMOND. 

operation  was  followed  not  only  by  the  relief  of  the  pains 
which  had  been  experienced  in  the  arms,  but  by  the  disap- 
pearance of  all  pain  and  ataxic  symptoms  from  the  lower 
extremities. 

3.  Erlenmeyer,  in  1880.  This  was  an  old  case.  The 
right  sciatic  was  stretched  June  22d,  the  incision  being 
made  between  the  great  trochanter  and  the  tuberosity  of 
the  ischium.  There  was  no  relief  of  the  symptoms.  Never- 
theless, on  July  3d,  the  left  sciatic  was  stretched,  but  the 
result  was  similar. 

4.  Debove,  Paris,  1880.  Patient  had  suffered  for  six  years 
with  pains  in  the  lower  extremities ;  subsequently  there 
were  incoordination  and  atrophy  of  the  same  parts. 

November  i8th,  the  left  sciatic  nerve  was  stretched,  the 
incision  being  made  in  the  middle  of  the  thigh.  The  pains 
at  once  ceased,  and  the  incoordination  began  to  diminish. 
Two  weeks  after  the  operation  the  sensibility  was  normal, 
and  the  patient  could  move  the  legs  without  exhibiting 
more  than  slight  traces  of  incoordination.  He  could  stand, 
and  could  walk  a  few  steps  with  the  assistance  of  another 
person. 

5.  Debove,  December  16,  1880.  Pains  mainly  confined 
to  the  upper  extremities,  although  there  were  plantar  anaes- 
thesia and  incoordination.  The  right  median  and  ulnar 
nerves  were  stretched.  Pain  lessened  in  right  arm  and 
abolished  altogether  in  left  arm.  The  incoordination  was 
so  much  diminished  that  the  patient  was  able  to  walk  with- 
out assistance. 

6.  Dr.  Fenger,  of  Chicago,  was  the  first  in  this  country  to 
perform  the  operation  in  question  in  locomotor  ataxia.  The 
case  was  an  undoubted  instance  of  the  disease,  and  had 
lasted  about  ten  years. 

December  28,  1880,  the  nerves  of  the  lower  extremities 
were  operated  upon.     The  crural  nerves  were  first  exposed 


ELONGA  TION  OF  THE  SCI  A  TIC  NER  VE.  555 

on  each  side  by  an  incision  just  below  Poupart's  ligament. 
They  were  stretched,  replaced  in  the  wounds,  drainage 
tubes  were  inserted,  the  incisions  were  closed  with  antisep- 
tic sutures,  and  Lister  dressings  applied.  The  patient  was 
then  turned  on  his  face,  and  both  sciatic  nerves  were  sub- 
jected to  like  treatment.  Both  wounds  healed  by  the  first 
intention,  but  there  was  no  relief  except  as  regarded  the 
pain.  Bed-sores  ensued,  and  on  February  15th  the  patient 
died  pyaemic, 

7.  Socin,  of  Basle,  1881.  The  patient,  a  man,  33  years 
of  age,  had  the  ordinary  symptoms  of  locomotor  ataxia. 
The  right  sciatic  nerve  was  stretched.  The  wound  did  not 
heal  by  the  first  intention,  but  the  pain  on  the  right  side 
ceased.  The  left  sciatic  was  then  operated  upon.  Four- 
teen days  afterward  the  patient  died  from  multiple  embo- 
lism, caused  by  thrombosis  of  the  right  popliteal  nerve. 

Up  to  the  present  time,  therefore,  seven  cases  of  nerve- 
stretching  for  the  cure  of  locomotor  ataxia  have  been  per- 
formed. Of  these,  two  (Fenger's  and  Socin's)  died  from  the 
effects  of  the  operation,  and  one  (Langenbuch's)  from  the 
narcosis  of  the  chloroform  administered.  In  one  (Erlen- 
meyer's)  there  was  no  improvement.  In  all  the  others  there 
was  more  or  less  amelioration,  even  in  those  in  which  death 
occurred.  I  have  now  to  report  the  results  of  my  own  ex- 
perience, which  is  based  upon  two  cases. 

Case  i. — Mr.  F.,  of  Newark,  Ohio,  consulted  me,  June  19,  1880, 
for  an  affection  which  there  was  no  difficulty  in  recognizing  as 
locomotor  ataxia.  There  were  electric-like  pains  in  the  lower 
extremities  and  marked  incoordination,  the  patient  being  obliged 
to  walk  with  a  cane.  The  patellar  tendon  reflex  was  abolished  on 
both  sides  ;  both  pupils  were  strongly  contracted.  There  was 
partial  paralysis  of  the  bladder. 

I  saw  him  at  intervals  till  May  5,  1881,  when,  at  my  suggestion, 
he  came  to  New  York  to  consider  the  question  of  having  the 
sciatic  nerves  stretched.     I  gave  him  the  reports  of  several  cases 


556  WILLIAM  A.  HAMMOND. 

to  read,  in  which  the  operation  had  been  performed  with  more  or 
less  success,  and  he  determined  to  submit  to  the  operation. 

Up  to  this  period  his  disease  had  steadily  advanced.  In  walk- 
ing he  required  not  only  the  assistance  of  a  cane,  but  also  that  of 
some  person  holding  him  by  the  arm  of  the  opposite  side.  The 
pains  were  very  distressing. 

On  the  8th  of  May,  assisted  by  Dr.  G.  M.  Hammond,  I  operated 
on  the  right  sciatic  nerve,  the  pains  in  the  right  leg  being  more 
severe  than  in  the  other  one  ;  the  incoordination  greater. 

I  made  an  incision,  three  inches  in  length,  at  about  the  junction 
of  the  middle  with  the  lower  third  of  the  thigh,  immediately  over 
the  usual  course  of  the  sciatic  nerve.  I  intended  to  stretch  it  just 
before  its  division  into  the  peroneal  and  popliteal,  but  I  found  that 
the  division  took  place  high  up,  the  two  nerves  being  situated,  as 
they  came  from  beneath  the  biceps  muscle,  over  an  inch  apart. 
The  internal  or  popliteal  being  by  far  the  larger  branch,  and  the 
pains  being  almost  entirely  limited  to  it  and  its  branches,  I 
placed  the  little  finger  of  my  right  hand  under  it  and  gradually 
lifted  it  from  its  bed.  It  was  apparently  stretched  about  an  inch. 
The  wound  was  then  closed  with  ordinary  sutures  and  adhesive 
plaster. 

During  the  operation  the  patient  held  a  cone,  made  of  a  towel, 
and  containing  a  sponge  saturated  with  ether,  to  his  mouth  and 
nose  ;  and  though  he  was  at  no  time  completely  under  the  influ- 
ence of  the  anaesthetic,  the  sensibility  was  so  benumbed  that  he 
felt  nothing  more  than  what  he  described  as  a  slight  scratching. 

At  his  earnest  request  I  allowed  him  to  walk  from  the  lounge  to 
the  bed,  a  distance  of  ten  or  twelve  feet.  He  did  so,  he  said,  with 
greater  ease  than  for  two  years  past.  That  night  he  had  almost 
constant  twitching  of  the  muscles  above  and  below  the  point  at 
which  the  operation  was  performed,  but  there  were  no  pains.  By 
the  third  day  the  wound  had  entirely  healed  by  the  first  intention, 
and  I  then  made  a  thorough  examination  with  the  view  of  ascer- 
taining the  results. 

I  found  that  the  pains  in  that  leg  had  entirely  ceased. 

That  the  coordination  was  so  much  improved  that  the  patient 
was  able  to  walk  without  any  assistance,  not  even  requiring  a 
cane. 

That  the  insensibility  of  the  sole  of  the  foot  had  almost 
disappeared. 

That  the  patient  could  flex  all  the  toes,  an  act  he  had  not  been 
able  to  perform  for  over  a  year. 


ELONGATION  OF  THE  SCIATIC  NERVE.  557 

Such  being  the  apparent  benefits  it  was  determined  to  operate 
on  the  nerve  of  the  left  side,  as  there  were  still  pains  in  that  ex- 
tremity. Accordingly  on  the  13th,  assisted  by  Drs.  G.  M.  Ham- 
mond and  H.  M.  Norris,  I  operated  as  in  the  first  instance.  The 
nerve  had,  on  this  side,  its  usual  course  and  distribution,  and  was 
stretched  about  an  inch,  rather  less  than  more.  The  pains  at 
once  ceased,  and  the  patient  the  next  day  noticed  the  most  de- 
cided improvement  in  his  coordinating  powers.  This  wound 
also  healed  entirely  by  the  first  intention.  On  the  15th  he  re- 
turned home  greatly  improved,  and  very  confident  of  an  ultimate 
cure.  He  was  then  walking  without  a  cane,  could  stand  alone 
with  his  eyes  closed — an  impossible  feat  with  him  before  the 
operation, — was  free  from  pains,  and  there  was,  on  both  sides, 
slight  patellar  tendon  reflex.  The  following  letter  just  received 
from  him,  details  his  present  condition  : 

Newark,  O.,  June  14,  1881. 
Dr.  Wm.  a.  Hammond. 
Dear  Sir  : 

Thirty  days  having  expired  since  I  left  New  York,  I  will  now 
report. 

During  the  past  thirty  days  I  have  only  had  two  slight  touches 
of  pain  in  my  legs,  and  they  were  both  very  slight,  and  traceable 
to  exposure  and  climatic  changes.  The  incoordination  in  both 
legs  is  somewhat  improved,  and  I  can  walk  more  erect,  and  do 
not  have  to  look  down  so  constantly  when  I  walk,  as  heretofore. 

There  is  still  a  weakness  in  my  right  ankle,  first  leg  operated 
on,  and  stiffness  of  the  foot,  which  seems  slow  to  improve,  and  it 
makes  walking  rather  tiresome.  The  cushiony  feeling  in  the  feet  still 
remains,  but  there  is  an  improvement  over  what  it  was  before  the 
operation. 

Upon  the  whole,  I' think  it  safe  to  say  that  I  am  pleased  with 
the  results  of  the  operation  and  would  urge  any  one  with  same 
trouble  to  try  it. 

If  you  perform  any  more  operations  for  this  disease  I  should 
like  very  much  to  hear  the  results.  From  my  own  feeling  in  the 
matter  I  think  you  are  on  the  right  track,  and  the  stretching  will 
result   in  a  cure  in  most  cases  if  done  in  time.. 

P.  S. — I  can  handle  a  pencil  better  this  morning  than  for  many 
a  day. 

Case  2. — C.  S.,  was  sent  to  my  clinique  at  the  University  of 
New  York,  by  Dr.  H.  T.  Boldt,  May  12,  1881.  It  required  very 
slight  examination  to  discover  the  existence  of  an  extensive  de- 
velopment of  locomotor  ataxia.  The  incoordination  was  bad,  and 
the  patient  described    the    pains  in  both  legs  as  being  very  se- 


55^  WILLIAM  A.  HAMMOND. 

vere.  Standing  or  walking  with  the  eyes  closed  was  impossible. 
The  disease  had  existed  for  over  two  years. 

I  described  to  the  class  the  operation  which  I  had  a  few 
days  before  peformed  on  Mr.  F.,  and  suggested  to  the  patient  that 
a  like  operation  should  be  performed  on  him.  He  consented, 
and  desired  that  it  should  at  once  be  done. 

He  was  accordingly  placed  on  the  operating  table,  a  towel  with 
ether  was  given  to  him  to  hold  and  inhale  from,  and  the  operation 
was  performed  on  the  left  leg.  An  incision  about  three  inches 
over  the  course  of  the  sciatic  nerve  was  made,  and  the  nerve  was 
found  in  its  usual  position.  A  very  smooth  director  was  bent 
and  inserted  under  the  nerve,  a  tolerably  thick  cushion  of  mus- 
cle being  between  it  and  the  nerve,  I  performed  the  operation 
in  this  way  so  as  to  avoid,  as  far  as  possible,  the  destruction  of 
the  axis  cylinder.  The  nerve  was  stretched  apparently  about  an 
inch.  The  anaesthesia  was  sufficient  to  prevent  pain,  but  not 
to  abolish  consciousness.  The  wound  was  closed,  and  the  pa- 
tient, getting  off  the  table  without  assistance,  walked  around 
the  room  rapidly  and  well,  exclaiming,  "  I  am  cured  !  I  am 
cured  !  "  and  stating  that  all  pain  had  ceased,  and  that  he 
was  as  well  as  ever.  I  was  assisted  by  Drs.  G.  M.  Hammond, 
Osborn,  and  Boldt. 

Although  not  showing  the  sanguine  convictions  of  the 
patient,  it  was  evident  that  he  had  very  much  improved  in 
his  coordinating  powers.  A  few  days  afterward,  I  received 
the  following  letter  from  Dr.  Boldt  : 

New  York,  May  20,  1881. 
My  Dear  Doctor  : 

According  to  promise  I  give  you  some  information  regarding 
the  case  of  locomotor  ataxia  in  which  you  stretched  the  sciatic 
nerve,  and  am  fortunate  enough  to  add  another  case. 

After  the  operation  the  man  felt  so  well  and  strong  on  the  leg 
operated  that  he  tvalked  home,  did  not  use  any  car,  as  he  was  told 
by  me,  from  the  College  to  nth  Avenue,  between  42d  and  43d 
Streets.  On  the  succeeding  day  he  complained  of  severe  pain 
along  the  course  of  the  nerve  and  leg,  which  pain  continued  at 
intervals  for  five  or  six  days,  but  I  ascribe  it  to  unusual  long  walk 
which  he  took,  the  distance  being  longer  than  any  he  had  made 
for  a  number  of  years  ;  besides,  he  being  a  barber  has  been  at 
work  at  his  trade,  disregarding  the  wound,  all  the  time.  He  says 
that  he  feels  much  "stronger  "  on  the  leg  operated  upon,  and  thinks 
he  will  have  the  other  one  attended  to  also.  Otherwise  the  stretch- 


ELONGATION  OF  THE  SCIATIC  NERVE.  559 

ing  has  made  no  change,  the  girdle-like  sensations  in  epigastrium 
and  abdomen  continuing,  etc.,  etc. 

Relative  to  the  ultimately  good  effects  of  the  operation, 
I  am  by  no  means  so  confident  as  some  European  neurolo- 
gists. At  the  same  time,  it  appears  to  me  that  there  is 
ground  for  hope  that  it  may  prove  successful  in  some  cases. 
I  am  convinced  that  in  those  instances  in  which  gangrene, 
thrombosis,  etc.,  have  occurred,  the  nerve  has  been  stretched 
too  much.  A  very  moderate  extension  is,  I  think,  suf- 
ficient. 

Relative  to  the  point  of  election,  I  think  the  best  place 
is  just  as  the  nerve  comes  from  under  the  biceps  muscle, 
at  the  junction  of  the  middle  with  the  lower  third  of  the 
thigh.  The  operation  at  this  point  is  very  simple,  the 
nerve  lying  immediately  under  the  aponeurosis. 

My  rules,  therefore,  are:  Make  an  incision,  three  inches 
in  length,  at  about  the  middle  of  the  posterior  face  of  the 
thigh,  at  such  a  point  that  the  middle  of  the  incision 
comes  over  the  border  of  the  biceps  muscle,  at  the  apex  of 
the  triangle  formed  by  it  and  the  external  ham-string,  that 
is,  at  the  junction  of  the  middle  with  the  lower  third  of  the 
thigh.  Cut  through  the  aponeurosis  carefully,  and  expos- 
ing the  nerve,  place  the  little  finger  of  the  right  hand  under 
it,  and  gently  lift  it  from  its  bed.  Let  the  line  of  traction 
be  alternately  downward  and  upward,  so  as  to  stretch  the 
nerve  in  both  directions.  Return  the  nerve  to  its  position, 
and  close  up  the  wound  hermetically. 


NOTE  ON  A  PECULIAR   EFFECT    OF   THE   BRO- 
MIDES UPON  CERTAIN  INSANE  EPILEPTICS* 

By  henry  M.  bannister, 

FIRST   ASSISTANT    PHYSICIAN,    ILLINOIS    EASTERN    HOSPITAL    FOR    THE    INSANE,    KANKAKEE,   ILL. 

THE  action  of  the  bromides  is  generally  supposed  to 
be  to  lessen  cerebral  excitement  and  the  activity  of 
the  spinal  reflexes,  through  an  influence  on  the  vaso-motor 
mechanisms  of  the  great  nervous  centres.  Its  therapeutic 
action  in  epilepsy  is  supposed  to  depend  on  some  regulat- 
ing effect  on  the  vaso-motor  centres  in  the  medulla,  and 
this  to  be  in  the  nature  of  a  sedative  to  the  circulation.  I 
am  not  aware  of  any  publication  of  its  effects  as  a  cerebral 
excitant  in  this  disorder,  or  any  statement  that  its  ad- 
ministration is  followed  by  symptoms  of  excitement  or 
furious  intoxication.'  A  considerable  experience  with  epi- 
lepsy in  private  and  dispensary  practice  had  about  con- 
firmed my  faith  in  the  usually  accepted  views  as  to  the  ef- 
fects of  the  bromides,  and  I  was  therefore  surprised  to  hear, 
when  proposing  to  employ  the  usual  treatment  in  the  case 
of  an  epileptic  patient  in  this  hospital,  that  the  bromide 
medication  was  followed  in  this  case  by  furious  excitement 
and  genuine  epileptic  mania.  The  patient,  G.  L.,  was  a 
powerfully  built  man  of  about  thirty  years,  in  robust  gen- 
eral health,  but  liable  to  very  frequent  attacks  of  the  grand 
vial,  not,  however,  as  a  rule,  very  severe.     Beyond  a  slight 

*  Read  before  the  American  Neurological  Association,  June  i8,  1881. 

'  I  would  here  except  the  mention  of  mania  following  the  use  of  bromides  by 
Dr.  Hammond  in  his  treatise  on  nervous  diseases,  which  did  not  occur  to  me 
when  I  first  wrote  this  paper. 

560 


PECULIAR  EFFECT  OF  THE  BROMIDES.  $6 1 

degree  of  general  mental  weakness,  there  are  no  very  pro- 
nounced psychic  symptoms,  no  delusions;  he  is  trustworthy 
and  ordinarily  peaceable,  and,  like  most  of  the  other  epi- 
leptics in  the  hospital,  he  is  very  religiously  inclined.  His 
attacks,  even  the  most  severe  ones,  are  followed  by  only  a 
very  temporary  dazed  or  confused  condition,  lasting  from  a 
minute  or  two  to  perhaps  half  an  hour  at  the  most,  and  be- 
tween them  he  is  as  well  as  ever.  He  says  he  never  had  a 
headache  in  his  life.  He  is  temperate,  not  using  even  to- 
bacco, and,  on  the  whole,  a  very  good  patient  for  an  insane 
asylum.  His  very  frequent  attacks,  to  which  he  has  been 
subject  for  twenty-seven  years,  have  naturally  suggested 
treatment  with  the  bromides,  and  it  has  been  repeatedly 
tried  in  the  hospital,  with  the  effect  of  stopping  his  con- 
vulsions, it  is  true,  but,  at  the  same  time,  rendering  him 
liable  to  attacks  of  genuine  epileptic  furor,  and  making 
him  generally  a  very  unsafe  patient.  He  had,  prior  to  his 
committal  to  an  asylum,  taken  enormous  quantities  of  the 
bromides,  and  he  was  declared  homicidal  in  the  verdict  on 
which  he  was  received. 

Dr.  H.  N.  Moyer,  who  had  had  the  immediate  care  of  the 
patient  for  nearly  a  year,  and  who  had  made  the  previous 
observations  on  the  effects  of  the  bromides  upon  him,  told 
me  that  with  large  doses  ( 3  ss  ter  die)  he  could  be  made 
almost  unmanageable  in  three  or  four  days;  with  small 
ones  two  or  three  weeks  might  be  required.  On  one  occa- 
sion he  almost  completely  wrecked  a  screen  room  into 
which  he  was  placed  in  one  of  his  attacks  of  fury,  in  a  few 
minutes  tearing  out,  with  his  naked  hands,  lathing  and 
plaster,  and  even  beginning  to  make  way  with  the  window 
and  door  casings  before  he  could  be  subdued.  The  stop- 
page of  the  bromide  medication  in  every  instance  caused  a 
complete  subsidence  of  all  such  unpleasant  symptoms,  and 
the  reappearance  of  his  epileptic  attacks. 


562  HENRY  M.  BANNISTER. 

Being  somewhat  curious  in  regard  to  these  facts,  though 
I  could  not  discredit  them,  I  resolved  to  observe  the  effects 
of  the  medicine  upon  the  patient  myself,  and  ordered  for 
him  Seguin's  prescription  of  ten  grains  of  the  potassium 
and  five  grains  of  the  ammonium  bromide  in  an  alkaline 
solution  three  times  a  day.  The  effect  on  his  general  con- 
dition was  excellent ;  there  were  none  of  the  unpleasant 
phenomena  of  bromism,  not  even  an  acne  pimple,  so  far 
as  observed.  The  attacks,  which  had  been  as  frequent  as 
two  or  three  a  week,  ceased  almost  entirely,  his  mind 
seemed  to  brighten,  he  became  somewhat  more  active 
physically,  his  functions  were  all  regular,  his  pulse  was  all 
the  while  normal,  circulation  and  sleep  good.  But  with 
this  general  physical  and  mental  improvement  in  most  re- 
spects, there  gradually  appeared  an  offensive  self-impor- 
tance and  quarrelsomeness ;  and  after  some  three  weeks  of 
the  treatment  he  was  a  very  disagreeable  and  decidedly 
dangerous  lunatic;  and  after  he  had  made  an  unprovoked 
assault  upon  an  attendant,  and  had  nearly  torn  the  clothes 
off  from  him,  it  was  not  considered  advisable  to  continue 
it  any  longer.  The  patient  was,  a  few  days  after  the  dis- 
continuance of  the  medicine,  the  same  rational  and  man- 
ageable subject  as  before,  with  also  the  former  frequency 
of  his  epileptic  attacks. 

Two  other  epileptics  in  the  hospital  were  reported  to  ex- 
hibit the  same  idosyncracy  as  regards  the  effect  upon  them 
of  the  bromides,  and,  as  far  as  I  have  observed,  correctly. 
One  of  these,  a  semi-demented  case,  became  under  the 
treatment  exceedingly  talkative  and  troublesome,  though 
never  dangerously  violent.  The  other  was  always  liable  to 
violent  outbursts  of  temper,  and  he  was  cautiously  tried 
with  hydrobromic  acid  in  moderate  doses,  with  the  appar- 
ent effect  of  increasing  this  tendency.  One  or  two  other 
epileptic   cases  were  not   benefited    by  the  bromides,  but 


PECULIAR  EFFECT  OF  THE  BROMIDES.  563 

none  of  the  others  in  the  hospital  showed  any  such  results 
of  treatment  with  these  drugs  as  did  the  cases  I  have  men- 
tioned. In  the  case  of  G.  L.  they  have  been  observed  by 
Dr.  Moyer  to  follow  the  administration  of  potassium, 
sodium,  and  ammonium  bromides,  both  when  used  sepa- 
rately and  in  combination  with  each  other. 

The  large  proportion  of  cases  showing  this  idiosyncracy 
— 3  out  of  21  epileptic  patients  in  the  hospital — would 
appear  to  indicate  that  it  is  not  very  rare,  yet,  as  I  have 
said  in  the  beginning,  I  have  not  seen  in  print  any  mention 
of  it.  It  has  undoubtedly  been  observed  before,  and,  in  fact, 
I  have  the  verbal  testimony  of  Drs.  J.  S.  Jewell  and  J.  G. 
Kiernan,  of  Chicago,  that  they  have  observed  similar  cases 
to  the  ones  I  have  mentioned  above.  It  is  not  at  all  strange 
that  such  cases  should  be  more  frequent  among  the  epilep- 
tics in  an  insane  hospital  than  among  the  ordinary  subjects 
of  the  disorder,  for  the  former  class  are  generally  those 
who$e  violent  manifestations  have  led  to  their  seclusion  as 
dangerous  lunatics.  It  is  easy  to  suppose  that  the  bromide 
medication  may  have  been  indirectly  the  main  cause  of  the 
commitment  as  insane  in  the  case  of  G.  L.,  though  there  is 
no  real  evidence  that  such  was  the  case. 

The  fact  that  in  these  cases  the  suppression  of  the  epilep- 
tic attacks  by  the  bromides  was  accompanied  by  cerebral 
excitement  and  outbursts  of  maniacal  furor,  is  strongly  sug- 
gestive that  the  attacks  themselves  are  somewhat  of  the 
nature  of  a  safety-valve  in  some  cases,  and  that  the  epilepsy 
is  itself  an  alternative  to  acute  and  dangerous  mania.  Bad 
as  it  is,  it  may  be  the  better  alternative.  The  cerebral  ex- 
citement is  perhaps  not  to  be  ascribed  directly  to  the  medi- 
cine, but  is  secondary  to  its  usual  therapeutic  effect — the 
suppression  of  the  fits, — and  this  may  be  the  best  explana- 
tion of  the  phenomena.  I  leave  these  suggestions,  however, 
as  simply  suggestions,  and   offer  the    facts   themselves  as 


564  HENR  V  M.    BANNISTER. 

illustrating  a  possible  action  of  the  bromides  in  epilepsy 
that  has  not,  to  my  knowledge,  been  very  prominently 
brought  before  the  profession. 

It  is  my  intention  to  make,  with  the  cooperation  of  Dr. 
R.  S.  Dewey  and  Dr.  Moyer,  some  further  observations  on 
the  effects  of  treatment  of  this  class  of  cases,  and  the  above 
may  be  considered  as  merely  a  preliminary  communication. 


THE  HYPOTHETICAL  AUDITORY  TRACT  IN 
THE  LIGHT  OF  RECENT  ANATOMI- 
CAL OBSERVATIONS  * 

By  GR^ME  M.  HAMMOND,  M.D., 

PHYSICIAN   TO   THE   DEPARTMENT   FOR   NERVOUS   DISEASES   IN   THE   METROPOLITAN   THROAT 

HOSPITAL. 

AT  a  meeting  of  the  New  York  Neurological  Society, 
held  on  February  ist,  of  this  year,  I  read  a  paper 
describing  and  giving  the  measurements  of  certain  gigantic 
nerve  cells  discovered  by  myself,  and  showing  by  compari- 
son that  these  cells  were  larger,  as  far  as  carnivora  were 
concerned,  than  any  of  the  giant  cells  described  by  Betz  in 
his  communication  -entitled  "An  Anatomical  Description 
of  Two  Brain  Centres,"  which  appeared  in  the  Centralblatt 
of  1874. 

In  this  article  Betz  claims  that  the  cells  discovered  by 
him  are  larger  than  the  cells  of  any  other  region  of  the  cen- 
tral nervous  system. 

In  making  this  statement  its  author  does  not  seem  to  have 
borne  in  mind  that  the  existence  of  as  large  and  larger  cells 
has  already  been  established.  While  the  statement  would, 
therefore,  be  inaccurate  as  applied  to  man,  it  is  demonstra- 
bly erroneous  as  applied  to  the  lower  animals,  on  whose 
brains  his  researches  were  first  made  ;  for  here  it  can  be 
shown  that  other  cells,  in  lower  centres,  are  decidedly 
larger  than  those  of  the  so-called  "  cortical  nests." 

*  Read  in  outline  before  the  American  Neurological  Association,  June  16, 
1881. 

565 


566  GRMME  M.  HAMMOND. 

From  the  brain  of  the  same  cat  in  which  I  discovered 
the  giant  cells  before  mentioned,  I  prepared  some  150  sec- 
tions from  a  larger  number  cut  transversely  to  the  cerebral 
axis,  and  embracing  that  portion  of  the  brain  included  be- 
tween the  lower  olivary  altitude  and  the  optic  lobes  of  the 
corpora  quadrigemina. 

These  sections  enabled  me  to  make  a  thorough  study  and 
examination  of  the  cells  contained  in  the  optic  lobes,  nu- 
cleus tegmenti,  and  auditory  nucleus.  These  cells  are  not  a 
new  discovery.  They  were  known  to  Meynert,  and  their 
dimensions  in  the  human  brain  have  been  given  by  him, 
but  no  one  that  I  am  aware  of  has  given  the  comparative 
measurements  of  these  cells. 

I  think  it  preferable  in  giving  the  comparative  measure- 
ments of  cells  and  their  nuclei  of  different  centres,  to  draw 
my  deductions  from  measurements  made  of  the  cells  con- 
tained in  different  centres  of  the  same  brain  rather  than  to 
compare  the  measurements  of  different  centres  of  different 
brains.  I  therefore  propose  in  the  present  paper,  to  give 
the  measurements  and  descriptions  of  cells  of  the  optic 
lobes,  nucleus  tegmenti,  and  the  auditory  nucleus,  from  sec- 
tions taken  from  the  same  brain,  and  also  to  compare  them 
with  the  cells  of  the  cortical  group  discovered  by  myself. 

Let  us  occcupy  ourselves  first  with  the  consideration  of 
the  large  multipolar  cells  of  the  optic  lobes  of  the  corpora 
quadrigemina. 

The  optic  lobes  differ  anatomically  from  the  post-optic 
lobes,  or  nates,  chiefly  in  the  fact  that  they  possess  a  true 
cortical  structure.  Looking  below  the  peripheral  layer  into 
the  deeper  structure  of  the  optic  lobes,  a  group  of  giant  cells 
can  be  seen  of  about  the  same  size  and  shape  as  those 
known  to  Betz.  They  resemble  very  closely  the  large  mul- 
tipolar cells  found  in  the  lumbar  enlargement  of  the  spinal 
cord.     Their  outlines  are  very  distinct  and  their  numerous 


THE  HYPO  THE  TIC  A  L  A  UDI  TOR  Y  TEA  CT.  5  6/ 

processes  plainly  visible.  Many  of  these  cells  appear  circu- 
lar in  the  sections,  but  this  is  probably  due  to  their  being 
obliquely  cut,  or  to  imperfect  staining.  In  their  long  diam. 
eter  they  measure  from  .03  mm.  to  .10  mm.,  and  transversly 
from  .02  mm.  to  .07  mm.  Their  nuclei  measuring  from  .01 
mm.  to  .025  mm.  in  diameter. 

These  cells  are  not  found  in  nests.  The  largest  cells  do 
not  always  possess  the  largest  nuclei ;  in  fact,  there  seems 
to  be  no  rule  governing  the  size  of  the  nucleus  in  propor- 
tion to  the  size  of  the  cell ;  for  a  very  large  cell  maybe  seen 
to  be  provided  with  one  of  the  smallest  nuclei,  and  a  small 
cell  may  possess  a  nucleus  whose  circumference  almost  equals 
that  of  the  cell  itself. 

The  cells  presented  for  observation  in  the  following  wood- 
cut, fig.  I,  are  specimens  of  cells  from  the  optic  lobes  of 
the  corpora  quadrigemina  of  the  cat.  Although  the  cell 
shown  in  the  centre  of  the  illustration  is  a  large  one,  its 
long  diameter,  exclusive  of  processes,  measuring  about 
.08  mm.,  it  possesses  one  of  the  smallest  nuclei.  The  pro- 
cesses in  this  cell  are  plainly  visible.  Let  us  now  proceed 
to  describe  the  cells  of  the  nucleus  tegmenti :  a  large  nu- 
cleus situated  in  the  same  altitude  as  the  optic  lobes,  and 
about  midway  between  the  central  tubular  gray  and  the 
ganglion  of  Soemmering.  Here  we  find  giant  cells,  circular 
and  ovoid  in  form,  with  a  central  round  nucleolated  nucleus. 
They  are  densely  settled,  but  are  not  arranged  in  any  regu- 
lar order.  They  possess  from  one  to  six  visible  processes. 
The  ovoid  cells  measure  from  .07  mm.  to  .12  mm.  in  their 
long  diameter,  and  from  .03  mm.  to  .05  mm.  transversely. 

The  circular  cells  measure  from  .04  mm.  to  .08  mm.  in 
diameter.  The  nuclei  of  both  varieties  measure  about  .025 
mm.  in  diameter.  In  fig.  2,  a  representation  of  both  va- 
rieties of  these  cells  is  given.  The  words  ovoid  and  circu- 
lar refer  to  the  cells  apparently  devoid  of  processes. 


568 


GR^ME  M.  HAMMOND. 


The  cells  discovered  by  myself  were  found  in  sections 
taken  from  the  brain  of  the  same  cat  from  which  the  sec- 
tions illustrating  the  cells  of  the  optic  lobes  and  nucleus 
tegmenti  were  made.  These  cells,  unlike  the  two  last 
mentioned,  were  found  in  the  true  cortical  structure  in  the 
first  primary  arched  gyrus,  anterior  to  the  fissure  of  Sylvius. 
They  were  found  in  both  hemispheres,  but  only  to  a  slight 
extent  in  the  right  one.  In  size  they  measured  from  .05 
mm.  to  .12  mm.  in  length,  and  from  .04  mm.  to  .06  in  width, 
with  a  central,  round,  nucleolated  nucleus  measuring  about 
.03  mm.  in  diameter. 

These  cells,  when  compared  to  the  cells  found  in  the 


Fig.  I. 


Fig.  2. 


optic  lobes  and  nucleus  tegmenti,  present  marked  similari- 
ties in  many  respects.  Regarding  their  dimensions  to  the 
dimensions  of  their  nuclei  they  are  nearly  identical  ;  and, 
though  many  of  the  cells  of  the  optic  lobes  resemble  some- 
what the  appearance  of  the  multipolar  cells  of  the  lumbar 
enlargement  of  the  spinal  cord,  yet,  when  groups  of  the 
three  varieties  are  compounded  together,  it  may  be  seen 
that  each  variety  is  nearly  a  reproduction  of  the  other. 

Since  reading  my  paper  describing  the  new  cells  in  the 
cat's  brain,  I  have  pursued  my  investigations  farther,  and 
examined  the  cortical  structure  of  the  human  brain  about 


THE  HYPOTHETICAL  AUDITORY  TRACT.  569 

that  area  supposed  to  correspond  to  the  point  where  I  lo- 
cated the  cells  found  in  the  cat's  brain. 

From  about  sixty  or  seventy  sections  made  from  both 
hemispheres,  I  was  enabled  to  find  five  or  six  sections  con- 
taining cells  in  every  respect  identical  with  those  discovered 
in  the  cat's  brain,  though  somewhat  smaller  and  less  nu- 
merous. 

It  is  my  purpose,  by  comparing  the  descriptions  and 
measurements  of  the  new  cortical  cells  with  the  cells  of  the 
auditory  nucleus  and  the  other  cells  of  the  auditory  tract,  to 
show  that  the  cells  I  discovered  are  presumably  related  to 
hearing,  and  to  advance  the  theory  that  the  cortical  auditory 
centre  is  composed  of  a  group  of  cells  identical  in  form  and 
structure  with  the  cells  of  the  auditory  nucleus  and  tract, 
and  that  it  is  situated  in  the  gyrus  angularis,  above  the 
horizontal  branch  of  the  fissure  of  Sylvius,  and  at  a  distance 
from  its  posterior  extremity  equal  to  about  one-fourth  of 
its  length. 

A  confirmation  of  this  theory  has  been  presented  by  Dr. 
A.  B.  Ball,  in  the  Archives  of  Medicine,  April,  1 881,  in  which, 
in  his  article  on  "  A  Contribution  to  the  Study  of  Apha- 
sia," he  mentions  the  phenomena  of  "  word-deafness,"  re- 
sulting from  a  spot  of  cerebral  softening  involving  that  por- 
tion of  the  cortex  situated  above  and  at  the  posterior  ex- 
tremity of  the  fissure  of  Sylvius.  Although  the  "  centre  " 
discovered  by  myself  was  located  about  18  mm.  anterior  to 
the  spot  of  cerebral  softening  shown  in  the  illustration  in 
Dr.  Ball's  article,  yet  their  proximity  is  not  without  cer- 
tain points  of  interest,  for  either  the  area  containing  the 
cells  may  have  been  more  extensive  than  I  supposed,  or 
it  is  possible  that  the  cells  of  that  region,  being  deeply 
seated,  may  have  undergone  softening  without  that  fact 
having  been  observed  at  the  autopsy. 

The  destruction  of  the  cortical  auditory  area  would   not 


570  GRMME  M.  HAMMOND. 

obstruct  the  hearing,  but  it  would  render  it  impossible  to 
convert  the  impression  received  into  a  logical  conception  of 
the  sound  heard.  Dr.  Ball,  speaking  of  his  patient,  says  : 
"  Early  in  his  illness,  on  my  remarking  to  him  one  day, 
'  Dr.  Peters  called  to  see  you,'  he  replied,  '  I  don't  know 
him.'  The  name  was  repeated  several  times,  but  he 
failed  to  recognize  it,  although  it  was  the  name  of  an  inti- 
mate friend.  The  written  name  was  then  shown  him. 
'  What  a  fool  I  am,'  he  exclaimed,  '  of  course  I  know  him.' 
This  was  the  first  instance  in  which  my  attention  was  drawn 
to  the  fact  that  certain  auditory  impressions  failed  to  be 
converted  into  concepts,  although  the  conceptive  faculty 
remained  intact." 

I  can  hardly  agree  with  Dr.  Ball  in  his  statement  "  that 
the  conceptive  faculty  remained  intact,"  for,  had  such  been 
the  case  a  logical  conception  would  have  followed  the 
auditory  impression  ;  on  the  contrary,  when  the  name  was 
mentioned  he  did  not  recognize  the  sound  of  it.  But  when 
the  written  name  was  presented  before  him,  the  impression 
was  optical  and  was  transmitted  as  such  to  the  cortical 
optical  centre  for  /^rception. 

The  fact  that  he  could  read  and  identify  the  name  with 
the  object  showed  that  so  far  and  no  further  the  concep- 
tion of  Dr.  Peters  had  not  suffered.  But  insomuch  as  per- 
ceptions  are  the  necessary  basis  for  ^(?«ceptions,  it  cannot 
be  said  that  the  patient's  conceptional  sphere  was  free,  as 
the  auditory  perceptions  were  absent. 

Quoting  from  Dr.  Ball,  the  patient  again  says  :  "  The 
words  I  can't  pronounce  are  the  words  I  can't  hear"  show- 
ing that  only  the  impressions  of  a  limited  number  of 
sounds  failed  to  produce  correct  conceptions.  This  proves, 
to  my  mind,  that  either  the  cortical  auditory  "  centre  "  was 
only  involved  in  the  process  of  softening  to  a  slight  degree, 
or  that  only  a  part  of  the  "  centre  "  came  within  the  range 


THE  H  YPO  THE  TICAL  A  UDITOR  V  TRA  CT.  5/1 

of  the  area  of  softening.  I  am  rather  inclined  to  the  latter 
view. 

Anatomically  it  is  well  established  that  after  abutment 
of  the  auditory  nerve  root  in  the  auditory  nucleus,  the 
auditory  tract  chiefly  takes  a  course  to  the  nucleus  den- 
tatus  in  the  cerebellum,  from  thence  through  the  brachium 
conjunctivum,  and  thence  to  the  nucleus  tegmenti.  From 
this  point  the  auditory  tract  is  imperfectly  traced,  but  it  is 
clear  that  either  through  the  lowest  medullary  laminae  of 
the  thalamus,  or  through  the  posterior  part  of  the  internal 
capsule,  it  is  continued  to  the  cortex. 

As  far  as  I  can  glean  from  Flechsig's^  great  monograph, 
the  fibres  of  this  region  can  be  traced  to  the  vicinity  of  the 
posterior  end  of  the  fissure  of  Sylvius.  This  theory  was  in 
part  anticipated  by  Meynert  ^  and  confirmed  by  Mendell, 
these  authors  tracing  the  tract  as  far  as  the  nucleus 
tegmenti  by  chiefly  anatomical  methods.  A  further  con- 
firmation was  offered  by  Spitzka,^  who  identified  the  nu- 
cleus tegmenti  in  those  reptiles  possessing  large  cells  in  the 
auditory  nucleus,  and  who  notes  that  throughout  the 
animal  range  the  cells  of  the  nucleus  tegmenti  and  the 
special  division  of  the  auditory  nucleus  seemed  to  keep 
step  in  development. 

The  cells  of  the  auditory  nucleus  are  larger  and  their 
processes  more  boldly  marked  than  any  of  the  other 
varieties  I  have  described  in  this  paper,  yet  in  their  gen- 
eral characteristics  they  are  similar  to  those  cells  found  in 
the  other  groups.  They  measure  from  .07  mm.  to  .15  mm. 
in  length,  and  from  .04  mm.  to  .09  mm.  in  width,  the  nuclei 
measuring  about  .03  mm.  in  diameter. 

While  I  would  hesitate  to  commit  myself  to  the  view 

^  Forel.  Unterschungen  uber  die  Haubenregion.  Archiv  fuer  Psychiatrie, 
vii.     Spitzka.     Journal  of  Nervous  and  Mental  Disease,  1880. 

*  Th.  Meynert.     Vom  Gehirn  der  Saugethiere.     Strieker's  Handbuch. 

•  Spitzka.     Further  notes  on  the  brain  of  the  Iguana  and  other  Sauropsida. 


572  GR^ME  M.  HAMMOND. 

that  resemblance  in  size  and  shape  of  nerve  cells  neces- 
sarily involves  similarity  of  function,  yet  it  must  be  ad- 
mitted that  there  is  a  certain  parallelism  between  the  cells 
connected  with  special  nerve  tracts.  In  this  respect  I  need 
but  instance  the  close  resemblance  existing  between  the 
giant  cells  of  Betz  and  the  cells  of  the  lumbar  enlargement 
of  the  spinal  cord. 

From  this  point  of  view  the  general  similarity  between 
the  elements  of  the  large-celled  division  of  the  auditory 
nucleus,  of  the  nucleus  tegmenti,  and  of  the  cortical  nest 
described,  lends  support  to  the  view  that  they  are  stations 
upon  one  tract.  But  a  still  stronger  support  is  to  be  found 
in  the  fact  that  the  size  and  development  of  the  auditory 
nucleus,  the  nucleus  tegmenti,  and  the  cortical  nest  keep 
step,  in  the  animal  range,  within  certain  limits,  and  as  far 
as  ascertained  ;  that  is,  where  the  large-celled  division  of 
the  auditory  nucleus  is  largest  the  nucleus  tegmenti  is  most 
massive  and  the  cortical  nest  most  numerous  in  cells. 

This  theory  is  in  part  confirmed  by  the  report  of  a  case 
of  "  Congenital  Atrophy  of  the  Brain,"  which  appeared  in 
the  paper  of  Rohon.'  Here,  though  the  mass  of  brain 
substance  was  diminished  to  a  remarkable  extent,  there 
was  no  atrophy  of  the  auditory  nucleus,  of  the  nucleus 
dentatus,  nor  of  the  nucleus  tegmenti. 

As  we  ascend  in  the  scale  we  find  this  progress  greater  in 
the  cortical  area  than  in  the  nucleus  tegmenti,  and  greater 
in  the  latter,  in  turn,  than  in  the  auditory  nucleus. 

This  presents  a  certain  resemblance  to  three  other  cell 
groups, — those  related  to  the  innervation  of  muscles  of 
animal  life.  Here  the  lowest  group,  that  is,  the  multipolar 
cells  of  the  anterior  horns  of  the  spinal  gray,  are  pre- 
sumably presided  over  by  the  multipolar  cells  of  the  teg- 
mentum, and  these  in  turn  by  the  giant  cells  of  Betz. 

'  Rohon.     Untersuchung  iiber  ein  Microcephalen-Gehim,  IVien,  1879, 


THE  H  YPO  THE  TIC  A  L  A  UDITOR  Y  TRA  CT.  573 

These  three  groups  of  cells  follow  the  same  laws  of  prog- 
ress that  have  already  been  cited  for  the  sensory  cells ;  that 
is,  where  there  is  an  increase  in  the  number  of  cells  in  the 
lowest  group  there  is  also  an  increase  in  the  higher  ones, 
and  this  increase  in  the  higher  group  is  greater  in  pro- 
portion to  that  in  the  lower;  for  example,  just  as  there  is 
progress  in  the  development  of  cells  in  the  anterior  spinal 
cornu  in  the  frog  as  contrasted  with  the  proteans,  so  there 
is  a  still  greater  increase  in  the  cells  in  the  reticular  field  in 
lower  mammalia  as  contrasted  with  the  reptiles  and  amphib- 
ians, and  a  still  more  rapid  stride  in  the  higher  mammalia 
over  the  lower,  in  whom  these  cell  groups  are  really  absent. 

This  anatomical  fact  is  in  parallelism  with  the  physio- 
logical observation  that  the  simple  reflex  acts  are  the  com- 
mon property  of  all  animals,  high  and  low  ;  that  progress 
in  function  is  first  manifested  in  the  development  of 
coordinate  reflexes,  which,  in  their  turn,  are  merely  step- 
ping-stones for  the  highest  nervous  combinations  of  psy- 
chical life. 


NOTES  ON  THE  CENTRAL  NERVOUS  SYSTEM 
OF  REPTILES. 

By  JOHN  J.  MASON,  M.D., 

NEWPORT,   R.  I. 

L  On  a  lateral  fibrous  cord  in  Ophidians  and  Saurians, 
the  homologue  oi  the  ligamentum  denticulatum. 

In  carmine-stained  cross-sections  this  structure  is  seen  as 
a  dark  oval  object  between  the  membranes,  Just  above 
the  ventral  roots.  When  the  membranes  are  removed  be- 
fore section,  a  deep  depression  is  left  in  the  outline  of  the 
myelon,  marking  the  position  of  the  ligament.  Longitudi- 
nal sections  show  that  it  is  composed  solely  of  fibrous 
tissue. 

These  statements  apply  to  the  myelon  of  serpents.  It 
has  been  present  in  seven  different  species  which  I  have 
examined,  including  the  rattlesnake,  moccasin,  and  black 
snake  (Gopher)  of  the  South.  Its  development  was  found 
to  be  alike  in  all  the  species  examined,  and  in  all,  it  ex- 
tended from  the  extreme  caudal  end  of  the  myelon  as  far 
forward  as  the  fourth  ventricle.  The  same  structure  is 
also  seen  in  Anolius  Carolinensis,  the  skinks,  horned 
toads,  Heloderma,  and  the  alligator,  but  developed  to  a 
much  less  degree  than  in  serpents.  In  the  horned  toad, 
throughout  the  spinal  cord,  it  is  but  rudimentary,  and  the 
same  is  true  of  the  dorsal  region  of  the  alligator.  I  have  not 
found  a  trace  of  it  in  any  of  the  Chelonia,  not  excepting  the 
caudal  region  of  the  snapping  turtle-Chelydra  serpentina. 

574 


THE  CENTRAL  NERVOUS  SYSTEM  OF  REPTILES.      575 

Reissner'  does  not  seem  to  have  found  it  in  the  lamprey 
(Petromyzon  fluviatilis),  and  Grim^  does  not  mention  nor 
figure  it  in  his  work  on  Vipera  berus. 

II.  On  a  normal  ventro-dorsal  compression  of  the  mye- 
lon  at  the  acute  angle  made  by  the  articulation  of  the  last 
cervical  vertebra  with  the  carapax  in  Cistuda  Carolina  (Hol- 
brook),  box  turtle.  In  this  animal  the  ventral  surface  of  the 
carapax  is  very  deeply  and  abruptly  concave,  and  during 
the  complete  retraction  of  the  neck  and  closure  of  the 
cephalic  portion  of  the  plastrum,  the  articulating  surface  of 
the  body  of  the  vertebra  named,  encroaches  upon  the  verte- 
bral canal,  causing  a  marked  change  in  shape  of  the  mye- 
lon  at  this  point.  In  cross-sections  the  entire  lateral  masses 
of  gray  matter  are  seen  separated  from  each  other  by  an 
interval  considerably  greater  than  at  any  other  plane  of 
section.  The  ventral  horns  stretch  out  laterally,  terminate 
in  pointed  extremities,  and  contain  but  few  ganglionic 
bodies,  although  at  a  plane  just  behind  the  cervical  en- 
largement. In  the  dorsal  part  of  the  spinal  cord,  just 
in  front  of  the  lumbar  enlargement,  there  are,  in  the  ven- 
tral horns,  many  cells  with  large  nuclei,  although  in  general 
conformation  these  horns  resemble  closely  those  of  the  mid- 
dle of  the  pars  dorsalis. 

Other  Chelonians,  with  much  the  same  abruptness  in 
the  curvature  of  the  carapax,  and  with  a  retractile  neck, 
have  spinal  cords  flattened  at  the  region  above  indicated, 
but  probably  never  to  the  same  extent  as  in  the  box  turtle 
with  its  movable  plastrum. 

III.  The  optic  chiasm  of  Anolius  Carolinensis — American 
chameleon. 

In  six  brains  from   this  species  which  I   have  examined, 

'  "  Beitrage  zur  Kenntniss  vom  Bau  des  Riickenmarkes  von  Petromyzon 
fluviatilis  L.,"  von  Prof.  Dr.  E.  Reissner  in  Dorpat  Arch.  f.  Anat.  u.  Phys., 
i860,  s.  545. 

*  "  Ein  Beitrag  zur  Kenntniss  vom  Bau  des  Riickenmarkes  von  Vipera  berus 
Lin.,"  von  J.  Grim.     Arch.  f.  Anat.  u.  Phys.,  1864,  p.  502. 


57^  JOHN  y.  MASON. 

the  optic  nerve  of  one  side  was  plainly  seen  to  enter  a  slit- 
like opening  in  the  nerve  of  the  other  side,  and  apparently 
to  traverse  the  latter  by  one  and  the  same  slit,  bodily,  as 
in  the  herring,  according  to  Wagner.'  Thin  longitudinal 
sections  show  a  complete  crossing  of  fibres,  but  the  nerve 
does  not  perforate  the  other  bodily,  but  divides  into  three 
or  four  large  bundles,  which  form  a  chiasm  with  equally 
large  bundles  from  the  nerve  of  the  opposite  side.  In  three 
of  the  five  specimens,  it  was  the  right  nerve  which  seemed 
to  perforate  the  left.  In  the  other  two  specimens  these 
conditions  were  reversed.  I  have  seen  this  external  appear- 
ance of  the  chiasm  in  no  other  reptile.  Goux*  found  that 
in  the  true  chameleon  the  optic  nerves  were  "plutot  accoles 
que  croises  1*  un  sous  1'  autre,"  while,  as  stated  in  his  commu- 
nication, Dug^s,  in  his  comparative  physiology,  asserts  : 
"  chez  le  cam^leon  le  nerf  gauche  semble  traverser  tout  en- 
tier  le  nerf  droit." 

'  Dalton's  Human  Physiology,  p.  519. 

"  Transactions  of  "Soc.  de  Biologic,"   1856.      I   am  indebted  to  an  extract 
made  by  Prof.  Seguin. 


CHOREA  IN  THE  AGED. 

By  WHARTON  SINKLER,  M.D., 

PHILADELPHIA. 

CHOREA  in  old  persons  is  regarded  as  a  rare  affection; 
but  I  believe  it  occurs  more  frequently  than  is  com- 
monly supposed,  or  than  the  books  would  lead  us  to  im- 
agine. 

The  disease  is  so  frequently  confounded  with  senile  trem- 
bling or  paralysis  agitans,  that,  no  doubt,  it  is  often  mis- 
taken for  one  of  those  disorders. 

I  have  several  times  met  with  well-marked  instances  of 
chorea  in  very  old  persons.  I  will  relate  two  cases,  which 
presented  striking  examples  of  the  disease  : 

The  first  is  Mary  R.,  aged  82  years,  who  applied  at  my  clinic  at 
the  Orthopaedic  Hospital  and  Infirmary  for  Nervous  Diseases,  in 
Jan.,  1879.  For  fifteen  years  she  has  been  an  inmate  of  a  Avidows' 
asylum.  She  says  that  she  has  always  been  uncommonly  healthy. 
For  the  past  three  or  four  years  she  has  been  nervous,  and  easily 
frightened  ;  she  thinks  because  several  of  her  associates  have 
died  in  that  time.  Last  winter  she  had  some  rheumatism  in  the 
knee,  but  has  had  no  acute  rheumatic  attack.  About  six  months 
ago  she  began  to  have  movements  of  the  hands.  She  did  not 
notice  them  herself  at  first,  but  her  friends  called  her  attention  to 
them.  A  short  time  later  she  found  herself  unable  to  keep  her 
legs  still.  The  movements  have  increased,  and  about  a  month 
ago,  having  been  frightened,  she  became  more  nervous,  and  could 
not  sleep  at  night.  She  thinks  the  movements  keep  her  from 
sleeping. 

577 


SyS  WHARTON  SINKLER. 

Present  condition. — The  patient  is  healthy-looking,  but  says  she 
is  worn  out  from  loss  of  sleep.  Her  appetite  is  good,  and  she  is 
not  troubled  with  dyspepsia  or  constipation.  She  walks  well,  but 
is  easily  fatigued,  and  is  short  of  breath  on  exertion.  She  is  un- 
usually intelligent  for  her  age,  and  seems  to  have  a  good  memory. 
She  seldom  has  headache. 

Movements. — The  legs  are  restless,  but  there  is  no  extreme  mo- 
tion. There  are  occasional  sudden  twitches,  or  throwings  out  of 
the  arms.  The  fingers  and  hands  are  in  constant,  irregular  move- 
ments. She  can  hold  a  glass  of  water  without  spilling  any  of  it, 
the  voluntary  effort  controlling  the  movements,  but  a  fine  tremor 
replaces  the  choreic  motions  when  these  cease.  There  is  no  diffi- 
culty of  speech.  The  eyesight  has  failed  recently,  but  is  still 
good. 

Heart. — There  is  a  systolic  murmur  heard  at  the  apex,  and  the 
action  of  the  heart  is  frequent,  feeble,  and  intermittent.  At  every 
fourth  beat  there  is  a  catch  or  interruption,  and  the  next  beat  then 
seems  to  come  hurriedly.  There  are  no  atheromatous  deposits  in 
the  radial  or  temporal  arteries.     The  urine  contains  no  albumen. 

Under  the  use  of  fluid  extract  of  gelsemium,  five  drops  three 
times  a  day,  and  twenty  grains  of  bromide  of  potassium  at  bed- 
time, the  patient  became  able  to  sleep  well,  and  gained  consider- 
able strength,  but  the  movements  did  not  diminish.  She  said, 
however,  that  they  did  not  annoy  her  as  much  as  formerly. 

She  came  to  my  clinic  in  March,  1881,  after  an  absence  of 
several  months.  She  was  very  choreic,  and  said  that  she  was 
sleeping  badly.  Her  general  health  and  her  mental  condition 
seemed  about  as  usual. 

Through  the  courtesy  of  Dr.  Weir  Mitchell,  I  had  the 
opportunity  of  seeing  a  patient  of  his  who  was  suffering 
from  chorea  at  the  age  of  86  years.  The  history  of  the 
case  is  briefly  as  follows  ; 

J.  M.,  set.  86  years,  a  man  of  sound  health,  and  free  from  taints, 
while  travelling  in  California,  a  few  months  before  I  saw  him, 
waked  one  morning  with  spasmodic  movements  of  the  whole  left 
side.  There  was  some  loss  of  power  in  this  side,  and  in  the  left 
side  of  the  face.  For  several  days  there  was  suffusion  of  the  left 
eye,  and  photophobia.  He  had  slight  derangement  of  digestion, 
and  the  bowels  were  sluggish.  He  had  no  headache,  his  mind 
was  clear,  and  his  memory  good,  except  at  times  for  words.     The 


CHOREA  IN  THE  AGED.  579 

movements  were  confined  to  the  left  arm,  leg,  and  the  left  side  of 
the  face.  They  varied  in  intensity  from  day  to  day,  but  abso- 
lutely disappeared  on  voluntary  effort,  and  during  sleep.  At  the 
end  of  a  month  the  movements  had  increased  in  severity,  but  the 
following  month  they  became  better,  and  he  was  able  to  walk 
about.  When  I  saw  him  the  left  arm  and  leg  were  in  constant 
irregular  motion.  The  movements  were  varied  in  form,  but  were 
not  extreme,  and  were  increased  by  excitement.  The  side  of  the 
face  occasionally  twitched.  There  was  a  loud  blowing  murmur 
at  the  apex  of  the  heart,  and  the  pulse  was  hard  and  intermittent. 
He  was  depressed  in  spirits,  but,  with  the  exception  of  poor 
memory,  his  mental  condition  was  very  good. 

This  gentleman  recovered  after  a  few  months'  treatment. 

Charcot,  in  a  lecture  on  chorea,'  states  that  in  old  persons 
suffering  from  St.  Vitus'  dance  there  is  almost  invariably  as- 
sociated with  it  a  condition  of  dementia.  This  was  certainly 
not  the  case  in  the  two  persons  whose  histories  I  have  just 
related.  I  have  also  seen  other  cases  where  the  mental 
faculties  were  unaffected. 

Chorea  in  the  aged  resembles  in  nearly  all  of  its  features 
the  same  disease  in  children.  The  movements  are  less  vio- 
lent and  less  varied  than  they  frequently  are  in  youth. 
Speech  is  not  often  affected,  and  the  facial  muscles  do  not 
seem  to  be  involved  in  many  instances. 

Rheumatism  probably  exerts  the  same  influence  o;i  the 
causation  of  the  affection  at  all  periods  of  life.  The  fact 
that  in  both  of  the  cases  I  have  reported  there  was  organic 
heart  disease,  indicates  the  connection  between  chorea  and 
heart  disease,  which  has  been  pointed  out  by  writers  on  the 
chorea  of  childhood. 

Besides  the  ordinary  chorea — Sydenham's  chorea,  as  it 
has  been  called, — we  have  the  variety  connected  with  hemi- 
plegia or  the  "  postparalytic  chorea."  In  this  variety  there 
is  a  history  of  paralysis  preceding  the  chorea,  and  the  ir- 
regular movements  take  place  chiefly  on  voluntary  effort, 

*  Med.  Times  and  Gazette,  March  9,  1878. 


580  WHARTON  SINKLER. 

while  in  true  chorea,  in  many  instances,  voluntary  effort 
controls  the  movements.  This  leads  me  to  observe  that  we 
see  the  two  types  of  chorea  in  old  persons,  namely,  the 
variety  in  which  the  motions  are  continuous  but  are  ar- 
rested for  the  time  by  an  effort  to  perform  some  movement, 
and  the  form  in  which  the  irregular  movements  continue 
under  all  circumstances. 

As  before  remarked,  senile  trembling  and  paralysis  agi- 
tans  may  be  mistaken  for  senile  chorea.  This  error  should 
not  be  made  when  we  consider  that  senile  trembling  is  gen- 
erally confined  to  the  head  and  consists  of  a  continuous 
rhythmical  tremor.  In  paralysis  agitans  there  is  loss  of 
power  in  the  parts  involved,  the  tremor  is  regular  and  not 
gesticulatory,  and  the  history  is  of  a  tremor  or  trembling, 
which  was  slight  at  first  and  under  control  of  the  will,  but 
which  has  gradually  increased  in  extent  and  violence. 

The  tremor  of  sclerosis  occurs  during  voluntary  effort, 
and  is  connected  with  loss  of  muscular  power. 

Chorea  in  aged  persons  is  by  no  means  an  incurable  affec- 
tion, Charcot,  to  the  contrary,  notwithstanding.'  Dr. 
Mitchell's  patient,  whose  case  I  related  above,  made  a  good 
recovery,  and  Dr.  James  Russell,  in  the  Med.  Times  and 
Gazette  for  April  27,  1878,  reports  the  case  of  a  lady,  'j'j 
years  of  age,  who  had  a  violent  attack  of  chorea  of  several 
months'  duration,  but  who  was  cured,  apparently  by  sul- 
phate of  zinc. 

*  Op.  cit. 


THE  ACTION  OF  AN  IRRITANT  * 

By  ISAAC  OTT,  M.D. 

WHEN  an  irritant  is  applied  to  the  skin  it  acts  upon 
the  nerve  endings  and  the  blood-vessels  of  the  part, 
it  having  also  a  general  and  local  action.  The  local  action 
dilates  the  blood-vessels  of  the  part,  whilst  it  causes  the 
other  arterioles  throughout  the  system  to  contract.  Besides 
the  local  irritation  of  the  nerves  of  the  part,  there  is  a  re- 
flected action  through  the  nerves  and  the  central  nervous 
system  upon  the  efferent  nerves  presiding  over  the  muscular 
movements,  circulation,  and  respiration.  When  a  drop  of 
bisulphide  of  carbon,  or,  after  the  skin  has  been  rendered 
hypersesthetic,  a  bull-dog  forceps  is  applied  to  the  back  of 
the  neck  of  a  pigeon,  the  bird  will  run  forward,  then  back- 
ward, rotating  his  body  to  the  side  opposite  to  that  receiving 
the  irritant,  after  which  a  hypnotic  condition  is  seen  for  a  few 
minutes,  when  he  rouses  up  upon  the  slightest  noise.  Dr. 
S.  Weir  Mitchell  has  produced  similar  results  with  rhigolene, 
and  lately  Brown-S^quard  has  noticed  similar  phenomena 
with  chloroform  and  chloral.  The  phenomenon  with 
bisulphide  I  have  already  described  a  few  years  back.^ 
Lately  I  have  been  trying  to  find  other  agents  which  would 
act  in  a  similar  manner  upon  the  pigeon.  The  agents  ex- 
perimented with  were  dry  and  moist  heat,  turpentine,  bro- 

*  Read  before  the  American  Neurological  Society. 
1  Journal  of  Nervous  and  Mental  Disease,  1879. 

581 


5^2  ISAAC  OTT. 

mide  of  ethylene,  parabromtoluene,  a  very  irritating  sub- 
stance to  the  eyes,  volatile  oil  of  mustard,  chloroform,  ether, 
and  alcohol.  Of  these  articles,  bisulphide,  turpentine,  and 
bull-dog  forceps  were  the  only  agents  producing  these 
phenomena  in  the  pigeon.  In  some  cases  the  opposite  leg 
and  wing  were  partially  paralyzed  with  anaesthesia  of  them, 
whilst  hyperaesthesia  ensued  on  the  side  of  application. 
Upon  cats  and  rabbits  the  carbon  applied  to  the  skin  of  the 
back  part  of  the  neck  produces  the  wildest  movements,  fol- 
lowed by  a  remarkable  disposition  to  sleep,  and  considerable 
anaesthesia  of  the  extremities.  These  phenomena  ensue  in 
the  pigeon  when  the  surface  of  the  cerebrum  is  destroyed, 
proving  that  the  movements  of  body  can  be  produced  by 
gray  matter  at  the  base  of  the  brain.  When  the  surface  of 
the  cerebrum  is  removed  no  primary  forward  progression 
ensues. 

Action  on  the  circulation. — These  phenomena  were 
studied  by  means  of  Ludwig's  kyniographion.  About  the 
end  of  a  minute  after  the  application  of  the  bisulphide  to 
the  neck,  the  pulse  falls  considerably,  whilst  the  pressure 
almost  immediately  rises,  and  continues  to  rise  for  some 
time. 

Section  of  the  vagi  abolishes  the  reduction  of  the  pulse, 
but  the  arterial  tension  increases  as  before.  When  the  end- 
ings of  the  trigeminus  in  the  nose  are  irritated,  the  pulse 
rapidly  decreases  as  well  as  the  number  of  respirations,  as 
has  been  shown  by  Kratschmer.  Brown-Sequard  believed 
this  cardiac  arrest  to  be  due  to  a  direct  reflex  action,  whilst 
Prof.  Rutherford  held  that  it  was  due  to  an  excess  of  car- 
bonic anhydride  in  the  blood  irritating  the  cardio-inhibitory 
ganglia,  this  excess  being  caused  by  arrest  of  respiratory 
movement.  When  he  kept  up  artificial  respiration  he  stated 
that  there  was  no  slowing  of  the  heart.  In  my  experiments 
with  the  bisulphide  to  the  nose,  with  or  without  woorari, 


THE  ACTION  OF  AN  IRRITANT.  583 

and  artificial  respiration  carried  on  through  a  tracheal 
canula,  the  heart  was  arrested  as  usual,  showing  that  it  is  a 
pure  inhibitory  reflex.  This  reflex  may  come  into  play  in 
operations  about  the  jaws,  causing  sudden  death. 

Anaesthetic  vapors  or  chloroform  may  bring  this  reflex 
into  play,  especially  if  anaesthesia  is  not  very  complete. 
The  irido-sensory  reflex,  in  ordinary  anaesthesia  by  chloro- 
form, is  active,  as  I  have  often  seen,  and  it  is  fair  to  presume 
that  the  play  of  the  other  reflexes  may  be  present  in  part. 

Effect  on  respiration. — When  bisulphide  is  applied  to  the 
skin  of  the  neck,  and  the  surface  of  the  cerebrum  destroyed, 
the  respiratory  movements  immediately  increase,  become 
deeper.  When  the  bisulphide  is  applied  to  the  nose,  then 
the  respiration  soon  decreases,  even  when  the  vagi  are 
divided,  showing  that  the  trigeminal  irritation  calls  into 
activity  centres  inhibiting  the  respiratory  centre,  like  the 
same  irritation  inhibiting  the  heart. 

Action  on  nervous  system. — The  inquiry  arises,  how  are 
nervous  phenomena  to  be  explained?  The  cause  of  the 
phenomena  is  not  circulatory,  as  the  heart  soon  returns  to 
its  normal  beat,  whilst  the  pressure  continues  high,  and  the 
nervous  symptoms  continue  some  time.  There  is  not  suf- 
ficient anaemia  of  the  brain  to  cause  the  series  of  phenom- 
ena. Their  origin  is  not  respiratory,  as  the  breathing 
becomes  deep  and  more  frequent,  which,  so  far  as  my 
experience  goes,  would  not  cause  these  changes.  It  seems 
to  me  that  the  phenomena  are  purely  due  to  an  excitation 
of  the  nervous  centres  themselves,  and  especially  the 
inhibitory  centres.  When  the  trigeminus  is  irritated  the 
heart  is  inhibited  as  well  as  the  respiratory  centres.  Fur- 
ther, I  have  shown  that  reflexes  can  be  inhibited  by 
ganglia  located  at  the  base  of  the  thalamus  and  head  of 
the  crura  cerebri,  and  that  these  centres  inhibit  the  gen- 
eral reflexes  of  the  body,  aided  by  spinal  inhibitory  centres. 


584  ISAAC  OTT. 

I  have  also  shown  that  these  centres  have  fibres  which 
demonstrate  in  the  medulla  and  pons.  The  anaesthesia  of 
the  opposite  side  is  explained  by  sensory  irritation  being 
carried  up  the  cord  on  the  same  side  and  calling  the  inhibi- 
tory centres  of  that  side  into  activity, — those  about  the 
base  of  the  thalamus  and  head  of  the  crura  cerebri,  which 
by  their  crossed  action  prevent  the  ascent  of  impressions, 
in  a  great  degree,  to  the  sensory  ganglia  above.  That  they 
pass  mainly  up  the  same  side  is  due  to  the  fact  that  the  im- 
pulses upward  meet  here  with  less  mechanical  resistance,  it 
not  being  necessary  to  traverse  the  gray  matter  of  the 
cord.  Not  only  do  irritations  of  the  skin  prevent  the 
transmission  of  the  pulses  upward,  but  they  weaken  or 
partially  paralyze  the  motor-nerves  of  the  opposite  side. 
Thus,  if  I  apply  in  a  rabbit  bisulphide  of  carbon  to  one 
side  of  the  body,  and  then  kill  the  animal  by  opening  the 
chest,  and  after  death  irritate  the  sciatics,  it  will  be  found 
that  the  opposite  sciatic  is  very  much  reduced  in  irritability. 
Reflex  palsy  upon  this  theory  would  be  "  inhibited  paraly- 
sis."  The  discovery  that  an  irritation  of  one  side  of  the 
body  will  produce  a  partial  paralysis  of  the  opposite  side  is 
worthy  of  the  attention  of  the  neurologist  in  the  explana- 
tion of  reflex  disturbances.  The  rotation  to  the  opposite 
side  is  explained  by  a  disturbance  of  equilibrium  between 
the  exciting  and  inhibiting  ganglia  of  the  central  nervous 
system,  which  results  in  a  deviation  to  that  side.  The 
state  of  hypnotism  is  simply  induced  by  a  peripheral  irrita- 
tion which  has  called  the  inhibitory  ganglia  into  activity 
and  temporarily  suspended  the  functions  of  the  will.  The 
substance  of  my  theory  about  the  nervous  system  is  as 
follows  :  that  the  gray  matter  is  divided  into  inhibitory 
and  excito-motor  material ;  that  the  inhibitory  is  mainly 
located  about  the  base  of  the  thalamus  and  the  head  of  the 
crura  cerebri ;  that  they  are  reinforced  by  inhibitory  centres 


THE  ACTION  OF  AN  IRRITANT.  585 

above  and  by  spinal  inhibitory  centres  below ;  that  these 
ganglia  have  their  special  fibres,  beginning  to  decussate  in 
the  pons  and  ending  a  little  below  the  rib  of  the  calamus, 
and  then  passing  down  the  internal  half  of  the  middle 
third  of  the  lateral  columns  of  the  spinal  cord ;  that 
anaesthesia  after  hemisection  of  the  spinal  cord  is  due  to 
an  excitation  of  these  ganglia,  whilst  hyperaesthesia  is  due 
to  a  removal,  in  part,  of  the  influence  of  these  ganglia ; 
hyperaesthesia  and  anaesthesia  may  also  be  due  to  affec- 
tions of  the  excito-motor  ganglia ;  that  some  partial 
palsies  are  to  be  explained  by  reflex  irritation  of  inhibitory 
ganglia.  Whilst  holding  these  ideas  I  believe  in  an  excito- 
motor  nervous  system,  that  the  motor  nerves  decussate, 
that  the  sensory  also  do,  and  that  the  cerebral  excito- 
motor  ganglia  are  also  localized. 

Effect  on  temperature. — When  a  pigeon  is  held  loosely 
in  the  hand  and  the  bisulphide  applied  to  the  skin  of  the 
neck,  the  rectal  temperature  falls. 

The  conclusions  on  the  effect  of  irritants  are  as  follows: 

1.  Certain  irritants  applied  to  the  skin  produce  a  variety 
of  phenomena  of  the  nervous  system.  Other  irritants  do 
not. 

2.  These  phenomena  are  not  due  to  circulatory  changes 
as  usually  held,  but  to  an  excitation  of  the  central  nervous 
system. 

3.  Irritations  of  the  skin  diminish  the  irritability  or 
partially  palsy  the  motor  nerves  of  the  opposite  side. 

4.  They  also  produce  anaesthesia  by  a  stimulation  of 
inhibitory  ganglia. 

5.  When  applied  to  the  nose  they  inhibit  the  heart 
and  respiratory  centres. 

6.  They  excite  the  monarchical  vaso-motor  centre. 

7.  They  lower  the  temperature. 

8.  They  dilate  the  pupil. 


AMERICAN  NEUROLOGICAL  ASSOCIATION. 

SEVENTH  ANNUAL  MEETING. 

(officially   reported   by   M.    JOSIAH   ROBERTS,    M.D.) 

First  day,  afternoon  session. 

The  American  Neurological  Association  convened  in  the 
New  York  Academy  of  Medicine,  June  15,  t88i,  for  its  seventh 
annual  meeting.  In  the  absence  of  Dr.  Miles,  the  retiring  Presi- 
dent, the  Secretary,  Dr.  Seguin,  called  the  Association  to  order  at 
2.30  P.M.,  and  introduced  the  President-elect,  Dr.  Roberts  Bartho- 
low,  of  Philadelphia. 

Present — Drs.  Amidon,  Beard,  Bartholow,  Birdsall,  Hammond, 
W.  A.,  Hammond,  G.  M.,  Jewell,  McBride,  Morton,  Ott,  Rock- 
well, Seguin,  Shaw,  Spitzka. 

Dr.  Bartholow  remarked  that  upon  his  arrival  in  New  York 
he  had  been  informed  of  the  customary  practice  of  the  incoming 
President  of  the  Association  to  make  a  few  introductory  remarks  ; 
but  as  this  information  was  a  surprise  to  him,  he  would  take  the 
liberty  of  proving  an  exception  to  the  rule. 

The  reading  of  the  minutes  of  the  last  annual  meeting  being 
called  for,  it  was  moved  by  Dr.  McBride  that  as  they  had  been 
printed  and  sent  to  each  member  for  perusal  their  reading  should 
be  dispensed  with.     Carried. 

The  Council  and  the  Secretary  had  no  reports  to  make. 

The  Treasurer,  Dr.  E.  C.  Seguin,  of  New  York,  read  his  report, 
which,  upon  motion  of  Dr.  Shaw,  was  adopted. 

NOMINATION    OF    CANDIDATES. 

Dr.  J.  S.  Jewell,  of  Chicago,  nominated  Drs.  S.  V,  Clevenger 
and  H.  Gradle,  of  Chicago,  for  active  membership, 

586 


AMERICAN  NE UROLOGICAL  A  SSOCIA  TION.  587 

The  Secretary  read  a  note  from  Dr.  E.  C.  Spitzka,  nominating 
Dr.  Burt  G.  Wilder,  of  Ithaca,  New  York,  for  active  membership. 

Dr.  E.  C.  Seguin  nominated  Drs.  Charles  K.  Mills  and  Wharton 
Sinkler,  of  Philadelphia,  for  active  membership. 

The  above  nominations  were  referred  to  the  Council  to  report 
at  a  future  session. 

COMMITTEE    ON    NOMINATION    OF    OFFICERS. 

The  President  appointed  the  following  Committee  on  Nomina- 
tions :  Drs.  Jewell,  of  Chicago  ;  Isaac  Ott,  of  Pennsylvania  ;  Ami- 
don,  Morton,  and  Rockwell,  of  New  York. 

MISCELLANEOUS    BUSINESS. 

Dr.  J.  Shaw  moved  that  no  case  be  presented  to  the  Associa- 
tion unless  it  formed  the  basis  of  a  written  communication.  He 
remarked  that  this  motion  was  not  intended  to  exclude  the  recita- 
tion of  cases  in  the  discussion  of  papers,  but  to  cut  off  some  irreg- 
ular work  which  had  been  found  unprofitable  to  the  Association. 
Carried. 

The  Secretary  read  a  letter  from  Dr.  J.  K.  Bauduy,  of  St. 
Louis,  to  the  effect  that  if  his  resignation  as  a  member  of  the 
Association,  which  had  been  transmitted  some  months  previous, 
had  not  been  presented  and  accepted  he  would  like  to  withdraw  it 
and  retain  his  membership.  As  his  resignation  had  already  been 
accepted,  upon  motion  of  Dr.  Shaw,  the  matter  was  referred  to  the 
Council  with  power  to  act. 

The  Secretary  read  a  letter  from  Dr.  T.  M.  B.  Cross,  of  New 
York,  tendering  his  resignation,  which  was  referred  to  the  Council 
for  action. 

Dr.  Seguin  stated  that  he  would  read  an  amendment  to  the 
constitution,  which  he  had  proposed  at  the  last  annual  meeting, 
and  was  to  be  acted  upon  at  this.     It  was  as  follows  : 

Article  III.  In  addition  to  Active  Members  there  shall  be  a 
class  of  Honorary  Members,  not  to  exceed  twelve  in  number,  and 
a  class  of  Associate  Members  not  to  exceed  twenty-five  in  number. 

Honorary  Members  shall  be  nominated  in  writing  by  six  Active 
Members,  reported  upon  by  the  Council,  and  elected  only  by  an 
unanimous  vote  of  the  members  present  at  the  session  following 
the  one  at  which  the  nomination  is  made. 

Associate  Members  shall  be  nominated  in  writing  by  two  Active 
Members  of  the  Association,  reported  upon  by  the  Council,  and 


588  TRANSACTIONS  OF  THE 

elected  by  a  majority  of  the  members  present  at  the  session  next 
following  the  nomination. 

Dr.  Jewell  moved  that  the  amendment  be  adopted.    Seconded. 

Dr.  Seguin  remarked  that  there  were  at  present  no  Honorary 
or  Associate  Members  of  the  Association.  The  reason  why  no 
step  had  been  taken  to  secure  the  same  was  that  the  original  pro- 
motors  of  the  Association  thought  it  best  to  wait  until  it  had  made 
some  substantial  progress  in  order  to  avoid  the  appearance  of  ask- 
ing for  names  merely  for  the  purpose  of  giving  the  organization  a 
standing.     Carried  unanimously. 

There  being  no  further  miscellaneous  business,  Dr.  J.  C.  Shaw 
was  called  upop  to  read  his  paper,  entitled  "  Tendon  reflex  in 
general  paralysis  of  the  insane." 

At  the  meeting  of  the  Association  in  1879  he  had  presented  a 
paper  on  the  "tendon  reflex  in  the  insane."  The  opinions  then 
expressed  had  been  confirmed  by  subsequent  extended  observa- 
tions, and  many  new  facts  had  been  learned.  The  object  of  his 
present  paper  was  to  communicate  these  to  the  Association.  Ob- 
servations had  been  made  on  70  cases  of  general  paralysis  in  men, 
and  10  cases  in  women.  In  the  men  it  was  found  that  the  reflex 
was  normal  in  28  cases,  that  it  was  slight  in  8  cases,  absent  in  13 
cases,  and  exaggerated  in  21  cases.  Of  these,  post-mortem  exami- 
nations had  been  made  in  18  cases,  and  the  spinal  cords  studied 
microscopically  after  hardening  and  mounting.  A  brief  history 
was  attached  to  each  of  these  cases,  and  the  state  of  the  reflex  as 
observed  during  life.  In  5  of  the  cases  the  reflex  was  found 
absent,  and  post-mortem  examinations  showed  sclerosis  of  the 
posterior  column.  In  4  cases  the  reflex  was  found  normal  during 
life,  and  post-mortem  examination  of  the  cords  showed  no  lesion. 
In  8  cases  the  reflex  was  found  exaggerated,  and  the  post-mortem 
revealed  sclerosis  in  the  lateral  columns  on  both  sides,  with  a  cer- 
tain amount  of  diffuse  sclerosis  in  all  parts  of  the  cords.  Obser- 
vation had  shown  that  this  exaggerated  reflex  is  in  direct  corre- 
spondence with  marked  difficulties  in  speech  and  hemiparetic 
attacks,  and  this  connection  was  susceptible  of  an  anatomical 
demonstration.  The  doctor  announced  his  intention  of  making 
another  communication  upon  this  subject. 

Remarks. 

Dr.  Jewell  inquired  for  Dr.  Shaw's  idea  of  the  inner  mechan- 
ism in  the  cases  cited,  in  which  there  was  abolition  of  the  tendon 


AMERICAN  NEUROLOGICAL  ASSOCIATION.  589 

reflex  accompanied  with  disease  of  the  posterior  columns  or  por- 
tions of  the  same  ;  remarking  at  the  same  time  that  an  answer  to 
his  question  might  involve  Dr.  Shaw's  idea  of  the  function  of  that 
part  of  the  cord. 

Dr.  Shaw  said  that  he  believed  the  disease  of  the  posterior 
column  interfered  with  conduction  in  the  sensory  parts,  and  in 
that  way  the  reflex  was  abolished.  Whenever  he  had  found  the 
reflex  abolished,  post-mortem  examination  had  shown  the  posterior 
columns  to  be  very  much  diseased. 

Dr.  Rockwell  thought  it  would  be  interesting  to  know  how 
much  experience  there  had  been  in  observing  cases  where  the 
tendon  reflex  was  absent  and  the  cord  healthy.  He  had  observed 
two  cases  in  which  there  was  no  tendon  reflex,  and  in  which,  so 
far  as  he  was  able  to  determine,  the  cord  was  perfectly  healthy. 

Dr.  Shaw  said  that  such  cases  had  been  observed,  and  that  he 
himself  had  seen  one.  Examples  of  this  sort  were  exceptional,  and 
he  could  give  no  explanation  of  them.  He  was  of  the  opinion 
that  Westphal  thought  there  was  in  such  cases  some  disease  of  the 
cord,  though  it  could  not  be  demonstrated. 

The  President  inquired  if  it  was  a  true  reflex. 

Dr.  Shaw  believed  that  it  was  now  claimed  to  be  a  true  reflex. 
There  had  been  several  points  observed  which  were  not  clear  to 
him.  He  had  observed  all  the  facts  he  could  in  hopes  of  ulti- 
mately arriving  at  a  rational  explanation  of  them. 

Dr.  Seguin  remarked  that  Dr.  Gray  had  read  a  paper  before 
the  Association  some  three  or  four  years  ago  upon  the  frequency 
of  tendon  reflex  in  healthy  persons.  He  had  examined  a  number 
of  students  in  the  Long  Island  College  Hospital,  and  reported 
several  examples  of  absence  of  the  tendon  reflex  in  healthy  indi- 
viduals. Dr.  Seguin  was  much  interested  in  Dr.  Shaw's  paper, 
and  thought  his  investigations  into  the  pathology  of  paralysis  in 
the  insane  might  lead  to  a  fundamental  pathological  classification 
of  general  paralysis.  The  cases  he  had  seen  he  had  been  only 
able  to  define  in  a  coarse  clinical  way,  owing  to  the  want  of  a 
pathological  basis  for  an  useful  and  intelligent  classification. 

Dr.  Jewell  remarked  that  he  had  been  much  interested  in  the 
subject  of  tendon  reflex  for  a  number  of  years,  and  the  conclusion 
which  he  had  at  present  reached  was  as  follows  :  Where  he  found 
it  absent  he  always  suspected,  unless  there  was  good  reason  to  the 
contrary,  disease  of  the  posterior  columns  of  the  spinal  cord. 
The  mechanism  of  such  cases  was  exceedingly  simple.  The  dis- 
eased parts  lay  in  the  path  of  the  ingoing  impulses,  which  have  to 


590  TRANSACTIONS  OF   THE 

pass  through  the  spinal  cord.  If  there  are  no  signs  of  disturbance 
besides  the  absence  of  the  reflex  he  regarded  it  as  one  of  a  class 
of  cases,  of  which  he  himself  was  an  example,  in  which  the  ten- 
don reflex  was  absent.  Some  persons  were  sensitive  in  this  way, 
others  hardly  at  all.  The  absence  of  this  sign  did  not  make  it 
necessary  for  us  to  suppose  that  there  is  disease  of  the  spinal  cord 
unless  there  was  some  unequivocal  sign  of  disease  of  the  sensory 
tract.  He  thought  the  matter  of  absent  and  exaggerated  reflexes 
had  been  made  to  appear  more  singular  than  it  really  is.  He 
concurred  with  Dr.  Seguin  as  to  the  great  value  of  Dr.  Shaw's 
paper,  for  it  brought  the  results  of  post-ftwrtem  examination  face 
to  face  with  symptoms  observed  during  life,  and  he  felt  sure  that 
the  author  of  the  paper  was  on  the  right  road,  though  a  very  long 
road,  to  a  solid  nerve  pathology. 

There  being  no  further  discussion,  the  Secretary  proceeded  to 
read  the  paper  of  Dr.  John  J.  Mason,  entitled,  "  Notes  on  the  cen- 
tral nervous  system  of  reptiles.  " 

The  paper  consisted  first,  of  observations  on  a  lateral  fibrous 
cord  in  ophidious  saurians,  the  homologue  of  the  ligamentum  den- 
ticulatum ;  second,  of  observations  on  a  normal  ventro-dorsal 
compression  of  the  myelon  at  the  acute  angle  made  by  the  articu- 
lation of  the  last  cervical  vertebra  with  the  carapax  in  Cistuda 
Carolina  (Holbrook),  box  turtle  ;  third,  of  observations  on  the 
optic  chiasm  of  the  Anolius  Carolinensis — American  Chameleon. 

J^emarks. 

Dr.  Spitzka  remarked  that  there  was  room  for  the  study  of 
other  peculiarities  of  the  appendages  of  the  nervous  system  which, 
without  any  presumable  physiological  value,  had  some  interest  as 
morphological  curiosities.  He  himself  had  observed  in  three  ma- 
rine turtles  that  there  was  a  thin  rod  of  cartilage  running  from 
the  dorsal  face  of  the  baso-occipital  bone  to  the  ventral  face  of 
the  myelancephalon  ;  whether  this  is  connected  with  the  nervous 
axis  directly,  or  fused  with  its  membranous  investments,  he  had 
not  ascertained.  It  certainly  appeared  to  be  a  very  aberrant  ana- 
tomical feature. 

The  next  paper  was  by  Dr.  Isaac  Ott,  "  The  action  of  an  irri- 
tant." 

The  paper  consisted  of  a  recitation  of  experiments  and  the  con- 
clusions reached  were  as  follows  : 


AMERICAN  NE  UROLOGICAL  A  SSOCIA  TION,  591 

1.  Certain  irritants  applied  to  the  skin  produce  a  variety  of 
phenomena  of  the  nervous  system  ;  other  irritants  do  not. 

2.  These  phenomena  are  not  due  to  circulatory  changes,  as 
usually  held,  but  to  an  excitation  of  the  central  nervous  system. 

3.  Irritations  of  the  skin  diminish  the  irritability  or  partially 
palsy  the  motor  nerves  of  the  opposite  side. 

4.  They  also  produce  anaesthesia  by  a  stimulation  of  inhibitory 
ganglia. 

5.  When  applied  to  the  nose  they  inhibit  the  heart  and  respira- 
tory centres. 

6.  They  excite  the  monarchical  vaso-motor  centre. 

7.  They  lower  the  temperature. 

8.  They  dilate  the  pupil. 

Remarks. 

Dr.  Spitzka  thought  it  was  a  defensible  statement  to  claim  that 
spontaneous  exciting  action  resided  in  no  special  centre  ;  he 
thought  that  there  was  no  central  action  that  could  not  be  traced 
back  to  a  starting-point. 

Dr.  Jewell  inquired  if  Dr.  Ott  was  of  the  opinion  that  these  in- 
hibitory centres  were  to  be  found  in  the  base  of  the  brain  and  that 
they  could  be  reinforced  both  from  centres  above  and  below. 

Dr.  Ott  replied  in  the  affirmative. 

Dr.  Jewell  held  a  loose  opinion  to  the  effect  that  the  reinforc- 
ing centres  could  not  be  looked  upon  as  subordinate  but  must 
always  be  looked  upon  as  super-ordinate  or  at  least  coordinate  ; 
this  was  only  an  opinion  and  he  would  not  undertake  to  defend  it. 
He  thought  that  the  reinforcing  centres  were  never  below.  Parts 
below  could  excite  those  above  but  not  charge  them  with  force.  He 
did  not  question  the  facts  brought  forward  by  Dr.  Ott,  but  only 
their  explanation  ;  he  thought  that  excitation  might  go  upward  or 
downward  from  the  basal  parts  of  the  brain  and  in  this  way 
launch  nerve  excitations  upon  the  central  nerve  axis,  but  rein- 
forcing centres  must  be  above  not  below  those  reinforced. 

Dr.  Seguin  remarked  that  it  would  be  interesting  in  this  con- 
nection to  recall  Brown-Sequard's  experiments  with  irritating  va- 
pors. He  (Brown-Sequardj  thought  it  was  possible  to  arrest  severe 
headache  by  forcing  carbonic  acid  gas  into  the  nostrils.  Dr. 
Seguin  had  seen  him  arrest  epileptic  fits  in  guinea-pigs  by  forcing 
carbonic  acid  into  their  throats  under  pressure.  A  quack  remedy 
for  the  cure  of  epilepsy,  used  in  France  some  thirty  years  ago,  was 


592  TRANSACTIONS  OF   THE 

the  application  of  ammonia  to  the  pharynx  by  means  of  a  swab. 
He  believed  one  of  the  German  physicians  interested  in  neurology 
had  suggested  the  swallowing  of  a  large  mouthful  of  salt  at  the 
time  of  aura. 

Dr.  Morton  remarked  that  in  two  or  three  instances  he  had 
observed  curious  facts  that  could  only  be  explained  in  this  way. 
One  patient  had  a  tonic  spasm  involving  most  of  the  muscles  of 
the  face.  This  spasm  would  come  on  and  last  for  several  hours 
and  then  pass  off.  He  made  the  experiment  frequently  of  apply- 
ing the  galvanic  current  to  the  facial  nerve,  which  would  quickly 
develop  the  spasm,  and  then  resolving  it  by  striking  three  or  four 
sparks  from  the  static-electrical  machine.  He  repeated  the  ex- 
periment with  the  Faradic  current  and  satisfied  himself  that  the 
spasm  was  truly  reflex  of  the  motor  track  of  the  trigeminal  nerve. 
He  then  tried  some  experiments  in  the  treatment  of  mimic  spasm. 

There  being  no  further  discussion,  the  Secretary  proceeded  to 
read  the  paper  of  Dr.  H.  M.  Bannister,  bearing  the  title  of,  "  A 
peculiar  effect  of  the  bromides  on  certain  insane  epileptics." 

Dr.  Bannister  related  in  his  paper  the  apparent  effect  of  the 
bromides  on  an  epileptic  under  his  observation  at  the  asylum  at 
Kankakee  in  Illinois.  After  the  use  of  the  drugs  in  question  for  a 
week  or  two,  the  epileptic  paroxysms  were  interrupted,  but  there 
came  on  gradually  a  state  of  mental  irritability,  which  at  last  rose 
to  the  pitch  of  homicidal  mania  with  delusions.  This  state  had 
been  often  produced  in  the  same  patient  by  the  same  means. 
Upon  withdrawing  the  bromide  the  maniacal  violence  gradually 
subsided,  and  entirely  disappeared  on  the  return  of  the  epileptic 
attacks. 

Dr.  Bannister  referred  to  other  cases  of  which  he  had  learned, 
and  to  the  rarity  of  similar  observations  in  medical  literature. 
He  thought  the  observation  important  and  suggestive,  but  offered 
ho  definite  opinion  as  to  whether  the  occurrence  ot  the  mania  was 
directly  or  indirectly  due  to  the  bromides. 

Remarks. 

Dr.  Spitzka  thought  Dr.  Bannister  was  mistaken  as  to  the  ab- 
sence of  records  of  this  kind.  There  was  a  German  alienist  by 
the  name  of  Stark,  who  had  published  a  very  carefully  written 
paper,  in  which  he  admitted  the  statement  made  by  the  author  of 
the  paper  just  read,  and  forbade  the  administration  of  the  bro- 
mides to  such  patients.     Dr.  Spitzka  thought  the  statement  would 


AMERICAN  NEUROLOGICAL  ASSOCIATION,  593 

apply  to  25  per  cent,  of  the  chronic  epileptics  in  institutions  for 
the  insane. 

Dr.  Jewell  remarked  that  the  alleged  action  of  the  bromides 
was  certainly  not  unknown,  but  its  importance  was  such  as  to  de- 
serve more  general  consideration.  In  the  case  of  epileptics  it 
was  important  to  recognize  this  action  of  the  bromides.  He 
thought  it  highly  probable,  at  least  feasible,  that  certain  of  the  epi- 
leptic insane  were  in  asylums  as  insane  persons  for  this  very  reason. 
Dr.  Bannister  had  mentioned  this  matter  to  him  before  writing  his 
paper,  and  it  was  chiefly  on  this  account  that  Dr.  Jewell  had  urged 
him  to  write  a  history  of  the  case. 

Dr.  Sh.\w  had  met  with  this  condition  in  the  asylum,  but  oftener 
in  the  dispensary,  especially  in  children  who  had  taken  large 
quantities  of  the  bromide. 

Dr.  Seguin  had  noticed  quite  a  number  of  such  cases,  but  did 
not  believe  it  was  the  bromides.  He  thought  it  was  the  suspension  of 
the  epilepsy  that  allowed  of  the  excitement  of  the  psychical  centres. 
Yesterday  he  had  seen  a  little  patient,  a  boy  of  twelve  years,  with 
a  singular  attack  of  petit-mal.  He  usually  had  more  attacks  in 
the  spring  ;  he  had  many  "chills."  The  physician  of  the  place  in 
which  he  was  attending  school  had  given  him  the  bromides,  and 
after  taking  these  two  or  three  weeks  he  had  no  chills  for  two 
months.  During  this  time,  however,  he  became  so  thoroughly 
unmanageable  that  his  schoolmaster  was  obliged  to  have  him  re- 
turn home. 

Dr.  Hammond  remarked  that  he  had  not  had  the  privilege  of 
listening  to  the  reading  of  the  paper,  but  thought,  as  Dr.  Seguin 
did,  when  we  came  to  remember  how  frequently  the  bromides 
were  given  to  epileptics  with  the  effect  of  having  the  paroxysms 
subside,  and  yet  did  not  have  these  symptoms  develop,  it  was  dif- 
ficult to  account  for  them,  when  they  did  occur,  as  being  due  to 
the  bromides.  In  1869  he  had  read  the  first  paper,  certainly  the 
first  in  this  country,  upon  bromism.  In  that  paper  he  had  given 
the  history  of  a  man  who  had  received  a  blow  upon  the  head. 

He  had  ordered  one  ounce  of  the  bromide  of  potassium  in  four 
ounces  of  water,  of  which  a  teaspoonful  was  to  be  given  three 
times  a  day.  The  patient  took  the  entire  contents  of  the  bottle 
every  day.  He  became  highly  maniacal,  was  arrested  in  the  street 
for  drunkenness,  and  convicted  of  the  same  before  a  police  magis- 
trate. At  the  instigation  of  Dr.  Hammond  he  was  placed  in  a 
lunatic  asylum,  where  he  remained  for  two  months  before  the 
effects  wore   off.      He    thought   it   should    be   known   that   the 


594  TRANSACTIONS  OF  THE 

bromides  would  kill  if  taken  in  sufficiently  large  doses  for  a  long 
time.  The  effect  of  the  bromides  was  apt  to  develop  very  sud- 
denly. The  best  way  to  avert  danger  or  relieve  a  patient  from 
the  effects  of  the  bromides  was  through  the  alimentary  canal  by 
purging.  He  never  gave  more  than  fifteen  grains  three  times  a 
day. 

Dr.  Rockwell  remarked  that  discussion  bore  upon  a  case  he 
had  under  treatment,  and  in  view  of  what  Dr.  Hammond  had 
said,  it  might  be  that  he  was  killing  his  patient.  A  lady  epilep- 
tic patient  of  his  had  been  taking  the  bromides  four  or  five  years 
with  the  effect  of  causing  a  cessation  of  the  attacks  for  fifteen  to 
twenty  months.  It  was  now  eighteen  months  since  she  had  had 
an  attack,  and  she  was  exceedingly  depressed  and  suffered  with 
hysteria.  The"  question  was  whether  to  keep  on  with  the  bro- 
mides. 

Dr.  Hammond  remarked  that  if  he  had  epilepsy  he  would  take 
the  bromides  all  his  life,  and  never  stop. 

Upon  motion  of  Dr.  Seguin,  the  Association  adjourned. 


First  day,  evenhig  session. 

The  Association  was  called  to  order  by  the  President,  Dr.  Bar- 
tholow,  at  8.30  P.M. 

Present:  Drs.  Amidon,  Bartholow,  Birdsall,  Gibney,  Ham- 
mond, W.  A.,  Hammond,  G.  M.,  Jewell,  Kinnicutt,  Morton, 
McBride,  Rockwell,  and  Seguin. 

The  Secretary  read  the  minutes  of  the  afternoon  session,  which 
were  approved. 

REPORT    OF    COUNCIL. 

The  Council  recommended  Drs.  S.  V.  Clevenger  and  H.  Gradle 
of  Chicago,  Burt  G.  Wilder  of  Ithaca,  N.  Y.,  and  Charles  K.  Mills 
of  Philadelphia  for  active  membership. 

The  Council  also  reported  that  the  resignation  of  Dr.  J.  K. 
Bauduy  had  been  rescinded,  and  that  he  was  restored  to  active 
membership. 

Upon  motion  of  Dr.  E.  C.  Spitzka,  the  by-laws  were  suspended 
and  the  Secretary  was  requested  to  cast  the  vote  of  the  Associa- 
tion for  the  election  of  members,  which  was  voted  in  the  affirma- 
tive. 


AMERICAN  NEUROLOGICAL  ASSOCIATION.  595 

REPORT    OF  THE    COMMITTEE    ON  NOMINATIONS. 

Dr.  J.  S.  Jewell,  chairman  of  the  committee,  reported  the  fol- 
lowing nominations  : 

President,  Dr.  William  A.  Hammond,  of  New  York. 

Vice-president,  Dr.  Landon  Carter  Gray,  of  Brooklyn,  N.  Y. 

Secretary  and  Treasurer,  Dr.  E.  C.  Seguin,  of  New  York. 

Councillors :  Dr.  J.  S.  Jewell,  of  Chicago,  and  Isaac  Ott,  of 
Easton,  Penn. 

The  first  paper  of  the  evening  session  was  by  Dr.  A.  D.  Rock- 
well upon  "  Electro-muscular  contractility  in  infantile  paralysis." 

At  the  meeting  of  the  Association  in  1879,  the  author  had 
presented  a  case  bearing  upon  this  point,  and  the  history  of  the 
present  case  was  a  supplement  to  the  first  as  illustrating  the  fact 
that  even  when  the  galvanic  current  proved  utterly  powerless  to 
cause  contraction  of  the  muscles,  and  the  paralysis  is  complete 
and  the  atrophy  extreme,  we  need  not,  necessarily,  despair  of  a 
favorable  issue.  The  patient  in  the  case  reported  was  injured 
by  forceps  in  delivery,  so  that  the  right  arm  was,  from  the  begin- 
ning, completely  paralyzed. 

A  number  of  months  subsequently  Dr.  Rockwell  found  the  arm 
atrophied,  seemingly  as  much  as  it  was  possible  for  it  to  be,  and 
with  an  entire  loss  of  electro-muscular  contractility. 

No  strength  of  galvanism  elicited  the  slightest  reaction.  The 
case  was  under  treatment  for  one  month  before  any  electrical  re- 
action was  obtained  ;  but  from  the  moment  this  took  place  im- 
provement was  rapid,  and  the  arm  was  now  of  considerable  use. 

In  the  case  which  he  had  previously  presented  to  the  Associa- 
tion, it  was  at  least  six  weeks  before  galvano  contractility  took 
place.  He,  therefore,  said,  bearing  this  fact  in  mind,  that  per- 
sistent effort  should  be  made  for  weeks,  or  in  some  cases  for 
months,  before  deciding  that  the  case  was  utterly  hopeless. 

Remarks. 

Dr.  Spitzka  inquired  what  had  been  Dr.  Rockwell's  experience 
in  regard  to  improvement  in  the  case  of  paralysis  of  central 
origin. 

Dr.  Rockwell  replied  that  he  did  not  refer  to  central  par- 
alysis. 

Dr.  Hammond  thought  that  all  the  members  of  the  Association 
would  agree  that  it  was  much  more  difficult  to  restore  paralysis 


$g6  TRANSACTIONS  OF  THE 

when  due  to  a  peripheral  injury  than  when  it  was  central.  He  had 
published  the  history  of  a  case  where  the  muscular  contractility 
was  entirely  abolished,  so  far  as  the  Faradic  current  was  con- 
cerned, but  the  muscles  reacted  to  the  current  from  a  hundred- 
pile  voltaic  battery. 

He  thought  Dr.  Rockwell's  case  was  interesting  as  showing  what 
could  be  done  in  peripheral  paralysis  by  persistent  efforts.  We 
all  knew,  he  said,  how  difficult  it  is  to  restore  peripheral  facial 
paralysis  with  any  current  that  we  could  apply  to  the  face.  Dr. 
Hammond  inquired  the  strength  of  current  used  by  Dr.  Rockwell. 

Dr.  Rockwell  remarked  that  at  first  the  strongest  current 
would  accomplish  nothing,  but  subsequently  the  current  from  fif- 
teen or  twenty  ordinary  carbon  cells  was  used. 

Dr.  Jewell  remarked  that  he  was  of  the  opinion  that  in  many 
of  these  cases  of  paralysis  arising  from  peripheral  disease,  where 
there  was  no  evidence  of  traumatic  destruction  of  nerve  tissue, 
even  though  the  duration  of  the  paralysis  had  been  long,  we  ought 
to  consider  them  far  more  hopeful  than  they  were  usually  consid- 
ered. He  remembered  the  case  of  a  lady  in  Moline,  111.,  who  had 
been  delivered  by  forceps,  and  whose  left  sciatic  nerve,  at  the 
point  where  it  passed  through  the  pelvis,  had  been  crushed  by  the 
instrument  and  head  of  the  child,  so  that  for  months  she  was 
paralyzed  in  that  member  from  the  hip  down.  At  the  end  of 
eleven  months,  the  atrophy  was  very  considerable  ;  the  limb  was 
utterly  useless.  There  was  paralysis  of  motion  and  sensibility  in 
all  parts  except  where  supplied  by  certain  nerve  branches  in  front. 
She  was  placed  under  treatment,  and  it  required  one  or  two 
months  of  careful  electrical  treatment  before  any  considerable 
sensitiveness  of  skin  or  muscles  of  the  member  was  obtained.  The 
galvanic  current  was  interrupted  in  the  various  ways  known.  At 
last  signs  of  improvement  began  to  appear,  the  patient  began  to 
move  the  limb,  and  finally  was  advised  to  take  a  trip  to  Europe. 
In  accordance  with  his  advice,  she  there  consulted  Professor 
Charcot,  and  finally  a  medical  gentleman  in  Belgium,  who  well 
understood  the  use  of  electricity,  and  who  applied  it  together  with 
massage  thoroughly.  The  patient  was  now  almost  entirely  well. 
He  heard  from  her  a  few  days  ago,  and  she  was  then  able  to  walk 
up  what  amounted  to  one  hundred  feet  of  elevation  without  the 
use  of  a  crutch  or  cane.  Although  it  was  customary  to  look  upon 
such  cases  as  utterly  hopeless,  he  thought  that  they  should  no 
longer  be  considered  as  such,  and  persistent  effort  should  be 
made  to  restore  the  paralyzed  muscles. 


AMERICAN  NEUROLOGICAL  ASSOCIATION.  S97 

There  being  no  further  discussion,  the  paper  of  Dr.  H.  D. 
Schmidt,  of  New  Orleans,  was  read  by  the  Secretary,  entitled  : 
"  Destructive  legion  of  the  left  cerebral  hemisphere,  with  gen- 
eral pachymeningitis,  and  a  large  hemorrhagic  cyst  pressing 
upon  the  right  hemisphere,  of  thirteen  years'  standing." 

This  case  of  cerebral  lesion  was  worthy  of  being  re- 
corded, not  only  on  account  of  the  extent  of  the  lesions,  but  also 
for  the  long  period  of  time  through  which  they  existed.  It  illus- 
trated the  ability  of  the  brain  to  bear  a  considerable  amount  of 
injury  without  causing  a  serious  disturbance  of  the  general  health, 
or  even  of  the  mental  faculties  of  the  patient.  The  paper  con- 
sisted of  a  history  of  the  case  so  far  as  could  be  obtained,  and  an 
exceedingly  interesting  and  remarkably  accurate  detailed  account 
of  the  pathological  findings.  Accompanying  the  paper  were  six 
admirably  executed  drawings  representing  various  pathological 
points,  to  which  special  attention  was  called  in  the  paper. 

There  being  no  remarks,  Dr.  J.  S.  Jewell,  of  Chicago,  proceeded 
to  read  his  paper  advocating  "  The  early  use  of  strychnia  in 
myelitis." 

He  said  his  object  was  to  call  attention  to  the  early  and 
free  use  of  strychnia  in  subacute  (diffuse)  myelitis  and  related 
affections  of  the  spinal  cord,  in  which  one  of  the  most  important 
conditions  presumed  to  exist  is  passive  congestion. 

He  then  gave,  in  some  detail,  the  histories  of  several  cases  in 
which  the  treatment  by  strychnia  has  been  employed  apparently 
with  success.  An  oral  abstract  of  the  paper  was  given  to  save 
the  time  of  the  Association.  He  closed  by  a  brief  statement  of  his 
views  as  to  the  pathology  of  the  cases  given,  and  as  to  the  mode 
of  action  of  strychnia. 

Jiemarks. 

Dr.  Hammond  said  that  he  would  like  to  ask  the  author  of  the 
paper,  three  questions  : 

First,  whether  the  drug  produced  any  tonic  spasm  ;  second, 
whether  the  cases  cited  were  uncomplicated  cases  of  spinal  dis- 
ease; and  third,  why  they  were  not  cases  of  spinal  ansemia  instead 
of  spinal  congestion.  He  wanted  to  know  what  distinction  the 
author  made  between  the  cases  cited  as  those  of  congestion  and 
those  which  were  called  spinal  anaemia.  He  had  met  with  such 
cases,  due  to  liver,  lung,  or  stomach  diseases,  which  were  cured 
by  large  doses  of  strychnia;  but  he  regarded  them  as  cases,  not  of 
congestion  but  of  anaemia. 


59^  TRANSACTIONS  OF  THE 

Dr.  Jewell  replied  that  the  distinction  was  to  him  quite  clear, 
though  difficult  to  define,  yet  he  did  not  despair  of  doing  this. 

Owing  to  the  late  hour,  upon  motion  of  Dr.  Spitzka,  the  dis- 
cussion of  Dr.  Jewell's  paper  was  postponed  until  the  beginning  of 
the  following  session. 

Upon  motion  of  Dr.  Spitzka,  the  Recording  Secretary  was  au- 
thorized to  cast  the  vote  of  the  Association  for  the  officers  which 
had  been  nominated  for  the  ensuing  year,  which  was  in  the  affir- 
mative. 

The  President  declared  the  Association  adjourned. 


Second  day,  afternooyi  session. 

The  meeting  was  called  to  order  by  President  Bartholow,  at 
2.30  p.  M. 

Present  :  Drs.  Amidon,  Bartholow,  Beard,  Birdsall,  Gray, 
Gradle,  Hammond,  W.  A.,  Hammond,  G.  M.,  Jewell,  Kinnicutt, 
Mills,  Morton,  Ott,  Rockwell,  Spitzka,  Seguin. 

The  President  announced  that  the  members  of  the  Association 
were  invited  to  be  present  at  a  reception  at  Dr.  Wm.  A.  Ham- 
mond's house,  at  nine  o'clock  in  the  evening. 

The  Secretary  read  the  minutes  of  the  previous  session,  which 
were  approved. 

The  Council  reported  that  they  had  examined  the  paper  of  an- 
other candidate,  that  of  Dr.  Wharton  Sinkler,  of  Philadephia,  and 
recommended  that  he  be  presented  to  the  Association  for  election. 

Upon  the  motion  of  Dr.  Spitzka,  the  Secretary  was  authorized 
to  cast  the  vote  of  the  Association,  which  was  in  the  affirmative. 

The  Secretary  read  letters  from  the  following  absent  members  : 
Drs.  Robert  T.  Edes,  J.  Van  Bibber,  and  J.  J.  Mason,  the  latter 
inviting  the  members  of  the  Association  to  a  meeting  in  Newport. 

Discussion  upon  Dr.  y^ewell's  Paper.     {Continued^ 

Dr.  Spitzka  remarked  that  he  had  made  some  experimental  re- 
searches upon  strychnia,  and  had  observed  some  very  remarkable 
phenomena.  He  would  not  dare  to  give  strychnia  in  myelitis. 
He  had  artificially  produced  myelitis  in  dogs  by  means  of  the  ap- 
plication of  ice-cold  water  to  their  hind  quarters.  Experimenting 
in   this  way  with   two  dogs,  to   one  he   gave  a  poisonous  dose  of 


AMERICAN  NEUROLOGICAL  ASSOCIATION.  599 

Strychnia,  and  then  killed  both  of  them.  In  the  case  of  the  dog 
to  whom  strychnia  had  not  been  given,  there  was  found  striking 
pathological  softening  ;  but  in  the  other  dog,  no  change  whatever 
was  found.  In  these  cases  both  dogs  had  been  subjected  to  the 
same  influences  which  are  known  to  produce  myelitis,  and  if  any 
thing  could  be  drawn  from  the  experiments  it  would  be  to  the 
effect  that  strychnia  was  of  use  in  myelitis.  Experiments  on  frog? 
show  that  strychnia  had  a  local  stimulating  effect.  Dr.  Spitzka 
thought  it  was  a  molecular  change  which  was  produced,  and  ac- 
cordingly, experimentally,  it  was  advisable  to  use  strychnia  in  the 
first  stages  of  myelitis  ;  however,  he  would  not  like  to  do  it. 
Opinions  formulated  in  regard  to  myelitis  seemed  to  be  vague. 
As  far  as  he  could  judge  there  were  cases  of  myelitis  and  hysteria 
that  went  together  ;  that  is,  he  meant  that  there  were  cases  of 
myelitis  with  irritation  where  strychnia  would  be  counter-indi- 
cated. There  was  a  class  of  hysterical  patients  in  which  the 
majority  bore  strychnia  well,  but  he  had  seen  strychnia  do  harm 
and  produce  characteristic  symptoms  when  it  was  given  in  small 
doses  within  the  normal  limits. 

Dr.  Hammond  wished  to  ask  Dr.  Spitzka  whether,  in  the  case 
of  the  dog  to  whom  he  had  given  a  poisonous  dose  of  strychnia, 
he  did  not  find  the  blood-vessels  in  the  substance  of  the  cord 
ruptured. 

Dr.  Spitzka  replied  that  whenever  he  gave  strychnia  in  suffi- 
cient doses  to  produce  death  immediately,  or  very  soon,  that  he 
had  found  hemorrhages. 

Dr.  Hammond  enquired  if  such  hemorrhages  were  not  due  to 
congestion  of  the  cord. 

Dr.  Spitzka  replied  that  he  had  always  considered  them  as  due 
to  respiratory  interferences,  and  he  could  produce  death  by 
strychnia  without  congestion  of  the  cord. 

Dr.  Hammond  wished  to  enquire  whether,  in  the  case  of  con- 
gestion of  the  cord,  the  spinal  cord  was  not  rendered  more  sus- 
ceptible to  the  influence  of  strychnia  than  when  it  was  not  con- 
gested. He  wished  to  have  this  point  discussed.  He  did  not 
doubt  Dr.  Jewell's  facts  or  results,  but  he  did  question  his  diag- 
nosis, and  did  not  believe  that  they  were  cases  of  congestion  of 
the  cord  ;  but,  on  the  contrary,  thought  they  were  cases  of  anaemia 
of  the  cord,  otherwise  strychnia  would  have  produced  its  physio- 
logical symptoms.  He  referred  to  the  questions  he  had  asked  the 
previous  evening,  and  particularly  to  the  distinguishing  points 
between  anaemia  and  congestion. 


6oO  TRANSACTIONS  OF  THE 

Dr.  Jewell  remarked  that  he  had  not  concluded  his  paper  on 
account  of  its  length  and  his  fear  of  worrying  the  members  of  the 
Association  by  reading  reports  of  cases.  First  of  all,  his  object 
was  to  call  attention  to  the  early  and  free  use  of  strychnia  in  what 
he  had  regarded  as  subacute  myelitis  and  related  diseases  of  the 
spinal  cord.  He  had  referred  only  to  the  practical  aspects  of  the 
cases,  knowing  full  well  that  their  diagnosis  would  be  questioned, 
and  he  was  pleased  that  it  had  been  done.  He  was  aware  that 
much  confusion  of  opinion  existed,  especially  in  regard  to  the 
diagnosis,  between  spinal  anaemia  and  spinal  congestion,  and  he 
had  pursued  his  studies  in  full  view  of  that  fact  ;  but  for  one  he 
could  not  admit  that  our  knowledge  on  this  subject  was  in  such  a 
confused  and  chaotic  state  as  some  seemed  to  think.  He  thought 
that  in  ninety-nine  cases  out  of  a  hundred  we  could  differentiate 
more  or  less  clearly  between  spinal  anaemia  and  spinal  congestion. 
He  alluded  to  acute  and  passive  congestion,  and  by  the  latter  term 
he  did  not  mean  that  which  was  of  purely  mechanical  origin.  That 
acute  and  passive  congestion  of  the  central  nervous  system  existed 
no  one  doubted,  and  all  would  probably  agree  that  we  could 
diagnosticate  congestion  of  the  nerve  centres.  Difficult  as  it 
might  seem,  a  diagnosis  could  be  made  between  passive  congestion 
and  anaemia  of  the  cord.  By  passive  congestion  he  meant  that 
which  was  of  purely  vaso-motor  origin,  and  pertained  not  to  the 
veins,  but  to  the  arteries  and  capillaries,  the  former  of  which  were 
almost  purely  muscular  in  their  middle  walls,  and  were  supplied 
with  local  vaso-motor  mechanisms.  The  congestions  which 
arose  in  consequence  of  loss  of  tonus  in  the  muscular  wall  of  the 
blood-vessels  were  those  he  had  in  his  mind,  whether  due  to  loss 
of  power  in  the  muscular  tissue  itself  or  to  loss  of  power  in  the 
vaso-motor  system.  In  either  case  the  vessels  dilated  under  the 
influence  of  the  expansive  pressure  of  the  passing  blood.  When 
this  happened  he  considered  that  we  had  passive  congestion,  and 
it  was  this  state  which  he  assumed  existed  in  the  blood-vessels 
of  the  spinal  cord  or  brain,  especially  when  we  consider  the  fact 
that  they  are  generally  surrounded  by  spaces,  truly  called  perivas- 
cular, so  that  a  better  chance  for  expanding  was  offered  than  was 
found  in  other  parts.  As  to  the  difference  between  spinal  anaemia 
and  spinal  congestion,  he  would  make  the  following  points  :  Cases 
of  spinal  anaemia  were  made  better  by  increasing  the  atmospheric 
pressure  ;  or,  in  other  words,  by  sending  patients  thus  affected  from 
high  altitudes  to  the  seaside.  Cases  of  spinal  anaemia  were  better 
when  the  barometer  stood  high,  and   especially  so  if  placed  in  a 


AMERICAN  NEUROLOGICAL  ASSOCIATION.  6oi 

chamber  where  atmospheric  pressure  was  increased  ;  and  they 
were  made  worse  when  the  barometer  stood  low,  and  by  removing 
them  to  mountainous  regions,  or  by  exhausting  the  air  from  a 
chamber  in  which  they  were  placed.  Passive  congestions  were 
made  worse,  as  is  easily  understood,  when  the  barometer  rises. 
If  such  cases  were  sent  from  the  region  of  Chicago  to  the  sea  level 
they  did  not  improve  ;  but  if  sent  to  higher  regions,  such  as  Colo- 
rado, they  got  better. 

The  mechanism  of  the  case  is  exceedingly  simple.  The  in- 
creased pressure  upon  the  body  forces  the  blood  from  the  surface 
into  the  air-tight  cerebro-spinal  cavity,  so  that  the  vessels  within 
weakened  vascular  areas  give  way  according  to  the  degree  of 
weakness  of  the  muscular  coat  or  interference  with  the  local  vaso- 
motor apparatuses.  Such  cases  he  never  sent  to  cold  regions,  but 
always  to  warm  regions.  That  was  the  case  with  spinal  congestion, 
not  so  with  anaemias.  These  latter  cases  were  made  better  by  ex- 
posure to  cold.  The  contraction  of  the  cutaneous  blood-vessels 
thereby  brought  about,  displaced  more  or  less  of  the  blood 
naturally  circulating  in  the  exterior,  and  caused  a  corresponding 
increase  in  the  amount  of  blood  that  circulated  in  the  interior  of 
the  body ;  this  could  be  demonstrated  experimentally.  He  had 
practically  demonstrated  this  matter  to  himself,  and  was  thoroughly 
convinced  that  cases  of  spinal  anaemia  were  invariably  better  by 
moderate  exposure  to  cold,  while  cases  of  spinal  congestion  were 
in  various  degrees  made  worse.  And  conversely,  spinal  anaemia 
was  made  worse  by  heat  to  the  surface  ;  but  spinal  congestion  was 
made  better  on  account  of  the  blood  flowing  more  freely  in  the 
surface.  The  dorsal  decubitus  benefited  spinal  anaemia,  but  not 
passive  congestion.  Then,  again,  in  passive  congestion  there  was 
marked  diminution  of  all  the  reflexes  effected  through  the  con- 
gested zones  of  the  cord.  By  the  term  vaso-motor  anaemia  he 
meant  that  rather  rare  condition  which  resulted  from  a  contrac- 
tion of  the  blood-vessels  in  consequence  of  a  change  in  the  action 
of  their  vaso-motor  nerves.  This  could  usually  be  traced  to  some 
source  of  irritation,  as  in  the  pelvic,  gastric,  genito-urinary,  or 
other  zones. 

Again,  electro-muscular  excitability  is  diminished  in  general 
passive  spinal  congestion,  but  not  so  or  to  the  same  degree  as 
in  vaso-motor  anaemias  of  the  same  regions.  There  were  various 
other  points,  a  consideration  of  which  would  aid  in  settling  posi- 
tively whether  we  had  to  deal  with  anaemia  or  cases  of  passive 
congestion. 


6o2  TRANSACTIONS  OF   THE 

As  regards  frequency,  he  remarked  that  spastic  contraction  of 
the  blood-vessels  of  the  spinal  cord,  continuing  for  a  great  length 
of  time,  was  a  rather  rare  phenomenon  ;  but  as  to  congestion  it 
was  not  an  uncommon  thing  for  it  to  occur  and  to  continue 
for  a  long  time.  He  spoke  of  cases  of  so-called  spinal  irritation 
supposed  to  be  due  to  spinal  anaemia.  These  he  had  been  led  by 
observation  to  divide  into  two  sections  ;  one  belonged  with  those 
cases  of  pachymeningitis  and  other  diseases  of  the  envelopes  of 
the  cord  in  which  there  was  not  simply  hyperalgia,  but  actual  sore- 
ness and  not  simply  tenderness  and  pain.  These  cases  were  fre- 
quently considered  as  instances  of  spinal  irritation.  Besides  these 
there  was  another  class  in  which  certain  zones  of  the  cord  became 
greatly  exhausted,  there  being  in  these  zones  a  loss  of  balance 
between  the  processes  of  waste  and  repair,  until  the  structure  of 
the  cord  became  worn  and  irritable — hyperalgic, — so  that  slight 
sensory  impressions  entering  the  affected  regions  were  interpreted 
as  being  severe.  The  pain  was  not  due  to  inflammation  of  the 
cord,  or  congestion,  or  anaemia  of  the  cord  ;  it  was  a  matter  of 
nutrition.  For  example,  a  diseased  spinal  pelvic  zone  might  arise 
from  irritative  disease  of  the  pelvic  organs  ;  in  the  gastric  zone 
the  spinal  disorder  might  be  due  to  gastric  catarrh  ;  and  so  on, 
where  any  part  of  the  cord  had  been  greatly  over-used  in  nutrition 
or  irritated  by  peripheral  disease,  it  became  unbalanced  in  nutri- 
tion, and  one  of  the  early  results  was  pain.  This  was  what 
happened  in  cases  of  true  spinal  irritation,  but  they  were  not  nec- 
essarily due,  in  his  judgment,  either  to  anaemia  or  congestion  of 
the  cord. 

Dr.  Hammond  remarked  that  it  was  rather  singular,  in  view  of 
what  had  been  said,  that  Dr.  Jewell,  living  in  Chicago,  should  see 
only  cases  of  spinal  congestion,  and  he,  living  in  New  York,  on  the 
sea  level,  should  see  only  cases  of  spinal  anaemia.  He  thought  that 
Dr.  Jewell's  remarks  were  based  upon  transcendental  pathology, 
and  that  his  argument  was  begging  the  question  altogether.  Be- 
cause Dr.  Jewell's  patients  got  better  under  the  use  of  strychnia, 
therefore,  it  was  concluded  by  him  that  they  were  suffering  from 
congestion.  Dr.  Hammond  gave  strychnia  to  patients  who  im- 
proved under  its  use,  and  he  considered  them  examples  of  anaemia. 
He  was  glad  to  hear  Dr.  Jewell  admit  that  case3  of  spinal  anaemia 
got  better  in  the  recumbent  posture.  He  thought  that  Dr. 
Jewell's  remarks  proved  just  exactly  the  opposite  of  what  he 
thought  they  did. 

Dr.  Seguin  remarked  that  the  subject  was  one  of  great  impor- 


AMERICAN  NEUROLOGICAL  ASSOCIATION.  603 

tance,  and  his  excuse  for  prolonging  the  discussion  was  that  he 
had  very  firm  convictions  in  regard  to  anaemia  and  hyperaemia  of 
the  spinal  cord,  and  the  possibility  of  making  a  diagnosis  between 
them,  and  the  therapeutics  of  this  class  of  cases.  It  was,  per- 
haps, because  he  had  tried  to  study  the  disease  of  the  nervous 
system  from  an  anatomical  standpoint,  rather  than  through  thera- 
peutical and  physiological  views,  that  he  had  felt  opposed  to  the 
accepted  ideas  in  regard  to  anaemia  and  hyperaemia.  With  re- 
gard to  the  brain,  he  thought  there  were  rare  cases  of  hyperaemia 
and  anaemia,  but  as  for  the  cord,  he  considered  the  conditions  of 
hyperaemia  and  anaemia  as  purely  hypothetical,  for  he  knew  of  no 
tangible  evidence  to  support  such  views.  He  knew  of  none  but 
clinical  and  therapeutical  phenomena  to  prove  the  existence  of 
such  conditions,  and  he  regarded  Dr.  Jewell's  argument  as  nothing 
more  or  less  than  begging  the  question.  There  was  no  solid  foun- 
dation for  the  doctrines  of  spinal  anaemia  and  hyperaemia  as  there 
was  for  locomotor  ataxia,  myelitis,  and  various  other  forms  of 
spinal  disease.  He  thought  the  whole  modern  doctrine  of  inflam- 
mation was  opposed  to  hyperaemia  being  a  cause  of  inflammatory 
action.  Probably  a  more  important  factor  was  the  condition  of 
morbid  activity  of  cells.  With  respect  to  the  spinal  cord,  the  re- 
searches in  pathological  anatomy  had  not  shown  any  basis  for 
hyperaemia  being  considered  the  first  step  in  myelitis.  Cases  could 
be  divided  into  ihrtc  post-mortem  categories  :  First,  those  in  which 
the  ganglion  cells  and  fibres  were  primarily  affected.  Second, 
those  in  which  the  connective  tissue  was  involved  primarily  ; 
and,  third,  degenerative  myelitis.  But  in  any  of  these  he 
would  defy  any  pathological  anatomist  to  point  to  hyperaemia 
as  an  important  factor.  In  his  specimens  there  were  no  evidences 
of  hyperaemia  ;  all  the  changes  were  tissue  changes  from  first  to 
last,  and  there  was  no  tangible  evidence  of  increased  vascularity. 
Within  two  or  three  years  several  specimens  had  been  shown  to 
the  Association  which  would  bear  him  out  in  this  statement.  The 
specimens  obtained  from  Dr.  Webber's  case,  as  well  as  his  own, 
did  not  justify  one  in  believing  that  there  was  hyperaemia  of  the 
spinal  cord  previous  to  the  inflammatory  action.  With  reference 
to  the  practical  observations  of  Dr.  Jewell's,  he  agreed.  He 
would  suggest  that  the  term  subacute  myelitis  be  altered  to  sub- 
acute diffused  myelitis.  In  the  cases  of  myelitis  transversa,  it 
made  no  difference  whether  acute  or  subacute.  Strychnia, 
produced  tonic  spasms  in  the  paralyzed  limbs,  whereas  in  the 
diffused  forms  of  myelitis  he  had  experimented  with  this  drug 


604  TRANSACTIONS  OF  THE 

apparently  with  the  best  results.  During  the  past  spring  he  had 
a  case  of  extensive  diffused  myelitis  following  anal  diphtheria,  in 
which  he  administered  strychnia  early  with  the  best  effects.  He 
was  prepared,  if  a  case  of  acute  diffused  myelitis  came  under  his 
treatment,  to  give  strychnia  a  little  more  heroically  than  before 
having  heard  Dr.  Jewell's  remarks.  He  agreed  with  the  author 
of  the  paper  as  to  the  beneficial  effects  of  massage  and  rest. 

Dr.  Gray  remarked  that  he  understood  Dr.  Jewell  to  advocate 
the  use  of  strychnia  in  cases  advanced  beyond  the  commencing 
stage,  or,  in  other  words,  that  its  use  was  not  to  be  limited  to  the 
early  stage. 

Dr.  Jewell  said  that  in  his  own  practice  he  had  not  only  used 
strychnia  in  the  early  stages,  but  most  of  all  in  the  later  stages, 
after  the  acute  symptoms  had  passed  away. 

Dr.  Gray  remarked  that  he  had  tried  strychnia  faithfully  in  two 
cases  of  what  might  be  called  transverse  myelitis,  and  had  ob- 
tained the  physiological  effect  of  the  drug  without  deriving  any 
benefit  whatever  from  its  use,  both  cases  having  lasted  five  or  six 
months.  He  did  not  know  but  that  the  point  to  which  Dr.  Se- 
guin  had  called  attention  would  explain  this. 

Dr.  Spitzka  said  that  he  had  always  held  the  same  view  in  re- 
gard to  this  question  hypothetically,  but  had  not  called  attention 
to  it,  for  he  thought  that  few  things  could  be  better  demonstrated 
than  that  the  treatment  of  transverse  myelitis  must  be  different 
from  that  of  diffused  myelitis.  He  had  felt  somewhat  embar- 
rassed by  the  theoretical  view  of  Dr.  Jewell  that  hyperaemia  was 
an  initial  factor  in  inflammation. 

Dr.  Jewell  remarked  that  he  supposed  that  he  owed  it  to  him- 
self, that  he  had  been  misunderstood.  He  had  not  been  talking 
of  how  congestions  arose,  but  of  congestions.  Dr.  Hammond 
had  misconceived  his  remarks.  He  agreed  with  Dr.  Seguin  in  re- 
gard to  hyperaemia  not  preceding  inflammatory  action.  He  had 
not  the  slightest  doubt  but  that  a  process  of  irritative  molecular 
change  antedated  the  active  congestion  of  inflammation.  He  be- 
lieved strychnia  acted,  not  upon  the  blood-vessels,  but  upon  the 
nerve  tissue.  As  to  the  far-reaching  scepticism  of  his  friend,  Dr. 
Seguin,  in  regard  to  anaemia  and  hyperaemia,  it  appeared  to  him 
his  friend  apparently  believed  in  nothing  in  medicine  except  what 
he  could  see,  smell,  feel,  or  physically  demonstrate.  He  partially 
shared  this  feeling,  but,  though  he  admired  caution,  he  was  not  in 
sympathy  with  such  a  general  nihilistic  movement  against  theoriz- 
ing in  medicine,  for  he  thought  that  when  we  saw  certain  evi- 


AMERICAN  NEUROLOGICAL  ASSOCIATION.  605 

dences  which  were  not  to  be  appreciated  wholly  by  the  senses,  we 
could  at  times  step  out,  not  into  the  dark,  but,  guided  by  the 
hand  of  rational   inference,  into  the  light  of  new  knowledge. 

The  next  paper  was  by  Dr.  F.  J.  Morton,  of  New  York,  upon 
*' A  new  current  of  induced  electricity." 

Remarks. 

Dr.  BiRDSALL  thought  that  it  was  unfortunate  that  Dr.  Morton 
had  chosen  the  terms  which  he  had  to  designate  his  current.  He 
referred  in  one  case  to  it  as  a  faradic  current,  and  again  as  a 
static  induced  current.  Since  Faraday's  time  an  induced  current 
had  always  been  considered  as  flowing  in  the  opposite  direction 
to  the  inducing  current,  and  occurred  only  when  the  current  was 
closed  ;  it  was  the  reverse  when  it  was  opened.  He  did  not  under- 
stand that  this  was  the  case  with  Dr.  Morton's  current.  Though  in 
truth  it  was  in  one  sense  an  induced  current,  yet  as  Faraday  had 
attached  the  term  induction  to  a  different  phenomenon,  he  thought 
it  was  improper  to  use  it  in  any  other  sense,  as  it  would  lead  to  a 
confusion  of  terms. 

Dr  Gray  remarked  that  the  point  in  the  paper  which  had  in- 
terested him  more  particularly,  was  that  in  regard  to  its  practical 
value.  He  would  like  to  ask  whether  the  pain  produced  by  the 
new  current  was  much  less  than  that  of  the  ordinary  faradic 
current.  If  so,  it  would  be  of  great  value  in  the  treatment  of 
children. 

Dr.  Morton  thought  that  Dr.  Gray  had  suggested  the  pith  of 
the  whole  matter,  viz.,  whether  the  new  current  could  be  made  of 
any  important  use.  One  difficulty  was  to  be  found  in  the  machine. 
Even  if  machines  were  made  that  could  be  operated  at  all  times, 
their  construction  was  of  such  a  nature  that  they  were  not  portable. 
However,  the  current  was  of  so  much  use,  he  believed  that  many 
would  have  these  machines  placed  in  their  offices.  As  to  the 
painfulness  of  the  current,  this  was  a  matter  merely  of  compari- 
son. The  softness  and  agreeableness  of  any  induction  current 
would  depend  upon  the  extreme  fineness  of  the  wires.  This  elec- 
tricity was  of  so  high  a  tension,  that  it  was  very  soft,  unless  inter- 
rupted. If  the  sponges  were  well  wet  with  it,  a  contraction  could 
be  obtained,  such  as  would  be  produced  with  a  strong  induced 
current.  He  had  found  in  his  office  practice  that  children  bore 
the  current  well. 


6o6  TRANSACTIONS  OF  THE 

Dr  Rockwell  confessed  that  he  was  a  little  astonished  that  the 
question  could  be  brought  up  in  regard  to  the  comparative  merits 
of  static  electricity  and  faradic  electricity.  In  regard  to  pain,  he 
had  learned  from  practice  that  the  faradic  current  was  not  at  all 
painful.  He  could  produce  contraction  of  every  muscle  of  the 
body  with  a  faradic  current,  without  the  slightest  sense  of  pain. 
It  was  exceedingly  pleasant  ;  not  disagreeable.  In  regard  to  the 
therapeutic  value  of  the  two  currents,  he  considered  it  was  impos- 
sible for  one  to  testify  unless  he  had  used  both  currents  thor- 
oughly. The  static  electrical  current  was  one  which  could  not  be 
utilized  extensively. 

Dr.  Morton  remarked,  that  he  would  add  a  word,  simply  in 
defense  of  the  name.  The  current  was  as  much  of  an  induction 
current  as  any  faradic  induction  current,  being  simply  an  electric 
influence  set  up  by  a  conductor  through  space,  by  the  presence  of 
an  active  source,  either  of  mechanisms,  galvanic  current,  or  other 
sources.  It  did  not  make  any  difference  what  kind  of  electricity 
was  used  ;  it  mattered  not  what  was  its  source.  For  the  purpose 
of  illustration,  he  stated  that  the  Leyden  jar  corresponded  to  the 
galvanic  current,  and  that  the  electricity  supplying  the  inside  of 
the  jar  was,  as  a  general  thing,  positive,  and  by  means  of  induc- 
tion we  had  on  the  outside,  negative  electricity.  The  induced 
current  was  only  a  transitory  current  set  up  through  a  dialectric. 
The  sparks  corresponded  to  the  making  and  breaking  of  an  ordi- 
nary induction  coil,  and  whether  the  spark  was  long  or  short,  as 
in  the  common  coil  apparatus,  was  due  to  whether  the  hammer 
struck  fast  or  slow.  He  was  of  the  opinion  that  the  new  current 
was  very  perfectly  induced.  As  to  Dr.  Rockwell's  criticism,  the 
painfulness  of  a  current  depended  upon  its  strength.  We  could 
use  it  so  as  to  give  absolutely  no  pain  ;  but  for  certain  electrical 
reactions  he  believed  it  was  found  necessary  to  use  a  faradic  cur- 
rent which  gave  some  pain,  which,  however,  depended  upon  the 
operator,  and  strength  of  current  used,  the  whole  matter  being 
one  of  comparison. 

Dr.  BiRDSALL  enquired  if  the  direction  of  the  current  was  the 
same  or  opposite  to  the  inducing  current. 

Dr.  Morton  replied,  that  he  had  not  been  able  to  tell  whether 
the  induced  current  corresponded  to  the  make  or  break,  or  which 
occurred  first,  or  whether  it  corresponded,  or  was  opposite,  to  the 
direction  of  the  inducing  current. 

Dr.  BiRDSALL  remarked  that  a  truly  induced  current  always 
flowed  in  the  opposite  direction  from  the  current  which  induced  it. 


AMERICAN  NEUROLOGICAL  ASSOCIATION.  607 

Dr.  Seguin  inquired  what  was  the  relation  of  the  current  as 
regards  the  time  of  its  occurrence  ?  A  true  faradic  current  oc- 
curred at  the  moment  of  the  break  of  the  inducing  current. 

Dr.  Morton  remarked  that  as  soon  as  the  circuit  took  place 
there  was  an  equalization  of  the  electricity  in  the  two  jars  and  the 
outer  tin-foil. 

Dr.  Seguin  said  that  the  faradic  current  occurred  at  the  mo- 
ment when  the  other  ceased.  He  was  of  the  opinion  that  we 
must  distinguish  two  kinds  of  induction,  viz.  :  induction  in  gen- 
eral, and  the  induction  of  Faraday,  which  occurred  at  the  moment 
of  cessation,  or  at  the  instant  of  the  appearance  of  the  current  in 
the  inducing  circuit. 

Dr.  Morton  remarked  that  there  was  constantly  an  alteration 
in  the  direction  of  the  currents,  but  that  in  batteries  now  in  use 
the  current  took  place  only  in  one  direction,  being  so  constructed 
for  convenience.  In  the  new  current  we  had  alternating  currents 
of  even  strength,  and  in  this  respect  it  differed  from  the  ordinary 
faradic  current,  in  being  more  perfect. 

Dr.  Gradle,  of  Chicago,  remarked  that  the  discharge  was  in- 
dependent of  the  charging  of  the  jar,  for  when  these  were  once 
charged,  they  would  discharge  as  soon  as  the  connection  was 
made.  There  was  a  constant  accumulation  of  electricity  upon 
the  inner  coat,  and  a  separation  upon  the  outer  coat,  the  constancy 
only  being  interrupted  by  discharges  when  the  tension  became 
high  enough  to  overcome  the  resistance  inter-opposed.  He  was 
of  the  opinion  that  the  new  current  was  not  induced. 

Dr.  Morton  said  that  he  would  agree  with  Dr.  Gradle,  if  in 
the  case  of  the  production  of  his  current  there  was  only  a  dis- 
charge corresponding  to  that  of  an  ordinary  Leyden  jar  ;  but  the 
discharge  was  not  the  same  as  that  of  an  ordinary  Leyden  jar  ;  it 
was  a  true  current,  for  it  had  different  potentialities. 

There  being  no  further  discussion,  Dr.  G.  M.  Hammond,  of 
New  York,  read  a  paper,  entitled,  "  The  hypothetical  auditory 
tract,  in  the  light  of  recent  anatomical  observations." 

At  a  meeting  of  the  New  York  Neurological  Society,  on  Febru- 
ary ist,  of  this  year,  the  author  had  read  a  paper  describing  and 
giving  the  measurements  of  certain  gigantic  nerve  cells  discovered 
by  him,  and  showed  by  comparison  that  these  cells  were  larger  as 
far  as  the  carnivora  were  concerned,  than  any  of  the  giant  cells 
described  by  Betz.  From  the  brain  of  the  same  cat  in  which  he 
discovered  the   giant   cells  before  mentioned,  he  mounted  some 


6o8  TRANSACTIONS  OF   THE 

one  hundred  and  fifty  sections  cut  transversely  to  the  cerebral 
axis,  and  including  that  portion  of  the  brain  between  the  lower 
olivary  altitude  and  the  optic  lobes  of  the  corpora  quadri- 
gemina.  These  sections  enabled  him  to  make  a  thorough  study 
and  examination  of  the  cells  contained  in  the  optic  lobes,  nu- 
cleus tegmenti,  and  auditory  nucleus.  These  cells  were  not  a 
new  discovery.  They  were  known  to  Meynert,  and  their  dimen- 
sions in  the  human  brain  had  been  given  by  him  ;  but  the  author 
of  the  paper  was  not  aware  of  any  one  having  given  any  compar- 
ative measurements  of  the  cells.  The  author  gave  the  measure- 
ments and  descriptions  of  the  cells,  of  the  optic  lobes,  nucleus 
tegmenti,  and  auditory  nucleus,  from  sections  taken  from  the  same 
brain,  and  compared  them  with  the  cells  of  the  cortical  group  dis- 
covered by  him.  A  microscopical  demonstration  of  these  cells 
was  afforded  the  members  of  the  Association.  These  three  groups 
of  cells  followed  the  same  law  of  progress  as  the  sensory  cells, 
that  is,  where  there  was  an  increase  in  the  number  of  cells  in  the 
lower  groups  there  was  also  an  increase  in  the  higher  ones,  and  this 
increase  in  the  higher  groups  was  greater  in  proportion  to  that  in 
the  lower.  For  example,  just  as  there  was  a  progress  in  the  de- 
velopment of  cells  of  the  anterior  spinal  cornu  in  the  frog  as  con- 
trasted with  the  proteans,  so  there  was  a  still  greater  increase  in 
the  reticular  field  in  the  lower  mammalia  as  contrasted  with  the 
reptiles  and  amphibians,  and  a  still  more  rapid  stride  in  the  higher 
mammalia  over  the  lower  mammalia,  in  whom  these  cortical  cell- 
groups  were  really  absent.  This  anatomical  fact  was  in  parallel- 
ism with  the  physiological  observation  that  the  simple  reflex  acts 
were  the  common  property  of  all  animals,  low  and  high  ;  that 
progress  in  functions  was  first  manifested  in  the  development  of 
coordinated  reflexes,  which,  in  their  turn,  were  merely  stepping- 
stones  for  the  highest  nervous  combinations  of  psychical  life. 

Re7narks. 

Dr.  Seguin  wished  to  call  attention  to  the  pathological  findings 
in  an  interesting  case  of  aphasia  published  in  the  Archives  of 
Medicine,  April,  1881.  This  case  was  that  of  the  late  Dr.  AUin, 
whose  aphasia  was  characterized  chiefly  by  word-deafness,  and 
who  had  no  appreciable  paralysis.  The  autopsy  revealed  a  patch 
of  softening  destroying  the  inferior  parietal  lobule,  a  region  which 
in  many  respects  was  identical  with  the  cortical  areas  which  Fer- 
rier's  and  Munk's  experiments  had  shown  to  be  intimately  con- 


AMERICAN  NEUROLOGICAL  ASSOCIATION.  609 

nected  wtth  the  functions  of  hearing  and  sight  in  monkeys  and 
dogs.  He  believed  this  case  might  serve  as  a  clinical  and  patho- 
logical support  of  Dr.  Hammond's  anatomical  deductions. 

Dr.  Hammond  remarked  that  in  his  specimens  he  found  a  great 
number  of  cells  upon  the  left  side,  while  upon  the  right  there  were 
a  very  few. 

Dr.  Spitzka  said  that  he  had,  on  the  previous  day,  an  interest- 
ing case  of  congenital  atrophy  of  the  cerebellum  in  a  patient 
markedly  ataxic,  and  yet  his  musical  sense  was  unusually  de- 
veloped. And  though  the  patient  was  practically  an  imbecile,  he 
could  repeat,  after  once  hearing,  classical  operas. 

The  next  paper  was  by  Dr.  George  M.  Beard,  of  New  York,  on 
"  The  medical  use  of  statical  electricity,  or  franklinism." 

The  history  of  franklinism  in  medicine  had  been  one  of  tre- 
mendous expectation  and  tremendous  disappointment.  He  said 
Berge  had  constructed  a  statical  machine  that  would  go  at  all  sea- 
sons of  the  year.  This  was  of  great  advantage,  and  would  en- 
able him  to  test  whether  there  were  or  were  not  cases  in  which 
this  form  of  electricity  would  be  superior  to  either  faradism  or 
galvanism.  The  question  was  not  whether  this  form  of  electricity 
produced  a  sedative  or  tonic  effect.  That  had  been  determined 
a  hundred  and  fifty  years  ago.  The  question  was  whether  the 
sedative  and  tonic  effects  differed  from  those  of  faradism  or 
galvanism.  This  question  had  not  been  answered.  The  pub- 
lication of  cases  treated  by  statical  electricity  proved  nothing  ex- 
cept when  compared  with  the  effects  produced  by  other  forms  of 
electricity.  We  could  not  say  that  franklinism  was  superior  to 
faradism  or  galvanism  unless  we  had  used  the  others,  and  thereby 
derived  a  standard  of  comparison.  We  were  now  in  a  position  to 
settle  the  question,  though  it  would  not  be  found  an  easy  thing 
to  do,  and  would  take  a  long  time.  He  stated  that  he  was  using 
franklinism  every  day  with  his  patients.  The  current  of  Dr.  Mor- 
ton was,  he  thought,  incorrectly  named.  It  was  induced,  but 
all  the  phenomena  of  static  electricity  were  phenomena  of 
induction.  The  current  from  the  outside  of  the  jars  was  really 
secondary  static  electricity,  and  he  thought  this  would  be  the 
proper  name  by  which  to  designate  it.  It  produced  muscular 
contractions  ;  it  was  milder  and  easier  of  application. 

Remarks. 

Dr.  Rockwell,  some  four  or  five  years  ago,  had  experimented 
with  statical  electricity,  and  had  drawn  certain  conclusions  from 


6lO  TRANSACTIONS  OF  THE 

his  experience.  At  the  beginning  of  its  recent  revival  he  had 
procured  a  new  machine,  but  as  yet  he  had  no  reason  to  change 
the  opinion  formed  some  years  ago.  He  did  not  care  to  be  de- 
structive in  criticism,  therefore  he  would  say  that  the  absolute 
value  of  statical  electricity  was  very  great  ;  but  in  comparing  it 
with  other  forms,  its  range  of  usefulness  was  inferior,  and  far  in- 
ferior to  the  two  forms  of  dynamic  electricity  combined.  In  elec- 
tricity, as  in  medicine,  benefit  was  often  derived  from  a  change. 
We  know  that  when  a  certain  tonic  had  been  given  for  a 
considerable  length  of  time,  the  patient  improved  if  it  was 
changed  for  some  other  tonic,  though  it  was  known  to  be  inferior 
to  the  first.  Therefore,  for  this  reason,  he  would  recommend  its 
use.  He  quite  agreed  with  Dr.  Beard  in  the  choice  of  galvanism 
first,  faradism  next,  franklinism  last,  but,  preferably,  all  three. 

Dr.  Amidon  said  that  what  little  experience  he  had,  while  with 
Dr.  Charcot,  in  Paris,  led  him  to  agree  with  Dr,  Beard.  Most 
commonly  the  good  effects  of  statical  electricity  were  due  to  men- 
tal impressions.  The  best  results  which  had  been  obtained  in 
Charcot's  practice  were  in  cases  of  hystero-epilepsy.  Drs.  Char- 
cot and  Vigouroux  claimed  that  only  in  this  way  was  it  superior 
to  galvanism  and  faradism.  They  used  it  in  a  variety  of  cases  and 
on  a  large  scale;  they  would  huddle  together  upon  a  single  isolated 
stool  cases  of  hystero-epilepsy,  locomotor  ataxia,  paralysis  agi- 
tans,  a  case  of  anaesthesia,  and  a  case  of  headache,  thus  forming 
a  series  of  pathological  conditions  which  had  nothing  in  common, 
and  apply  the  same  current  to  all  of  them.  He  considered  this 
wholesale  way  of  dealing  with  patients  not  advisable,  and  that  it 
was  adopted  only  as  a  means  of  saving  time.  He  had  noticed 
that  when  Dr.  Vigouroux  had  a  case  of  infantile  paralysis  he  took 
it  to  the  galvanic  machine  and  applied  the  current  with  great 
care.  Dr.  Onimus,  one  of  the  best  electricians  in  Europe,  never 
used  static  electricity.  He  had  watched  the  application  of  static 
electricity,  had  taken  histories  of  cases,  and  with  the  exception  of 
temporary  relief  in  hysterical  patients,  he  had  never  seen  any 
benefit  derived  from  its  use. 

Dr.  BiRDSALL  remarked  that  he  observed  that  Dr.  Beard  held 
partially  to  the  view  that  while  the  general  term  induction  was  ap- 
plicable to  Dr.  Morton's  current,  the  term  was  not  well  taken.  He 
thought  we  should  be  exact  in  regard  to  the  use  of  our  terms  in 
these  matters.  The  name  given  by  Faraday  should  be  maintained 
as  describing  a  particular  condition.  He  would  state  again  that 
he  considered,  as  Faraday  had  considered,  a  current  in  a  conduc- 


AMERICAN  NE UROLOGICAL  A SSOCIA  TION.  6 1  I 

tor  to  be  an  induced  current,  when  it  was  produced  by  another 
current  or  magnet  at  the  moment  when  the  circuit  was  made  and 
broken,  and  that  the  current  ordinarily  passed  in  the  opposite  di- 
rection from  the  inducing  current.  In  regard  to  its  uses  he  could 
confirm  to  a  slight  extent  Dr.  Amidon's  statement. 

Dr.  Morton  thought  that  Dr.  Amidon  took  rather  a  humor- 
ous view  of  Dr.  Charcot's  use  of  statical  electricity.  Charcot  and 
his  associate  Dr.  Vigouroux  had  to  administer  to  the  wants  of  a 
large  number  of  patients,  and  he  saw  no  inconsistency  in  giving 
electricity  in  the  manner  described.  Professor  Charcot  had  re- 
cently written  a  long  article,  in  which  he  had  analyzed  the  histori- 
cal position  of  static  electricity,  together  with  the  different  ma- 
chines and  appliances  which  had  been  used,  and  then  proceeded 
to  state  the  class  of  cases  in  which  he  thought  its  use  was  of  value. 
Hysteria  was  one  of  the  diseases  in  which  he  thought  it  of  great 
value.  He  stated  that  static  electricity  was  of  the  greatest  value 
in  a  large  number  of  diseases. 

Dr.  Rockwell  wished  to  ask  Dr.  Morton  if  he  had  ever  put  to 
a  thorough  test  the  tonic  effects  of  general  faradization  in  all  its 
power. 

Dr.  Morton  replied  that  he  had  never  used  general  faradiza- 
tion. 

Dr.  Beard  remarked  that  the  question  was  not  whether  the 
static  electricity  helped  to  cure  disease,  nor  was  it  what  Charcot 
or  Vigouroux  thought  of  it.  That  question  had  been  settled  even 
in  this  country  before  Charcot  or  Vigouroux  were  born.  The 
question  was  whether  there  was  any  comparative  superiority  of 
the  two  forms  of  electricity,  and  he  thought  this  was  the  only  thing 
to  be  considered.  He  thought  there  were  a  great  many  gentle- 
men in  this  country  and  in  Europe  who  could  make  the  compari- 
son between  the  different  varieties  of  electricity,  and  who  knew 
what  electricity  could  do,  and  that  they  would  make  this  compar- 
ison. 

There  being  no  further  discussion.  Dr.  Beard  read  a  second 
paper  giving  directions  "  How  to  use  the  bromides." 

He  regarded  the  bromides  as  among  the  great  and  few  remedies 
which  we  had,  and  that  they  ranked  with  opium,  quinine,  and 
electricity.  As  far  as  we  knew,  their  good  effects  depended  upon 
their  being  administered  in  the  treatment  of  functional  nervous 
diseases.  What  he  had  to  say  had  especial  reference  to  other  dis- 
eases than  epilepsy.     Their  use  in  epilepsy  had  been  much  writ- 


6l2  TRANSACTIONS  OF  THE 

ten  upon,  but  it  was  not  so  well  known  that  they  were  of  value  in 
the  treatment  of  various  functional  nervous  disturbances  or  dis- 
eases, though  in  these  conditions  they  had  proved  as  efficacious  as 
in  epilepsy,  and  far  more  so.  In  giving  the  bromides  for  the 
above-named  conditions,  the  object  aimed  at  was  first  to  produce 
the  effect  of  bromization  to  a  greater  or  less  degree.  When  the 
bromides  were  given  in  such  small  doses  that  they  did  not  pro- 
duce bromization,  they  did  not  accomplish  much  good  for  the  pa- 
tient. Bromization  was  an  abnormal  state,  a  disease,  but  in 
therapeutics  we  cured  diseases  by  producing  disease.  Second,  to 
rapidly  induce  bromization  it  was  usually  of  advantage,  though 
not  absolutely  necessary,  to  give  immense  doses,  from  30  to  100 
grains,  more  or  less.  Idiosyncrasies  were  sometimes  met  with, 
where  patients  were  susceptible  to  small  doses  of  the  bromides. 
They  should  be  watched  for.  In  some  cases,  as  in  attacks  of  hys- 
teria or  sea-sickness,  a  single  large  dose,  say  100  or  120  grains,  or 
more,  given  in  one  or  two  tumblers  full  of  water,  would  be  suffi- 
cient, without  any  more,  to  accomplish  the  purpose  for  which  they 
were  given.  To  sea-sickness  bromization  was  what  vaccination 
was  to  small-pox  ;  it  absolutely  prevented  it  in  nearly  every  case. 
There  was  no  nerve  disease  known  to  science  so  absolutely  under 
medical  control  as  sea-sickness.  Third,  the  bromides  were  to 
be  given  in  these  immense  doses,  for  a  short  time  only,  save,  of 
course,  in  epilepsy  and  epileptoidal  conditions — a  few  days,  some- 
times two,  or  three,  or  four,  or  more  days.  The  secret  of  success 
in  the  use  of  the  bromides,  as  with  every  thing  else,  is  to  know 
when  to  stop. 

It  was  because  of  the  want  of  this  knowledge  that  we  heard 
so  much  about  the  evil  effects  of  the  bromides.  He  cited  cases 
where  bromization  had  been  produced  within  half  an  hour,  and 
stated  that  it  was  possible  to  kill  a  person  with  the  bromides  as 
surely  as  with  a  pistol.  In  some  cases  bromization  sprung  upon 
one  suddenly  after  a  long  delay  ;  it  did  not  usually  creep  upon 
the  patient  slowly.  Fourth,  the  bromides,  if  used  long  or  frequently 
on  any  patient,  should  be  used  alternately  with  tonics  ;  this  was 
very  important  and  not  generally  known  in  connection  with  other 
diseases  than  epilepsy.  Fifth,  it  was  of  advantage  to  use  a  number 
of  the  bromides  in  combination.  The  bromides  which  he  usually 
used  in  combination  were  the  bromide  of  potassium,  calcium, 
sodium,  ammonium,  and  lithium.  He  also  used  other  bromides 
such  as  the  bromide  of  camphor,  zinc,  and  iron.  Sixth,  some 
nervous  patients,  who  were  not  epileptic  or  epileptoidal,  needed  to 


AMERICAN  NEUROLOGICAL  ASSOCIATION.  613 

use  the  bromides  for  a  time,  just  as  though  they  had  epilepsy, 
subject  to  the  directions  above  given.  There  was  such  a  thing  as 
the  habit  of  taking  the  bromides. 

Remarks. 

Dr.  Hammond  enquired  if  Dr.  Beard  attributed  the  effects 
to  the  bases,  or  to  the  bromine.  He  said  that  he  had 
been  somewhat  struck  with  the  idea  that  the  same  effect, 
in  epilepsy,  could  be  obtained  from  thirty  grains  of  a  salt, 
three  times  a  day.  He  was  inclined  to  think  that  the  bro- 
mide condition  was  a  modified  condition  of  scurvy  ;  he  had 
been  giving  the  pure  bromine  in  drop  doses,  and  had  obtained  the 
same  effect  upon  the  epileptic  phenomena,  but  without  giving  rise 
to  scurvy.  He  simply  mentioned  it  as  a  point  needing  investiga- 
tion. So  far  as  the  influences  which  particular  bromides  had,  he  did 
not  see  any  particular  difference  between  them,  or  any  advantage 
in  combining  them.  He  almost  invariably  administered  bromide 
of  sodium  because  it  was  more  pleasant  to  the  taste. 

Dr.  Gray  remarked  that  there  was  one  source  of  fallacy  in  get- 
ting at  the  effects  of  the  bromides,  which  was  almost  universally 
overlooked,  viz.,  that  these  effects  were  generally  estimated  from 
their  use  in  cases  of  epilepsy.  After  having  given  one  of  the  bro- 
mides until  its  good  effects  had  ceased  to  be  manifest,  as,  for  in- 
stance, with  the  bromide  of  potassium,  if  it  were  stopped,  and  the 
bromide  of  sodium  were  given  instead,  good  effects  would  follow 
its  administration,  and  after  this  failed  to  act,  if  the  patient  was 
put  upon  the  bromide  of  ammonium  he  would  improve.  Not  only 
so,  if  their  administration  were  stopped  altogether,  the  patient  would 
get  better,  or  if  he  was  put  upon  almost  any  other  remedy,  or  if 
they  became  the  subjects  of  an  injury,  and  were  confined  to  the 
bed,  they  did  not  have  epileptic  seizures  for  a  long  time  at  least. 
A  tap  on  the  head  would  also,  sometimes,  stop  epileptic  convul- 
sions for  a  few  days.  Hence,  one  in  an  enthusiastic  frame  of 
mind  might  attribute  undue  therapeutic  value  to  some  particular 
bromide  or  plan  of  treatment,  when,  in  reality,  epileptics  im- 
proved upon  almost  every  new  remedy  which  was  administered  to 
them. 

Dr.  Seguin  rose  to  protest  against  the  comparison  of  bromiza- 
tion  to  scurvy.  He  had  a  very  clear  picture  in  his  mind  of  the 
latter  condition.  He  had  seen  a  shipload  of  scorbutic  sailors 
with  multiple   hemorrhages,  some   of  them  as  large  as  a  hand. 


6 14  TRANSACTIONS  OF  THE 

without  any  nervous  symptoms.  The  tendency  to  hemorrhage 
was  characteristic  of  scorbutus,  not  so  in  the  case  of  bromides. 
Their  administration  was  followed  by  loss  of  power.  In  regard 
to  Dr.  Hammond's  question,  he  thought  he  had  answered  that  in 
a  series  of  experiments  which  he  performed  while  in  charge  of 
the  hospital  for  epileptics  on  Blackwell's  Island,  in  1874.  He 
tested  the  comparative  value  of  the  chloride  of  potassium,  and  the 
bromide  of  potassium,  with  the  following  results  :  Three  male 
patients  one  month  under  KBr,  22  attacks;  under  KCl,  115 
attacks.  Eighteen  female  patients,  one  month  under  KBr,  205 
attacks  ;  one  month  under  KCl,  410  attacks. 

Again,  thirteen  female  epileptics  under  KBr,  average  monthly 
number  of  attacks  in  a  period  of  three  months,  70  attacks  ; 
the  same,  one  month  under  KCl,  348  attacks. 

These  results  were  published  in  xSxq  New  York  Medical  Journal, 
April,  1878.  He  had  come  to  the  conclusion  that  the  efficient 
agent  was  bromine,  and  not  potassium.  Upon  most  points  as  re- 
gards administration  he  agreed  with  Dr.  Beard. 

Dr.  Hammond  wished  to  give  the  Association  the  formula 
which  he  used,  which  was  one  drachm  of  bromine  to  eight  ounces 
of  water.  Of  this  he  gave  a  teaspoonful,  properly  diluted,  three 
times  a  day. 

Dr.  Jewell  remarked  that  he  had  had  a  somewhat  similar  expe- 
rience in  regard  to  the  use  of  bromine,  and  merely  rose  to  declare 
it.  He  thought  some  patients  would  bear  the  bromine,  when  they 
could  not  take  it  in  connection  with  the  alkaline  base.  He  no- 
ticed this  particularly  in  one  patient  who  had  been  taking  the 
bromides  constantly,  he  believed,  under  the  direction  of  one 
physician  or  another  for  thirteen  years,  and  who  was  obliged  to 
abandon  them  entirely  on  account  of  their  bringing  out  immense 
sores,  especially  upon  the  legs.  This  same  patient  had  been  us- 
ing bromine  alone  for  a  considerable  while  without  any  return  of 
the  disorder  spoken  of. 

Dr.  Seguin  considered  Dr.  Jewell's  observation  a  very  valuable 
one,  A  recent  patient  of  his  had  an  eruption  produced  upon  her 
legs  in  a  few  days  by  moderate  doses  of  the  bromide  of  potassium. 
The  same  condition  was  caused  by  mixture  of  chloral  and  bro- 
mide. He  had  placed  this  patient  now  upon  bromide  of  camphor, 
which  controlled  the  epileptic  fits  without  giving  rise  to  cutaneous 
lesions.  He  wished  to  inquire  if  this  eruption  had  been  noticed 
principally  upon  the  lower  members. 

Dr.  Jewell  remarked  that  the  eruption  in  his  case  was  found 


A  ME  RICA  N  NE  UROLOGICAL  A  SSOCIA  TION.  6 1  5 

upon  the  legs  from  the  knee  down,  and  also  on  the   face,  in  the 
distribution  of  the  trigeminus,  in  which  location  it  was  very  bad. 

There  being  no  further  discussion,  upon   motion  of  Dr.  Ham- 
mond, the  Association  adjourned. 


Third  day,  afternoon  session. 

The  Association  was  called  to  order  by  President  Bartholow,  at 
2.30  p.  M. 

Present. — Drs.  Amidon,  Bartholow,  Beard,  Birdsall,  Gradle, 
Hammond  W.  A.,  Hammond  G.  M.,  Jewell,  McBride,  Miles, 
Morton,  Rockwell,  Seguin,  and  Spitzka. 

The  Secretary  read  the  minutes  of  the  previous  session,  which 
were  approved. 

The  Council  recommended  the  acceptance  of  the  resignation  of 
Dr.  Cross. 

Upon  motion  of  Dr.  Spitzka,  the  resignation  of  Dr.  T.  M. 
B.  Cross  was  accepted  by  the  Association. 

The  Secretary  announced  the  receipt  of  excuses  for  absence 
from  Drs.  Eads  and  Putnam,  of   Boston. 

The  amendment  to  the  constitution  offered  by  Dr.  Gray, 
upon  motion  of  Dr.  Hammond,  was  deferred  for  action,  in 
consequence  of  the  absence  of  its  author. 

The  first  paper  was  by  Dr.  Wm.  A.  Hammond,  of  New 
York,  entitled,  "Nerve-stretching  in  locomotor  ataxia." 

His  paper  consisted  of  an  enumeration  of  the  published  ac- 
counts of  cases  in  which  the  operation  had  been  performed, 
together  with  the  history  of  the  cases  in  which  he  had  oper- 
ated. His  practice  had  been  to  expose  the  sciatic  nerve  on 
the  posterior  part  of  the  thigh  at  about  the  junction  of  the 
upper  with  the  middle  third,  and,  introducing  his  little  finger, 
pull  alternately  up  and  down,  until  the  nerve  had  been  stretched 
about  an  inch  or  less,  when  it  was  returned  to  its  bed  and 
the  wound  dressed  antiseptically.  He  was  led,  by  the  favor- 
able results  attained  in  his  three  cases,  to  the  opinion,  that 
the  operation  might  prove  of  decided  value. 

Remarks. 

Dr.  Jewell  reported  that  he  had  recently  received  informa- 
tion  by    letter  from    a  well-known  physician    of  the    successful 


6l6  TRANSACTIONS  OF  THE 

performance  of  the  operation  in  two  cases  in  which  it  afforded 
marked  relief.  The  history  of  these  cases  was  unpublished,  so  far 
as  he  knew,  and  they  should  be  added  to  those  in  which  the  op- 
eration had  been  performed  with  benefit. 

Dr.  Spitzka,  without  wishing  to  adopt  the  opinion  of  the  author 
of  the  paper  on  European  operations,  considered  the  amelioration 
of  pain  following  the  operation  no  positive  evidence  that  it  was  in 
consequence  of  the  operation.  The  case  of  a  physician  in  the 
U.  S.  army  had  recently  come  to  his  notice,  in  whom  such  re- 
markable symptoms  were  caused  by  the  taking  of  morphine  that 
the  diagnosis  from  posterior  sclerosis  of  the  cord  was  exceedingly 
obscure.  He  had,  however,  unquestionable  disease  of  the  spinal 
cord.  The  suspension  of  the  morphine  caused  a  sudden  cessation 
of  the  pain.  The  same  claim  had  been  made  for  static  electricity 
in  ataxia  that  was  now  made  for  this  operation,  and  until  the  proof 
was  more  conclusive  than  at  present  he  thought  we  had  better  re- 
serve our  opinion  as  to  the  curative  or  beneficial  effects  of  the 
operation. 

Dr.  BiRDSALL  referred  to  Dr.  Westphal's  case,  and  said  that  in 
that  instance  no  lesion  of  the  spinal  cord  was  found,  and 
that  during  life  a  good  deal  of  doubt  was  expressed  as  to  whether 
it  was  a  case  of  locomotor  ataxia.  There  was  no  degeneration  of 
the  posterior  columns,  and  the  history  given  by  Dr.  Langenbeck 
was  exceedingly  meagre.  He  stated  that  the  disease  developed 
within  a  few  months,  and  that  at  the  time  of  the  operation  the 
patient  had  ataxic  symptoms  in  the  upper  and  lower  extremities. 
He  did  not  describe  the  nature  of  the  disease.  As  to  the  existence 
of  pains  and  the  absence  of  the  tendon  reflex  before  there  was 
any  change  in  the  spinal  cord,  he  considered  it  a  doubtful  point, 
and  one  that  could  hardly  be  credited.  He  might,  perhaps,  refer 
to  a  case  mentioned  by  Dr.  Seguin  in  a  published  paper.  In  this 
case  there  was  pain  and  absence  of  tendon  reflexes  for  30  years, 
without  any  ataxic  symptoms  being  manifest.  Dr.  Birdsall  did 
not  mean  to  say  that  doubt  should  be  thrown  upon  all  these  cases, 
but  probably  a  great  many  cases  would  be  met  with  that  would 
not  be  carefully  examined,  and  a  diagnosis  not  carefully  made. 
In  a  certain  number  of  cases  the  symptoms  to  which  Westphal 
referred  were  acute  and  disappeared  rapidly.  In  regard  to  the 
effect  of  nerve-stretching,  the  experiments  of  Brown-Sequard  in 
stretching  the  nerves  of  animals  were  probably  familiar  to  the 
members  of  the  Association.  The  general  view  which  was  gaining 
ground,  that  the   effect  of  stretching  a  nerve  did  influence  the 


AMERICAN  NEUROLOGICAL  ASSOCIATION.  617 

central  nervous  system,  at  least  temporarily,  was  one  that  was 
deserving  of  a  good  deal  of  consideration  ;  but  he  judged  that 
the  effects  were  to  a  great  extent  temporary,  and  perhaps  would 
be  followed  by  bad  ones,  as  happened  in  Westphal's  case. 

Dr.  Seguin  remarked  that  it  had  always  seemed  to  him  that 
sclerosis  of  the  posterior  columns  was  characterized  by  periods  of 
amelioration,  and  he  agreed  with  Dr.  Spitzka  that  the  subsidence 
of  pains  after  the  operation  was  not  conclusive  that  it  was  due  to 
the  operation.  He  had  frequently  known  the  pains  of  sclerosis  to 
be  apparently  arrested  by  treatment,  and  sometimes  without  any 
treatment  whatever ;  and  from  what  we  know  of  the  disturbing 
effects  of  operations  upon  the  central  nervous  system,  it  might  be 
that  the  operation,  as  an  operation,  might  explain  the  subsidence 
of  the  symptoms.  It  was  known  that  the  operation  of  removal  of 
the  testicle  was  at  one  time  a  favorable  remedy  for  epilepsy,  and 
it  no  doubt  did  suspend  the  attacks  for  a  time.  He  had  no  prej- 
udices against  the  operation  of  nerve-stretching  and  might  try  it, 
but  before  doing  so  he  should  hardly  be  led  to  expect  much  per- 
manent benefit.  He  was  of  this  opinion,  perhaps,  because  he 
believed  that  the  changes  in  the  posterior  columns  were  grave  and 
incurable.  In  the  case  referred  to  by  Dr.  Birdsall  the  patient 
had  had  pains  for  30  years,  and  he  found  marked  sclerosis  in  the 
external  part  of  the  posterior  columns.  He  had  examined  the 
cord  of  another  patient,  that  of  a  man,  who  for  two  years  suffered 
from  numbness  in  his  legs  and  arms.  The  patient  died  of  acute 
anaemia.  There  was  no  ataxia.  Before  dying  he  experienced 
sharp  pains  in  one  heel.  After  the  death  of  the  patient  Dr.  Seguin 
learned  that  he  had  experienced  sharp  pain  in  one  thigh  during 
the  preceding  summer  while  at  a  water  cure  ;  these  were  the  only 
pains  that  the  patient  had  had  in  a  two  years'  illness. 

Post-mortem  examination  showed  typical  sclerosis  of  the  external 
part  of  the  posterior  columns.  He  had  had  an  opportunity  some 
two  years  ago  of  examining  a  sciatic  nerve  stretched  by  Dr.  Weir 
for  tetanus,  and  he  found  very  few  nerve  fibres  in  a  state  of  de- 
generation. There  was  marked  perineuritis  at  the  seat  of  hand- 
ling, but  the  inflammation  did  not  seem  to  proceed  very  far  within 
the  bundle  of  the  nerve,  and  he  was  quite  surprised  at  the  com- 
paratively healthy  condition  of  the  nerve. 

Dr.  Amidon  called  attention  to  the  fact  that  in  Dr.  Weir's  case, 
besides  stretching,  the  nerve  was  taken  upon  the  curved  side  of  a 
director  and  rubbed.  He  enquired  if  Dr.  Hammond  considered 
the  effects  due  to  any  thing  further  than  several  counter-irritations. 


6l8  TRANSACTIONS  OF  THE 

Dr.  Hammond  remarked  that  he  most  certainly  did.  He 
thought  those  who  first  saw  a  case  of  tetanus,  and  made  a  post- 
mortem  examination,  would  not  be  disposed  to  think  the  dis- 
ease due  to  a  slight  cut  in  the  thumb,  but  where  we  know  that 
such  slight  injuries  as  this  might  give  rise  to  so  grave  a  disease  as 
tetanus,  he  did  not  think  it  impossible  for  nerve-stretching  to 
benefit  locomotor  ataxia. 

Dr.  Rockwell  had  no  doubt  that  relief  of  pain  in  locomotor 
ataxia  might  be  brought  about  by  various  methods  of  treat- 
ment. He  thought,  however,  that  in  many  of  the  cases  coming 
from  German  sources  functional  disease  had  been  mistaken  for 
organic. 

Dr.  Morton  had  no  doubt  but  that  various  measures  would 
relieve  the  pains  of  locomotor  ataxia,  and  from  the  experience 
which  he  had  had  in  one  case  with  static  electricity,  he  would  say 
that  ataxia  and  pains  had  disappeared.  In  reporting  this  case  he 
had  been  incorrectly  understood  as  stating  that  he  had  cured  a 
case  of  locomotor  ataxia,  whereas  he  simply  said  that  the  pains 
and  ataxia  were  relieved  by  the  treatment.  He  did  not  consider 
it  an  instance  of  remission,  for  it  would  be  strange  if  the  remis- 
sion should  occur  just  at  the  moment  of  treatment,  especially 
when  the  pains  had  existed  for  a  long  time.  In  reviewing  the 
observations  of  Dr.  Hammond,  it  seemed,  in  view  of  the  amelior- 
ation and  improvement  immediately  following  the  operation,  that 
it  was  worthy  of  consideration,  especially  inasmuch  as  the  oper- 
ation was  extremely  simple.  He  performed  the  same  opera- 
tion in  the  case  of  a  patient  having  lateral  sclerosis,  cutting  down 
upon  the  sciatic  nerve  in  the  sciatic  notch.  In  this  locality  he 
found  it  a  little  more  difficult  than  it  would  be  at  the  point  recom- 
mended by  Dr.  Hammond  on  account  of  the  depth  of  the  nerve. 
He  raised  the  nerve  with  his  finger,  and  stretched  it  vigorously. 
In  the  stretching  he  would  avoid  the  use  of  instruments.  He 
stretched  it  until  he  could  feel  something  give  way,  and  then  re- 
turned the  nerve,  and  sewed  up  the  wound.  The  patient  wrote 
that  he  was  immensely  better  ;  he  walked  better.  He  considered 
the  operation  extremely  simple,  and,  in  view  of  this  fact,  he  would 
stretch  as  many  sciatic  nerves  for  locomotor  ataxia  as  he  could 
get  patients  who  would  allow  him  to  do  it. 

Dr.  Hammond  remarked  that  some  recent  experiments  had 
showed  the  sciatic  nerve  capable  of  sustaining  a  weight  of 
seventy  pounds.  He  spoke  of  the  undue  stretching  which  had 
been  practised  in  some  cases,  which   in  one   instance  was   so  ex- 


AMERICAN  NEUROLOGICAL  ASSOCIATION.  619 

treme  that  the  nerve  lay  as  a  loop  upon  the  thigh,  having  been 
stretched  two  or  three  inches. 

Dr.  G.  M.  Hammond  called  attention  to  a  case  which  had  been 
operated  upon  by  Dr.  W.  A.  Hammond,  at  the  college  clinic,  and 
in  which  the  symptoms  had  been  aggravated. 

Dr.  Spitzka  enquired  if  the  girdle  sensation  was  relieved. 

Dr.  Hammond  replied,  that  in  one  of  his  cases  the  girdle 
sensation,  was  not  relieved.  In  the  other  cases  there  had  been 
none  of  it  at  any  time,  but  the  bladder  symptoms  were  very  much 
improved,  and  the  tendon  reflexes  slightly  restored. 

Dr.  BiRDSALL  remarked  that  in  a  case  referred  to  by  him  the 
girdling  sensation  was  not  improved,  though  the  symptoms  in  re- 
gard to  walking  were. 

Dr.  Gradle,  of  Chicago,  reported  a  case  of  "  Spasm  of  the  ciliary 
muscle  of  central  origin."  A  young  healthy  lady  suffered  from  an 
attack  of  left  hemiplegia  during  a  protracted  labor.  Both  the 
positive  and  negative  symptoms  pointed  to  a  small  hemorrhage  in 
the  vicinity  of  the  right  internal  capsule.  The  motion  returned 
soon  in  the  face  and  lower  extremity,  but  there  persisted  a  paresis 
of  the  arm  and  paralysis  of  its  extensor  muscles.  Shortly  after 
attack  the  patient  complained  of  hazy  sight,  which  trouble  did  not 
change  in  the  course  of  six  months.  Upon  examination  there 
was  found  an  apparent  myopia  of  both  eyes,  amounting  to  1.5 
dioptrics.  Both  eyes  were  healthy.  The  myopia  was  measured 
with  identical  result  with  the  ophthalmoscope,  but  changed  to 
emmetropia  on  instillation  of  atropine.  The  spasm,  however,  re- 
turned after  the  effect  of  the  atropine  had  passed  off.  Very  dilute 
solutions  of  this  alkaloid  removed  the  contracture  of  the  ciliary 
muscle  temporarily,  without  interfering  to  an  annoying  extent 
with  the  accommodation. 

Remarks. 

Dr.  Seguin  remarked  that  Charcot  had  called  attention  to 
monocular  amblyopia  in  cases  of  hemiplegia,  and  he  thought 
that  there  was  no  evidence  to  show  that  these  cases  had  been 
carefully  examined  for  errors  of  refraction,  and  hence  we  could 
not  say  that  they  were  unlike  Dr.  Cradle's  case.  Dr.  Seguin  had 
a  case  of  apparent  monocular  amblyopia,  with  paralysis  upon  the 
right  side.  He  sent  the  patient  to  the  Manhattan  Eye  and  Ear 
Hospital,  for  examination  by  one  of  the  staff,  and  it  was  found 
that  the  amblyopia  upon  the  paralyzed  side  was  due  to  hyper- 
metropia,  which  must  have  been  an  original  defect. 


620  TRANSACTIONS  OF   THE 

Dr.  Spitzka  remarked  that  it  had  been  observed,  in  general 
paralysis  of  the  insane,  in  which  the  lesions  were  diffused,  that 
the  patients  within  a  short  period  changed  the  size  of  written  letters. 
For  instance,  they  would  write  letters  three-fourths  of  an  inch  in 
height  on  one  day,  and  the  following  day,  and  for  months  afterward, 
they  would  write  letters  of  less  than  a  millimeter  in  height.  It 
might  not  be  impossible  that  a  condition  similar  to  that  described 
by  Gradle  might  obtain  in  such  cases.  These  patients  were  not 
usually  examined  carefully.  He  thought  the  question  introduced 
by  Dr.  Seguin  was  not  one  that  should  be  confounded  with  the 
one  under  discussion.  It  seemed  to  have  been  referred  by  its 
discoverer  to  a  different  mechanism  entirely. 

Dr.  Jewell  would  simply  say  that  the  case  reported  in  the 
paper  was  one  that  had  interested  him  very  much,  and  that  as  Dr. 
Gradle  had  been  kind  enough  to  ask  his  opinion  in  regard  to  pre- 
senting such  a  paper  to  the  Association,  he  had  given  it  as  his 
judgment  that  it  was  perfectly  suitable,  and  he  wished  to  say  be- 
fore he  sat  down  (for  it  was  one  of  his  purposes  in  rising  at  this 
time),  that  it  seemed  to  him  that  not  enough  care  was  likely  to  be 
taken  in  the  examinations  of  ocular  manifestations  by  those  who 
cultivated  neurological  science.  He  thought  they  took  place 
many  times  unnoticed.  He  thought  it  was  necessary  to  investi- 
gate the  states  of  the  special  senses.  He  had  observed,  for  ex- 
ample, many  peculiar  phenomena  in  regard  to  the  color-sense  of 
cerebral  origin. 

The  next  paper  was  by  Dr.  W.  R,  Birdsall,  describing  "  A  new 
foot  dynamometer." 

The  instrument  described  consisted  of  a  base-board  eighteen 
inches  by  six  inches,  in  which  were  mortised  two  upright  sup- 
ports for  an  iron  rod,  which  formed  an  axis  on  which  the  foot- 
board turned.  Three  grooves  were  cut  in  the  base-board  at  one 
end,  and  corresponding  grooves  in  the  under  surface  of  the  foot- 
board, on  to  which  slipped  the  ordinary  elliptical  spring  dyna- 
mometer used  for  testing  the  grasp.  An  adjustable  long  guage  slid 
on  the  upper  surface  of  the  foot-board  for  the  purpose  of  giving 
a  definite  position  for  the  foot.  In  order  to  fasten  the  foot 
firmly  to  the  board,  and  furnish  a  point  for  traction,  a  broad  toe- 
strap  was  used  when  the  anterior  tibial  group  of  muscles  was  to 
be  tested,  and  a  narrow  heel-strap  for  testing  the  posterior 
group.  The  method  of  recording  the  observations  made  by 
means  of  this  apparatus  was  also  explained. 


AMERICAN  NE  UROLOGICAL  A  SSOCIA  TION.  62  I 

Remarks. 

Dr.  G.  M.  Hammond  gave  a  blackboard  illustration  of  an  in- 
strument which  he  had  invented  for  the  same  purpose  about  a 
year  previous,  and  which  would  indicate  the  amount  of  pressure 
in  pounds,  by  means  of  a  spiral  spring. 

Dr.  Morton  remarked  that  he  had  used  Dr.  Hammond's  in- 
strument and  with  the  utmost  satisfaction.  He  thought  an  instru- 
ment which  would  indicate  the  actual  expenditure  of  force  pref- 
erable to  one  indicating  only  relative  force. 

Dr.  Seguin  thought  that  for  comparative  measurements  the 
instrument  devised  by  Dr.  Allan  McLane  Hamilton  was  excellent. 
It  consisted  of  a  rubber  ball  to  be  compressed,  which  was  con- 
nected with  a  graduated  tube  filled  with  colored  fluid  or  mercury. 

Dr.  Miles,  of  Baltimore,  had  not  been  satisfied  with  Dr.  Ham- 
ilton's instrument,  except  for  testing  sustained  power,  for  which 
purpose  he  liked  it  very   much. 

Dr.  BiRDSALL  remarked  that  at  first  he  thought  of  using  a 
spiral  spring,  but,  in  order  to  reduce  expense  and  simplify  matters, 
conceived  the  idea  of  utilizing  the  ordinary  hand  dynamometer, 
which  most  neurologists  already  possessed.  He  could  see  no 
special  advantage  in  indicating  absolute  force  ;  but  if  that  was 
thought  necessary  it  could  be  done  with  his  instrument  by  cal- 
culating what  the  force  represented. 

The  Secretary  read  the  following  papers  by  title  : 

First,  a  candidate's  paper,  that  of  Dr.  Burt  G.  Wilder,  of  Ith- 
aca, N.  Y.,  on  "  The  Brain  of  a  Hydrocephalous  Dog  (King 
Charles  Spaniel)." 

Second,  a  candidate's  paper,  that  of  Dr.  Charles  K.  Mills,  of 
Philadelphia,  "  Tumor  of  the  Motor  Zone  of  the  Brain." 

Third,  a  candidate's  paper,  that  of  Dr.  Wharton  Sinkler,  on 
"  Chorea  in  the  Aged." 

Fourth,  a  candidate's  paper,  that  of  Dr.  S.  V.  Clevenger,  of 
Chicago,  on  the  "  Function  of  the  Nerve  Cells." 

Fifth,  a  member's  paper,  that  of  Dr.  J.  J.  Putnam,  of  Boston, 
"A  Preliminary  Notice  of  an  Investigation  into  the  Earlier  and 
Obscurer  Symptoms  of  Lead  Poisoning." 

Sixth,  the  paper  of  Dr.  E.  C.  Seguin,  "  A  Second  Contribution 
to  the  Study  of  Localized  Cerebral  Lesions." 

Dr.  F.  T.  Miles,  of  Baltimore,  next  gave  a  verbal  account  of 
a  novel  case  of  myelitis,  which  he  said  was  one  of  a  class,  and 
therefore  interesting. 


622  TRANSACTIONS  OF  THE 

The  patient  was  a  man  about  32  years  of  age,  living  in  the 
West,  in  a  malarious  part  of  the  country.  He  was  seized  with 
symptoms  of  what  his  physician  called  congestive  fever, — symp- 
toms of  chill  followed  by  fever, — and  treated  with  quinine.  He 
was  to  be  brought  to  Dr.  Miles,  but  had  a  relapse.  He  then  suf- 
fered from  weakness  and  pain  in  the  lower  limbs,  as  his  physician 
called  it.  He  insisted  on  continuing  his  occupation  until  he  be- 
came so  weak  that  he  had  one  or  two  falls,  and  continued  to 
have  pains  and  numbness  in  his  legs.  In  this  condition  he  was 
sent  to  Baltimore,  where  Dr.  Miles  saw  him  in  consultation.  His 
condition  was  one  of  almost  complete  paralysis  of  the  lower  as 
well  as  the  upper  extremities,  and  of  the  face  upon  both  sides. 
He  could  close  neither  eye,  and  this  gave  him  a  marked  appear- 
ance. It  was  supposed  that  deglutition  and  his  lungs  were  af- 
fected, but  Dr.  Miles  discovered  that  such  was  not  the  case,  ex- 
cept he  could  not  grasp  the  food  with  his  lips.  Tongue  could  be 
protruded.  No  tendon  reflex  nor  ankle  clonus.  There  was 
delayed  skin  sensation  of  the  soles  of  the  feet  ;  strong  tickling 
of  feet  gave  rise  to  an  exaggerated  reflex.  There  was  decided 
hyperaesthesia  upon  slight  pressure  with  compasses.  No  contrac- 
tion from  faradic  current,  except,  perhaps,  one  or  two  of  the 
muscles  of  the  legs  ;  none  in  the  upper  limbs  or  face.  There 
was  the  degenerative  reaction  of  the  galvanic  current.  Dr  Miles' 
prognosis  was  that  he  would  recover,  and  he  did  so  completely 
within  two  months.  There  was  no  bladder  trouble,  nor  paresis 
of  the  abdominal  muscles.  He  thought  the  case  illustrated  a 
new  phase  of  myelitis.  The  case  had  a  remarkable  resemblance 
to  polio-myelitis  in  the  loss  of  faradic  contractility  and  altera- 
tion of  galvanic  reaction.  We  had  here  an  alteration  of  the  sen- 
sitive nerves,  an  affection  not  confined,  as  in  polio-myelitis,  to 
the  anterior  horns,  but  invading  the  posterior  horns,  and,  per- 
haps, the  lateral  columns.  One  thing  that  threw  light  upon  the 
case,  although  the  gentleman  did  not  admit  it,  was  that  he  was 
affected  with  syphilitic  disease. 

Dr.  Miles  thought  we  frequently  saw  cases  where  there  was 
more  or  less  interference  with  sensorial  phenomena  in  polio-mye- 
litis, and  he  was  of  the  opinion  that  we  could  not  say  it  was 
an  affection  which  left  the  posterior  horns  unaffected. 

Remarks. 

President  Bartholow  inquired  as  to  the  condition  of  the  res- 
piration. 


A M ERICA N  NE  UROLOGICAL  A  SSOCIA  TION.  62  3 

Dr.  Miles  had  not  been  able  to  make  out  the  affection  of  any 
of  the  cranial  nerves  except  the  seventh  ;  respiration  was  good. 

Dr.  Bartholow  inquired  as  to  the  treatment  of  the  case. 

Dr.  Miles  replied  that  it  consisted  in  the  administration  of 
iodide  of  potassium  in  gradually  increasing  doses  up  to  twenty  or 
twenty-five  grains,  three  times  a  day,  and  the  application  of  gal- 
vanism to  the  spine  and  muscles. 

Dr.  Amidon  inquired  if  there  was  any  suspicion  that  the  febrile 
attack  might  not  have  been  due  to  a  septic  disease  like  diphtheria, 
and  followed  by  paralysis,  which  simulated  myelitis. 

Dr.  Miles  replied  that  there  was  nothing  in  the  history  of  the 
case  upon  which  he  could  hang  such  a  suspicion. 

Dr.  Jewell  remembered  to  have  had  a  case,  as  nearly  as  might 
be,  similar  to  Dr.  Miles'.  The  patient  was  a  gentleman  who  came 
walking  with  a  couple  of  sticks  into  his  office  one  day,  and  whose 
face  was  in  the  same  condition  as  described  by  Dr.  Miles,  or  in  a 
day  or  so  after  became  so.  There  was  no  suspicion  of  syphilis. 
He  had  been  affected  in  the  autumn  and  spring  with  intermittent 
fever.  He  continued  to  improve  under  treatment  for  four  or  five 
weeks,  and  went  home  with  the  idea  of  attending  to  some  of  his 
duties  in  the  capacity  of  principal  of  a  high  school.  Dr.  Jewell 
told  him  he  could  safely  go,  if  he  would  not  undertake  any  work. 
He  felt  obliged  to  work  and  commenced  walking  up  and  down 
stairs,  got  a  little  cold,  and  had  a  return  of  the  symptoms  that  he 
had  when  first  taken  sick.  Dr.  Jewell  visited  the  patient  at  his 
home  two  or  three  times.  He  was  improving  again  when  he  had 
another  relapse  ;  the  symptoms  became  of  a  very  aggravated  char- 
acter. It  was  now  three  years  since  the  man  had  been  able  to  raise 
himself  from  a  chair,  having  most  remarkable  contractions  of  all 
of  the  flexor  muscles  of  the  members.  There  was  also  stiffness  of  the 
muscles  of  the  back  of  the  neck  and  back,  together  with  very  great 
wasting  of  muscles.  The  sensory  as  well  as  the  motor  tracts 
were  affected.  This  case  passed  from  subacute  diffuse,  right 
along  into  what  Dr.  Jewell  called  acute  myelitis.  The  man  was 
permanently  ruined  in  health. 

Dr.  Seguin  remarked  that  he  had  upon  record  a  case  of 
polio-myelitis,  in  which  the  only  voluntary  muscles  that  could 
be  moved  were  those  of  the  eyes,  and  one  of  the  toes,  and  left 
fingers.  The  face  was  a  perfect  mask,  there  being  paralysis  of 
the  muscles  on  both  sides.  There  was  no  difficulty  in  deglu- 
tition. In  this  case  he  thought  there  was  diffuse  myelitis  in 
addition  to  the  polio-myelitis.     The  pains  which  some  of  these 


624  TRANSACTIONS  OF   THE 

patients  have  were  of  two  kinds.  Some  had  neural  or  neural- 
gic pains,  and  since  the  publication  of  Prof.  Leyden's  paper'  it 
had  been  questioned  whether  some  of  these  cases  of  so-called 
polio-myelitis  were  not  cases  of  disseminated  neuritis.  He 
had  thought  the  same  of  this  case.  He  had  seen  a  case  with 
Prof.  Delafield,  in  which  the  pains  were  of  a  fulgurating 
character, — not  neuralgic.  He  was  led  to  infer  from  the  in- 
volvement of  the  posterior  columns  that  a  good  prognosis  was 
not  possible.  He  had  always  held  that  there  were  transitional 
forms  between  polio-myelitis  and  other  forms,  and  he  was  pre- 
pared to  see  almost  any  grouping  between  simple  relapsing 
polio-myelitis  and  cases  like  that  of  Dr.  Miles'  and  Jewell's, 
and  other  cases,  as  in  Prof.  Delafield's,  where  there  were  indi- 
cations of  involvement  of  the  posterior  segments  of  the  cord. 
What  was  wonderful  about  these  cases  was  their  curability.  Dr. 
Jewell's  case  was  the  only  one,  so  far  as  he  knew,  that  had  not 
been  cured.     All  of  his  cases  had  done  well. 

Dr.  Hammond  said  he  had  recorded  a  similar  case  to  the  one 
reported,  but  had  never  seen  a  case  where  the  paralysis  extended 
as  high.  In  one  reported  in  his  book  the  paralysis  extended  as  high 
as  the  neck,  but  the  facial  muscles  were  unaffected.  The  singular 
feature  about  the  case  was  the  suddenness  of  the  development  of 
the  symptoms.  Having  eaten  his  breakfast  and  started  down 
stairs  he  suddenly  found  himself  unable  to  move.  He  fell  down 
stairs,  and  being  brought  to  New  York,  Dr.  Hammond  found  his 
motor  functions  on  the  second  day  after  the  fall  entirely  abolished, 
though  sensation  was  intact.  He  made  a  good  recovery  under 
the  use  of  ergot  and  faradism.  Dr.  Hammond  did  not  believe 
the  treatment  had  much  to  do  with  the  result,  because,  as  Dr. 
Seguin  had  pointed  out,  these  patients  seemed  to  get  well  under 
any  treatment. 

Dr.  Seguin  inquired  if  he  (Dr.  Hammond)  did  not  think  there 
was  any  localized  myelitis. 

Dr.  Hammond  replied  that  he  thought  the  lesion  was  local,  and 
of  the  anterior  horns,  or  anterior  columns,  because  there  was  no 
perversion  of  the  sensibility,  and  no  paralysis  of  the  muscles  of 
the  face. 

Upon  motion  the  Association  was  declared  adjourned. 

'  Ueber  polio-myelitis  und  neuritis.     Zeitschrift  fiir  Klin.  Medicin,  1880. 


A  ME  RICA  AT  NE  UROLOGICAL  A  SSOCIA  TION.  62  5 

Third  day,  evening  session. 

The  Association  was  called  to  order  at  8.30  p.m.  by  the  Presi- 
dent. 

Present. — Drs.  Amidon,  Bartholow,  Beard,  Birdsall,  Gradle, 
Hammond,  W,  A.,  Hammond,  G.  M.,  Jewell,  Kinnicutt,  Miles, 
Mills,  Morton,  Seguin,  and  Spitzka. 

The  Secretary  read  the  minutes  of  the  afternoon  session,  which 
were  approved. 

The  Council  reported  through  Dr.  Seguin  that  their  recommen- 
dations for  Honorary  and  Associate  Membership  were  as  follows  : 

Honorary  Members. 

Prof.  J.  M.  Charcot,  Paris  ;  Prof.  J.  Hughlings  Jackson,  Lon- 
don ;  Prof.  W.  Erb,  Leipsic  ;  Prof.  C.  Westphal,  Berlin  ;  and 
Prof.  Theodore  Meynert,  of  Vienna. 

These  gentlemen  were  nominated  by  the  following  members  : 
Bartholow,  Hammond  (W.  A.),  Jewell,  Miles,  McBride,  Seguin, 
Spitzka. 

Associate  Members. 

Dr.  Thomas  Stretch  Dowse,  London;  Dr.  Moritz  Bernhardt,  of 
Berlin  ;  Dr.  W.  R.  Gowers,  of  London  ;  Prof.  David  Ferrier,  of 
London  ;  Dr.  Camillo  Golgi,  of  Pavia,  Italy ;  Dr.  H.  Charlton 
Bastian,  of  London;  Dr.  J.  Russell  Reynolds,. of  London;  Dr. 
Obersteiner,  of  Vienna.  Nominated  by  Drs.  Hammond  and  Jew- 
ell.    These  gentlemen  were  unanimously  elected. 

Under  the  head  of  miscellaneous  business.  Dr.  E.  C.  Spitzka 
moved  the  adoption  of  the  following  rule  : 

That  at  as  early  a  date  as  possible,  before  the  annual  meeting  of 
the  Association,  the  members  shall  be  informed  by  the  Secretary 
of  the  titles  of  papers  which  are  to  be  read  at  the  meeting,  and 
arranged  in  the  order  received. 

Carried. 

Dr.  L.  C.  Gray  gave  notice  that  he  had  submitted  the  follow- 
ing amendment  to  Art.  IV  of  the  Constitution  at  the  annual  meet- 
ing of  1880  : 

To  read  that 

"  They  be  nominated  by  the  Association  at  the  first  day  of  the 
annual  meeting,"  instead  of  "  They  shall  be  nominated  by  a  Com- 
mittee on  Nomination  of  five  members,  appointed  by  the  President 
on  the  first  day  of  the  annual  meeting." 


626  TRANSACTIONS  OF   THE 

Upon  motion  the  amendment  was  adopted. 

By  a  vote  of  the  Association,  Dr.  N.  B.  Emerson,  of  Honohilu, 
and  Dr.  J.  S.  Lombard,  of  London,  England,  were  transferred 
from  Active  to  Associate  Membership. 

In  view  of  further  removals  from  the  United  States  of  Active 
Members,  Dr.  J.  S.  Jewell,  of  Chicago,  gave  notice  that  he  would 
submit  the  following  amendment  to  the  Constitution  at  the  next 
annual  meeting  : 

That  all  Active  Members  of  the  Association  who  shall  hereafter 
remove  from  within  the  limits  of  the  United  States  shall  thereby 
become  Associate  Members,  should  they  so  desire. 

Dr.  F.  T.  Miles,  of  Baltimore,  presented  a  specimen  of  "  Tumor 
of  the  pons."  The  patient,  a  woman,  was  brought  into  the  hospi- 
tal with  motor  paralysis  of  one  side  ;  on  the  opposite  side  the 
paralysis  was  not  absolute.  She  was  semi-comatose,  which  condi- 
tion continuing  for  a  little  time,  the  cornea  became  opaque,  and 
she  died  in  this  condition.  He  thought  the  lesion  consisted  of  a 
thickening  of  the  dura  mater  pressing  upon  the  fifth  and  seventh 
pairs  of  nerves  at  about  the  points  of  decussation,  but  the  post- 
mortem examination  had  proved  him  to  be  wrong,  there  being  a 
tumor  in  the  central  portion  of  the  pons.  The  tumor  was  sup- 
posed to  be  of  syphilitic  origin. 

Remarks. 

Dr.  Spitzka  enquired  if  there  were  no  vaso-motor  phenomena. 

Dr.  Miles  replied  that  he  did  not  recollect  of  observing  any. 
The  trophic  influence  on  the  cornea  was  noticed. 

Dr.  Spitzka  asked  if  choked  disc  existed. 

Dr.  Miles  said  that,  as  far  as  it  could  be  observed,  the  Gasserian 
ganglion  was  intact. 

Dr.  Spitzka  called  attention  to  the  distortion  of  the  specimen 
by  twisting. 

Dr.  Miles  said  that  the  twisting  was  in  it  when  he  found  it. 

Dr.  Spitzka  thought  if  that  was  the  case  it  was  one  of  the 
most  remarkable  conditions  ever  known. 

Dr.  Chas.  K.  Mills,  of  Philadelphia,  next  proceeded  to  read  a 
paper  upon  the  same  subject,  entitled  "  Tumor  of  the  pons  Varolii, 
with  conjugate  deviation  of  the  eyes  and  rotation  of  the  head." 

The  case  upon  which  this  paper  was  founded  was  one  that 
could  not  fail  to  be  of  great  interest  to  the  students  of  close  local- 


AMERICJLN  NEUROLOGICAL  ASSOCIATION.  627 

ization.  The  patient,  R.  C,  aet.  32,  single,  groom,  had  a  history 
of  intemperance  and  of  syphilis.  He  had  several  times  fallen 
from  horses,  and  had  been  kicked  on  the  head.  Four  weeks  be- 
fore coming  under  observation  he  had  an  attack  of  dizziness  and 
fell,  but  was  not  unconscious.  A  few  days  later  his  eyes  began  to 
trouble  him,  and  he  noticed  some  loss  of  power  in  his  right  arm 
and  leg.  On  examination,  he  was  found  to  be  anaemic,  weak,  and 
apathetic  mentally.  He  had  right  hemiparesis.  Sensation  was 
diminished  on  the  left  side  of  the  face  and  in  the  right  limbs. 
Hearing,  smell,  and  taste  were  preserved.  The  most  prominent 
symptoms,  however,  were  a  conjugate  deviation  of  the  eyes  and 
rotation  of  the  head  to  the  right.  He  could  not,  by  the  utmost 
effort,  bring  the  eyes  around  even  to  the  median  line.  Dr.  E.  O. 
Shakespeare  examined  the  eyes  in  addition  to  Dr.  Mills.  In  at- 
tempted movements  of  the  eyes  to  the  left  the  right  eye  turned 
slightly,  the  left  scarcely  at  all.  A  slight  tendency  to  ptosis  was 
present  on  the  right  side.  The  power  of  accommodation  was  not 
greatly  impaired.  The  media  were  clear.  The  pupils  were  about 
normal.  The  ophthalmoscopic  examination  of  the  left  eye  showed 
a  subacute  neuritis.  In  consequence  of  the  extreme  deviation  of 
the  eyes  to  the  right,  the  right  eye  could  not  be  satisfactorily  ex- 
amined by  the  ophthalmoscope.  A  scar  and  a  narrow  cleft  in  the 
skull  were  found  in  the  squamoso-temporal  region.  Two  slight 
scars  were  also  found  in  the  scalp  of  the  right  parietal  region. 
The  patient  was  placed  upon  potassium  iodide^  and  tonics,  but 
did  not  improve.  Persistent  epislaxis  set  in,  and  was  not  relieved 
by  treatment.  He  died  of  general  exhaustion.  Before  death  the 
face  and  limbs  of  the  left  side  became  paretic,  and  right-sided 
paralysis  became  more  marked.  The  pupils  became  contracted, 
the  left  being  a  little  smaller  than  the  right.  The  conjugate  devi- 
ation and  other  symptoms  remained  about  the  same. 

Autopsy. — A  slight  cleft  or  fracture,  without  displacement  or 
depression,  was  found  in  th«  inner  table  of  the  skull,  correspond- 
ing to  the  scar  and  fissure  in  the  squamoso-temporal  region.  The 
dura  mater  was  here  slightly  adherent,  and  a  hard,  yellowish 
tumor,  no  larger  than  a  pea,  was  present  beneath  the  adhesion,  on 
the  inner  surface  of  the  dura.  It  was  attached  below  to  the  pia 
mater  also,  and  caused  a  slight  depression  near  the  middle  of  the 
first  temporal  convolution.  On  exposing  the  floor  of  the  fourth 
ventricle,  a  distinct  bulging  of  its  left  upper  portion  was  observed. 
On  making  a  transverse  incision  through  this  bulging  mass,  a 
small  tumor  was  discovered  in   the  body  of  the  pons,  both  the 


628  TRANSACTIONS  OF  THE 

anterior  and  posterior  surfaces  of  the  latter  retaining  their  in- 
tegrity. The  tumor  was  distinctly  limited  to  the  left  upper  quarter 
of  the  pons,  coming  close  to,  but  not  crossing,  the  median  line.  On 
section  it  was  found  to  be  of  firm  consistence,  and  of  a  greenish- 
gray  color.  It  was  examined  microscopically  by  Drs.  J.  H,  C. 
Simes  and  H.  Formad,  who  concluded  that  it  was  a  gumma. 

Dr.  Mills  concluded  that  the  peculiar  ocular  symptoms  present 
in  this  case  were  due  to  the  tumor  of  the  pons  Varolii.  Vulpian, 
Lockhart  Clarke,  Prevost,  Brown-Sequard,  Bastian,  and  others, 
have  devoted  much  attention  to  the  subject  of  conjugate  devia- 
tion of  the  eyes,  and  rotation  of  the  head.  This  lateral  deviation 
occurs  from  lesions  of  various  parts  of  the  brain — of  the  cortex, 
centrum  ovale,  capsules,  ganglia,  crura  cerebri,  and  pons.  Fer- 
rier,  Hughlings-Jackson,  and  Priestly  Smith,  have  particularly 
studied  the  question  of  oculo-motor  monoplegias  and  monospasms, 
that  is,  of  ocular  palsies  and  spasms  due  to  cortical  lesions.  Dr. 
Mills  believed,  with  Jackson,  that  ocular,  and  indeed  all  other 
movements,  are  represented  in  the  cerebral  convolutions.  It  is 
necessary,  however,  carefully  to  diagnosticate  such  cases  from 
those  due  to  lesions  at  lower  levels. 

During  the  life  of  the  patient  it  was  a  question  whether  we  had 
or  had  not  to  deal  with  a  case  of  oculo-motor  monoplegia  or 
monospasm  from  lesion  of  cortical  centres. 

Ferrier,  in  one  of  his  experiments,  found  that  irritation  of  a 
certain  limited  area  of  the  surface  of  the  brain  of  the  monkey 
caused  elevation  of  the  eyelids,  dilatation  of  the  pupils,  conjugate  de- 
viation of  the  eyes,  and  turning  of  the  head  to  the  opposite  side. 
This  area  corresponds  to  a  region  in  the  brain  of  man,  at  the  base 
of  the  first  frontal,  and  extending  partly  into  the  second  frontal 
convolution.  A  few  cases  are  on  record  in  which  conjugate  de- 
viation of  the  eyes  and  rotation  of  the  head  have  occurred  with- 
out hemiplegia  or  hemiparesis.  Five  such  cases,  or  rather  sup- 
posed cases,  have  been  collected  by  Ferrier.  Some  of  these  were 
probably,  like  the  case  here  reported,  examples  of  pontine  lesion. 

It  did  not  seem  probable  that  the  fissured  skull,  and  the  small 
meningeal  tumor  in  connection  with  it,  had  any  thing  to  do  with 
the  production  of  the  symptoms.  The  lesion  was  comparatively 
remote  from  the  oculo-motor  centres  of  Ferrier,  at  the  bases  of 
the  first  and  second  frontal  convolutions.  Efforts  have  been 
made  to  localize  a  centre  for  the  levator  palpebrae  superioris 
muscle  in  the  angular  gyrus,  and  if  such  a  centre  could  be  made 
out  to  exist  in  this  region,  it  is  probable  that  centres  for  the  other 


AMERICAN  NEUROLOGICAL  ASSOCIATION.  629 

ocular  movements  would  be  in  proximity.  The  weight  of  evi- 
dence, however,  both  pathological  and  physiological,  is  against 
this  localization,  and  the  phenomena  in  the  case  under  consider- 
ation are  well  accounted  for  by  the  pontine  lesion.  The  tumor 
was  also  a  little  too  far  forward  for  the  angular  gyrus  proper. 

The  case  seemed  to  bear  out  the  usual  view  with  reference  to 
the  direction  of  conjugate  deviation  in  pontine  lesions.  In  such 
cases  the  deviation  is  away  from  the  side  of  the  lesion,  and  toward 
the  side  of  the  paralysis.  When  the  lesion  is  of  the  cerebrum,  the 
deviation  is  toward  the  side  of  the  lesion,  and  away  from  that  of 
the  paralysis. 

When  the  question  of  differential  diagnosis  is  as  to  whether 
conjugate  deviation  of  the  eyes  and  rotation  of  the  head  are  due  to 
pontine  or  cortical  lesion,  the  following  points  would  seem  to 
favor  disease  of  the  pons  :  The  presence,  at  some  stage  of  the  case, 
of  paresis  or  paralysis  on  both  sides  of  the  body  ;  the  existence  of 
disturbances  of  sensation  ;  contraction  of  the  pupils  ;  depressed 
farado-contractility  ;  and  peculiarities  of  temperature. 

Remarks. 

Dr.  Hammond  remarked  that  he  had  listened  to  the  paper  with 
a  great  deal  of  interest,  and  he  would  ask  whether  the  author  was 
familiar  with  the  researches  of  Landouzy  and  Grasset. 

Dr.  Mills  replied  that  he  was. 

Dr  Hammond  said  they  gave  a  very  different  interpretation  to 
such  cases. 

Dr.  Spitzka,  being  called  upon  for  an  opinion,  remarked  that 
he  could  say  nothing  in  a  critical  spirit,  but  with  regard  to  the 
point  just  brought  up,  he  doubted  whether  the  cases  supported 
the  theory  of  Grasset.  The  influence  would  have  to  be  more  or 
less  constant.  On  the  contrary,  we  found  that  the  ocular  move- 
ments were  not  constantly  interfered  with.  As  in  Dr.  Gradle's 
case,  all  the  influences  exerted  in  the  ocular  movements  by  the 
cerebral  hemispheres  could  be  carried  on  for  both  eyes  by  one 
hemisphere.  If  the  disturbance  affected  both  eyes,  there  might 
be  a  cortical  disturbance  ;  but  if  upon  one  eye,  a  cortical  lesion 
was  entirely  excluded. 

Dr.  Mills  remarked  that  he  supposed  the  experiments  referred 
to  by  Dr.  Hammond  had  reference  to  the  discussion  of  the  ques- 
tion whether  it  was  the  first  or  second  convolution  of  the  angular 
gyrus  which  was  the  seat  of  the  oculo-motor  centre.     He  was  in- 


630  TRANSACTIONS  OF  THE 

clined  to  think  Dr.  Spitzka's  explanation  was  correct.  The  one 
strong  practical  point  from  his  paper  was  the  fact  that  we  might 
believe  that  in  conjugate  oculo-monoplegia  we  must  make  a  differ- 
ential diagnosis. 

Dr.  Mills  also  reported  the  following  case  of  "Tumor  of  the 
motor  zone  of  the  brain  "  : 

The  case  was  one  seen  by  Dr.  Mills,  with  Dr.  F.  Dercum, 
of  Philadelphia.  The  patient,  a  married  woman,  aged  32  years, 
in  September,  1878,  during  an  attack  of  typhoid  fever,  had  a 
severe  convulsion,  which  left  her  partially  paralyzed  in  the  face 
and  limbs  of  the  left  side  for  four  days.  In  March,  1880,  she  had 
a  spasmodic  seizure,  which  began  with  numb  sensations  in  the 
fingers  of  the  left  hand.  These  sensations  were  followed  by 
twitchings  of  the  fingers  ;  a  spasm  soon  involved  the  left  arm  ; 
and  before  the  attack  passed  off  a  general  convulsion  occurred. 
After  the  attack,  the  left  upper  extremity  was  found  to  be  de- 
cidedly weaker  than  the  right  ;  subsequently,  the  patient  had  half 
a  dozen  similar  seizures.  They  nearly  always  began  with  twitch- 
ings of  the  fingers  of  the  left  hand.  The  spasm  was  always  most 
severe  upon  the  left  side,  was  usually  limited  to  it,  and  was  most 
violent  in  the  arm.  When  examined  early  in  August,  1880,  the 
left  side  of  the  face  was  partially  paralyzed  ;  the  left  upper  ex- 
tremity was  almost  completely  helpless  ;  and  the  left  lower  ex- 
tremity was  paralyzed,  but  not  quite  so  markedly.  Her  mind 
acted  slowly.  Opththalmoscopic  examination  showed  double  op- 
tic neuritis.  Hearing  was  defective  in  the  right  ear  ;  she  com- 
plained of  torturing  headache,  most  severe  in  the  right  fronto- 
parietal region.  Percussion  above  and  around  the  ear  caused 
greater  pain  than  at  any  other  region  of  the  head.  Sensibility 
was  impaired  in  the  left  side  of  the  face  and  left  limbs. 

She  died  after  great  suffering,  August  27,  1880. 

Post-mortem  examination  revealed  a  firm,  nodulated  tumor, 
having  a  mottled  appearance  on  section.  It  was  adherent  to  the 
pia  mater  of  the  convexity  of  the  right  hemisphere,  and  invaded 
the  middle  portion  of  the  ascending  parietal  and  the  upper  part  of 
the  inferior  parietal  convolutions,  pushing  aside  the  interparietal 
fissure.  On  the  inner  side  of  the  tumor,  the  white  matter  of  the 
hemisphere  was  broken  down.  No  other  lesion  was  found,  except 
a  slight  adhesion  of  the  dura  to  the  pia  mater  over  the  upper  ex- 
tremities of  the  ascending  convolutions  of  the  left  side.  Micro- 
scopical examination  by  Dr.  L.  B.  Hall  showed  that  the  growth 
was  probably  a  carcinoma. 


AMERICAN  NEUROLOGICAL  ASSOCIATION.  63 1 

The  position  of  this  tumor  was  accurately  diagnosticated  during 
life.  The  spasm,  beginning  in  the  fingers  of  the  left  hand,  and 
more  marked  upon  the  left  side,  and  particularly  in  the  left  arm, 
pointed  to  the  brachial  centres  of  the  motor  zone  of  the  cortex  of 
the  right  side.  The  left-sided  paralysis,  greatest  in  the  arm,  in- 
dicated the  same  region  of  the  right  hemisphere.  Impaired  sensi- 
bility on  the  left  side  showed  that  the  parieto-temporal,  or  sen- 
sory zone  was  probably  involved  either  by  extension  of  the  lesion 
or  by  pressure.  Localized  headache,  and  the  results  of  percussion, 
confirmed  the  diagnosis  of  the  situation  of  the  tumor. 

"  Atrophy  of  the  cerebellum,"  by  Dr.  Shaw.  The  paper  upon 
this  subject,  owing  to  its  author's  absence,  was  not  read. 

Dr.  F.  P.  KiNNicuTT,  of  New  York,  reported  a  case  of  "Chorea 
major,"  which  was  chiefly  interesting  on  account  of  the  high  tem- 
perature, 103°  F.,  and  upward,  thought  to  be  dependent  upon  the 
ceaseless  and  violent  muscular  contractions,  the  improvement  un- 
der chloral  hydrate,  and  the  tolerance  of  the  drug  by  the  patient, 
a  girl  of  fourteen,  who  took  from  seventy  to  one  hundred  grains  a 
day. 

Remarks. 

Dr.  Mills  remarked  that  he  believed  the  author  of  the  paper 
had  referred  to  the  connection  of  malarial  disease  with  the  case, 
and  it  suggested  itself  to  his  mind,  that  the  symptoms  might  be 
due  to  pigmentary  embolism  in  the  capillaries  of  the  brain.  He 
doubted  if  the  persistent  elevation  of  temperature  noted  was  in 
consequence  of  the  muscular  action. 

Dr.  KiNNicuTT  knew  that  such  a  high  temperature  was  not  or- 
dinarily produced  by  muscular  action  in  chorea,  but  in  his  case  the 
muscular  actions  were  so  violent  that  he  thought  the  high  tem- 
perature was  produced  by  them. 

Dr.  Jewell  said  he  had  seen  two  cases,  one  of  which  was  very 
similar  to  the  one  reported,  and  in  a  person  of  the  same  age,  and 
in  whom  it  seemed  to  him  it  would  have  been  a  physical  impossi- 
bility for  the  child  to  have  had  any  more  violent  muscular  con- 
tractions than  were  observed  ;  there  was  no  marked  elevation  of 
temperature.  The  muscular  contractions  in  this  instance  were  so 
severe  that  the  patient  could  not  be  kept  upon  the  bed,  except 
when  held  by  two  or  three  individuals,  and  at  last  it  was  neces- 
sary to  place  her  upon  the  floor.     In  reference  to  the  administra- 


632  TRANSACTIONS  OF   THE 

tion  of  chloral  to  such  patients  he  thought  it  should  be  at  the 
hour  of  retiring,  and  in  very  large  doses — what  would  ordinarily 
be  considered  almost  toxic. 

The  next  paper  was  by  Dr.  E.  C.  Seguin,  of  New  York,  bearing 
the  title  of  "Aconitia  in  posterior  spinal  sclerosis  :  a  new  sign  of 
its  existence." 

I  have  observed  in  six  well-marked  cases  of  posterior  spinal 
sclerosis,  in  the  first  and  second  stages,  a  remarkable  resistance  to 
the  action  of  aconitia  as  shown  by  numbness  of  the  periphery. 

These  six  patients  took  large  doses  of  the  alkaloid,  from  three 
to  six  tablets  of  y^  grain  each  in  a  day,  without  numbness  in 
the  ataxic  or  neuralgic  parts.  Numbness  showed  itself  in  the 
parts  of  the  body  above  the  supposed  seat  of  sclerosis,  and  several 
of  the  patients  felt  faint,  dizzy,  and  quite  sick  from  the  medicine. 

Dr.  W.  R.  Birdsall,  at  my  request,  administered  aconitia  in  full 
doses  to  several  ataxic  patients  under  his  charge  with  substantially 
the  same  effect ;  one  case  experienced  no  tingling,  another  case  had 
a  little  numbness  in  toes,  and  a  third  case,  after  taking  four  doses 
of  yJt  grain,  used  at  intervals  of  three  hours,  felt  some  numbness 
in  ends  of  fingers  ;  a  few  hours  later  was  "  numb  all  over." 

It  appears  from  these  nine  cases  that  tabetic  patients  are  peculiarly 
insusceptible  to  the  characteristic  sensory  symptoms  of  aconitia. 
This  resistance,  apparently  absolute  in  some  cases,  is  shown  in 
the  first  stage  of  the  disease.  One  of  the  cases  which  took  at  one 
time  \  (.01)  of  aconitia  in  less  than  forty-eight  hours,  was  exam- 
ined post  mortem,  and  the  cord  found  sclerosed.  The  aconitia  used 
in  these  tests  was  Duquesnel's  crystallized  aconitia,  prepared  by 
Caswell,  Hazard  &  Co.,  in  tablet  form.  The  specific  effects  of 
these  tablets  were  obtained  during  the  same  period  in  other  cases 
of  disease  and  in  healthy  patients.  For  example,  in  my  own  case, 
j-Jtj-  grain  at  10  a.m.  and  at  12  noon,  made  me  numb  from  head  to 
foot,  and  chilly  for  nearly  five  hours. 

While  not  now  prepared  to  advance  a  theory  of  the  manner  in 
which  sclerosis  of  the  posterior  columns  prevents  the  sensation  of 
tingling  and  numbness  in  tabetic  patients  charged  with  aconitia, 
I  feel  confidence  in  my  facts,  and  would  offer  them  as  constituting 
a  new  negative  test  or  symptom  of  the  disease. 

Remarks. 

Dr.  Jewell  wished  to  ask  a  question.  The  facts  recited  in  the 
paper  of  course  spoke  for  themselves  up  to  a  certain  point,  but  he 


A M ERICA N  NE  UROL 0 GICA L  A  SSOCJA  T/ON.  63  3 

wished  to  know  if  Dr.  Seguin  thought  the  disease  of  the  sensory 
apparatus  interfered  with  the  action  of  the  remedy. 

Dr.  Seguin  replied  that  he  thought  so. 

Dr.  Hammond  wished  to  ask  if  the  author's  results  did  not  in- 
dicate that  there  were  lesions  of  the  gray  matter  of  the  cord  of 
more  frequent  occurrence  than  was  indicated  by  post  mortem  ex- 
amination, for  sclerosis  of  the  posterior  columns  of  the  cord,  and  in- 
volving the  lower  segments  of  the  cord,  could  not  account  for  the 
phenomena  in  the  upper  portion  of  the  body  unless  there  were  con- 
ditions which  we  could  not  find,  and  which  this  aconitia  might 
show.  He  thought  the  experiments  showed  that  there  was  a  lesion 
the  whole  length  of  the  cord. 

Dr.  Spitzka  wished  to  ask  Dr.  Seguin  what  support  he  had  for 
the  claim  that  the  remedy,  in  acting  upon  the  central  gray  matter, 
did  not  give  rise  to  the  peculiar  sensory  disturbances,  because  the 
sensory  impressions  were  interfered  with  in  going  outward. 

Dr.  BiRDSALL  remarked  that  in  confirmation  of  the  case  re- 
ported in  the  paper,  he  would  say  that  he  had  tested  the  effects  of 
the  medicine  upon  a  patient  not  affected  with  a  disease  of  this 
character,  in  whom  the  physiological  effects  of  the  drug  were  ob- 
tained in  the  usual  time. 

Dr.  Jewell  remarked  that  if  the  remedy  acted  in  the  sensorium 
itself  or  in  the  higher  parts  of  the  sensory  tract,  the  numbness 
ought  to  reach  the  consciousness  of  the  patient  the  same  as  com- 
ing from  a  peripheral  nerve,  according  to  a  well-known  law.  Do 
not  such  observations  teach  that  either  the  remedy  acted  upon  the 
peripheral  nerves  or  upon  their  points  of  entrance  into  the  gray 
matter  of  the  cord,  which  was  the  seat  of  disease  in  locomotor 
ataxia?  If  it  acted  on  more  central  portions  of  the  nervous 
system,  the  impressions  would  be  more  subjective  and  break  into 
the  field  of  consciousness  from  other  regions  as  well  as  from  the 
diseased  tracts.  He  asked  if  these  observations  did  not  throw 
some  light  upon  the  question  as  to  what  part  of  the  nervous 
system,  comprehensively  considered,  peripheral  or  central,  was 
acted  upon  by  the  drug.  If  upon  the  peripheral,  it  was  not  diffi- 
cult to  understand  the  numbness. 

Dr.  Seguin  thought  the  objections  raised  and  suggestions 
thrown  out  by  Drs.  Spitzka  and  Jewell  might  lead  to  valuable  re- 
sults, which  he  thought  would  be  in  one  of  two  ways  :  Either 
there  was  an  unknown  lesion  in  the  gray  matter  in  ataxia,  and  in 
that  gray  matter  the  passage  of  the  abnormal  sensation  was  inter- 
fered with  ;  or,  second,  that  the   drug  did  not  act  upon  the  gray 


634  TRANSACTIONS  OF   THE 

matter,  but  upon  the  nerve  fibres,  and  as  these  were  diseased,  the 
sensations  did  not  arise. 

Dr.  Seguin  then  proceeded  to  read  a  second  paper,  entitled 
"  A  case  of  diphtheritic  ataxia  and  paralysis  from  anal  diphtheria — 
cure." 

Mr.  B.,  aged  58  years,  has  enjoyed  good  health  with  exception 
of  hemorrhoids.     Never  any  fulgurating  pains,  or  diplopia. 

Nov.  12,  1880,  was  operated  for  large  hemorrhoids  by  injection 
of  carbolic  acid  and  oil.  Reaction  followed,  with  diphtheritic  ex- 
udation in  hsemorrhoidal  masses,  chill,  febrile  movement,  and 
much  prostration..    Anus  well  about  Thanksgiving  (27th). 

Early  in  December  seemed  fairly  well,  but  a  few  days  before 
Christmas  legs  were  weak  and  feet  numbish.  Gradual  increase  in 
weakness  of  legs,  and  a  few  days  before  examination  hands 
weak,  awkward,  and  numbish.  Bladder  unaffected  ;  no  spinal  or 
peripheral  pain,  or  cincture  feeling. 

Examined  January  25,  1881.  Presents  paresis  of  upper  and 
lower  extremities,  with  numbness  and  slight  but  distinct  anaesthe- 
sia of  feet,  legs,  and  hands.  The  striking  symptom,  however,  is 
the  ataxia,  which  is  typical  both  in  hands  and  legs  ;  no  trace  of 
patellar  tendon  reflex.  Pupils  normal.  During  the  ensuing  two 
weeks  the  paresis  increased,  and  gradually  obscured  the  ataxia. 

Feb.  5th.  Lies  quite  helpless  on  couch,  almost  no  voluntary 
power  in  arms  or  legs  ;  sensory  symptoms  as  above.  No  atrophy 
or  degeneration  reaction.  Improvement  in  voluntary  power  be- 
gan February  15th,  and  progressed  steadily,  with  corresponding 
diminution  of  the  anaesthesia. 

March  29th.     Walks  with  a  cane. 

May  3d.  Is  practically  cured  ;  only  remains  of  attack  is  a 
slight  occasional  numbness  in  soles  of  feet ;  no  tendon  reflex. 

May  17th.     A  trace  of  patellar  tendon  reflex  on  both  sides. 

The  treatment  consisted  at  first  in  the  use  of  belladonna  and 
ergot  ;  later  nux  vomica  and  iron  :  At  the  last  a  simple  solution  of 
strychnia  in  nitro-muriatic  acid,  was  given. 

A  thorough  electrical  treatment  and  massage  were  also  had. 
Until  March  i6th  galvanism  was  used  only  ;  stabile  ascending 
current  to  limbs  and  spine.  After  this  date  faradism  was  care- 
fully used  on  the  recovering  muscles.  The  massage  was  made 
proportionate  to  the  paralysis,  and  in  the  last  few  weeks  was  vig- 
orously done. 


AMERICAN  NEUROLOGICAL  ASSOCIATION.  635 

Remarks. 

Dr.  Miles  had  seen  a  most  complete  case  of  ataxia  about  six 
years  previous  in  a  child  three  or  four  years  old.  He  had  had  an 
attack  of  diphtheria,  and  from  the  first  there  was  paralysis  or  pare- 
sis. The  paresis  disappeared,  but  the  ataxia  remained.  Electro- 
contractility  was  somewhat  diminished.  The  knee-jerk  was  not 
tested,  for  he  was  not  then  familiar  with  it.  The  patient  recov- 
ered in  three  months  under  the  use  of  strychnia  and  faradism. 

Dr.  Spitzka  remarked  that  there  was  one  interesting  point  in  a 
case  of  the  kind  reported,  and  that  was  the  location  of  the  diph- 
theritic sore. 

Dr.  Seguin  said  he  looked  upon  the  case  reported  by  him  as  one 
of  myelitis,  probably  infectious,  with  deposits  of  minute  organisms 
around  all  the  anterior  and  posterior  nerve  roots  entering  the 
spinal  cord,  probably  first  in  the  posterior  segments  of  the  cord, 
ancithe  anterior  afterward,  judging  from  the  succession  of  events. 
He  had  been  much  interested  in  the  case  because  of  the  diffi- 
culty of  diagnosis.  Dr.  Seguin  was  strengthened  in  his  suspicion 
of  diphtheria  from  the  absence  of  pupillary  symptoms  and  fulgu- 
rating pains. 

There  being  no  further  discussion,  Dr.  Jewell  moved  that  the 
designation  of  the  place  and  time  of  holding  the  next  annual 
meeting  be  referred  to  the  Council  for  action.     Carried. 

The  President  then  declared  the  Association  adjourned  sine 
die. 


IzTiiUxos  awjd  giMi00trap^ltical  glotitjes. 


Lectures  on  diseases  of  the  nervous  system,  espe- 
cially in  women.  By  S.  Weir  Mitchell,  M.D.  With  five 
plates.     Philadelphia  :  Henry  C.  Lea's  Son  &  Co  ,  1881. 

Dr.  Weir  Mitchell  has  published  in  this  little  volume,  under  the 
form  of  a  series  of  clinical  lectures,  a  number  of  interesting  pa- 
pers upon  some  of  the  nervous  maladies  that  especially,  but  <not 
exclusively,  affect  the  female  sex,  which  have  not  received  general 
detailed  attention  from  medical  writers.  Several  of  the  lectures 
cover  observations  that  are  altogether  or  in  large  part  new  in 
medical  literature  ;  others  are  clinical  studies  of  fairly  well-known 
disorders,  but  which  are  here  presented  in  the  light  of  numerous 
original  and  interesting  observations.  Dr.  Mitchell's  large  clini- 
cal experience  with  this  class  of  diseases,  and  his  well-known  abil- 
ity as  an  acute  and  critical  observer,  give  to  his  statements  a  force 
and  apparent  value  that  would  be  wanting  in  a  work  by  a  less  dis- 
tinguished author.  There  can  be  no  doubt  as  to  his  eminent  fitness 
to  produce  such  a  work,  the  only  question  is,  does  the  volume 
fully  bear  out  the  author's  well-deserved  reputation  ?  We  must 
admit  a  slight  amount  of  disappointment  at  first  in  the  examina- 
tion of  the  work,  which,  however,  seems  hardly  justified  in  a  closer 
perusal.  It  is  simply  a  collection  of  clinical  essays  on  certain 
manifestations  or  phases  of  nervous  disease,  and  not  an  elaborate 
and  consecutive  treatise  ;  and  so  far  as  it  has  aimed  it  has  fairly 
hit  the  mark.  The  subjects  treated  are  of  interest,  and  are 
handled  by  one  who  has  had  opportunities  for  observation  such  as 
very  few  are  favored  with  ;  and  while  the  cases  reported  are  not  so 
remarkable  as  occur  in  the  practice  of  so  prominent  a  specialist 
in  nervous  disorders,  they  are  such  as  only  rarely  come  within  the 
experience  of  the  general  practitioner.  Yet  they  are  liable  to  be 
met  with  at  any  time,  and  the  perusal  of  a  work  like  this  will  do 
much  to  prepare  him  for  their  recognition. 

636 


DISEASES  OF  THE  NERVOUS  SYSTEM.  637 

The  subjects  discussed  are,  in  the  order  in  which  they  occur  in 
the  book  :  The  Paralyses  of  Hysteria,  Hysterical  Motor  Ataxia, 
Hysterical  Paresis,  Mimicry  of  Disease,  Unusual  Forms  of  Spas- 
modic Affections  in  Women,  Tremor,  Chronic  Spasms,  Chorea  of 
Childhood,  Habit  Chorea,  Disorders  of  Sleep  in  Nervous  or  Hys- 
terical Persons,  Vaso-motor  and  Respiratory  Disorders  in  the  Ner- 
vous or  Hysterical,  Hysterical  Aphonia,  Gastro-Intestinal  Dis- 
orders of  Hysteria,  and  the  Treatment  of  Obstinate  Cases  of  Ner- 
vous Exhaustion  and  Hysteria  by  Seclusion,  Rest,  Massage,  Elec- 
tricity, and  Full  Feeding.  The  majority  of  these  chapters  are 
simply  clinical  lectures  upon  rare  or  peculiar  phases  of  nervous  dis- 
ease of  the  so-called  functional  varieties.  While  very  interesting 
and  profitable  reading,  they  do  not  for  the  most  part  require  de- 
tailed notice  here.  Some  of  the  subjects  have  been  discussed  per- 
haps more  exhaustively  by  other  writers,  such  as  the  hysterical 
aphonias  and  paralyses,  but  many  of  the  observations  here  re- 
corded are  absolutely  new  and  of  especial  value  on  that  account. 
The  chapter  on  chorea  of  childhood  is  an  interesting  study  of  the 
relations  of  chorea  to  race,  climate,  season,  etc.,  and  is  illustrated 
by  several  tables  and  diagrams  which  are  inserted  in  a  rather  un- 
usual place, — the  beginning  of  the  volume.  Dr.  Mitchell  finds  that 
the  weight  of  evidence  is  in  favor  of  the  view  that  chorea  is  less 
prevalent  in  country  districts  than  in  large  towns,  that  there  is  a 
less  liability  to  it  in  the  negro  than  in  the  white  race,  that  the  spring 
is  the  season  of  the  year  in  which  it  is  most  liable  to  occur  or  recur, 
and  that  there  is  an  apparent  relation  between  the  condition  of 
the  weather  and  the  prevalence  of  the  disease.  He  divides  the 
disorder  into  three  varieties  as  follows  : 

"  Group  first. — The  common  type;  awkwardness  and  incoordi- 
nation of  voluntary  movement,  followed  soon  or  late  by  automatic 
or  unwilled  clonic  spasms  of  various  parts. 

"  Group  second. — The  disease  never  gets  beyond  the  first  stage 
of  incoordination.  Just  as  in  some  scleroses  of  the  cord  there  is 
no  tremor  save  during  volitional  acts,  so  here  the  irregular  mo- 
tions only  occur  during  willed  actions. 

"  Group  third  is,  I  think,  the  most  unusual  type,  but  I  see  occa- 
sional cases  every  spring.  In  this  there  are  constant  automatic,  ir- 
regular clonic  spasms  usually  of  the  hands,  but  during  volitional 
acts  these  entirely  vanish,  and  the  most  complicated  acts  are  well 
performed  and  without  obvious  incoordination.  In  other  cases 
voluntary  motion  merely  lessens  the  spasmodic  activity,  but  does 
not  abolish  it." 


638  REVIEWS. 

If  this  last  class  or  group  is  to  include  those  cases  in  which 
the  choreic  incoordination  is  more  or  less  controllable  by  the  will 
of  the  patient,  we  should  hardly  consider  it  a  rare  form.  We 
have  seen  a  number  of  cases  in  which  complicated  voluntary  mo- 
tions were  not  interfered  with  to  any  great  extent  by  the  chorea, 
which  was  at  other  times  quite  marked. 

The  last  chapter  is  simply  a  restatement  of  the  author's  plan  of 
treatment  by  rest,  and  skim-milk,  and  massage  of  certain  neuras- 
thenic conditions.  It  appears  to  us  here  that  some  allusion  to 
the  recent  memoir  of  Drs.  Putnam-Jacobi  and  White  on  the  com- 
bination of  the  cold  pack  with  the  massage  in  some  of  these  cases 
might  have  been  appropriate.  These  authors  seem  to  have  de- 
monstrated that  there  is  a  decided  value  to  this  form  of  hydro- 
pathy in  the  treatment  of  some  of  these  anaemic  and  neurasthenic 
cases. 

In  conclusion,  we  will  say  of  the  work  that  it  is  in  very  many 
respects  an  excellent  one,  and  one  that  we  have  found  profit  in 
reading.  And  yet  we  must  still  confess  a  feeling  that  to  have 
produced  it  would  have  been  more  to  the  credit  of  a  medical 
writer  with  a  reputation  less  exalted  than  is  that  of  Dr.  Mitchell. 

Das  hirngewicht  des  menschen.  Eine  studie  von  Dr. 
Theodor  L.  W.  v.  BisCHOFF,  Bonn,  18S0.  {^The  brain-weight  of 
man.) 

The  material  upon  which  Dr.  Bischoff  has  based  this  volume  is 
the  examination  of  about  900  bodies,  with  reference  to  the  brain- 
weight  as  influenced  by  sex,  age,  weight,  and  size  of  body.  His 
actual  measurements  he  tabulates  in  four  different  orders  in  the 
appendix,  and  thereby  places  his  material  at  the  command  of  any 
one  who  chooses  to  utilize  it.  He  criticises  justly  all  his  prede- 
cessors for  having  omitted  such  tabulations,  as  the  reader  is 
thereby  confined  to  the  author's  personal  deductions.  Bischoff's 
measurements  were  taken  with  a  care  commanding  full  confidence. 
He  claims  himself  that  the  greatest  objection  which  can  be  raised 
against  some  of  his  comparisons,  is  the  fact  that  the  bodies  ex- 
amined were  dead  from  all  varieties  of  disease,  altering  the  bodily 
weight,  though  evidently  influencing  but  very  little  the  weight  of 
the  brain.  Moreover,  the  occurrence  of  loss  of  weight  by  wast- 
ing diseases  is  about  balanced  in  his  large  statistics  by  the  gain 
from  dropsy  in  other  instances. 

The  deductions  from  these  statistics,  as  well  as  the  results  of 
other  authors,  are  discussed  in  some  170  pages  in  a  very  unas- 
suming way,  avoiding  any  display  of  ingenious  theorizing  which 


THE  BRAIN-WEIGHT  OF  MAN.  639 

the  subject  does  not  warrant.  The  influence  of  sex  is  first  con- 
sidered. A  table  is  given,  quoting  the  average  weight  calculated 
by  different  observers  for  male  and  female  brains.  Wide  varia- 
tions are  to  be  found  amongst  the  authors,  which  must  really  be 
expected,  unless  very  large  figures  can  be  commanded.  The 
author  has  found  the  male  brain  to  vary  from  1,018  to  1,925 
grams,  and  the  female  from  820  to  1,565.  His  averages  are  1,362 
for  the  male,  and  1,219  ^'^^  ^^^^  female,  showing  an  average  differ- 
ence of  143  grams.  His  figures  agree  best  with  those  of  other 
authors  of  similar  experience,  like  Rob.  Boyd.  All  these  statis- 
tics refer  to  Europeans,  mostly  of  the  lower  classes,  to  be  found 
in  hospitals.  All  authors  admit  the  difference  between  the  sexes, 
usually  amounting  to  about  8  to  9  per  cent.  This  difference 
shows  itself  also  by  the  fact  that  the  healthy  male  brain  rarely,  if 
ever,  weighs  less  than  1,000,  and  may  amount  to  2,000,  while  a 
female  brain  of  830  is  no  great  rarity,  and  female  brains  above 
1,600  are  not  met  with.  This  sexual  difference  cannot  be  ex- 
plained alone  by  differences  in  weight  and  stature,  since  no  other 
factor  possesses  so  marked  an  influence  as  the  sex. 

The  weight  of  the  brain  does  not  appear  proportionate  at  all  to 
the  bodily  weight,  when  a  few  instances  only  are  taken  at  hap- 
hazard. It  is  only  when  large  numbers  are  considered  that  the 
parallelism  becomes  apparent.  By  grouping  his  results  in  classes, 
increasing  each  by  10  kilo,  in  weight,  Bischoff  shows  that,  other 
influences  aside,  the  heavier  the  body  the  heavier  also  may  we 
expect  the  brain  to  be.  In  the  individual  instance,  however,  we 
cannot  predict  the  brain-weight  thereby.  His  tables  show  clearly 
the  difference  of  sex,  since  in  comparing  classes  of  the  same 
weight  the  male  brains  have  still  the  advantage. 

The  relative  weight  of  the  brain  to  that  of  the  body  is  accord- 
ingly a  figure  within  wide  limits.  As  the  mean  of  all  observa- 
tions, Bischoff  states  it  as  i  in  about  35.  On  the  whole  the  pro- 
portion increases  as  the  weight  diminishes,  so  that  small  indi- 
viduals have  a  relatively  heavier  brain. 

The  influence  of  the  bodily  size  is,  on  the  whole,  parallel  to 
that  of  the  weight.  In  small  series  the  individual  variations  m.ay 
mask  this  factor  completely,  but  Bischoff's  extensive  figures  show 
after  all  that  the  larger  the  stature  the  heavier  may  we  expect  the 
brain,  with  this  provision,  that  a  relatively  heavier  brain  is  pos- 
sessed by  smaller  individuals.  This  general  statement  applies  to 
comparisons  amongst  various  animal  species  as  well. 

The  relation  of  age  to  the  brain-weight    is    illustrated   by   the 


640  KE  VIE  WS. 

author  by  very  copious  statistics,  but  which  do  not  really  teach 
much.  The  normal  brain,  of  course,  continues  to  increase  in 
weight  until  growth  is  completed,  which  seems  to  require  about 
20  years  for  the  female,  but  between  20  and  30  years  for  the 
male.  Amongst  a  small  number  of  embryos  Bischoff  found  rather 
wide  variations  not  corresponding  alone  to  the  age.  The  mean 
brain-weight  of  12  new-born  boys  was  367  grams,  and  of  12  girls 
396.  The  difference  is  here  reversed  ;  perhaps  on  account  of  the 
small  numbers.  The  relative  weight  of  the  brain  to  the  body  is 
about  I  to  8  at  birth  ;  which  proportion  decreases,  of  course,  with 
the  age.  The  brain  loses  again  in  weight  about  the  sixtieth  year 
of  age  ;  perhaps  earlier  in  the  female. 

The  influence  of  race  is  discussed,  but  only  very  few  reliable 
figures  can  be  quoted.  The  numbers  examined  by  most  observers 
were  too  small,  and  the  various  factors  of  influence  were  insuf- 
ficiently quoted.  Anthropologists  have  often  attempted  to  esti- 
mate the  brain-weight  by  gauging  the  skull-capacity.  Bischoff, 
however,  objects  to  this  method.  According  to  his  comparative 
measurements  the  error  may  amount  to  even  15  percent.,  or  more. 
The  chances  for  comparative  researches  on  different  races  are 
certainly  much  more  favorable  in  this  country,  but  we  can  find  the 
name  of  no  American  author  in  the  book  but  that  of  Morton. 

Hereupon  follow  two  interesting  chapters  on  the  relative  weight 
of  the  separate  cerebral  portions,  and  the  relation  of  the  weight  to 
the  extent  of  convolutions.  No  distinct  formulations  can  be  ab- 
stracted from  this  discussion.  In  the  next  place  he  compares  the 
brain-weight  to  the  intelligence,  admitting  as  the  result  of  rather 
limited  observations  that  a  parallelism  does  exist,  but  is  often 
masked  by  individual  variations  and  the  influence  of  other  factors. 

The  final  chapter  is  devoted  to  a  general  summary,  with  at- 
tempts at  explanations.  It  cannot  be  said,  on  the  whole,  that 
many  wholly  new  statements  are  to  be  found  in  the  work.  Its 
main  merit  is  the  discussion  of  mooted  questions  upon  the  basis 
of  more  positive  and  larger  material  than  has  hitherto  been  em- 
ployed. The  book,  hence,  amounts  to  a  complete  summary  of  our 
present  knowledge  upon  the  subject,  rendered  more  positive  by 
the  author's  personal  researches.  While  speculative  theorizing  is 
avoided  on  the  whole,  the  work  is  still  quite  suggestive  on  many 
points.  The  enjoyment  of  reading  it  is  badly  marred  by  the 
often  cumbersome  style  of  the  author.  H.  G. 


Editorial  ^tpitxUntnt 


T^HE  highly  important  and  intensely  practical  question  as  to 
the  relation  of  insanity  to  crime,  or,  to  state  the  matter  an- 
other way,  as  to  the  responsibility  of  the  insane  before  the  law, 
has  been  brought  to  the  attention  of  the  people  of  this  country  as 
never  before,  in  consequence  of  the  recent  horrible  endeavor  to 
assassinate  the  President  of  the  United  States.  Opinions  without 
number  have  been  expressed,  of  course,  as  to  the  sanity  of  the 
dangerous  wretch  by  whom  the  attempt  was  made. 

Whether  he  is  sane  or  insane  is  a  question,  however,  which  can 
be  decided  only  in  full  view  of  all  the  facts  germane  to  his  case, 
and  in  a  calmer  state  of  feeling  than  has  been  known  up  to  this 
time  by  any  right-minded  citizen. 

The  startling  character  of  the  case  grows  out  of  its  unusual  and 
widespread  relations,  rather  than  from  its  novelty.  Such  crimes 
are  committed  with  great  frequency,  in  which  persons  treading 
the  humbler  walks  of  life  are  the  victims,  and  in  which,  in  the  eye 
of  the  law,  the  same  aggravating  features  are  present.  Almost 
daily,  in  some  part  of  our  broad  land,  the  life  of  some  person  is 
unexpectedly  endangered  or  sacrificed  at  the  hands  of  some 
ill-balanced  or  insane  individual.  In  no  class  of  cases  is  well- 
tempered  justice  more  likely  to  be  baffled  than  in  dealing  with 
such  insane  criminals.  Society,  horror-stricken  by  such  events, 
cries  out,  with  the  instinct  of  self-preservation,  for  the  speedy  and 
condign  punishment  of  the  criminal,  and  yet  the  hand  of  justice 
is  stayed,  as  it  ought  to  be,  by  the  plea  of  irresponsibility. 

641 


642  EDITORIAL  DEPARTMENT. 

That  there  are  insane  criminals  there  can  be  no  question. 
That  responsibility  in  the  presence  of  the  law  is  attenuated  in 
various  degrees  by  unsoundness  of  mind  cannot  be  doubted. 
That  the  plea  of  insanity  will  be  set  up  whenever  possible,  is  to 
be  expected,  for,  as  a  rule,  it  is  in  human  nature  to  adopt  every 
possible  expedient  to  avoid  the  extreme  penalties  of  the  law. 
According  to  the  rule  in  such  cases,  it  may  he  confidently  ex- 
pected that  the  plea  of  insanity  will  be  made  in  behalf  of  the 
criminal  Guiteau.  For  the  credit  of  human  nature,  and  in  view 
of  such  facts  as  have  been  already  made  public,  we  do  not  see 
how  it  can  be  held  that  the  criminal  was  sane.  We  have  no 
reasonable  doubt  of  his  unsoundness  of  mind. 

The  important  question  with  this  class  of  cases  is,  what  shall 
be  done  with  them  ?  We  have  long  been  convinced  as  to  what 
the  proper  course  is  to  adopt  in  such  cases.  It  is  this  :  When- 
ever, in  the  case  of  murder  or  any  other  flagrant  crime  against 
society,  the  plea  of  insanity  is  set  up  and  successfully  maintained, 
then  the  penalty  should  be  the  incarceration  of  the  criminal  for 
life  in  a  prison  asylum.  Under  no  circumstances  should  such  a 
person  be  turned  loose  into  society  again  after  having  manifested 
such  dangerous  tendencies. 

It  is  our  hope  that  one  of  the  results  which  may  grow  out  of 
the  event  which  has  so  shocked  the  nation,  may  be  the  passage  of 
simple,  stringent,  well-considered  laws  providing  for  the  disposal 
in  this  way  of  all  dangerous  insane  criminals.  In  this  way  only 
can  society  protect  itself  and  justice  considerately  avoid  blind 
and  useless  severity.  If  such  a  plan  were  adopted  and  rigor- 
ously carried  into  effect,  the  plea  of  insanity  would  be  made  more 
rarely  than  at  present. 


"^tviscopt. 


a.— ANATOMY   AND   PHYSIOLOGY   OF   THE   NERVOUS 
SYSTEM. 

The  Nerve  Cells  in  the  Cerebro-Spinal  Ganglia  and 
Peripheral  Cranial  Ganglia  have  been  very  exhaustively 
studied  by  G.  Retzius  in  a  recent  article  in  the  Archiv  f.  Anato- 
mie  (1880,  p.  396).  He  examined  a  number  of  species  through- 
out the  entire  vertebrate  series.  While  there  is  nothing  startlingly 
new  in  his  results,  the  thoroughness  of  the  author  renders  his  de- 
scriptions authoritative,  and  does  away  with  much  of  the  obscur- 
ity hitherto  prevailing  in  this  subject.  He  finds  that  in  the 
spinal  ganglia  divisions  of  myelated  nerve  fibres  are  a  very  com- 
mon occurrence.  In  batrachia,  birds,  and  mammals  the  nerve 
cells  of  these  ganglia  present  only  one  process,  and  this  filament, 
after  receiving  an  investing  sheath  of  myeline  and  assuming  the 
appearance  of  an  ordinary  myelated  nerve  fibre,  joins,  probably  in 
all  cases,  another  nerve  fibre  at  a  point  of  constriction  forming 
the  T-shaped  junction  of  Ranvier.  But  this  apparent  junction  is 
probably  really  to  be  considered  a  division  of  the  myelated  cell- 
process.  Whether  one  of  the  resulting  branches  runs  peripher- 
ally and  the  other  toward  the  spinal  cord,  cannot  be  decided  with 
present  means.  It  can,  likewise,  not  be  decided  whether  all  cell- 
processes  undergo  this  division. 

The  jugular  and  cervical  ganglia  of  the  vagus,  the  jugular  and 
petrosal  ganglia  of  the  glosso-pharyngeal,  the  geniculate  ganglia 
of  the  facial,  and  the  semilunar  ganglia  of  the  trigeminus  must 
rank  as  true  cerebro-spinal  ganglia  as  judged  by  their  structure. 
The  ganglion  of  the  auditory  nerve  can  also  be  included  in  this 
category,  though  presenting  some  peculiarities.  In  the  cerebro- 
spinal ganglia  even  the  smallest  nerve  cells  are  seen  to  have  pro- 
cesses, which  assume  the  appearance  of  non-myelated  fibres,  and 

643 


644  PERISCOPE. 

are  sometimes  found  to  divide.  Whether  these  processes  ulti- 
mately obtain  a  sheath  of  myeline  could  not  be  decided.  The  oc- 
currence of  apolar  cells  is  highly  improbable.  Of  the  other  cra- 
nial ganglia,  the  otic,  spheno-palatine,  and  submaxillary  ganglia 
must  be  considered  as  belonging  to  the  sympathetic  system,  by 
reason  of  their  histological  structure.  As  regards  the  ciliary  gan- 
glia the  author  is  not  quite  decided.  His  histological  researches 
compel  him  to  regard  it  as  a  sympathetic  ganglion,  while  Schwalbe's 
investigations  in  comparative  anatomy  demonstrate  it  as  the 
true  ganglion  of  the  motor  oculi. 


The  Dilator  Nerves  of  the  Pupil. — M.  Fran^ois-Franck 
publishes  in  the  laboratory  reports  of  Marey,  iv,  1879-79,  the  fol- 
lowing interesting  researches,  of  which  we  find  an  abstract  in  the 
Centralblatt  f.  d.  Med.  Wt'ss.,  No.  15,  1881. 

The  movements  of  the  iris,  as  well  as  of  all  other  delicate  tis- 
sues, are  under  the  influence,  at  least  to  some  extent,  of  the  blood- 
vessels, but  not  entirely  so.  The  dilator  nerves  of  the  iris  sepa- 
rate themselves  from  the  vaso-motor  nerves  at  two  points — one 
right  over  the  superior  cervical  ganglion,  the  other  at  the  level  of 
the  ciliary  nerves.  Franck  found  that  above  the  superior  cervical 
ganglion  two  fibres  enter  the  skull  through  the  carotid  canal.  One 
of  these  dilates  the  pupil,  when  irritated,  without  influencing  the 
vessels.  On  testing  the  nerves  which  pass  from  the  ophthalmic 
(ciliary)  ganglion  along  the  optic  nerve,  two  sets  of  fibres  are  like- 
wise found,  mainly  contractors,  but  also  some  dilators.  It  can 
likewise  be  shown  that  irritation  of  the  sympathetic  nerve  pro- 
duces dilatation  of  the  pupil  much  sooner  than  vascular  contrac- 
tion, and  that  the  former  result  does  not  last  as  long  as  the  latter. 

Division  of  the  fifth,  fourth,  and  third  dorsal  communicating 
rami  (of  the  sympathetic)  causes  a  slight  momentary  dilatation  of 
the  pupil.  The  same  result  is  obtained  by  dividing  the  first  and 
second  dorsal  rami,  as  well  as  the  branches  passing  from  the 
eighth,  seventh,  sixth,  and  fifth  cervical  roots  to  the  first  thoracic 
ganglion.  This  ganglion,  therefore,  receives  dilator  fibres  coming 
from  the  cord  in  an  ascending  as  well  as  in  a  descending  direction. 
They  ascend  thence  through  the  anterior  branch  of  the  loop  of 
Vieussens  to  the  inferior  cervical  ganglion.  The  upper  thoracic 
ganglion  serves  as  a  tonic  centre  for  the  dilator  nerves  of  the 
pupil. 

The  dilator  fibres  thence  ascend  with  the  cervical  sympathetic 


ANATOMY  AND  PHYSIOLOGY.  645 

through  the  first  cervical  ganglion,  reaching  the  iris  ultimately  by 
way  of  the  Gasserian  ganglion  and  ophthalmic  branch  of  the  tri- 
geminus. Other  dilator  fibres  exist  in  the  fifth  nerve  even  before  it 
reaches  its  ganglion,  but,  on  cutting  these,  the  reflex  dilatation  of 
the  pupil  is  not  interfered  with  as  long  as  the  filaments  derived 
from  the  sympathetic  are  intact.  Section  of  the  ophthalmic  ra- 
mus (5th  nerve)  of  course  contracts  the  pupil,  but  irritation  of  its 
peripheral  end  does  not  dilate,  on  account  of  reflex  activity  of 
the  motor  oculi  started  by  the  irritation  of  fibres  of  recurrent 
sensibility.  Total  dilatation  of  the  pupil  can  be  induced  by  irritat- 
ing a  single  one  of  the  ciliary  nerves.  The  effect  is  very  sloiv  on 
having  a  mild  current,  but  prompt  with  stronger  stimulus. 

The  contracting  fibres  exist  in  the  trunk  of  the  third  nerve  pas- 
sing through  the  ciliary  ganglion  into  the  ciliary  nerves.  Section 
of  the  latter  produces  a  more  decided  effect  than  division  of  the 
motor  oculi,  on  account  of  a  tonic  action  of  the  ganglion.  The 
entire  iris  can  be  affected  by  irritation  of  a  single  ciliary  nerve, 
probably  on  account  of  abundant  peripheral  inosculation.  Simul- 
taneous and  equal  irritation  of  ciliary  nerves  and  cervical  sympa- 
thetic produces  only  dilatation  (by  interference).  But  on  using 
feeble  currents  on  the  sympathetic  nerves  and  subjecting  the  mo- 
tor oculi  to  strong  reflex  stimulation  by  light,  the  pupil  contracts 
at  first,  dilating  moderately  afterward. 


The  Influence  of  the  First  Cervical  Ganglion  on  the 
Iris  has  been  examined  in  frogs  by  J.  Tuwim  {PJluger's  Archiv, 
vol.  24,  p.  115).  By  cutting  the  cervical  sympathetic  on  one  side, 
and  extirpating  the  ganglion  on  the  other,  he  finds  on  the  latter 
side  a  narrower  pupil.  In  other  words,  the  presence  of  the  gan- 
glion exerts  a  tonic  influence  on  the  musculature  of  the  iris.  In 
order  to  avoid  errors,  the  definite  observations  should  be  made  24 
hours  after  the  operation,  to  escape  the  effects  of  transitory  irri- 
tation. The  statement  is  one  of  capital  importance,  since  this 
would  be  the  first  instance  of  any  well-proven  action  of  a  sympa- 
thetic ganglion.  The  result  can  be  demonstrated  also  by  the  de- 
struction of  the  cord  and  brain  and  of  the  ganglion  of  one  side, 
whereupon  the  corresponding  pupil  contracts  more  than  the  pupil 
still  connected  with  its  ganglion.  The  ganglion  does  not  receive 
any  pupil-dilating  fibres  by  anastomosis  from  the  hypoglossal,  as 
Budge  had  asserted.  For  the  mammal  the  author  claims,  likewise, 
a  direct  influence  of  the  first  cervical   ganglion  on   the  iris.     He 


646  PERISCOPE. 

maintains  that  the  degeneration  of  the  divided  sympathetic  does 
not  occur  as  long  as  the  ganglion  exists.  But  his  article  does  not 
furnish  adequate  proof.  He  claims,  further,  a  difference  in  the 
size  of  the  pupil  according  to  whether  the  sympathetic  nerve  is 
severed  alone  or  the  ganglion  removed.  But  his  observations  are 
so  imperfectly  reported  as  not  to  inspire  confidence,  at  least  for 
his  experiments  on  mammals. 


Irritability  and  Conductibility  of  Nerve  fibres. — 
Many  attempts  have  been  made  to  separate  these  two  properties, 
for  instance,  by  Schiff  and  by  Griinhagen,  who  both  claimed  that 
the  irritability  of  a  portion  of  a  nerve  could  be  destroyed,  while 
influences  generated  higher  up  could  yet  pass  through  this  part. 
Extending  an  experiment  proposed  by  Griinhagen,  J.  Szpilinan 
and  Luchsinger  have  arrived  at  some  interesting  results  {PJIuger's 
Archiv,  vol.  24,  p.  347).  The  experiment  consists  in  exposing  a 
part  of  the  trunk  of  a  frog's  nerve  to  the  action  of  C  Og  in  a  glass 
tube,  through  which  the  nerve  is  drawn.  The  irritability  is  tested, 
both  at  the  cut  end  and  at  the  part  exposed  to  the  gas,  by  electrodes, 
connected  with  an  induction  coil.  Griinhagen  had  claimed  that 
the  C  O2  could  deprive  the  nerve  of  its  local  irritability,  but  leave 
intact  the  power  of  conduction.  But  the  authors  found  different 
results.  In  the  first  place,  they  were  struck  with  the  greater  irri- 
tability of  the  nerve  at  the  cut  end,  which  diminished  gradually 
as  the  nerve  is  tested  nearer  to  the  muscle.  They,  hence,  contend 
for  Pfltiger's  avalanche  theory,  but  overlook  that  this  result  is  to 
be  found  only  in  divided  nerves.  On  poisoning  a  part  of  the 
nerve  with  COg,  Griinhagen's  result  is  apparently  obtained,  but 
on  continuing  the  experiment  the  following  was  noticed  :  The 
lower  (poisoned)  part  is  not  irritable  ;  it  merely  requires  a  stronger 
current.  But  on  allowing  the  agent  to  act  further,  the  upper  end 
is  now  found  wholly  deprived  of  irritability,  while  the  lower  part 
is  still  excitable.  In  other  words,  the  effect  of  C  Og,  and  still 
more  of  ether  or  any  other  anaesthetic,  or  N  H3  applied  to  one 
part  of  the  nerve,  causes  the  nerve  to  lose  its  excitability  from 
the  centre  toward  the  periphery.  On  removing  the  poisonous 
vapor  by  a  current  of  air,  the  excitability  is  recovered  in  the  re- 
verse order.  The  authors,  hence,  claim  that  conductibility  de- 
pends upon  the  propagation  of  the  excited  state  from  one  mole- 
cule to  the  other. 


A NA  TOM  V  A ND  PH  YSIOLOG  V.  ^47 

The  Physiological  Connection  between  the  Ganglion 
Cervicale  Supremum  and  the  Iris  and  the  Arteries  of 
THE  Head. — Tuwim,  Pfliigers  Archtv,xyi\v,  p.  115  (abst.  in  Cen- 
tralbl.f.  d.  Med.  Wissensch.,  No.  16),  has  found  that,  in  frogs,  the 
contraction  of  the  pupil  during  the  first  half  hour  after  section  of 
the  sympathetic  has  not  attained  its  maximum,  and  that  its  subse- 
quent increase  cannot  be  due  to  the  removal  of  the  influence  of 
the  ganglion  supremum  by  the  section,  as  Liegois  and  Vulpian 
have  supposed.  The  dimensions  of  the  pupil  are  always  smaller 
after  than  before  the  operation  ;  but  the  pupil  of  the  side  on  which 
the  ganglion  supremum  remains  is  always  greater  than  that  of 
the  other  side  on  which  it  has  been  torn  out.  This  reveals  the 
fact  that  the  ganglion  supremum  actually  exerts  a  tonic  influence 
on  pupil-dilating  fibres  given  out  by  it,  which  asserts  itself  in 
frogs  by  increased  pupillary  dilatation. 

Rabbits  and  cats,  in  whom  the  ganglion  supremum  of  one  side 
had  been  extirpated,  showed  a  greater  dilatation  of  the  pupil  from 
atropine  on  the  side  operated  upon  than  on  the  other.  If  only 
the  sympathetic  was  divided  on  the  one  side  before  it  reached  the 
superior  cervical  ganglion,  together  with  all  the  nerve  twigs  con- 
necting with  the  latter,  the  pupil  of  that  side  was  more  contracted 
than  that  of  the  side  not  operated  upon.  In  a  third  series  of  ex- 
periments, the  pupil  of  the  side  on  which  the  ganglion  had  been 
extirpated  was  always  wider  than  that  of  the  side  on  which  it  had 
been  separated  from  its  connection  with  the  central  nervous  sys- 
tem. Hence  it  appears  that  there  pertains  to  the  ganglion  supre- 
mum positive  influence  over  the  movements  of  the  iris,  which  is 
not  abolished  by  the  section  of  all  its  connections  with  the  cen- 
tral nervous  system. 

If  the  ganglion  of  one  side  in  a  frog  is  extirpated,  and  on 
the  other  side  the  sympathetic  is  divided  before  its  entry  into  the 
ganglion,  an  equally  marked  vascular  dilatation  is  observed  on 
both  sides  of  the  tongue.  If  this  operation  is  performed  upon 
rabbits,  the  same  condition  is  observable  in  the  vessels  of  the  ears. 
Hence  it  follows  that  the  ganglion  cervicale  supremum  has  not 
the  least  influence  on  the  vessels  of  the  tongue  or  of  the  ears. 


Vaso-Motors  of  the  Ly.mphatics. — MM.  Paul  Bert  and 
Laffont  have  discovered  the  vaso-motors  of  the  chyliferous 
glands.  They  opened  the  abdomen  of  an  animal  in  warm  water, 
while  the  process  of  digestion  was  in  full  play.     The  lacteals  then 


648  PERISCOPE. 

reveal  themselves  in  the  form  of  white  cords,  and  it  suffices  to 
simply  excite  the  solar  plexus  or  the  great  splanchnic  nerve,  to 
render  visible  the  nodosities  that  form  along  these  vessels. 
These  experiments  were  announced  to  the  Societe  de  Biologic, 
Apr.  2,  and  repeated  in  Le  Progres  Medical,  No.  15. 


Influence  of  the  Section  of  the  Trigeminus  upon  the 
Eye. — At  the  session  of  the  Societe  de  Biologic,  Apr.  2  (reported 
in  Le  Progres  Medical),  M.  Poncet  (of  Cluny)  reported  the  re- 
sults of  the  experiments  he  had  made  on  this  subject. 
After  showing  the  agreement  among  physiologists  at  the  pres- 
ent time  as  to  the  traumatic  origin  of  the  consecutive  corneal 
ulcer,  he  pointed  out  the  role  that  the  discoveries  of  Franclc  and 
of  Dastre  and  Morat  should  play  in  the  pathological  physiology 
of  the  trigeminus,  the  former  having  demonstrated  the  action  of 
a  special  filament  of  the  sympathetic,  the  latter  having  proved 
the  vaso-dilator  action  of  the  sympathetic  on  the  labial  mucous 
membrane.  M.  Poncet  has  found  with  M.  Dastre  that  the  vaso- 
dilatation by  excitation  of  the  sympathetic  extends  to  the  veins 
of  the  retina. 

In  the  eyes  of  a  rabbit,  after  section  of  the  trigeminus,  per- 
formed by  M.  Laborde  himself,  and  after  periods  of  eight,  fifteen, 
and  thirty  days,  and  one  year,  he  observed  the  following  :  (i) 
In  the  nerves  of  the  cornea,  the  degeneration  of  which  has  been 
so  well  described  by  Ranvier,  he  found  also,  after  a  year,  the 
complete  regeneration  of  the  corneal  plexus  in  a  mode  altogether 
different  from  the  normal  one.  In  the  midst  of  the  inextricable 
nervous  maze,  he  found  nerve  sheaths  or  old  tubes  that  had  not 
been  regenerated.  (2)  The  keratitis,  which  may  be  accompanied 
by  an  exudation  into  the  internal  chamber,  especially  affected  the 
superficial  corneal  lamina.  Neither  iritis,  nor  suppuration  of 
the  processes,  nor  posterior  choroiditis,  nor  disorder  of  the 
humors,  nor  migration  of  pigment  in  the  retina,  nor  detachment 
of  that  membrane,  existed,  but  in  the  retina  the  most  internal  lay- 
ers are  the  seat  of  an  oedema,  characterized  by  the  presence,  be- 
tween the  optic  fibres,  of  oedematous  masses,  perhaps  due  to 
hypertrophic  degeneration  of  the  ganglion  cells  ;  finally,  by  the 
increased  volume  of  the  protoplasm  of  the  internal  granulations. 
The  other  layers  are  healthy.  These  alterations  differ  essentially 
from  those  produced  by  the  optico-ciliary  section  described  by 
the  author  in  preceding  communications. 


A NA  TOM y  A ND  PH  YSIOLOG  V.  649 

The  Neuro-Pathological  Signification  of  the  Condition 
OF  the  Pupil,  Raehlmann,  Volk7nami  s  Klin.  VortrcEge,  No.  186, 
1880  (abstr.  in  St.  Petersb.  Med.  Wochenschr.). — The  condition  as 
to  the  diameters  of  the  pupil  depends  upon  these  factors,  the  ex- 
citation by  light,  the  convergence  of  the  visual  axis  in  accommo- 
dation, and  the  condition  as  to  excitation  of  the  sympathetic. 
The  author,  after  a  brief  physiological  introduction,  considers 
the  movements  of  the  pupil  in  their  relations  to  neuro-pathologi- 
cal  conditions,  and  lays  down  the  following  valuable  practical 
propositions  : 

/. — Reaction  from  light. 

1.  If  the  illuminated  pupil  does  not  react,  but  the  other  one 
not  illuminated  acts,  then  the  optic  nerve  of  the  former  is  not 
at  fault,  but  the  failure  depends  rather  upon  unilateral  paralysis 
of  the  pupillary  branch  of  the  corresponding  oculomotorius,  or 
upon  some  affection  of  the  iris  itself. 

2.  If  the  pupil  reacts  in  spite  of  complete  blindness,  the  cause 
of  the  phenomenon  must  be  looked  for  on  the  other  side  of  the 
corpora  quadrigemina,  which,  according  to  Meynert  and  Druim, 
are  directly  connected  with  the  motor  oculi  nucleus. 

//. — Reaction  from  convergence  movements. 

3.  If  both  pupils  react  from  convergence  of  the  optic  axis, 
then  the  pupillary  functions  of  both  motor  oculi  nerves  are  in- 
tact ;  the  pupils  contract  ;  and  it  is  practically  important  in  this 
experiment  to  have  the  subject  try  to  look  at  the  tip  of  his  own 
nose. 

4.  If  the  two  pupils  do  not  react  either  directly  or  sympatheti- 
cally to  light,  but  do  react  with  movements  of  convergence,  and 
the  power  of  sight  is  returned  to  any  extent  in  one  or  both  eyes, 
there  exists  a  hindrance  to  conduction  in  the  fibres  between  the 
corpora  quadrigemina  and  the  motor  oculi. 

///. — Reaction  from  innervative  conditions  of  the  sympathetic. 

After  a  short  but  exhaustive  statement  of  the  physiological 
alterations  of  the  iris  dependent  upon  excitations  of  the  sympa- 
thetic, the  author  comes  to  the  conclusion  that  pupillary  dilata- 
tion especially  depends  upon  the  amount  of  irritation  conveyed 
to  the  sympathetic  from  the  cervical  cord,  through  sensory  routes 
and  psychic  excitations.  In  a  pathological  condition  it  is  noticed 
that : 


650  PERISCOPE. 

5.  In  physically  debilitated  cases,  nervous  individuals,  and 
maniacs,  an  unusually  dilated  pupil  is  frequently  observed,  so 
constantly,  indeed,  that  contracted  pupils  are  looked  upon  in 
these  cases  as  ominous  symptoms  of  coming  paralysis.  There 
often  occurs  in  these  conditions,  as  well  as  in  hysterical  subjects 
and  epileptics,  a  rhythmic  alteration  of  the  pupil,  independent  of 
the  illumination  or  the  convergence  of  the  visual  axes. 

6.  Narrow  pupils  are  symptomatic  of  the  disorders  attended 
with  diminution  of  the  cortical  function,  especially  in  dementia 
paralytica. 

7.  Myosis  is  especially  frequent  in  diseases  of  the  spinal  cord 
and  medullo-spinal  myosis  ;  in  tabes  the  contracted  pupil  is  often 
perfectly  insensible  to  light,  while  still  reacting  well  with  con- 
vergence movements. 

8.  Alterations  of  the  pupil  depend  upon  the  simultaneous  in- 
nervation of  the  sympathetic  ;  an  irritation  of  this  latter  in  its 
peripheral  course  or  in  its  cervical  ganglia  may  show  itself  by 
pupillary  dilatation  (hemicrania,  lead  colic,  Basedow's  disease,  in- 
testinal irritation  in  children). 

9.  A  dilated  pupil  is  a  very  characteristic  symptom  of  embar- 
rassed respiration  from  the  effects  of  carbonic  acid  on  the  me- 
dulla, as  in  whooping  cough,  vomiting  attacks,  eclamptic  and  epi- 
leptic attacks,  labor  pains,  and  phthisis.  This  symptom  is  of  im- 
portance in  chloroform  narcosis  ;  the  utmost  contraction  showing 
when  the  extreme  degree  of  narcosis  is  attained,  that  its  dilata- 
tion from  sensory  irritation  indicates  that  the  patient  is  coming 
out  from  its  effects.  But  if  the  pupil  suddenly  dilates  while  the 
narcosis  persists,  threatened  asphyxia  from  carbonic  acid  poison- 
ing is  indicated. 

10.  The  pupils  are  dilated  with  cerebral  compression,  tumors 
of  the  brain  with  choked  disk,  chronic  hydrocephalus,  hemor- 
rhages in  the  cranial  cavity,  and  in  simple  cerebral  congestion. 

11.  Differences  in  the  normally  mobile  pupil  are  signs  of  ir- 
regular innervation  of  the  sympathetic,  due  to  some  irritation  of 
the  nerve  either  in  its  periplieral  course  or  in  its  connection  with 
the  cerebral  or  spinal  centres.  A  little  atropia  in  the  eye  will 
show  in  any  given  case  whether  it  is  to  a  paralysis  or  to  an  irri- 
tation that  the  dilatation  is  due  ;  in  the  first  case  it  will  be  very 
slight,  in  the  second  very  pronounced. 

Unilateral  mydriasis  of  a  mobile  pupil  is  a  very  important 
symptom  of  threatening  brain  disease,  while  the  same  with  im- 
mobility (paralysis  of  the   motor    oculi)  is  not  of  much   signifi- 


ANA  TOM  Y  AND  PH  YSIOLOG  Y.  65  I 

cance.  Unilateral  dilatation  in  a  normally  reacting  pupil  is  al- 
ways a  sign  of  unilateral  irritation  of  the  sympathetic,  and  is,  es- 
pecially when  sometimes  one,  sometimes  the  other  eye  is 
affected,  a  very  unfavorable  one.  The  dilated  pupil  from  sym- 
pathetic irritation  reacts  poorly  to  stimuli  of  light,  but  contracts 
with  movements  of  convergence,  and  is  thus  distinguished  from 
mydriasis  due  to  oculo-motor  paralysis,  and,  besides,  coexists  with 
absolutely  intact  accommodation.  Pupillary  inequalities  are  very 
frequently  met  with  in  the  insane,  especially  in  paralytics  and  de- 
mented cases. 


Cortical  Centres  of  Vision. — Dr.  J.  C.  Dalton,  N.  Y. 
Med.  Record,  March  26th,  has  repeated  Ferrier's  experiment  of 
destroying  the  angular  gyrus  in  monkeys  and  dogs,  and  with  the 
same  result — blindness  of  the  eye  on  the  side  opposite  the  hemi- 
sphere of  the  brain  operated  upon.  But  he  found  the  blindness 
persistent,  instead  of  temporary,  as  was  the  case  in  Ferrier's  mon- 
keys.    He  deduces  the  following  conclusions  : 

1.  Extirpation  of  the  angular  convolution  causes  loss  of  visual 
perception  on  the  opposite  side. 

2.  This  operation  is  not  followed  by  any  disturbance  of  the  in- 
telligence attitude,  power  of  locomotion,  or  general  sensibility. 

3.  It  does  not  interfere  with  the  local  sensibility  of  the  retina 
or  conjunctiva,  the  reaction  of  the  pupil  to  light,  nor  with  the 
normal  consentaneous  movements  of  winking.  Its  effects,  there- 
fore, are  confined  to  the  exercise  of  visual  sensibility. 


A  NEW  Cortical  Centre. — Dr.  Graeme  M.  Hammond,  in  a 
paper  read  at  the  New  York  Neurological  Society,  N.  Y.  Med. 
Record,  March  19th,  has  studied  the  location  of  the  giant  cells  of 
Betz,  in  the  brain  of  the  cat.  He  finds  that  they  are  not  localized, 
as  Betz  had  stated,  but  were  less  numerous  near  the  sulcus  cru- 
ciatus  than  posteriorly  to  it,  and  he  has  even  found  them  not  far 
from  the  base  of  the  brain.  The  largest  group  of  these  cells  he 
found  in  a  locality  not  determinately  fixed  by  physiologists  as  a 
motor  centre, — in  the  first  primary  arched  gyrus,  between  the  Syl- 
vian and  anterior  Sylvian  fissures.  It  is  nearer  to  a  locality  which 
Ferrier  designated  as  a  centre,  excitation  of  which  caused  partial 
divergence  of  the  lips,  than  to  any  other  discovered  motor  centre, 
but  it  does  not  correspond  exactly  to  that.  The  cells  here  are 
more  ovoid  or  circular  than  the  pyramidal  ones  of  Betz  and  Mier- 
zejewski,  and  even  longer  than  the  latter. 


652  PERISCOPE. 

Dr.  Hammond  concludes  his  paper  as  follows  :  "  Taking  the 
deductions  which  have  been  based  upon  the  existence  of  these 
cells,  on  their  merits,  we  find  that  those  who  have  relied  on  this 
demonstration  for  the  support  of  the  theory  of  motor  centres  are 
reduced  to  a  number  of  predicaments,  i.  That  the  largest 
giant  cells  have  been  found  in  the  brain  of  carnivora,  where  no 
motor  centre  has  been  clearly  demonstrated,  and  near  which  only 
small  muscles  are  supposed  to  receive  their  cortical  innervation. 
2.  That  if,  after  all,  this  is  a  motor  centre,  the  method  of 
localized  electrization  was  incompetent  to  detect  it.  I  have  lim- 
ited myself,  this  evening,  to  this  fact.  I  need  not  say  that  the 
giant  cell  was  known  to  Meynert,  although  its  locality  was  not  ac- 
curately described  by  him.  He  claimed  that  the  larger  gyri  of 
the  frontal  lobe  contained  the  largest  cells.  On  the  other  hand, 
cells  as  large  as  the  giant  cells  can  be  seen  through  the  entire  oc- 
cipital lobe,  according  to  this  observer,  in  the  two  white  strata, 
and  were  described  by  him  by  the  name  of  '  solitary  cells.'  I 
trust,  at  no  distant  date,  to  review  the  entire  question  of  the  dis- 
tribution of  large  cortical  cells,  with  measurements,  and  to  submit 
them  to  the  Society. 

"  For  the  present,  I  think  the  existence  of  the  large  cortical  cell- 
group  which  I  have  described,  shows  conclusively,  that  before  the 
existence  of  large  cells  can  be  considered  a  demonstration  of  the 
correctness  of  functional  localization,  a  more  extended  study  must 
be  made." 


Anatomical  Nomenclature  of  the  Brain. — Dr.  Burt  G. 
Wilder  {^Science,  March  19  and  26)  proposes  a  new  nomenclature 
of  the  brain,  which  he  supports  by  rather  satisfactory  arguments. 
Inasmuch  as  cerebral  anatomy  is,  in  a  measure,  in  an  unsettled 
condition,  and  in  all  its  details  is  yet  unfamiliar  to  the  great  major- 
ity of  physicians  and  students,  the  proposed  system  may  not  be 
objected  to,  though  novel  in  its  appearance. 

It  will  be  seen  that  it  does  not  extend  to  the  external  convolu- 
tions and  fissures  of  the  brain,  and  no  purely  histological  features 
are  included.  Some  parts  of  the  cerebellum  and  medulla  are  also 
omitted,  but  without  these  about  150  distinct  names  are  given, 
most  of  them  referring  to  more  or  less  distinct  parts,  but  a  few  in- 
dicating general  regions  distinguishable  by  color  or  elevation. 

"  Most  of  the  names,"  he  says,  "are  those  in  common  use,  with 
the  omission  of  superfluous  elements  like  corpus,  and  the  genitives 
of  the  names  of  more  comprehensive  parts.      Most  of  the  appar- 


ANATOMY  AND  PHYSIOLOGY.  653 

ently  new  names  will  be  found  to  be  old  acquaintances  under  such 
thin  disguises  as  translation,  transposition,  abridgment,  and  the 
substitution  of  prefixes  for  qualifying  words.  In  a  few  cases  the 
old  names  are  wholly  discarded  for  briefer  new  ones.  Most  of 
the  new  names,  however,  refer  to  parts  apparently  unobserved 
hitherto  {e.  g.,  crista,  corina,  delta)  or  to  parts  which — although 
probably  observed — seem  not  to  have  been  regarded  as  needing  a 
special  designation  {e.  g.,  aula,  quadrans,  corpus proeJ>ontile)." 

Dr.  Wilder  asks  for  the  fullest  and  freest  criticism,  both  as  to 
the  general  idea  of  his  proposition  and  the  special  terms  pro- 
posed. 

The  following  is  the  nomenclature  he  proposes  : 

Albicans  (corpus). — abn. — C.  candicans,  c.  niammilare,  etc.  Unable  to  as- 
certain which  of  its  many  titles  has  priority,  I  select  that  which  indicates  its 
most  obvious  feature  on  the  fresh  brain. 

Amygdala  (cerebelli). — ag.  cbl. 

Arachnoidea  (membrana). — Ach. — The  arachnoid  layer. 

Arbor  vit^  (cerebelli). — Arb. 

Area  cruralis. — Ar.  cr. — The  general  region  of  the  base  of  the  brain  be- 
tween the  pons  and  the  chiasma.  The  middle  region,  or  region  of  the 
isthmus. 

Area  elliptica. — Ar.  el. — An  area,  in  the  cat,  just  laterad  of  the  ventripy- 
ramis.     Perhaps  it  represents  the  "  inferior  olive." 

Area  intercruralis. — Ar.  icr. — The  interpeduncular  space.  The  mesal 
part  of  the  Area  cruralis. 

Area  postpontilis. — Ar  ppn. — The  ventral  aspect  of  the  metencephalon 
(medulla).  The  caudal  one  of  the  three  general  regions  into  which  the  base  of 
the  brain  may  be  conveniently  divided  for  description.  It  is  more  extensive, 
relatively,  in  the  cat  than  in  man. 

It  will  be  noted  that  the  adjective  pontilis  follows  the  analogy  of  gentilis 
rather  than  montanus  ox  fontinalis.  The  form  pontal,  however,  has  been  used 
by  Owen.     (A.  III.) 

Area  pr^chiasmatica, — Ar.  prch. — The  cephalic  one  of  the  three  areas  of 
the  base  of  the  brain.     The  space  cephalad  of  the  chiasma. 

Aula. — a. — The  cephalic  portion  of  the  third  ventricle  ;  the  prethalamic 
part  of  the  "  third  ventricle,"  between  the  "  two  portae,  or  foramina  Monroi ; 
'  aula,'  Wilder,  3  and  5."  "  The  here  common  ventricular  cavity,"  in  Meno- 
branchus,  Spitzka,  6,  31.  This  represents  the  cavity  of  the  "  unpaired  hemi- 
sphere vesicle,"  formed  by  a  protrusion  from,  or  constriction  of,  the  "anterior 
primary  encephalic  vesicle  ;  "  the  aula  is  relatively  larger  in  some  of  the  lower 
vertebrates. 

AULIPLEXUS. — apx. — The  plexus  of  the  aula.  The  free  border  of  the  fold 
oi pia,  known  as  the  velum,  forms  a  vascular  plexus  in  the  aula,  in  td^ch. porta, 
and  in  the  medicornu  of  ih.^  procalia.  In  place  of  compound  terms,  \\kt  plexus 
aulcB,  I  suggest  that  single  terms  be  formed,  atiliplexus,  portiplexus,  and  pro- 
plexus.  For  the  plexuses  of  the  dicoelia  and  metacoelia — the  "  third  "  and 
"  fourth  ventricles  " — we  may  use  diplexus  and  metaplexus. 


654  PERISCOPE. 

Basicommissura. — bcs. — "  The  basilar  commissure  of  the  thalami,"  Spitzka, 
2,  14.      The  ventral  continuity  of  the  two  thalami. 

BlVENTER  (cerebelli). — bv. — The  biventral  lobe  of  the  cerebellum. 

BuLBUS  OLFACTORius. — B.  ol. — The  olfactory  bulb.  The  more  or  less  ex- 
panded cephalic  part  of  each  lateral  half  of  the  rhinencephalon,  consisting  of 
\!ti^  pes  zxidi  pero .     Often  called  olfactory  lobe. 

Calamus  (scriptorius). — elm. 

Calcar  (avis). — clc. — Hypocampa  or  hippocatnpus  mhior. 

Callosum  (corpus). — el. — Commissura  cerebri  ynaxima,  trabs  medullaris, 
etc. 

Canalis  centralis  (myelonis).  —  C«.  ce. — The  central  canal  of  the  spinal 
cord. 

Carina  (fornicis). — <a. — The  mesal  ridge  of  the  caudo-ventral  surface  of  the 
fornix,  dcrso-caudad  of  the  crista.      I  am  not  sure  of  its  existence  in  man. 

Cauda  striati. — cd.  s. — "Surcingle,"  Dalton  (i,  13)  ;  the  slender  continua- 
tion of  the  striatum  caudo-ventrad.  If  a  new  name  is  required  for  this  longer 
"tail,"  which  was  described  by  Cuvier  (B.  iir,  51)  as  forming,  with  the  stria- 
tum proper,  a  "horse-shoe,"  Prof.  Dalton's  "surcingle"  may  be  technically 
rendered  "  cingulum."     I  have  not  yet  looked  for  the  cauda  in  the  cat. 

Cerebellum. — cbl. — Several  of  the  external  features  of  the  cerebellum  are 
omitted  from  this  paper. 

Cerebrum. — cb. — T\\e prosencephalon,  less  the  striata.     The  hemisphcErce. 

Chias.MA  (opticum,  or  nervorum  opticorum). — ch. — The  optic  chiasma  or 
commissure. 

CiMBlA. — cmb. — "  Tracttis  transversus  pedtinctili"  Gudden,  as  quoted  by 
Meynert  (A.  737).  A  slender  white  band  across  the  ventral  surface  of  the  crus 
cerebri.  It  is  a  distinct  ridge  in  the  cat.  The  word  is  used  in  architecture  to 
denote  a  bajid  ox  fillet  about  a  pillar,  and  is  here  proposed  as  a  fitting  substitute 
for  Gudden's  descriptive  name. 

Cinerea  (substantia). — c. — The  gray  matter  of  the  nervous  organs. 

Claustrum. — els. — The  ^'  claustrum"  (Burdach),  "nucleus  tceniceformis  " 
(Arnold),  as  stated  by  Quain,  A.   II,  564. 

CcELiA. — C. — A  ventricle  of  the  eticephalon.  For  a  brief  statement  of  the 
reasons  for  substituting  this  for  the  word  ventriculus,  see  elsewhere  in  this  ar- 
ticle. 

Columna  fornicis.  —  Co.  f. — The  anterior  pillar  of  the  fornix,  assuming 
that  there  is  one  upon  each  side.  It  would  be  convenient  to  have  a  single  short 
name. 

Commissura  fornicis.  —  Cs.  f. — In  the  cat,  a  distinct  band  across  the  caudal 
aspect  of  \}nt  fornix  just  ventrad  of  the  crista,  and  apparently  uniting  the  two 
columnse  more  closely. 

Commissura  habenarum. — Cs.  h. — A  white  band  connecting  the  caudal  ends 
of  the  habenae,  and  forming  the  dorsal  border  of  the  Fm.   conarii. 

CONARIUM. — en — The  glandula  pinealis.  Epiphysis  cerebri.  Penis 
cerebri. 

Corona  radiata. — Cn.  r. — C.  radians. 

Corpus  pr^^pontile. — Cp.  prp. — A  slight  white  longitudinal  ridge  of  the 
postperforatus,  near  the  meson.  It  is  distinct  in  the  cat.  When  more  fully 
known,  perhaps  a  better  name  may  be  found. 


ANA  TOM  V  AND  PHYSIOLOG  V.  65  5 

Cortex  (cerebri,  or  cerebelli). — c/x. — The  ectal  layer  of  gray  and  white  sub- 
stance at  the  surface  of  the  cerebrum  and  cerebellum. 

Crena  (calami). — cm. — The  caudal  end  or  notch  of  the  metacoelis. 

Crista  (fornicis). — crs. — A  small  but,  in  the  cat,  very  distinct  ovoid  mesal 
elevation  of  the  caudal  surface  of  ihe  /oi-nix,  ventrad  of  the  carina,  and  dorsad 
ot  the  commissura  _fornicis,  and  the  recessus  aulce.  It  is  also  prcicnt  in  the 
human  brain.     Wilder,  7. 

Crus  cerebri. — Cr.  cb. — Pedunculus  cerebri. 

Crus  OLFACTORIUM. — Cr.  ol. — The  isthmus  by  which  the  bulbus  olf.  is  con- 
nected with  'Ca.Q  proseti. 

Crusta  (cruris  cerebri). — est. 

Decussatio  piniformis. — dc.  pnf. — "  Piniform  decussation,"  Spitzka, 

Decussatio  ventripyramidum. — dc.  vpy. — The  "  decussation  of  the  an- 
terior pyramids." 

Delta  (fornicis). — d. — A  subtriangular  area  of  the  ventro-caudal  surface  of 
the  fornix  of  the  cat.  The  lateral  angles  are  the/i?r/^,  and  the  apex  points  dor- 
so-caudad.  It  is  bounded  by  the  lines  of  reflection  of  the  endyma,  and  repre- 
sents the  entocoelian  surface  of  the  fornix.  Wilder,  5.  It  probably  exists  in 
man. 

Dentatum  (corpus  cerebelli). — dnt. 

DiCCELIA. — dc. — The  "third  ventricle,"  or  ''■  venbicubis  tertius,"  less  the 
aula.     The  interthalamic  space,  reduced  in  mammals   by   the  medicommissura. 

Diencephalon. — den. — The  thalamencephalon,  deutencephalon,  inter-brain. 
enclosing  the  diccelia.  Whether  it  should  include  also  the  aula  and  its  walls 
is  to  be  determined  by  reference  to  the  condition  of  the  parts  in  some  of  the 
lower  vertebrates. 

Diplexus. — dpi. — The  plexus  of  the  "  third  ventricle." 

Distela. — dtl. — The  tela  vasculosa  forming  the  membranous  roof  of  the 
diccelia  or  "third  ventricle." 

Dorsipyramis. — dpy. — The  posterior  pyramid  of  the  metencephalon. 

Encephalon. — en. — The  brain,  including  the  medulla  or  metencephalon. 

Endyma. — end. — Ependyma.     Lining  membrane  of  the  ventricles. 

Epexcephalon. — epen. — The  hind-brain,  or  cerebellum  with  the  pons  and 
its  peduncles,  and  the  corresponding  part  of  the  medulla.  It  is  difficult,  per- 
haps impossible,  to  define  exactly  the  limits  of  the  epen.  and  the  metencepha- 
lon, and  of  their  respective  cavities. 

Epiccelia. — epc. — The  division  of  the  ventricular  cavity  corresponding  with 
the  cerebellum.  Perfectly  distinct  in  the  cat,  and  even  in  man,  but  relatively 
more  extensive  in  many  of  the  lower  vertebrates. 

Fasciola. — fscl. — May  not  this  single  word  take  the  place  of  fasciola  cin- 
erea  d^nd  fascia  dentata?  The  parts  are  continuous,  and  the  latter  is  not  den- 
tate in  the  cat. 

FiLUM  terminals  (myelonis). — -fl.  t. 

Fimbria. — fmb. — Corpus  fmbriatum.  Tcenia  hippocampi.  "Fimbria," 
Meyn.,  A.  667. 

Flocculus. — -flc. — Lobulus  pneumogastricus.  The  flocks.  This  seems  to 
be  a  different  part  from  the  lobulus  appendicularis  of  the  carnivora,  with  which 
it  has  been  sometimes  confounded. 

Foramen  OECUM. — Fm.  c. — "  Fossa  cceca,"   Spitzka,  3,  6.     Foramen   cczcum 


656  PERISCOPE. 

isused  by  Dunglison  and  Vicq  D'Azyr  (A.  pi.  xviii,  "48"),  and  should  be  re- 
tained, notwithstanding  the  somewhat  unusual  application  of  the  -w ox d  foramen. 

Foramen  infundibuli. — Fm.  inf. — The  orifice  in  the  tuber  cinereum  left 
after  the  removal  of  the  hypophysis   and  infundibulum. 

Foramen  magendie. — Fni.  mg. — The  communication  of  the  metaccelia 
with  the  "  subarachnoid  space."  Not  having  satisfied  myself  as  to  the  nature 
of  this  communication,  I  prefer  to  quote  from  Quain,  A.  ii,  513. 

Fornix. — f. — Camara.      Tesiudo  cerebri,  etc. 

Genu. — g.-^Genu  callosi. 

Habena.  — /^. — Habenula.  Pedunculis pinealis.  There  seems  to  be  no  need 
of  using  the  longer  word.  According  to  my  observations,  the  habencE  have  a 
distinct  morphical  significance  as  nearly  corresponding  with  the  lines  along 
which  the  endyma  is  reflected  toward  the  opposite  side  ;  5  and  7. 

Hypocampa. — hym. — Hyppocampus  major.  The  reasons  for  preferring  the 
form  employed  by  Vicq  D'Azyr  are  presented  elsewhere  in  this  article. 

Hypophysis. — hy. — Pituitary  body. 

Infundibulum. — inf. — Infundibulum  cerebri,  etc. 

Insula. — ins. — Island  of  Reil.  Lobus  centralis.  Insula  cerebri.  Gyri 
operti. 

Interopticus  (lobus). — iop. — The  interoptic  lobe,  Spitzka,  4,  98  ;  5.  In 
some  reptiles. 

Iter. — i. — Iter  a  tertio  ad  ventriculum  quartum.  Aquaducius  Sylvii.  A 
convenient  name  for  the  contracted  mesocoelia  of  man  and  most  mammals. 

Lemniscus  inferior. — Imn.  i. — Spitzka,  4,  95,  and  100, 

Lemniscus  superior. — Imn.  s. — I  have  not  been  able  to  identify  these  parts 
in  the  cat. 

Ligula. — Ig. — "  Ponticulus."     Ligula,  Quain,  A.  II,  506. 

Limes  alba. — Im.  a. — Limes  alba  radicis  lateralis  rhinencephali.  The  white 
stripe  of  the  lateral  root  of  the  rhinencephalon.  Perfectly  distinct  in  the 
fresh  brain  of  the  cat. 

Limes  cinerea. — Im.  c. — The  gray  stripe  of  the  radix  lateralis. 

Liquor  ventriculi. — Iq.  vn. — This  term  is  used  by  Mihalk,  A.  163.  Is  a 
belter  one  to  be  found  ? 

LOBULUS  APPENDicuLARis  (cerebelli).  LI.  ap.  The  appendicular  lobule  of 
the  cerebellum  of  many  carnivora,  and  perhaps  other  mammals.  It  seems  to 
have  been  confounded  in  some  cases  with  the  hurm.nfocculus,  but  more  prob- 
ably represents  the  lateral  lobes  of  the  cerebellum.  Its  relations  should  be 
studied  in  a  series  of  related  forms.     See  my  paper,  11,  217. 

Lobulus  olfactorius. — LI.  ol. — The  olfactory  lobe  of  the  hemisphere.  A 
part  of  the  hemisphere  said  to  be  in  more  direct  connection  with  the  rhinen- 
cephalon. 

Lobus  olfactorius. — L.  ol. — A  general  name  for  either  half  of  the  rhinen- 
cephalon, including  the  crus  and  the  bulbus. 

Locus  nicer. — Ic.  n. — The  locus  niger  of  the  crus  cerebri,  between  the  teg- 
mentum and  the  crusta. 

Medicommissura. — mcs. — Commissura  mollis.  Middle  commissure. 
"  Thalamic  fusion,"  Spitzka. 

Medicornu  (procoelioe). — 7ncu. — Cornu  temporale.  The  middle  or  descend- 
ing horn  of  the  "  lateral  ventricle." 


ANATOMY  AND  PHYSIOLOGY.  657 

Medipedunculus  (cerebelli). — mpd. — Crus  ad  pontetn.  Middle  peduncle  of 
the  cerebellum. 

Mesencephalon. — men. — The  mid-brain.  The  lobi  optici,  postoptici,  and 
interoptici,  with  the  corresponding  crura  cerebri. 

Mesoccelia. — msc.  The  ventricular  division  corresponding  with  the  mesen- 
cephalon. In  man  and  most  mammals  it  is  usually  reduced  and  known  as  iter, 
or  aquadnctus  Sylvii. 

Metaccelia. — 77itc. — The  "  fourth  ventricle,"  z/^w/rjVw/Mj  quarius.  Ventri- 
cle of  the  metencephalon. 

Metaplexus. — mtpl. — 'Y\\&  plexus  choroideus  of  the  metacalia. 

Metatela. — mil. — The  membranous  roof  of  the  metacslia,  or  "fourth 
ventricle." 

Monticulus  (cerebri). — mnt. — The  ventral  prominence  of  the  lobus  tem- 
poralis.    Natiform  protuberance.     Alveus.     Subiculttm. 

Myelencephalon. — myen.—-T\ie  cerebro-spinal  axis.  The  term  was  pro- 
posed by  Owen. 

Myelon. — my. — The  spinal  cord.     Owen.     Huxley. 

Nervus  olfactorius. — N.  ol.  — Olfactory  nerve. 

Nucleus  lenticularis. — nc.  In. — Nucleus  lentiformis.     Meynert. 

Obex. — I  have  not  identified  this  part. 

Oliva. — 0. — Corpus  olivarium.  Olivary  body.  Olive.  The  "  inferior 
olive."     Spitzka. 

Opticus  (lobus).  Natis  cerebri.  An  optic  lobe,  excluding  the  postopticus 
and  interopticus. 

Pero  (olfactorius). — po. — The  softer  cap,  or  shoe-like  covering  of  the  rhin- 
encephalic  lobe,  from  which  the  nervi  olfactorii  directly  spring.  In  tlie  cat 
this  may  be  accurately  removed  from  \h.t.  pes  ol.  The  Latin /dTf  denoted  a  sort 
of  boot  made  of  raw  hide. 

Pes  olfactorius. — ps.  ol. — The  firmer  ental  portion  of  each  rhinenceph- 
alic  lobe.  As  it  is  the  termination  of  the  crus,  and  has,  in  the  cat,  a  somewhat 
foot-like  shape,  I  suggest  the  above  name  for  it. 

PlA  (mater). — pi — In  the  cat's  brain  there  are  indications  of  at  least  two  lay- 
ers of  the  pia. 

Pons  (Varolii). — pn. —  Tuber  annulare,  ^\q.  There  seems  to  be  no  need  of 
the  qualifying  genitive. 

Pontibrachium. — pnbr. — "  Brachium  pontis,"  Spitzka,   4,  lOO. 

PORTio  depkessa  (prgeperforati). — Ft.  d. — In  the  cat  the  {locus)  prccperfora- 
tus  is  distinctly  divided  into  two  portions,  the  caudal  of  which  is  depressed, 
while  the  cephalic  is  elevated,  and  sometimes  furrowed.  Briefer  names  are 
desirable. 

PoRTio  prominens  (praeperforati). — Pt.  p. 

Portiplexus. — -///. — The  small  portion  of  the  free  border  of  the  velum 
which  hangs  in  \\\^  porta. 

POSTBRACHIUM  (mesen.). — pbr. — Brachium  posterius. 

PosTCOMMissuRA. — pes. — Commissura  posterior  cerebri.  The  posterior  com- 
missure. 

POSTGENICULATUM  (corpus). — pgn. — Corpus  geniculatum  internum. 

Postopticus  (lobus). — pop. —  Testis  cerebri.  The  caudal  eminence  of  the 
'^corpus  quadrigeminum."     "  Postoptic  lobe,"  Spitzka,  4,  100,  and  103. 


658  PERISCOPE. 

POSTPEDUNCULUS  (cerebelli). —//</. — Crus  cerebelli  ad  medullam.  Inferior 
peduncle. 

PosTPERFORATUS  (locus).— ///. — Locus  perforatus  posticus.  Posterior  per- 
forated space.     Pons  Tarini. 

Pr^brachium  (mesen.).— /r-Jr. — Brachium  anierius.  I  have  not  identified 
these  parts. 

Pr/ECOMMISSURA. — prcs. — Commissura  anterior. 

Pr^GENICULATUM  (corpus)^^r^«. — Corpus  geniculatum  externum. 

PRitPEDUNCULUS.— /;7>i/. — Crus  seu  p^vcessus  ad  corpus  quadrigeminum . 
Superior  peduncle  of  cerebellum. 

PRitPERFORATUS. — prpf. — Locus  perf.  anticus. 

Proccelia. — pre. — Ventricle  of  the  prosencephalon,  "  Lateral  ventricle." 

Proplexus. — prp. — The  plexus  of  the  medicornu  oi  ihe  procceiia.  It  is  the 
long  free  border  of  the  velum,  and,  still  covered  by  the  endyma,  enters  by  the 
rima.  It  is  continuous  with  \.)\q  portiplexus,  and  extends  to  near  the  tip  of  the 
ntedicornu. 

Prosencephalon. — pren. — The  cerebral  hemispheres  ;  cerebrum  less  the 
striatum  ;  the  fore-brain. 

Proterma. — prlr. — The  primitive  lamina  terminalis  or  /.  cifierea.  Terma 
embryonis.  My  reason  for  suggesting  different  terms  for  the  adult  and  embry- 
onic terminal  plate,  is  that,  as  now  understood,  the  latter  includes  not  only 
the  lamina  cinerea  of  anthropotomy,  but  also  the  parts  afterward  differentiated 
to  form  the  columnce  fornicis,  and  the  prcecommissura,  with  perhaps  some  other 
parts  of  the  fornix. 

PSEUDOCCELIA. — psc. —  Ventriculus  septi  pellucidi.  "Duncan's  hohle," 
Loewe,  A.  13.  Fifth  ventricle.  This  is  not  a  true  member  of  the  coelian  seri- 
es. If  it  ever  presented  an  opening  into  the  aula,  it  is  because  of  some  in- 
jury which  has  torn  the  brain.  This  point  was  urged  by  be  in  the  unpublished 
paper  No.  4. 

Pulvinar. — plv. — Pulvinar  thalami.  The  posterior  tubercle  of  the  human 
thalamus. 

QuADRANS  (cruris  cerebri). — q. — In  the  cat,  a  depressed  area  approximately 
equal  to  the  fourth  of  a  circle,  upon  the  ventral  surface  of  the  crus,  in  its  meso- 
cephalic  angle. 

Radix  intermedia  (rhinencephali). — Rx.  i. — The  middle  root  of  the  rhin- 
encephalon.  In  anthropotomy,  the  middle  root  of  the  olfactory  nerve.  In  the 
cat  it  is  little  more  than  a  sub-triangular  interval  between  the  RR.  lateralis 
and  mesalis. 

Radix  lateralis. — Rx.  I. — The  lateral  root  of  the  rhinen.  The  "external 
root  of  the  olf.  nerve."  In  the  cat  it  presents  a  gray  and  white  stripe — limes 
cinerea  and  /.  alba. 

Radix  mesalis. — Rx.  m. — The  mesal  root  of  the  rhinencephalon.  The 
"  internal  root  of  the  olf.  nerve."  In  the  cat  it  turns  pretty  sharply  from  the 
ventral  to  the  mesal  aspect  of  the  brain. 

Recessus  aul^. — R.  a. — A  small  depression  between  the  two  columnce  for- 
nicis,  and  ventrad  of  the  crista.     The  aulic  recess. 

Recessus  co.varii. — R.  en. — "  Recessus  pinealis,"  Reich.,    A.  Taf.  ix,  rp. 

Recessus  opticus. — R.  op. — This  is  a  pyramidal  recess,  just  dorsad  of  the 
fAi'ajwa,  the  apex  pointing  laterad.     The  term  is  used  by  Mihalkovics,  A.  7g. 


A NA  TOM  Y  A ND  PH  YSIOLOG  Y.  659 

Recessus  pr>epontilis. — J?,  prpn. — The  mesal  depression  which  is  over- 
hung by  the  cephalic  border  of  the  poyts.  Its  floor  is  formed  by  the  caudal 
part  of  t.\\t  postper/oratus. 

Regio  aulica. — Rg.  a. — It  may  be  convenient  sometimes  to  employ  this 
term  as  a  designation  for  the  general  region,  of  which  the  aula  is  the  centre. 
Within  a  short  distance  of  the  aula  are  many  parts  of  great  morphical  impor- 
tance ;  the  whole  brain  seems  to  converge  thereto.  Whoever  understands  the 
aulic  region  will  find  no  serious  difficulty  with  the  gross  anatomy  of  other 
parts. 

Restiforme  (corpus). — I?/. — The  restlform  body  of  the  metencephalon. 

Rhinencephalon. — rhen. — The  division  of  the  brain,  which  is  united  with 
the  cephalic  end  of  the  base  of  \}nQ  prosencephalon,  and  connected  by  the  nemi 
olfactorii  with  the  nares.  Each  lateral  lobus  includes  a  crus  with  its  radices, 
and  the  bulbus  olfactorius,  consisting  of  the  pes  and  pero, 

Rhinoccelia. — rhc. — The  cavity  or  ventricle  of  each  lateral  part  of  the 
rhinencephalon,  and  connected  with  the  procoelia. 

RiMA  (cerebri). — r. — The  interruption  of  nervous  tissue  between  the  fimbria 
and  the  tcenia,  by  which  the  fold  of  pia — still  covered  by  the  endynia — enters 
the  proccclia  to  form  the  proplexus.  It  extends  from  the  dorsal  border  of  the 
corresponding  porta  to  near  the  tip  of  the  niedicornu.  In  a  general  way  it 
coincides  with  a  lateral  half  of  the  "fissure  of  Bichat,"  or  "great  trans- 
verse fissure."  That,  in  the  cat,  the  borders  of  this  rima  are  closely 
united  by  the  intruded  pia,  and  that  the  thalamus  is  wholly  excluded 
from  the  proccelia,  was  demonstrated  by  me  on  the  25th  of  November, 
187-,  in  the  presence  of  my  assistant.  Prof.  S.  H.  Gage,  who  recorded  it 
at  the  time.  It  was  affirmed  in  my  lectures  on  physiology  at  the  Medi- 
cal School  of  Maine  in  the  spring  of  1877,  and  in  subsequent  courses  there 
and  at  Cornell  University  ;  and  was  one  of  the  points  made  in  a  paper  (4) 
read  at  the  meeting  of  the  Am.  Assoc.  Adv.  of  Sci.  in  1879.  While  affirm- 
ing this  of  the  cat,  I  stated  that  the  material  at  my  disposal  had  not  ena- 
bled me  to  demonstrate  it  upon  the  human  brain,  but  there  was  no  doubt  that 
the  same  condition  would  be  ascertained  when  a  human  brain  could  be  pre- 
pared and  examined  with  sufficient  care  with  reference  to  that  feature.  In  the 
spring  of  1880,  Dr.  Spitzka  informed  me  that  Hadlich  had  denied  lately  the 
appearance  of  the  thalamus  in  the  lateral  ventricle,  presumably  of  man.  The 
fact  is,  whoever  begins  his  studies  of  encephalic  anatomy  with  the  brains  of 
the  lower  vertebrates  will  soon  perceive  that — excepting  for  some  rupture  of 
the  parts — the  thalamus  can  no  more  form  a  part  of  the  floor  of  the  "  lateral 
ventricle  "  than  can  the  cerebellum  or  any  other  part  of  the  brain. 

RlPA  (deltse). — rp. — The  border  of  the  delta  formed  by  the  reflection  of  the 
endyma  upon  the  intruded  auliplexus.     Probably  also  in  man. 

Rostrum  (callosi). — rm. — The  rostrum  of  the  callosum  ;  much  shorter  in  the 
cat  than  in  man. 

Septum  lucidum. — spt.  I. — This  term  is  not  only  compound,  but  based  upon 
two  misconceptions  :  that  it  is  always  or  even  usually  translucent  in  mammals, 
and  that  it  forms  a  partition  between  the  ivJoproccBlicz  in  the  ordinary  sense.  A 
new  term  is  desirable,  which  may  refer  to  either  of  the  two  lateral  halves  of  the 
septum,  in  connection  with  the  proccelia,,  or  the  rest  of  the  wall  of  the  hemi- 
sphere. 


66o  PERISCOPE. 

Splenium  (callosi). — sp. — The  splenium. 

Striatum  (corpus). — s. — The  intraventricular,  or  entoccelian  portion  of 
what  is  sometimes  called  the  corpus  striatum.  The  nucleus  caudatus.  The 
caudate  lobe. 

Sulcus  haben^. — SI.  h. — The  slight  furrow  along  the  dorsal  border  of  the 
habena. 

Sulcus  intercruralis  lateralis. — SI.  ic  I. — In  the  cat,  a  distinct  lateral 
furrow  in  the  area  intercruralis. 

Sulcus  intercruralis  mesalis. — SI.  ic.  m. — A  mesal  furrow  in  the  area 
intercruralis  of  the  cat. 

Sulcus  limitans. — SI.  li. — The  furrow  between  the  thalamus  ^xiA  striatum, 
in  which  lies  the  free  border  of  the  fimbria  in  contact  with  the  tcenia.  The 
qualifying  word  is  given  in  reference  to  the  fact  that  this  furrow  is  the  line  of 
separation  between  the  entoccelian  surface  of  the  striatum  and  the  ectocoelian 
surface  of  the  thalamus.     A  shorter  and  more  significant  term  is  desirable. 

Sulcus  monroi. — SI.  Mn. — The  term  -is  employed  by  Reichert  (A.  65, 
Taf.  11),  to  designate  a  part  of  the  diccelia  of  man  ventrad  of  the  medicommis- 
sura. 

TAENIA  (semicircularis). — tn. — There  seems  to  be  no  reason  why  this  single 
word  may  not  replace  the  numerous  compounds  by  which  the  part  is 
known. 

Tegmentum. — tg. — The  more  dorsal  layer  of  fibres  of  the  crus  cerebri,  sep- 
arated from  the  crusta  by  the  locus  niger. 

Tela. — //. — A  general  name  for  the  membranous  roofs  of  the  diccelia  and 
metaccelia.      "  Tela  vasciilosa  "  is  employed  by  Huxley,  /. 

Terma. — tr. — Lamina  cinerea.      The  adult  lamina  terminalis. 

Thalamus. — th. —  Thalamus  opticus  seu  nervorum  opticorum.  As  has  been 
well  remarked  by  Spitzka  (2),  this  single  word  is  to  be  preferred  upon  all 
grounds  to  the  compounds  which  have  been  applied  to  this  part. 

Tractus  opticus. — tr.  op. — The  optic  tract. 

Trapezium. — tz. — The  trapezium  of  the  metencephalon.  Exposed  in  the 
carnivora,  but  in  man  concealed  by  the  caudal  margin  of  \h&  pons. 

Tuber  cinereum. —  T.  en. — The  elevation  just  caudad  of  the  chiasma,  to 
which  is  attached  the  hypophysis  by  the  infundibulum. 

TUBERCULUM  ROLANDO. — tbl.  R. — The  tuberclc  or  tuber  of  Rolando, 
lluguenin,  A.  83. 

V.\LVULA  (cerebelli). — vv. — The  valve  of  Vieussens. 

Velu.m  (interpositum). — vl. — The  ectocoelian  portion  of  the  fold  oi pia,  the 
entoccelian  free  border  of  which  forms  the  plexuses  of  the  aula,  portse,  and 
procceliae. 

Vena  choroidea. — v.  ch. —  Vena  Galeni. 

Ventripyramis. — vpy. — The  anterior  pyramid.  The  "  prepyramid, " 
Owen,  A. 

Vermis  (cerebelli). — vm. — The  median  lobe  of  the  cerebellum,  This  and 
the  other  external  features  of  the  cerebellum  are  not  here  presented  with  any 
fulness. 

If  I  venture  to  hope  that  a  few  of  the  changes  proposed  in  this 
paper  may  escape   disapprobation,  and   that  all  my  readers  may 


ANATOMY  AND  PHYSIOLOGY.  66l 

not  be  hostile  critics,  it  is  because  the  times  have  changed,  and 
such  an  undertaking  is  now  more  likely  to  be  viewed  in  its  true 
light.  I  have  endeavored  simply  to  define  more  clearly  the  ne- 
cessity for  terminological  improvement  which  has  been  admitted. 
in  some  cases  unconsciously  perhaps,  by  all  who  have,  for  ex- 
ample, substituted  ventral  for  anterior,  ectoglutceus  for  glutceus 
maximus,  hypophysis  for  pituitary  gland,  corpus  callosum  for  com- 
missura  cerebri  maxima^  adrenals  for  suprarenal  capsules,  and  basi- 
occipital  for  basilar  portion  of  the  occipital  bone. 

Dr.  E.  C.  Spitzka,  Science,  April  9th,  after  commenting  on  some 
of  Prof.  Wilder's  terms,  suggests  the  following  additions  : 

Cappa  (cinerea'') — The  gray  cap  covering  the  Optici;  well  developed  in  mo^t 
mammalia,  rudimentary  in  man. 

ECTOTHAi-AMUS*. — The  outer  gray  thalamic  zone. 

Entothalamus*. — The  inner  gray  thalamic  zone. 

Intercrurale*  {Gans^lion^. — Ganglion  Interpeduncttlare^ •  *. 

Sigma*. — The  5-shaped  involution  of  the  nerve-cell  layer  of  the  cortex  which 
constitutes  the  basis  of  the  Hypocampa. 

Nucleus  trapezii*. — The  superior  olive.  The  development  of  this  body 
seems  to  bear  an  inverse  relation  to  that  of  the  true  olive.  In  man  the  olive 
proper  is  highly  developed,  in  the  cat  poorly — in  the  latter  the  nucleus  of  the 
trapezium  is  well  marked  and  folded  ;  in  man  it  is  ill-marked. 

Oblo.ngata.* — The  post-pontinal  area  of  man  ;  the  medulla  oblongata. 

Stride*. — The  stria:  medullares  albce  of  the  fourth  ventricle. 

Velum  cerebelli*. — The  valve  of  Vieussens  ;  this  is  the  true  embryonic 
starting-point  of  the  cerebellum.      The  velutn  medullare  anterizts. 

Velu.M  oblongata*. — The  velum  medullare posterius.  It  arises  from  the 
internal  division  of  the /^j-Z/^i/z^wcw/wj  in  its  oblongata  portion,  and  covers  the 
posterior  part  of  the  fourth  ventricle. 

Velum  flocculi*. — The  velum  medullare  inferius. 

Gracilis*  {Funiculus). — Funiculus  gracilis,  continuation  of  corresponding 
column  in  cord  ;  part  of  the  posterior  pyramids. 

CUNEATUS*  {Funiculus). 

Tuberis*  {Funiculus). — Funiculus  of  Rolando  ;  the  columnar  field  contain- 
ing the  tuberculum  of  Rolando.  There  is  a  lobulus  tuberis,  which  is  other- 
wise provided  for. 

Nodi*. — Two  symmetrical  eminences,  situated  each  in  the  shallow  depres- 
sion bounded  by  the  opticus  thalamus  and  habena,  probably  corresponding  to 
the  ganglion  habence  (Gangl.  habenulce^).  There  is  a  notable  large  opening 
cephalad  of  these  eminences,  which  resembles  the  opening  under  the  tcEnia  con- 
taining the  vein  which  gives  the  latter  its  bluish  color.  I  can  find  no  notice  of 
this  opening  anywhere.  The  eminences  are  represented  obscurely  in  fig.  70 
of  Henle^. 

Decussatio  Fontinalis**. — Fontanen  artige  Haubenkrenzung^. 

♦Terms  proposed  by  myself,  not  to  be  found  in  previous  publications. 
*  *  A  single  afSx  or  pretix  might  be  devised  in  place  of  decussatio,  or  /ontidecussatio. 
pinidecussatio,pyridecussatio. 


662  PERISCOPE. 

In  conclusion,  I  would  urge  the  adoption  of  some  brief  arbitrary  affix  or  pre- 
fix in  place  of  the  words  commissure  and  ganglion.  He  who  limits  himself  to 
a  study  of  surface  contours  will  not  appreciate  the  absence  of  such  abbreviations 
as  much  as  he  who  is  compelled  to  wade  through  the  labyrinth  of  the  internal 
cerebral  structure. 

Gris  for  Ganglion  would  perhaps  do  ;  thus  Grishabena,  Gristegmentum, 
Grisfastigium  for  Ganglion  habence.  Ganglion  and  Nucleus  tegmenti,  A'ucleus 
fastigii.  The  term  nucleus  is  a  very  unfortunate  one,  as  it  has  another  and 
very  different  meaning  which,  in  my  experience  as  a  teacher  of  cerebral  ana- 
tomy, has  led  to  confusion  in  the  mind  of  every  beginner.  Professor  Wilder, 
who  appears  to  be  as  much  at  home  in  etymology  as  in  cerebral  anatomy,  will 
solve  these  problems  no  doubt  better  than  I  could  pretend  to. 


Among  others,  the  following  articles  have  been  recently  pub- 
lished on  the  anatomy  and  physiology  of  the  nervous  system  : 

Lewis  :  Methods  of  preparing,  demonstrating,  and  examining 
cerebral  structure  in  health  and  disease,  Brain,  vol.  4,  No.  i, 
April,  1881.  MiCKLE :  Cerebral  localization,  Journ.  Mental 
Science,  April,  1881.  Poolev,  T.  W.  :  Some  fallacies  of  phys- 
iological experimentation  regarding  nerves  and  muscles,  N.  V. 
Med.  Record,  March  26th.  Prever,  W.  :  Theory  of  color- 
blindness, Centralbl.  f.  d.  Med.  IVissench.,  Jan.  i.  Mann  :  A 
contribution  to  the  study  of  nervous  diseases — somnambulism, 
catalepsy,  Med.  6^  Surg.  Rep.,  June  18,  1881.  Engel  :  Descend- 
ing sclerosis  of  the  tract  for  tactile  sensations  and  coordination  ; 
locomotor  ataxia,  its  anatomy,  physiology,  pathology,  diagnosis, 
and  treatment,  Atn.  Specialist,  June  and  July,  1881.  Sieffert  : 
Spinal  meningitis,  Indiatia  Med.  Rep.,  May,  1881.  Sanders:  A 
study  of  primary,  immediate,  or  direct  hemorrhage  into  the  ven- 
tricles of  the  brain,  Am.  Journ.  Med.  Sci.,  July,  1881.  Hutch- 
inson :  Case  of  spinal  inflammation  due  to  traumatism,  Mich.  Med. 
News,  May  25,  1881.  Ferguson  :  Peripheral  paraplegia.  Can. 
yourn.  Med.  Sci.,  June,  1881.  Dickinson  :  Two  cases  of  cere- 
bral embolism,  Brit.  Med.  yourn..  May  21,  1881.  Althaus  : 
Lecture  on  the  physiology  and  pathology  of  the  olfactory  nerve. 
The  Lancet,  May  21,  1881.  Crothers  :  Clinical  studies  of  ine- 
briety, Med.  &'  Surg.  Rep.,  May  7,  1881.  Beard  :  Terminology 
of  trance,  N.  V.  Med.  Rec,  May  21,  1881.  BiXBV :  Case  of 
hystero-neurosis,  Boston  Med.  &•  Surg,  yourn.,  June  30,  1881. 
Mills,  C.  K.:  Four  cases  of  tubercular  meningitis,  Med.  6^  Surg. 
Reporter,  July  2,  1881. 


PATHOLOGY.  663 

b. — PATHOLOGY   OF   THE   NERVOUS   SYSTEM   AND   MIND, 
AND   PATHOLOGICAL  ANATOMY. 


Diagnosis  of  Hydrophobia. — Three  interesting  cases  have 
been  recently  reported,  which  throw  much  light  on  the  origin  of 
the  many  cures  of  hydrophobia  which  from  time  to  time 
appear  in  the  medical  journals.  Dr.  Jas.  G.  Kieman,  in  the 
Chicago  Medical  Review,  March  20,  1881,  describes  a  case  in 
which  the  post-epileptic  condition  of  a  patient  suffering  from  a 
congenital  form  of  that  disease  presented  all  the  usually  given 
symptoms  of  hydrophobia,  even  to  the  laryngeal  spasm  on  attempt- 
ing to  drink.  In  same  communication,  Dr.  Kieman  alludes  to  a 
case  of  acute  mania,  which  at  one  time  came  under  his  observa- 
tion, and  presented  marked  hydrophobic  symptoms.  These  symp- 
toms disappeared  in  both  cases  under  the  use  of  conium.  Dr. 
Wm.  B.  Hazard,  in  the  St.  Louis  Clinical  Record,  April,  1881,  re- 
ports a  case  of  acute  alcoholism,  in  which  he,  being  at  the  time 
a  recent  interne  of  a  hospital,  made  the  diagnosis  of  hydropho- 
bia from  the  symptoms.  The  three  cases,  which  are  well  re- 
ported, indicate  that  there  are  many  neurotic  conditions  which 
closely  simulate  hydrophobia,  and  that  it  is  extremely  probable 
that  the  great  majority  of  the  contradictions  in  the  history  of  this 
disease  result  from  errors  in  diagnosis. 


The  Semeiological  Value  of  the  Permanent  Retarda- 
tion OF  THE  Pulse. — We  copy  the  following  from  the  editorial 
review  of  clinical  facts  of  importance  of  the  Gaz.  des  HSpitaux, 
No.  36,  March  26th. 

M.  Charcot,  in  his  lectures  at  the  Salpetriere  on  diseases  of 
the  nervous  system,  notices,  as  one  of  the  most  interesting  facts, 
but  also  one  of  the  least  remarked  ones,  of  the  symptomatology 
of  cervical  spinal  lesions,  the  permanent  slowing  of  the  pulse. 
Recognizing  thoroughly  that  the  phenomenon  of  retarded  pulse 
may  have  as  its  cause  an  organic  affection  of  the  heart,  as  many 
authors  have  demonstrated,  M.  Charcot,  having  observed  this 
phenomenon  many  times  existing  for  years  in  aged  persons  with 
perfectly  healthy  hearts,  was  led  to  ask  himself  whether,  at  least  in 
those  cases  in  which  cardiac  lesions  were  lacking,  the  organic 
cause  of  the  retardation  was  not  in  some  lesion  of  the  cervical 
cord  or  the  medulla,  rather  than  in  the  heart.  He  has  seen  also 
serious  accidents  occur  in  these  conditions. 


664  PERISCOPE. 

"  These  accidents  which  occur  in  the  form  of  attacks  repeated 
at  varying  intervals,  sometimes  present  all  the  characters  of  syn- 
cope, sometimes  their  symptoms  partake  at  once  of  the  characters 
of  syncope  and  the  apoplectic  attack.  There  are,  finally,  cases  in 
which  epileptiform  movements,  with  change  in  the  colora- 
tion of  the  face,  foaming  at  the  mouth,  etc.,  occur.  The  pulse, 
which  in  the  intervals  was,  on  the  average,  30  or  40  per  minute,  be- 
comes still  slower  during  the  attacks,  falling  to  even  as  low  as  fif- 
teen beats  a  minute.  It  may  even  stop  altogether  momentarily. 
The  attack  always  begins  like  syncope  ;  the  apoplectic  state  with 
stertor  comes  next,  at  the  moment  when  the  pulse,  suppressed  for 
an  instant,  reappears,  and  when  the  pallor  of  the  face  gives  way  to 
flushing." 

M.  Charcot  is  led  to  believe  that  the  cause  of  the  slowing  of  the 
pulse  and  the  accompanying  accidents,  must  be  sought  for  in  the 
spinal  cord  and  medulla. 

In  a  recent  thesis  on  the  same  subject  by  Dr.  Blondeau  (1879) 
we  find  an  analysis  of  seventeen  observations  of  permanent  slow 
pulse,  from  which  it  follows  that  advanced  age  is  a  predisposing 
cause  of  this  anomaly,  all  the  cases  being  aged  persons  from  at 
least  fifty  years  to  seventy  and  above  ;  and  that  by  the  side  of  this 
we  must  place  alcoholism  and  depressing  emotions,  misery,  cha- 
grins ;  that  the  duration  of  the  accidents  is  usually  long,  varying 
between  one  and  a  number  of  years  ;  that  their  termination  is  or- 
dinarily serious,  death  occurring  most  frequently  (10  times  out  of 
17  cases)  in  a  very  sudden  manner.  The  temperature  is  generally 
lowered,  but  the  thermometric  observations  leave  something  to  be 
desired.  The  respiratory  disorders  in  some  of  the  cases  (6)  ap- 
parently resembled  those  which,  like  the  pupillary  dilatation  and 
vomiting  observed  in  some  of  the  cases,  were  manifestly  of  bulbar 
origin.  The  heart  in  seven  cases  revealed  to  auscultation  nothing 
abnormal ;  in  four  cases  there  were  simply  palpitations,  and  in 
only  three  cases  was  there  a  little  fatty  alteration  of  the  heart. 
Finally,  in  sixteen  out  of  the  seventeen  cases  epileptic  or  epilep- 
tiform attacks  occurred,  under  the  form  oi  grand  ox  petit  mal ; 
either  the  syncopal  attacks  preceded  the  convulsive  symptoms,  or 
vertigoes,  or  fainting  spells,  followed  by  a  period  of  unconscious- 
ness. 

Comparing  these  three  orders  of  symptoms,  the  epilepsy,  the 
cardiac  or  respiratory  disorders,  and  the  retardation  of  the  pulse, 
which  all  appear  to  be  factors  of  the  same  morbid  condition,  M. 
Blondeau  demands  whether  it  may  not  be  possible  to  explain  this 


PATHOLOGY.  665 

State  by  the  existence  of  an  alteration  in  the  medulla,  exercising  on 
the  heart  a  moderating  influence  through  the  pneumogastric  and 
the  cervical  sympathetic. 

Finally,  in  the  article  Pauls  in  the  Noiiveau  Dictionnaire  de 
Midicine  et  de  Chirurgie  Pratiques,  by  Dr.  Aug.  Rigal,  the  perma- 
nently slow  pulse  is  mentioned  as  coexistent  with  syncopes  and 
epileptiform  attacks  that  lead  us  to  refer  all  these  symptoms  to  a 
disorder  of  medullary  innervation  in  which  an  abnormal  excita- 
tion of  the  nuclei  of  the  pneumogastric  will  account  for  the  re- 
tarded cardiac  impulse,  and  to  be  considered  as  the  indication  of 
a  condition  which,  with  a  deceptive  appearance  of  harmlessness, 
frequently  terminates  in  sudden  death.  We  find  also,  in  support  of 
this  theory  of  cardiac  retardation,  some  observations  reported  by 
Rosenthal,  and  by  Th.  Halberton,  in  which  slow  pulse  was  the  se- 
quence of  an  interesting  injury  to  the  cervical  cord,  and  a  case  of 
Thornton's  where  the  same  phenomenon  was  observed  in  a  syphilitic 
female,  presenting  the  symptoms  of  cerebral  syphilis.  We  have 
also  observations  by  Stokes  and  M.  Cornil,  in  which  the  slowness 
of  the  pulse  was  apparently  due  to  a  fatty  condition  of  the  myo- 
cardium. 

Writers'  Cramp. — Wernicke  has  lately  found  a  peculiarity 
which,  if  present  in  all  instances,  sheds  an  entirely  new  light  on 
this  affection.  In  an  ordinary  case  reported  to  the  Berlin  Physio- 
logical Society  {Arch./.  Phys.,  1881,  p.  197),  he  observed  an  iso- 
lated paralysis  of  the  extensor  pollicis  longus  muscle,  which 
muscle  according  to  Duchenne,  is  not  immediately  concerned 
in  the  act  of  writing.  However,  it  is  of  decided  influence  on  the 
position  of  the  thumb,  and  hence  the  author  believes  the  paraly- 
sis to  be  an  etiological  factor  in  the  disease. 


The  Neuro-Muscular  Hyperexcitability  in  Hysteria. — 
The  following  is  an  abstract  of  a  more  extensive  memoir  in  the 
Archives  de  Neurologie,  by  MM.  Charcot  and  Paul  Richer,  which 
we  take  as  published  in  advance  in  the  Gaz.  des  Hdpitaux,  No. 
37,  Mar.  29. 

Among  the  somatic  phenomena  that  characterize  the  condition 
of  artificial  hypnotism  in  hysterical  cases,  there  is  one  that  con- 
sists in  a  special  aptitude  of  the  muscle  to  contract  under  the  in- 
fluence of  mechanical  excitations,  and  which  one  of  us,  at  the 
beginning  of  our  researches  on  the  subject  in  1878,  has  described 
under  the  name  of  neuro-muscular  hyperexcitability  (Charcot), 


666  PERISCOPE. 

Neuro-tnuscular  hyperexcitability  pertains  to  only  one  phase, 
or,  if  it  is  preferred,  one  mode,  of  hypnotic  slumber.  It  is  one 
of  the  fundamental  characters  of  the  artificial  hysterical  lethargy 
{Uthargie  hystirique  proroqu^e)  (Charcot).  It  must  not  be  con- 
founded with  the  phenomena  of  true  catalepsy  in  the  ^tat  catalep- 
tique.  Finally,  there  is  a  third  form  of  nervous  slumber,  resem- 
bling more  nearly  the  so-called  "  magnetic  "  sleep,  and  altogether 
different  from  the  phenomenon  now  under  consideration.  The 
principal  characteristics  of  these  three  kinds  of  hypnotic  slumber 
have  been  described  in  detail  by  one  of  us  in  a  recent  memoir  on 
hysteria  epilepsy  (Richer). 

The  muscular  contraction  consequent  to  the  nervous  condition 
designated  as  neuro-muscular  hyperexcitability,  is  not  merely  the 
result  of  direct  mechanical  muscular  action  ;  it  follows  equally 
excitations  applied  to  the  tendons  or  to  the  nerves 

I.  Excitation  of  the  tendons.  The  exaltation  of  the  tendon 
reflexes  is  one  of  the  most  constant  characters  of  the  hysterical 
lethargy.     It  may  exhibit  itself  in  two  different  ways  : 

1.  By  extension  and  diffusion  of  the  reflex  action. 

2.  By  modification  of  the  muscular  contraction  resulting  from 
it. 

a.  The  contraction  is  more  lively  without  increasing  in  dura- 
tion. 

b.  The  duration  of  the  contraction  is  prolonged,  and  there  is 
a  tendency  for  it  to  become  transformed  into  contracture. 

c.  The  contraction  becomes  permanent  ;  there  is  actual  con- 
tracture. 

These  two  kinds  of  exaltation  of  the  tendon  reflexes  may  exist 
either  singly  or  united  in  the  same  individual. 

Shock  is  not  the  only  method  of  mechanical  excitation  which, 
applied  to  the  tendon,  provokes  contracture.  This  follows 
equally  simple  friction  or  pressure. 

These  researches  on  the  modifications  produced  in  the  tendon 
reflexes  under  the  influence  of  hypnotism,  tend  to  unite  the  phe- 
nomena of  the  neuro-muscular  hyperexcitability  and  that  of  the 
tendon  reflexes,  of  which  it  is,  after  a  fashion,  only  the  highest 
and  most  delicate  expression. 

II.  Excitation  of  the  nerves.  The  mechanical  excitation  of 
the  nerves  causes  contracture  of  the  muscles  to  which  they  sup- 
ply branches. 

Thus  in  exercising  pressure  on  the  ulnar  nerve  behind  the  olec- 
ranon, the  hand  contracts  itself  in  a  characteristic  attitude,  the 


PA  THOLOG  V.  '  667 

reason  of  which  is  to  be  found  in  the  physiological  action  of  the 
muscles  of  the  forearm  and  of  the  hand  innervated  by  this  nerve, 
and  which  we  may  designate  the  ^riffe  cubitale. 

The  same  is  the  case  with  the  median  and  radial  nerves,  which, 
when  mechanically  excited,  cause  various  characteristic  attitudes 
of  the  hand,  explained  by  the  distribution  of  the  branches  of 
these  nervous  trunks. 

III. — Excitation  of  the  muscles.  The  contraction  that  follows 
the  direct  excitation  of  the  muscular  mass  is  easily  demonstrated. 
Our  experiments  upon  the  muscles  of  the  neck  (sterno-mastoid), 
upon  those  of  the  trunk  (deltoid,  trapezius,  etc.),  of  the  arm  and 
forearm,  have   led  us  to  the  following  conclusions  : 

a.  Excitation  applied  to  a  limited  portion  of  a  large  muscle 
causes  contraction  of  the  whole  mass. 

b.  The  contraction  of  one  muscle,  produced  under  these 
<  onditions,  almost  invariably  causes  the  simultaneous  action  of 
its  synergetic  muscles. 

IV.  In  \X\^  face  this  neuro-muscular  hyperexcitability  presents 
some  special  features.  The  muscles,  the  same  as  in  the  members, 
are  both  directly  and  indirectly  excitable  by  mechanical  means, 
but  the  excitation  only  causes  a  temporary  muscular  contraction, 
never  a  contracture. 

Therefore,  with  ample  mechanical  excitation,  we  can  reproduce 
on  our  patients  the  majority  of  the  experiments  of  Duchenne 
(of  Boulogne)  on  the  partial  action  of  the  muscles  of  the  face. 

These  facts  we  have  stated  are  interesting  in  a  double  point  of 
view  : 

In  a  clinical  sense,  we  find  in  the  regular  production  of  these 
phenomena  certain  diagnostic  signs  that  put  the  observer  in  posi- 
tion to  detect  simulation. 

In  a  physiological  point  of  view,  they  may  aid  in  the  solution 
of  more  than  one  problem  pertaining  to  the  science  of  life. 


Alterations  of  the  Nerves  in  Chronic  Rheumatism. — 
MM.  Leloir  and  Degerine  reported  to  the  Societe  de  Biologie, 
Apr.  2  (abst.  in  Le  Progrh Me'dical),  that  in  case  of  chronic  rheu- 
matism, with  considerable  muscular  atrophy  and  rapid  eschars, 
they  found  the  cutaneous  nerves  adjacent  to  the  eschars  affected 
with  atrophic  parenchymatous  neuritis.  They  thought  that  the 
alteration  in  the  nerves  was  anterior  to  the  eschars,  and  saw  evi- 
dence of  this  in  the  rapidity  of  the  ulceration  itself.  The  histo- 
logical examination  of  the  cord  remained  yet  to  be  made. 


668  PERISCOPE. 

Development  of  the  Cranial  Nerves. — M.  Mathias  Duval, 
Soc.  de  Biologic,  Apr.  2  (rep.  in  Le  Progres  Medical),  had  an  op- 
portunity of  studying  the  head  of  a  lamb  embryo  at  times,  struck 
with  an  arrest  of  development.  It  was  an  otacephalus  ;  the  head, 
reduced  to  the  middle  and  internal  ears,  seemed  to  have  been  cut 
by  a  ligature  above  the  basilar  apophysis.  In  a  section  of  the 
encephalic  stump,  at  the  level  of  the  fourth  ventricle,  the  nucleus 
of  origin,  the  emmentia  teres,  and  the  beginning  of  the  facial 
nerve,  and  also  the  origin  of  the  external  motor  oculi,  were  recog- 
nizable. The  nucleus  of  origin  of  the  trigeminus,  situated  in  the 
same  plane,  and  usually  readily  exposed  by  the  horseshoe  section, 
was  absolutely  invisible.  What  is  the  explanation  of  this  phe- 
nomenon ?  M.  Duval  finds  it  in  the  study  of  the  development  of 
the  spinal  nerve-roots. 

We  are  aware,  in  fact,  that  in  the  embryo,  before  the  closure  of 
the  canal  in  the  cord,  there  are  to  be  seen  two  prolongations 
arising  in  its  anterior  portion,  which  are  the  origin  of  the  anterior 
roots.  Later,  when  the  canal  is  closed  in,  there  are  seen  starting 
from  the  posterior  portion  two  lateral  prolongations,  nervoso-epi- 
thelial  colonies.  These  diverticula  become  the  spinal  ganglia, 
they  commence  to  become  pediculated,  then  they  become  alto- 
gether isolated  from  the  spinal  canal,  and  it  is  only  later  that 
they  send  toward  the  cord  on  the  one  hand,  and  toward  the 
periphery  on  the  other  hand,  the  prolongations  that  become  the 
sensory  roots. 

For  the  trigeminus,  in  the  same  way,  the  medullary  root  should 
start  from  the  ganglion  of  Gasser,  which  explains  why,  in  the  pres- 
ent instance,  no  trace  of  it  could  be  discovered  in  the  medulla. 


Tabes  and  Syphilis. — Prof.  W.  Erb,  Centralbl.  f.  d.  Med. 
Wtssensch.,  Nos.  11  and  12,  has  made  a  recent  careful  study  of 
over  one  hundred  well-marked  male  cases  of  locomotor  ataxia, 
and  finds  the  result  to  still  further  confirm  his  previously  experi- 
enced views  {Deutsch  Arch.  f.  Klin.  Medicin,  Bd.  24,  1879)  as  to 
the  connection  of  this  disease  and  syphilis.  In  the  first  one  hun- 
dred cases  he  found  only  twelve  without  a  previous  history  of 
syphilis  or  chancre  ;  of  the  remaining  eighty-eight,  fifty-nine  had 
had  the  secondary  manifestations  of  the  disease,  and  twenty-nine 
had  had  simply  chancres.  Of  these  last  eleven  had  been  treated 
constitutionally  with  mercury  and  iodide  of  potash,  so  that  it  is 
presumed  that  their  sores  were  of  the  infecting  variety  ;  in  fifteen 


PATHOLOGY.  €l6g 

of  the  others  particulars  as  to  the  nature  of  the  sore  are  want- 
ing ;  in  only  three  was  it  specified  as  a  "  soft  "  chancre.  As  re- 
gards the  time  of  the  first  manifestation  of  tabetic  symptoms 
after  the  syphilitic  infection,  the  following  are  the  facts  :  The 
symptoms  of  tabes  developed  between  the 

I  St   and    5  th   year   in    17    cases 


6th     "    loth 

37 

nth   "    15th 

21 

16th   "    20th 

3 

2ISt      "      25th 

5 

After  the  31st 

2 

Unknown 

3 

88       " 

In  order  to  meet  the  objection  that  syphilis  occurred  so  fre- 
quently in  the  class  of  people  under  his  observation  that  it  might 
be  considered  as  an  accident  always  to  be  looked  for,  Prof.  Erb 
gives  a  comparative  statement  of  a  similar  examination  to  that  of 
his  tabetic  patients,  of  four  hundred  of  his  adult  male  patients 
suffering  from  other  affections,  chiefly  nervous,  and  finds  that 
seventy-seven  per  cent,  of  these  had  no  history  of  syphilis  or 
chancre  whatever,  that  twelve  per  cent,  had  had  secondary  syphi- 
lis, and  eleven  per  cent,  simply  chancre.  Thus  in  the  general 
adult  male  invalid  population  under  his  observation,  the  tabetic 
cases  excluded,  only  twenty- three  per  cent,  were  in  any  way  syph- 
ilitic, while  in  the  tabetics  alone  eighty-eight  per  cent,  had  a  his- 
tory of  syphilis.  "  In  fact,"  he  says,  "  if  one  will  not  refuse  all 
assistance  from  statistics  and  logic  in  the  solution  of  this  ques- 
tion, it  must  be  admitted  that  these  figures  speak  most  emphati- 
cally in  favor  of  the  view  that  there  is  an  etiological  relation  be- 
tween syphilis  and  locomotor  ataxia."  Of  course  they  are  not 
absolutely  conclusive,  but  they  go  far  to  support  the  author's 
views.  It  is  well  worth  while  for  others  who  have  large  oppor- 
tunities for  observation  in  this  line  to  make  similar  examinations. 
It  cannot  be  said  that  if  syphilis  be  proven  to  be  at  the  bottom 
of  most  cases  of  this  disease  that  its  prognosis  is  necessarily  im- 
proved, but  it  does  not  render  it  any  more  unfavorable,  and  it 
will  be  a  very  interesting  practical  point. 


Hallucinations. — Victor  Kandinsky,  Archiv  f.  Psychiatric^  as 
the  result  of  a  study  on  the  origin  and  nature  of  hallucinations, 
comes  to  the  following  conclusions  : 


670  PERISCOPE. 

1.  Hallucinations  are  never  the  expression  of  an  aroused 
activity  of  the  psychic  sphere,  but  on  the  contrary  are  indications 
of  the  exhaustion  of  the  same,  /.  e.,  of  the  cortex  of  the  anterior 
part  of  the  brain.  The  period  of  intellectual  delirium  does  not 
coincide  with  that  of  hallucinations.  With  the  arousal  of  the 
psychic  activity  the  hallucinations  become  less  real  and  disappear. 
The  ability  of  the  patient  during  convalescence  to  engage  in  in- 
tellectual work  contributes  largely  to  the  suppression  of  the  hal- 
lucinations. 

2.  The  mechanism  and  origin  of  hypnotic  hallucinations  are 
identical  with  those  of  insane  hallucinations. 

3.  Hallucinations  are  distinguishable  from  phantasy  and  rec- 
ollection images,  however  lifelike  these  latter  may  be,  by  their 
peculiar  objective  character. 

4.  Hallucinations  dependent  upon  irritation  of  the  nerves  of 
the  organs  of  sense  are  characterized  by  their  simplicity  ;  pe- 
ripheral visual  hallucinations  frequently  possess,  in  addition,  the 
peculiarity  of  moving  in  series  and  of  following  the  movements 
of  the  eyes. 

5.  The  influence  of  recollection  and  of  the  tenor  of  intellect- 
ual delirium  on  hallucinations  is  extremely  slight.  Indeed,  in 
delirious  or  insane  persons  the  images  of  the  fancy  are  not  al- 
ways transformed  into  hallucinations. 

"  The  only  difference  between  my  view  of  hallucinations,"  says 
Kandinsky,  "and  that  of  Prof.  Meynert  is  the  following:  Ac- 
cording to  Meynert,  hallucinations  depend  upon  the  relations  of 
the  excitation  of  the  cortex  of  the  fore-brain  to  those  of  the  infra- 
cortical  centres.  It  is  difficult  for  me  to  accept  the  notion  that 
very  complicated  and  systematic  hallucination  images,  consisting 
of  numerous  regularly  coordinated  parts,  and  perceived  by  con- 
sciousness in  perfected  shape  (for  example,  a  landscape  with 
water,  sky,  clouds,  trees,  houses,  etc.,  all  in  their  natural  colors, 
shades,  and  perspective),  can  originate  anywhere  else  than  in  the 
cortical  cells. 

The  latest  researches  (Ferrier,  Munk,  and  others)  have  shown 
that  there  are  in  the  cortex  strictly  marked-out,  special  sensory 
spheres.  These  cortical  regions  are  the  highest  centres  of  sense- 
perception,  and  special  conceptions.  Besides  consciousness  and 
abstract  thought,  the  function  of  the  fore-brain  includes  the  reg- 
ularities and  inhibition  of  the  excitations  coming  from  other  por- 
tions of  the  cortex.  The  power  of  imagery  plays  a  great  part 
in  our  mental  activities,  and  the  function  of  the  cortex  of  the 


PATHOLOGY.  6^1 

fore-brain  is  always  accompanied  with  activity  of  the  cortical  sen- 
sory regions  (for  example,  the  visual  or  auditory  centres  of  Fer- 
rier).  If  the  cortical  visual  centre  is  excited,  not  from  the  fore- 
brain,  but  from  a  corresponding  infra-cortical  centre  (such  as  the 
corpora  quadrigemina),  then  the  result  of  its  activity  is  not  a  mere 
imaginary  object,  but  one  that  assumes  an  objective  character, 
/'.  e.,  there  is  a  genuine  act  of  vision,  or,  in  the  lack  of  an  external 
impression,  a  visual  hallucination.  If  the  control  of  the  cortical 
sensory  centres  by  the  cortex  of  the  fore-brain  is  prevented,  then 
the  spontaneous  excitations  that  go  to  them  from  the  correspond- 
ing infra-cortical  centres  (resulting  from  variations  of  the  circula- 
tion or  nutrition)  give  rise  to  the  occurrence  of  hallucinations. 
The  conditions  favorable  to  the  latter  are  diminution  of  the  ac- 
tivity of  the  fore-brain,  together  with  an  excited  condition  of  the 
sensory  centres,  cortical  as  well  as  infra-cortical.  This  excitation 
may  pass  from  the  nerves  to  the  infra-cortical  centres,  hence  hy- 
peraesthesia  of  the  sensory  organs  is  a  common  accompaniment 
of  hallucinations.  But,  on  the  other  hand,  we  can  in  no  case 
admit  a  centrifugal  (from  higher  to  lower  centres)  transmission  of 
the  excitation. 


Nerve-Stretching. — At  the  Societe  de  Biologic,  February 
26th,  M.  P.  Bert  announced  that  he  was  convinced  that  nerve- 
stretching  produced  its  effects  on  the  cord  and  not  on  the  nerve. 
What  is  it  that  occurs  when  a  mixed  nerve  is  destroyed  by  heat, 
cold,  or  by  a  caustic  ?  Motion  is  first  affected,  while  after  nerve- 
stretching  the  reverse  phenomenon  exhibits  itself.  It  is  therefore 
natural  to  suppose  that  in  stretching  a  nerve  it  is,  in  reality,  the 
cord  on  which  we  perform  the  operation. 

At  the  session  of  March  19th,  M.  Quinquaud  exhibited  a 
guinea  pig,  in  which  he  had,  six  weeks  previously,  stretched  the 
sciatic,  according  to  M.  Laborde's  method,  and  in  which  the  oper- 
ation had  been  followed  by  trophic  troubles  and  the  spontaneous 
amputation  of  the  toes  to  which  the  nerve  was  distributed.  This 
is  the  same  lesion  as  that  produced  by  division  of  the  nerve.  In 
another  guinea  pig  he  observed  a  curious  phenomenon  to  which 
he  gave  the  name  of  tnechanical  transfer  ;  he  stretched  the  sciatic 
on  one  side  just  sufficiently  to  produce  anaesthesia,  and  then  re- 
peated the  operation  to  the  same  extent  on  the  opposite  side.  He 
found  then  the  sensibility  revived  and  very  pronounced  on   the 


672  PERISCOPE. 

side  originally  operated  upon.  Numerous  experiments  gave  the 
same  results,  provided  that  the  stretching  and  the  consequent 
anaesthesia  were  not  carried  too  far. 

This  interesting  phenomenon  proves  that  we  modify  the  activity 
of  the  nerve  cells  in  the  cord  by  this  operation,  and  that  we  do  not 
have  to  do  with  the  results  obtained  from  a  simple  nervous  lacer- 
ation, but  with  phenomena  acting  at  a  distance,  like  those  de- 
scribed by  M.  Brown-Sequard. 


TiNNiTUS'AuRiUM. — After  a  careful  study  of  the  subject  of  tinni- 
tus, Dr.  P.  Hermet,  Z'  Union  Me'dicale,  January  29th,  February 
5th,  8th,  and  loth,  arrives  at  the  following  conclusions  : 

1.  That  the  tinnitus  compared  by  the  patients  to  the  roaring 
sound  of  a  shell,  to  the  sighing  of  the  wind,  or  to  the  sound  of 
waves,  is  a  symptom  of  the  lack  of  equilibrium  between  the  at- 
mospheric pressure  and  that  of  the  air  contained  in  the  middle 
ear,  and  is  the  kind  experienced  in  cases  of  obstruction  of  the 
Eustachian  tube,  or  of  foreign  bodies  in  the  ear. 

2.  That  that  of  which,  the  timbre  may  be  rendered  by  the 
word  djiii,  and  which  the  subjects  compare  to  the  sound  of  a  jet 
of  steam,  or  the  fizzling  of  green  wood  on  fire,  to  the  whistling  of 
a  gas  jet  running  free  and  not  lighted,  is  a  sign  of  compression, 
met  with  wherever,  through  derangements  in  the  chain  of  ossicles, 
the  liquid  of  Cotugno  is  compressed. 

This  kind  of  tinnitus  is  observed  sometimes  temporarily  in 
cases  of  foreign  bodies  in  the  meatus,  and  more  frequently  and 
continuous  with  anchylosis  of  the  chain  of  ossicles,  with  adhesions 
between  the  tympanum  and  the  incus,  and  contraction  or  retrac- 
tion of  the  tensor  tympani. 

3.  Musical  sounds  are  always  associated  with  an  affection  of 
the  internal  ear,  and  may  be  accompanied  with  titubation,  vertigo, 
etc. 

4.  Tinnitfis  isochronous  with  the  pulse  and  simulating  a  bruit 
de  souffle,  are  produced  by  congestion  of  the  arterioles  in  the  han- 
dle of  the  malleus  and  vascular  alterations  elsewhere  than  in 
the  ear. 


Transitory  Insanity  from  Cold  in  Children. — Dr.  H. 
Reich,  of  Miillheim,  Baden,  Berliner  Klin.  Wochenschr.,  xviii,  8, 
i88i  (abstr.  in  Schmidt's  yahrb.,  189,  No.  i),  gives  an  account  of 
four  boys,  from  6  to  10  years  of  age,  who,  after  exposure  to  rather 


PATHOLOGY.  '  (>Jl 

severe  cold  weather,  were  seized,  shortly  after  being  placed  in  a 
warm  room,  with  violent  excitement,  with  hallucinations,  in  short, 
with  a  sort  of  acute  mania.  These  symptoms  lasted  till  near  the 
next  morning,  when  they  fell  into  quiet  sleep,  from  which  they 
awoke  perfectly  sane,  but  with  no  recollection  of  the  circumstances 
of  the  attack,  and  complaining  of  nothing  except  a  slight  temporal 
headache.  In  one  case  there  was  also  clonic  muscular  contrac- 
tions ;  in  two,  outward  divergence  of  the  bulbi ;  in  one  case,  pain 
in  the  ears,  changing  from  one  to  the  other  ;  and  in  one  of  the 
cases,  severe  pain  in  the  joints.  Other  somatic  symptoms  were 
cyanosis  of  the  face,  heat  of  the  head,  quickened  pulse,  but  no 
rise  of  temperature  was  observed  during  the  attack. 

In  all  four  the  symptoms  were  characteristic  of  true  transitory 
mania,  the  sudden  onset,  the  maniacal  excitement,  with  delirium 
and  sensory  hallucinations  continuous  throughout  the  attack,  and 
the  whole  closing  with  a  critical  slumber,  the  awaking  finding  the 
patient  with  no  recollection  of  the  seizure  through  which  he  had 
passed.  The  designation  "  mania  transitoria,"  in  the  sense  now 
applied  to  it  in  modern  psychiatry,  may,  therefore,  be  properly 
given  to  these  cases. 

The  pathology  of  these  attacks  is  thus  explained  by  the  author: 
The  exposure  to  severe  cold  (i6°  to  22°  C.  ^=  5.2°  to  7.6°  F.)  for 
several  hours  had  driven  the  blood  from  the  periphery  to  the  in- 
ner organs.  The  sudden  change  to  a  room  heated  by  a  warm 
stove,  whether  by  reversing  this  condition  and  producing  anaemia 
of  the  brain,  with  increase,  perhaps,  of  the  cerebro-spinal  fluid 
and  slight  oedema,  or  whether  by  causing  actual  hypersemia,  es- 
pecially of  a  venous  nature,  is  uncertain,  no  doubt  gave  rise  to  a 
very  marked  change  in  the  vascular  condition  generally,  including 
that  of  the  brain,  enough  to  account  for  the  phenomena.  From 
their  analogy  to  the  phenomena  of  transitory  mania  caused  by 
alcohol,  emotional  disturbances,  etc.,  the  author  is  inclined  to  at- 
tribute a  cerebral  hypersemia  as  the  cause  in  his  cases.  The  symp- 
toms of  headache,  delirium,  hallucinations,  and  maniacal  excite- 
ment, can,  he  thinks,  be  better  explained  by  this  than  by  the  pre- 
sumption of  an  anoemic  condition.  The  cases  fall  into  the  gen- 
eral category  of  the  already-observed  cases  of  transitory  mania 
otherwise  induced  by  changes  of  temperature,  and  which  have 
been  designated  as  "  delirium  caloricum." 

In  conclusion  he  calls  attention  to  the  forensic  aspects  of  these 
cases.  They  show  that  transitory  mania  may  be  induced  in 
healthy  persons  by  sudden  changes  of  temperature,  during  which 


674  PERISCOPE. 

acts  of  violence  may  be  committed  (as  has  been  already  observed 
in  mania  transitoria  from  sunstroke),  without  the  patient  having 
any  subsequent  recollections  of  the  same. 


Albuminuria  as  a  Symptom  of  Epilepsy. — Dr.  Klendgen, 
Physician  of  the  Provincial  Insane  Hospital  at  Bunzlau,  ends  an 
extensive  memoir  on  the  significance  of  the  presence  of  albumen 
in  the  urine  of  epileptics,  Archiv  f.  Psychiatrie  u.  Nervenkrank- 
hciten,  xi,  Hft.  ii,  in  which  he  discusses  the  subject  exhaustively, 
with  the  following  conclusions  : 

Traces  of  albumen  are  demonstrable  in  any  urine  possessing  a 
certain  degree  of  density. 

Periodic  slight  augmentations  of  the  quantity  of  albumen,  with- 
out any  simultaneous  rise  of  specific  gravity,  are  not  so  uncommon 
as  to  afford  reason  to  be  suspicious  of  them  as  symptoms  of  renal 
disease. 

The  urine  voided  after  epileptic  attacks  exhibits  no  peculiarities 
in  regard  to  its  reaction  or  density. 

Any  demonstrable  increase  of  albumen,  due  to  an  epileptic  at- 
tack, is  always  very  rare  and  slight  in  degree,  and  in  male  epilep- 
tics can  generally  be  traced  to  the  presence  of  semen  in  the  urine. 

Cylinders  were  found  only  once,  in  an  epileptic  suffering  from 
nephritis,  but  not  after  attacks. 

The  utilization  of  the  symptom  of  an  increase  of  albumen  in 
the  urine  after  epileptic  attacks  in  the  diagnosis  of  dubious  cases 
or  those  of  forensic  importance,  as  is  often  claimed,  is  clearly  de- 
monstrated to  be  not  practicable  by  the  above-stated  results. 


The  Cephalic  Souffle  in  the  Adult.  In  1838  Fisher  (of 
Boston)  published  in  the  American  Journal  of  Medical  Sciences  a 
paper  in  which  he  described  the  bruit  de  souffle  in  the  head,  and 
stated  that  he  had  met  with  this  sound  in  auscultation  of  the  cra- 
nium in  cases  of  chronic  hydrocephalus,  cerebral  congestion,  either 
simple  or  coincident  with  dentition  or  whooping-cough,  in  acute 
encephalitis  or  meningitis,  in  suppuration  of  the  brain,  induration 
of  that  organ,  etc.  Other  authors  recognized  the  same  sound 
later,  and  reported  it  with  other  affections  ;  among  others,  M. 
Henri  Roger,  who  found  it  only  exceptionally  after  the  closure  of 
the  fontanelles,  and  expressed  the  opinion  that  cranial  auscultation 
is  not  really  applicable  to  persons  past  the  first  two  or  three  years 
of  life.     Subsequent  writers  to  M.  Roger  have,  as  a  rule,  agreed 


PATHOLOGY.  675- 

with  him  in  this  opinion,  though  it  has,  perhaps,  not  been  alto- 
•gether  denied  that  the  cerebral  souffle  might  occur  in  the  adult 
also. 

M.  Raymond  Tripier,  in  a  memoir  published  in  the  Revue  de 
Me'decine  (the  continuation  of  the  Revue  Mensueile),  Nos.  2  and 
3  of  this  year,  takes  up  the  subject  anew  and  reports  six  cases 
of  the  occurrence  of  this  intracranial  souffle  in  the  adult,  with  a 
very  thorough  discussion  of  the  conditions  of  its  occurrence  and 
its  significance.  The  following  are  the  conclusions  of  his 
memoir  : 

1.  The  cephalic  souffle  occurs  in  the  adult  as  Fisher  and  Whit- 
ney have  stated,  and,  contrary  to  the  opinion  of  M.  Henri  Roger, 
now  generally  accepted. 

2.  I  have  met  with  it  in  one  case  of  anaemia  from  neuralgia,  in 
several  cases  of  chlorosis,  in  one  patient  suffering  from  cachectic 
anaemia,  in  one  case  of  intracranial  tumor,  and  in  a  case  of 
hydrocephalus. 

3.  It  is  a  profound  systolic  souffle  that  can  be  heard  over  the 
whole  cranium,  but  principally  over  the  lateral  portion  at  the  hori- 
zon of  the  temples  ;  its  maximum  intensity  is  in  the  right  temporal 
region,  and  it  does  not  appear  to  be  modified  by  changes  of  posi- 
tion of  the  head  and  trunk. 

4.  The  patients  in  whom  it  occurs  have  no  intermittent  sound 
synchronous  with  the  soiffle  heard  on  auscultation,  and,  conse- 
quently, with  the  cardiac  systole,  the  intensity  of  which  is  in  direct 
relation  with  that  of  the  cephalic  souffle. 

5.  Both  this  subjective  sound  and  the  souffle  may  be  modified 
or  suppressed  momentarily  by  the  compression  of  the  carotid  on  the 
side  auscultated,  or  even  that  of  the  opposite  side.  Simultaneously 
we  observe  in  the  anaemic  patients  the  production  of  a  general 
}fialaise,  with  numbness  of  the  hand  of  the  side  opposite  the  com- 
pressed carotid.  These  phenomena  are  most  marked,  or  are  only 
produced  by  compression  of  the  right  carotid. 

6.  The  cephalic  souffle  may  be  diminished  or  disappear  with  a 
cure  or  an  aggravation  of  the  disorder  which  it  accompanies. 

7.  The  cephalic  souffle,  being  perfectly  synchronous  with  the 
carotid  systole,  ought  to  have  its  origin  in  the  arterial  system.  It 
is  not  due  to  a  transmission  of  the  systolic  soiffle  of  the  heart  that 
we  observe  in  anaemic  or  chlorotic  patients,  nor  to  that  of  a  souffle 
occurring  in  the  arteries  or  veins  in  the  neck.  By  exclusion,  we 
locate  it  in  the  terminal  portion  of  the  internal  carotid,  at  the 
point  where  it  enters  the  cranial  cavity.    Not  only  are  there  many 


^•jS  PERISCOPE. 

reasons  militating  in  favor  of  this  location,  but  in  one  case  there 
was  found  a  small  tumor,  situated  alongside  the  artery  at  this 
horizon,  which  gave  rise  to  a  sound  altogether  similiar  to  that 
found  in  the  other  cases.  The  souffle  may  be  produced  on  both 
sides,  or  only  on  one  side,  and  that,  preferably,  the  right. 

8.  In  anaemias  due  to  hemorrhages  or  to  cachexia,  as  well  as 
in  chlorosis,  the  cephalic  souffle  is  met  with  when  the  symptoms 
of  ansemia  are  especially  intense  and  of  long  duration,  notably 
when  there  is  a  very  pronounced  discoloration  of  the  integuments, 
palpitations  and  breathlessness  with  the  slighest  exertion,  diges- 
tive disturbances,  and  especially  vomiting,  together  with  great 
weakness. 

9.  In  these  cases  there  exists  a  cardiac  systolic  souffle,  which  is 
lacking  in  cases  connected  with  an  intracranial  lesion. 

10.  A  cephalic  souffle  without  any  corresponding  sound  at  the 
base  of  the  heart,  and  especially  without  coexisting  anaemia, 
ought  to  suggest  the  possibility  of  compressions  of  the  internal 
carotid  in  its  terminal  portion,  when  there  is  no  disease  of  the 
orbit. 

11.  The  cephalic  souffle  can  be  distinguished  by  the  above  con- 
dition from  the  continuous  souffle  with  reinforcements,  which  may 
appear  intermittent,  produced  by  communication  of  the  carotid 
with  the  cavernous  sinus,  as  well  as  from  the  intermittent  souffle 
due  to  aneurisms  of  the  carotid  and  the  ophthalmic  arteries,  since 
in  both  these  cases  there  are  characteristic  symptoms  on  the  part 
of  the  orbit. 

12.  We  have  not  met  with  the  cephalic  souffle  in  the  cerebral 
affections  mentioned  by  Fisher  and  Whitney,  with  the  exception 
of  hydrocephalus. 

13.  We  have  also  not  found  it  in  the  healthy  adult. 

14.  Is  there  a  continuous  cephalic  souffle?  We  have  not  met 
with  it  in  the  adult.  But  the  patients  may  hear  sounds  that  are 
probably  venous  bruits,  either  continuous  or  intermittent,  but 
which  must  not  be  confounded  with  those  accompanying  the 
cephalic  souffle. 

15.  The  cephalic  souffle  may  afford  important  indications  for 
the  diagnosis,  prognosis,  and  the  treatment  of  the  disease  in  which 
it  occurs. 


Hairy  Growths  in  Insane  Females. — Dr.  A.  McLane  Ham- 
ilton, N.  Y.  Med.  Record,  March  12th,  in  a  paper  read  before  the 
N.  Y.  State  Medical  Society,  Feb.  ist,  calls  attention  to  abnormal 


PATHOLOGY.  ^77 

hairy  growths  in  insane  females  as  connected  with  their  mental 
affection.  He  divides  the  subject  of  abnormal  hairy  growths 
into  two  groups  : 

1.  Those  in  whom  trophic  cutaneous  changes,  such  as  acne, 
depositions  of  pigment,  lesions  of  the  nails,  or  hang-nails,  as  well 
as  slight  hairy  growths,  occur  in  young  women  in  connection  with 
ovarian  irritation,  and  with  mental  trouble  or  emotional  disturb- 
ance, evidenced  by  melancholia  and  perverted  moral  sense  ;  the 
altered  sexual  state  being  often  connected  with  masturbation. 

2.  Those  cases  in  which  prolonged  vaso-motor  changes  have 
existed,  and  in  which  uterine  and  ovarian  functions  have 
disappeared. 

From  time  to  time  Dr.  Hamilton  has  observed  insane  women 
with  beards  or  growths  of  hair,  and  most  of  these  cases  presented 
some  history  of  sexual  trouble,  and  in  nearly  every  case  the  growth 
of  hair  was  coincident  with  the  onset  of  the  mental  disorder.  At 
first  he  did  not  attach  much  importance  to  the  phenomenon,  but  of 
late  he  has  been  inclined  to  attribute  to  it,  in  its  connection  with 
some  other  conditions,  as  important  a  significance  as  to  the  condi- 
tion of  the  hair  of  the  insane  mentioned  by  Bucknill  and  Tuke, 
and  Darwin.  He  has  investigated  the  matter  in  the  Blackwell's 
Island  Lunatic  Hospital,  and  found  many  cases  illustrating  his 
views.  He  reports  several  cases,  and  terminates  his  paper  with 
the  following  conclusions  : 

1.  "Abnormal  growth  of  hair,  especially  upon  the  face,  is  fre- 
quently closely  connected  with  disturbed  functions  of  the  pelvic 
organs  of  women. 

2.  "  That  in  the  insanity  of  women,  especially  when  it  relapses 
into  dementia,  and  cutaneous  nutritive  changes  exist,  such  growths 
of  hair  are  by  no  means  of  uncommon  appearance. 

3.  "  That  their  unilateral  character,  as  far  as  preponderance  in 
growth  is  concerned,  and  their  association  with  unilateral  cutane- 
ous lesions,  such  as  bronzing  and  nail-changes,  indicate  their  ner- 
vous origin. 

4.  "  Their  appearance  chiefly  upon  the  face  in  insane  patients, 
and  relation  to  trophic  disorders  incident  to  facial  neuralgia,  point 
to  the  fifth  nerve  as  that  concerned  in  the  pathological  process. 

5.  "  The  development  of  hair  with  the  deposit  of  pigment,  and 
skin  lesions,  and  occasional  goitrous  swellings,  suggests  the  infer- 
ence that  the  neuro-pathological  process,  which  leads  to  the  growth 
of  hair  in  the  chronic  insane,  is  akin  to  that  which  gives  rise  to 
Addison's  disease. 


6/8  PERISCOPE. 

"As  I  have  said,  there  are  many  cases  which  do  not  impress  us, 
because  they  include  women  of  advanced  age.  These  I  exclude 
altogether,  but  I  shall  be  satisfied  if  I  succeed  in  convincing  my 
hearers  that  when  any  considerable  growth  of  hair  occurs  upon 
the  face  of  female  insane  patients,  it  is  indicative  of  an  unfavor- 
able form  of  insanity,  and  such  especially  is  the  case  in  those 
women  who  have  not  reached  middle  as;e." 


Unilateral  Trismus.  The  only  case  of  unilateral  trismus 
recorded,  says  the  Detroit  Laficet  man,  has  been  observed  by  Dr. 
Thenee,  Elberfield  ^Intern.  Jour,  of  Med.  and  Surg.,  January  15, 
1881  ;  Berlin.  Klin.  Wochenschr.,  No.  37,  1880).  It  was  caused 
by  an  injury  to  the  nasal  bones,  denuding  them  of  their  perios- 
teum, produced  by  a  fall.  It  was  accompanied  by  facial  paral- 
ysis of  the  same  side,  and  continued  four  days.  The  other  side 
then  became  involved,  and  the  patient  died  next  day. 

The  above  case  is  certainly  not  the  only  one  on  record,  as  stated, 
though  the  unilateral  symptom  does  not  appear  to  have  been  ob- 
served in  many  cases.  But  in  a  paper  on  the  "  Pathology  of 
Tetanus,"  in  this  Journal  for  Jan.  1876,  Dr.  H.  M.  Bannister  re- 
ports a  case  in  which  the  trismus  was  at  the  beginning  unilateral,  and 
on  the  side  of  the  face  opposite  to  the  injury  that  originated  the  dis- 
ease. He  then  expresses  the  opinion  that  this  phenomenon  is  in  ac- 
cordance with  the  theory  of  the  involvement  of  the  higher  centres 
in  the  disorder.  It  is  probable  that  the  unilateral  tonic  spasm,  in 
most  cases  where  it  occurs,  is  of  very  short  duration,  and  that  the 
tetanus  becomes  symmetrical  at  a  very  early  period,  probably  as 
soon  as  or  before  the  disorder  is  correctly  diagnosed.  Dr. 
Thenee's  case  is,  therefore,  chiefly  remarkable  for  the  duration  of 
this  phase  of  the  attack. 


The  Initial  SymptOiM  of  Tabes.  Fr.  Miiller,  Brochure, 
Graz,  1880  (abstr.  in  Cetitralbl.  fiir  Med.  Wissensch.,  January  8th), 
has  noted  the  following  in  the  initial  stage  of  locomotor  ataxy  : 
In  twenty-one  observations,  he  observed  eight  times  a  sudden  and 
unilateral  paralysis  of  accommodation,  which  was  corrected  by 
convex  glasses,  and  which  generally,  even  if  bilateral,  disappeared 
in  a  few  weeks.  This  may  be  the  only  symptom  of  commencing 
tabes,  but  it  is  more  frequently  with  paralytic  mydriasis.  Spinal 
myosis  was  entirely  lacking  in  four  of  the  twenty-one  cases.  An 
early  and  constant  symptom  is  reflex  pupillary  rigidity,  which  was 


PATHOLOGY.  679 

lacking  in  only  three  out  of  seventeen  cases  examined  in  this  par- 
ticular. The  atrophy  of  the  optic  nerve,  connected  with  dis- 
seminated sclerosis  is,  according  to  Miiller,  to  be  distinguished 
from  that  due  to  tabes,  by  the  fact  that  in  it,  with  decided  im- 
pairment of  vision,  the  color-sense  is  retained  intact.  In  four 
cases  out  of  his  twenty-one,  the  author  found  a  retardation  of 
pain-conduction,  but  he  found  much  more  common  and  early 
to  appear  was  a  decrease  of  the  sense  of  pressure.  Although  he 
considers  the  absence  of  the  patellar  tendon  reflex  as  an  early 
symptom  of  the  disorder,  yet  he  finds  it  now  and  then  retained 
with  well-marked  disease  of  the  posterior  column.  In  the  vegeta- 
tive sphere  the  author  noticed  the  obstinate  gastric  catarrh,  inde- 
pendent of  indigestion  or  chilling,  that  had  been  previously  de- 
scribed by  Erlenmeyer,  and,  further,  the  presence  of  profuse 
perspiration  of  the  feet,  occurring  even  before  the  fulgurant  pains, 
but  which,  later,  disappeared  altogether.  As  to  whether  articular 
or  osseous  disorders  belong  to  the  primary  (the  author  adds  "  and 
rarest ")  symptoms  of  tabes  or  not,  the  opinions  of  other  observers 
must  be  considered.  In  regard  to  the  therapeutics,  he  agrees 
with  most  other  authorities  in  recommending  the  application  of 
the  constant  current,  of  moderate  strength,  along  the  spinal 
columns,  with  baths  of  from  89°-78°  F.,  with  corresponding 
frictions,  and  nitrate  of  silver  and  ergot  internally.  He  does  not 
recognize  a  causal  nexus  between  syphilis  and  tabes  ;  only  when 
tlie  symptoms  of  syphilis  are  manifest  the  specific  treatment 
should  be  employed. 

The  Gait  in  Chronic  Alcoholism.  Westphal,  in  the 
Charite  Annalen,  calls  attention  to  a  peculiar  gait  which  he  has 
observed  in  two  cases  of  chronic  alcoholism.  This  anomaly  con- 
sists in  the  fact  that  the  patient,  in  carrying  forward  the  foot  lifts 
the  limb  to  a  considerable  height  at  the  hip  joint  ;  while,  at  the 
same  time,  the  leg  remains  flexed  at  the  knee  joint,  and  the  foot 
is  allowed  to  fall  upon  the  ground  with  a  quick,  abrupt  movement, 
as  in  stamping.  The  gait  here  described,  though  similar  in  re- 
gard to  the  motion  at  the  hip  and  knee  joints,  differs  from  that  in 
paralysis  of  the  peroneus  muscle  in  these  respects  :  that  the  foot 
does  not  hang  down,  the  point  of  the  foot  is  not  trailed  forward, 
the  manner  of  placing  the  foot  is  not  the  same,  and  the  dorsal 
flexion  of  the  latter  is  strong.  Those  suffering  from  tabes,  also 
flex  the  limb  markedly  at  the  hip  joint,  but  their  gait  differs  from 
that  under   discussion,   by  the   extension   and   hyperextension  of 


680  PERISCOPE. 

the  leg,  and  the  swinging  of  the  lower  extremities.  It  is  possible 
that  a  portion  of  the  disturbance  may  be  due  to  the  existing  sen- 
sation of  painful  tension  in  the  calf  and  knee  joint.  An  impair- 
ment of  the  sensibility  and  of  muscular  irritability  was  not  ob- 
served. According  to  Westphal's  experience,  this  abnormality  of 
gait  in  chronic  alcoholism  is  not  frequent.  The  International 
your,  of  Med.  and  Surgery,  February  19,  1881. 


The  following  are  some  of  the  recently  published  articles  on  the 
pathology  of  the  nervous  system  and  mind,  and  pathological 
anatomy  : 

Bramwell  :  The  differential  diagnosis  of  paralysis.  Brain, 
April.  1881.  Ring  ROSE  Atkins  :  Case  of  paretic  dementia. 
Brain,  April,  1881.  Ashby  :  Case  of  injury  to  the  left  frontal 
lobe,  Brain,  April,  1881.  Beard  :  A  case  of  prolonged  trance, 
N.  Y.  Med.  Record,  May  7.  Bramwell  :  Clinical  lectures  on 
intracranial  tumors,  Edinburgh  Med.  "yournal,  March  and  May, 
1 88 1.  Beard,  G.  M.:  Mesmeric  trance,  Boston  Med.  and  Surg. 
Jour.,  March  24th.  Wood.  H.  C:  On  hystero-epilepsy  and 
hysterical  rhythmical  chorea,  Phila.  Med.  Times,  Feb.  26th. 
Da  Costa,  J.  M. :  On  arsenical  paralysis,  Ibid.,  March  26th. 
CoFFiGNY,  J.  O.:  On  Jacksonian  epilepsy,  Cronica  Med-Quir. 
de  la  Habana,  Feb.  Bull,  C.  S.:  Some  points  in  the  pathology 
of  ocular  lesions  of  cerebral  and  spinal  syphilis,  illustrated  by 
cases.  Am.  Jour,  of  Med.  Sci.,  April.  Arnold,  A.  B.:  Neuralgia, 
Maryland  Med.  Journ.,  Jan.  15th.  Valin,  H.  D.:  Report  of 
three  peculiar  cases  of  paralysis,  with  recovery  in  each  case, 
Chicago  Med.  J^ourn.  and  Ex.,  March.  Roger,  H.  V.  Damas- 
CHiNO  :  The  alterations  of  the  spinal  cord  in  infantile  spinal 
paralysis  and  in  progressive  muscular  atrophy,  Revue  de  Me'de- 
cine.  No.  2,  Feb.  loth.  Crothers,  T.  D.:  Some  of  the  problems 
of  inebriety,  JV.  V.  Med.  Record,  April  9th.  Stewart,  T.  G.: 
On  paralysis  of  hands  and  feet  from  disease  of  nerves,  Edinb. 
Med.  Jour.,  March.  Booth  :  Case  of  traumatic  facial  paralysis, 
Edin.  Med.  yourn.,  June,  1881.  Hammond,  W.  A.:  Cerebral 
embolism,  Gaillard's  Med.  yourn..  May,  1881.  Wood:  Case  of 
severe  injury  to  the  brain,  with  recovery,  Arn.  yourn.  Med.  Sci., 
July,  1881.  McDowall  :  Large  calcareous  tumor  involving 
chiefly  the  inner  and  middle  portions  of  the  left  tempero-sphe- 
noidal  lobe,  and  pressing  upon  the  left  crus  and  optic  thalamus, 
Edin.  Med.  yourn.,  June,  1881.     Mann  :    Pathology  and  treat- 


THERAPEUTICS.  68 1 

ment  of  chorea,  Coll.  6^  Clin.  Rec,  May,  1881.  Mickle  :  On 
general  paralysis  of  the  insane,  consequent  to  locomotor  ataxy, 
The  Lancet,  May  21  and  28,  1881. 


C. — THERAPEUTICS   OF    THE   NERVOUS   SYSTEM   AND    MIND. 


Vomiting  of  Pregnancy. — Dr.  J.  S.  Warren,  N.  Y.  Med. 
Record,  March  26th,  considers  the  vomiting  of  pregnancy  due  to 
various  influences,  mental  ones  included,  and  to  remedy  it  re- 
quires a  careful  diagnosis  of  its  cause,  whether  it  be  simply  reflex, 
or  due  to  some  other  organic  condition.  Its  treatment,  therefore, 
resolves  itself  into  the  correction  of  all  disturbances,  functional  or 
organic,  as  far  as  possible,  which  are  known  to  excite  dyspeptic 
symptoms,  before  a  simple  irritation  becomes  a  confirmed  gastri- 
tis, and  the  stomach  rejects  the  remedies  that  would  most  easily  re- 
lieve the  original  disorder.  First  among  these,  Dr.  Warren  recog- 
nizes a  constipated  habit  and  the  emotional  element,  and  these,  he 
holds,  should  receive  prompt  attention  in  pregnancy.  The  latter 
of  these  is,  he  says,  relieved  by  no  remedies  more  generally  than 
by  the  bromides  of  potash  and  soda,  given,  as  a  rule,  in  full  doses 
late  in  the  day,  on  an  empty  stomach.  Constipation  can  be  over- 
come by  any  simple  laxative.  After  these,  the  purely  sympathetic 
disorder  must  be  attended  to  if  vomiting  persists.  The  most 
patent  remedy  for  this,  in  his  experience,  is  Fowler's  solution,  in 
drop  doses,  on  an  empty  stomach.  When  thus  given  with  a  re- 
stricted diet,  it  has  seemed  to  him  nearer  a  specific  for  this  com- 
plaint than  any  other  medicine.  After  it  has  been  used  for  a 
while  it  may  be  found  of  advantage  to  suspend  it  and  use  nitro- 
muriatic  acid,  with  tine,  nucis  vomicae,  especially  if  there  is  any 
inactivity  of  the  liver  or  kidneys,  or  if  anorexia  exists. 


Static  Electricity. — The  following  are  the  conclusions  of 
an  article  by  Dr.  W.  J.  Morton  (iV.  Y.  Med.  Record,  April  2d  and 
9th)  on  the  therapeutic  use  of  Franklinism,  or  static  electricity. 

First. — Static  electricity  as  a  curative  agent  in  medicine  may 
fairly  be  placed  on  a  level  with  galvanism  and  Faradism.  In  cer- 
tain diseased  conditions  it  is  superior  to  either. 


682  PERISCOPE. 

By  insulation  and  sparks  paralyzed  muscles  and  nerves  are  stim- 
ulated, just  as  by  induced  currents. 

Second. — The  main  objections  to  static  electricity  are  based 
upon  the  inconvenience,  the  working  uncertainties  of  the  appara- 
tus, and  the  difficulty  of  measuring  and  controlling  the  electricity 
administered. 

These  objections  fail  to  have  weight  with  the  use  of  a  modern 
improved  Holtz  machine,  and  a  proper  electrometer. 

Third. — Insulation  and  sparks,  both  or  either,  more  notably 
sparks,  relieve  cutaneous  anaesthesia  more  quickly  than  galvanism 
or  Faradism.  In  hemiplegia  with  organic  lesion,  numbness  and 
anaesthesia  is  at  once  relieved  by  this  treatment. 

Fourth. — Decided  motor  improvement  may  be  obtained  in  hemi- 
plegia of  long  standing.  The  dragging  of  the  toe,  the  tread  on 
the  outer  side  of  the  foot,  the  outer  swing  to  the  leg,  the  rigidity 
at  the  knee,  elbow,  and  shoulder,  may  all  be,  to  a  very  apparent 
degree,  and  often  entirely  removed. 

The  contracture  at  the  wrist  and  fingers  is  incurable. 

Fifth. — In  paraplegia  and  systemic  diseases  of  the  spinal  cord 
in  general,  there  is  every  reason  to  expect  that  by  means  of  long 
and  strong  sparks  to  the  spine  results  not  now  attainable  may 
be  reached. 

A  distinguished  and  careful  observer,*  familiar  with  the  treat- 
ment by  sparks,  thinks  that  "patients  suffering  from  paraplegia, 
who  are  now  benefited  by  the  constant  current,  were  previously 
cured  by  static  electricity." 

Sixth.—  In  the  sense  that  medicines  are  tonic,  the  positive  elec- 
trical insulation  is  tonic. 

Seventh. — Statical  electricity  by  insulation  and  sparks  is  princi- 
pally useful  in  conditions  of  paralysis,  spasm,  and  neuralgia,  and 
preeminently  in  subacute  and  chronic  rheumatic  affections, 
whether  tendinous,  fascial,  or  muscular. 

Eighth. — Static  electricity  cures  disease,  as  other  forms  of  elec- 
tricity do  by  stimulations  of  nerves  and  muscles,  organs  and  nerves 
of  special  sense.  It  likewise  cures,  by  aid  of  the  spark,  in  virtue 
of  a  sharp,  deep,  mechanical  agitation  of  the  diseased  tissue,  act- 
ing in  this  instance  like  physical  exercise  and  massage,  by  causing 
alteration  of  nutrition. 

But  above  and  beyond  these  methods  of  curative  action  is  the 
principle,  as  lately  established  by  Brown-Sequard,  of  reflex  action 

*Dr.  Wilks,  a  physician  of  long  experience  at  Guy's  Hospital,  London,  where 
statical  electricity  was  formerly  largely  used. 


THERA  PE  U  TICS.  683 

in  remote  parts  by  peripheral  irritation  of  the  terminal  distribu- 
tion of  the  sensory  nerves.  In  electrification  by  insulation,  elec- 
tricity of  high  tension  is  actively  accumulating  on  and  beneath 
the  skin,  i.  e.,  the  nerve  distribution,  and  as  actively  discharging  : 
the  effects  of  static  electricity  are  then  in  this  instance  produced 
from  the  periphery  ;  and  owing  to  the  fact  that  the  electrification 
is  general  and  the  tension  high,  no  other  form  of  electricity  offers 
equal  promise  in  the  treatment  of  diseases  or  conditions  that  can 
be  affected  either  in  a  sedative  or  stimulating  manner  from  the 
general  peripheral  nerve  distribution.  The  recent  experiments  of 
Brown-Sequard  lead  us  to  believe  that  many  diseases  may  be  thus 
acted  upon. 

Ninth. — The  invention  by  the  author  of  a  method  of  obtaining 
an  interrupted  static  induction  current  from  a  frictional  electrical 
machine,  adds  to  medical  electricity  a  new  and  practical  means  of 
electrical  treatment. 

This  current  is  more  agreeable  in  its  administration  than  ordin- 
ary induction  currents.  Both  nerves  and  muscles  are  stimulated 
by  it  to  a  higher  degree  than  is  possible  by  means  of  any  other  in- 
duction current  now  in  use,  and  a  corresponding  advance  in  the 
efficacy  of  electrical  therapeutics  in  these  two  directions  may  be 
confidently  expected. 

The  new  current,  furthermore,  greatly  enlarges  tlie  scope  of 
statical  electrical  machines  in  medicine  by  combining  in  a  single 
machine  all  the  advantages  both  of  static  and  induction  electricity. 


Electrotherapy  of  the  Brain. — The  following  is  a  transla- 
tion of  a  short  article  by  Dr.  Leopold  Lowenfeld,  in  the  Central- 
blatt  fur  die  Med.   IVissensch.,  No.  8,  February  19th. 

Up  to  date  there  have  been  published  no  actual  experimental 
researches  on  the  action  of  the  electrical  current  applied  through 
the  integument,  in  a  longitudinal  or  transverse  direction  through 
the  head,  on  the  circulation  within  the  cranial  cavity.  The  only 
previous  investigations,  especially  upon  the  action  of  an  electric 
current  passed  through  the  head,  on  the  cerebral  (meningeal)  ves- 
sels, are  those  of  Legros  and  Onimus,  and  Latourneau.  Legros 
3ir\6.0n\vi\\x?>{Traite  d'  £lectriciie'  Me'dicale,  Paris,  iS72,p.  197)  tre- 
panned a  dog  and  passed  the  current  from  a  battery  of  ten 
Remak  cells  through  the  brain,  applying  one  pole  to  the  denuded 
brain  and  the  other  to  a  wound  in  the  neck  in  the  neighborliood 
of  the  superior  cervical  ganglion.     They  found  with  the  descend- 


684  PERISCOPE. 

ing  current,  a  contraction,  and  with  the  ascending  current,  a  dila- 
tation of  the  vessels.  Latourneau  {^Gaz.  Hebdom.,  1879,  No.  40), 
with  the  assistance  of  Laborde,  performed  a  single  experiment  : 
in  a  five- weeks-old  kitten  he  applied  the  positive  pole  of  a  battery 
of  eighteen  elements  (Onimus-Brewer)  behind  the  ascending  ramus 
of  the  lower  jaw,  and  the  negative  pole  to  the  forehead.  He  ob- 
served the  vessels  of  the  dura  mater  (?),  and  after  ten  to  fifteen 
seconds  saw  contraction  of  the  arteries  and  later  of  the  veins. 
With  every  interruption  (reversal  ?)  the  ansemia  increased  for  a 
moment,  after  which  the  vessels  slowly  dilate  again.  The  con- 
traction of  the  vessels  could  be  produced  at  will  in  the  denuded 
pia  mater.  I  have  repeated  Latourneau's  experiment,  and  have 
obtained,  in  place  of  the  expected  contraction,  a  dilatation  of  the 
vessels,  and  this  with  the  same  location  of  the  poles.  Hence  the 
importance  of  Latourneau's  experiment  is  by  this  much  lessened. 

I  have  performed  a  large  series  of  experiments  to  ascertain,  on 
the  one  hand,  facts  relative  to  the  action  of  therapeutic  currents 
applied  percutaneously  on  the  cerebral  circulation,  and,  on  the 
other  hand,  to  establish  a  basis,  though  a  narrow  one,  for  the  elec- 
trotherapy of  the  brain.  In  these  experiments  I  used  forty  ani- 
mals, thirty  of  them  rabbits.  In  most  cases,  the  effect  of  currents 
directed  in  longitudinal  and  transverse  directions  percutaneously 
through  the  head  was  studied,  but  a  number  of  experiments  with 
the  arrangement  of  Legros  and  Onimus  (one  pole  on  the  neck  and 
the  other  on  the  denuded  brain)  were  instituted. 

The  most  notable  results  of  these  experiments  can  be  stated  as 
follows  : 

1.  A  descending  current  (positive  pole  to  the  forehead,  nega- 
tive pole  to  the  neck)  causes  a  contraction  of  the  arteries  of 
the  pia. 

2.  An  ascending  current  (positive  pole  to  the  neck,  negative  to 
the  forehead)  causes  dilatation  of  the  arteries. 

3.  With  a  current  sent  transversely  through  the  head,  there  is 
dilatation  of  the  arteries  on  the  side  of  the  anode,  and  contrac- 
tion on  that  of  the  cathode. 

4.  Induction  currents  carried  through  the  head  in  a  longitudi- 
nal direction  cause  increase  of  the  amount  of  blood  in  the  brain. 

This  last  point  requires  a  still  further  study.  It  appears  that 
the  action  of  the  induction  current,  like  that  of  the  constant  cur- 
rent, is  not  restricted  merely  to  the  dilatation  of  the  vessels. 


THERAPEUTICS.  ,  685 

Bromide  of  Ethyl. — The  following  are  the  conclusions  de- 
duced by  MM.  Bourneville  and  H.  d'Olier  from  a  series  of  re- 
searches on  the  physiological  and  therapeutic  effects  of  bromide 
of  ethyl,  published  in  the  Progres  Midical,  March  28th. 

1.  The  pupillary  dilatation  at  the  beginning  of  the  inhalation 
of  bromide  of  ethyl  is  not  at  all  constant. 

2.  Complete  muscular  resolution  is  the  exception. 

3.  The  anaesthesia  produced  varies  to  a  large  degree  in  differ- 
ent subjects. 

4.  The  temperature,  the  secretions,  and  the  general  condition 
appear  to  undergo  no  modifications. 

5.  The  pulse  and  the  respiration  are  slightly  accelerated. 

6.  A  tremor,  more  or  less  pronounced,  of  the  members  may  be 
produced  during  the  inhalation,  but  it  does  not  persist  beyond 
this. 

7.  Hysterical  attacks  are  generally  easily  arrested  by  the  bro- 
mide of  ethyl. 

8.  Epileptic  attacks  may  sometimes  be  cut  short  by  giving  the 
drug  during  the  tonic  period,  but  more  frequently  the  inhalations 
are  ineffectual. 

9.  In  epilepsy  the  regular  employment  of  bromide  of  ethyl,  ad- 
ministered in  daily  inhalations  during  a  period  of  two  months, 
notably  diminished  the  frequency  of  the  attacks. 


Anesthetics. — At  the  session  of  the  Soci6te  de  Biologie,  Feb- 
ruary 26th  (reported  in  Le  Progrh  Medical),  M.  P.  Bert  announced 
the  results  of  experimentation  with  various  anaesthetics  on  dogs, 
squirrels,  etc.,  which  are  noteworthy.  The  anaesthetics  employed 
were  ether,  chloroform,  amylene,  chloride  of  methyl,  and  bromide 
of  ethyl.  The  method  of  experimentation  was  as  follows  :  The 
dog  being  tracheotomized,  he  introduced  into  the  canula  the 
short  branch  of  a  Y  tube.  The  two  equal  branches  are  furnished 
with  two  so7ipapes,  opening  in  the  opposite  direction  ;  by  the  one 
enters  air  containing  a  known  quantity  of  anaesthetic  vapor,  and 
through  the  other  departs  the  product  of  expiration.  He  found 
that  with  the  same  quantity  of  pure  air,  say  one  hundred  litres, 
and  with  animals  of  the  same  species,  whatever  their  size  or 
strength,  the  weight  of  the  anaesthetic  liquid,  the  vapor  of  which  is 
mixed  with  one  hundred  litres  of  air,  is  always  the  same  at  the 
moment  when  anaesthetic  sleep  appears,  and  at  the  moment  when 
death  occurs  the  amount  of  the  anaesthetic  has  reached  another 


686  PERISCOPE. 

fixed  amount;  in  a  word,  that  the  zone  maniable  in  a  given  quantity 
of  air  is  fixed  for  each  anaesthetic.  In  the  dog,  37  grains  of  ether 
are  needed  for  each  100  litres  of  air  to  cause  anaesthesia,  and  74 
grains  to  cause  death  ;  if  chloroform  is  employed,  the  figures  are 
15  and  30  grains  ;  if  amylene,  30  and  55  grains  ;  if  bromide  of 
ethyl,  22  and  45  grains  ;  and  if  the  gas  chloride  of  methyl,  21  and 
42  cubic  centimetres  are  required  for  100  cubic  centimetres  of 
air.  It  follows  from  this  that  the  zojte  maniable  varies  from  the 
single  to  the  double  to  cause  anaesthesia  or  death. 

In  the  usual  method  of  inducing  anaesthesia  with  the  saturated 
compress  or  the  sponge,  we  always  play,  so  to  speak,  with  a  mor- 
tal dose.  When  we  bring  the  compress  from  3  to  6  centimetres 
of  the  face  the  result  just  varies  between  the  single  and  the 
double.  How  much  better  to  so  regulate  the  operation  as  to  ad- 
minister a  dose  corresponding  to  the  medium  figure  of  the  zone 
maniable.  In  the  dog,  if  we  give  at  once  45  grains  of  ether,  in- 
spired in  100  litres  of  pure  air,  anaesthesia  is  produced  at  once 
without  accident,  and  the  sleep  lasts  for  a  long  time.  It  is,  there- 
fore, not  necessary  to  say  that  30  or  50  grains  of  an  anaesthetic 
were  used  during  an  operation  ;  these  figures  signify  absolutely 
nothing,  since  it  is  not  the  absolute  quantity  that  is  important, 
but  the  tension  of  the  vapor  of  the  anaesthetic  in  the  inspired 
air,  and  consequently  the  quantity  contained  in  the  blood. 

The  practical  application  of  the  above  is  clear.  If  the  limits  of 
the  zone  7naniable  of  an  anaesthetic  be  known  for  man,  it  will  be 
enough  to  lay  aside  all  fears  of  asphyxia,  and  to  cause  to  be  in- 
spired a  mixture  perfectly  adapted  and  prepared  in  advance  in 
any  recipient  whatever. 

Phosphide  of  Zinc  in  Locomotor  Ataxy. — Dr.  Hastings 
Burroughs  ^Medical  Press  and  Circular^  February  9,  1881)  gives 
this  drug  in  one-eighth-grain  pills,  one  a  day  for  a  week,  and 
then  two  daily,  and  so  on  up  to  five.  He  has  treated  his  cases 
successfully  thus  far.     Phila.  Med.  Times,  March  12th. 


Alcohol. — Dr.  M.  Dumouly,  Brochure,  Paris,  1880,  from  ex- 
periments performed  under  the  inspiration  of  MM.  See  and 
Bochefontaine,  at  the  laboratory  of  the  medical  clinic  of  the 
Hotel  Dieu  (abstr.  in  La  France  Afedicale),  concludes  that  al- 
cohol in  small  doses  aids  digestion,  while  in  larger  quantity  it 
hinders  it.     It  is  not  an  aliment  but  a  substance  aepargne,  a  waste- 


THERAPEUTICS.  68/ 

decreasing  agent.  It  accelerates  the  respiration,  and,  with  large 
doses,  causes  a  slight  acceleration  of  the  pulse.  In  moderate 
doses  it  is  a  stimulant,  in  large  ones  a  depressant,  to  the  nervous 
system. 

As  regards  its  action  on  the  temperature,  alcohol  in  very  large 
doses  causes  a  considerable  reduction  ;  in  small  doses,  exceeding 
twelve  grains,  the  reduction  is  only  some  tenths  of  a  degree  Centi- 
grade, this  temporary  effect  being  in  no  measure  influenced  by  di- 
gestion. In  very  small  doses,  between  six  and  eleven  grains,  M. 
Dumouly  obtained  a  rise  of  two-  or  three-tenths  of  a  degree.  Be- 
low six  grains  there  was  no  appreciable  effect.  Curiously  enough, 
the  dose  of  twelve  grains  seemed  to  be  intermediate,  and  gave  rise 
to  no  effect  whatever. 

In  point  of  view  of  pathology  and  therapeutics,  alcohol  acts  in 
pyrexias  as  a  stimulant  ;  it  is  a  powerful  remedy  against  delirium 
and  adynamia.  Large  doses  (thirty  grains  of  pure  alcohol)  pro- 
duce in  fever  cases  a  slight  refrigeration  of  a  few  tenths  of  a  de- 
gree. This  effect  is  transitory  ;  its  maximum  occurs  in  an  hour 
and  a  half,  and  it  is  completely  over  in  three  hours.  Divided 
doses  do  not  have  this  temporary  effect.  The  action  of  alcohol 
on  the  pulse  is  very  slight.  Large  doses  fail  to  produce  intoxica- 
tion in  the  febrile  patient,  while  they  surely  have  this  effect  on  the 
healthy  individual. 

En  resume,  if  alcohol  has  any  effect  in  fever,  it  is  not  as  an 
antipyretic,  as  is  generally  thought  to  be  the  case. 


Nerve-Stretching. — M.  Quinquaud  reported  to  the  Societe 
de  Biologic,  Mar.  12th  (abstract  in  Gaz.  des  HSpitaux,  No.  32),  that 
he  had  observed  a  certain  number  of  facts  that  indicated  that  the 
therapeutic  effects  sought  for  can  only  be  obtained  when  there  is 
produced  a  complete  anaesthesia  of  the  whole  limb  supplied  by 
the  nerve  ;  that  it  succeeds  only  when  this  anaesthesia  is  persistent, 
and,  finally,  that  the  principal  indication  for  nerve-stretching  is 
neuralgia. 

Next,  taking  up  the  subject  histologically,  he  asked  what  was 
the  process  taking  place  in  the  elongated  nerves  ?  There  is,  first, 
according  to  him,  a  dynamic  action  ;  an  irritation  of  the  nerve 
itself  or  of  the  cord. 

When  the  anaesthesia  obtained  is  only  temporary  there  is  no 
lesion  of  the  stretched  nerve.  When  it  is  persistent  there  is  a 
secondary  degeneration  of  the  nerve.     This  is  an  incontestable 


688  PERISCOPE. 

fact,  that  when  a  nerve  is  sufficiently  stretched  it  becomes  the  seat 
of  a  secondary  degeneration. 

At  the  same  meeting  M.  Laborde  presented  a  memoir  of  M. 
Marcus  on  the  subject.  The  author  had  studied  the  anatomical 
modifications  in  the  stretched  nerve.  When  a  nerve,  stretched 
during  life,  is  submitted  to  the  action  of  osmic  acid,  it  is  seen  that 
the  cylinder  axis  is  separated  from  the  myeline  by  a  yellowish  sub- 
stance, and  the  usual  signs  of  nerve  degeneration  are  observed.  In 
the  cat,  especially,  M.  Marcus  found  the  exact  place  in  the  nerve 
where  stretching  had  been  applied  eight  days  after  the  operation. 
The  lesions  always  existed  in  the  central  portion  of  the  nerve. 
The  effects  obtained  are  quite  different  according  as  the  traction 
is  made  on  the  central  or  the  peripheral  portion  of  the  nerve.  In 
the  former  case  we  only  abolish  sensibility,  motility  remaining  in- 
tact, while  in  the  latter  case  both  are  destroyed. 

In  reply  to  questions,  M.  Laborde  stated  that  while  the  lesions 
of  the  central  portion  were  very  slightly  marked,  it  was  not  aston- 
ishing that  the  peripheral  portion  remained  intact ;  and  that  as 
regards  the  persistence  of  motor  power  with  the  degenerative 
changes  observed,  it  could  be  explained  by  the  fact  that,  in  a 
stretched  mixed  nerve,  the  sensory  roots  would  be  affected  while 
the  motor  ones  would  remain  intact.  It  is  certain  that  the  ele- 
ments of  compression  of  the  nerve  must  also  be  considered,  and 
the  phenomena  showed  relations  with  those  obtained  by  MM. 
Bastian  and  Vulpian  by  compressing  the  nerves. 

At  the  session  of  the  Soc.  de  Biologie,  Apr.  22d  (reported  in 
Gaz,  des.  Hopitaux),  M.  Quinquaud  reported  that  in  his  observa- 
tion he  had  found  that  a  spinal  epilepsy,  analogous  to  that  follow- 
ing section  of  the  cord  or  the  sciatic  nerve,  might  result  from 
simple  nerve-stretching.  In  his  experiments  he  produced  epilepsy 
by  irritating  or  pinching  the  epileptogenic  zone  of  Brown-Sequard 
on  the  same  side  as  that  of  the  stretching,  sometimes  on  the  oppo- 
site side.  If  the  stretching  was  done  on  the  right  or  left  side  the 
spinal  epilepsy  followed  irritation  of  this  zone  on  the  right  or  left 
side ;  but  irritation  of  the  right  side  only  produced  epilepsy  of  the 
right  side ;  it  was  needful  to  apply  the  irritation  anew  to  the  left 
side  to  cause  the  convulsions  on  that  side  ;  it  reached  its  maximum 
ia  the  posterior  member  of  the  same  side,  rarely  in  that  of  the 
opposite  side. 

This  spinal  epilepsy  is  not  constant,  and  its  course  is  yet  ob- 
scure ;  nevertheless,  it  is  rational  to  admit  that  nerve-stretching 
acts  powerfully  upon  the  spinal  cord,  of  which  we  have  further 
proofs  in  the  following  facts  : 


THERAPEUTICS.  689 

The  stretching  of  a  nerve  may  cause  functional  disorders,  in  the 
corresponding  nerve  of  the  opposite  side  ;  these  are  sometimes 
phenomena  of  arrest,  sometimes  those  of  dynamic  hyperexcitabil- 
ity.  Thus,  if  the  right  sciatic  be  stretched,  anaesthesia  is  produced 
not  only  in  the  sphere  of  the  right  nerve,  but  also  in  that  of  the 
left  crural,  and  sometimes  in  the  region  innervated  by  the  right 
crural  or  the  left  sciatic.  When  the  stretching  has  been  sufificient, 
the  anaesthesia  is  persistent  in  the  last  two  toes  innervated  by  the 
elongated  right  sciatic,  while  the  anaesthesia  produced  in  distinct 
parts  is  transitory. 

The  same  effects  may  occur  in  the  nerves  of  the  anterior  limbs. 
They  may  be  observed  also  in  the  fore  limbs  after  stretching  the 
nerves  of  the  posterior  ones  ;  the  modifying  influence  on  the  cord, 
therefore,  traverses  a  certain  distance  in  that  organ. 

Moreover,  even  insufficient  stretching  causes,  first,  an  anaesthesia, 
the  duration  and  intensity  of  which  are  proportional  to  the  amount 
of  stretching  ;  if  the  latter  is  slight  the  anaesthesia  will  soon  disap- 
pear, if  it  is  moderate  the  duration  will  be  longer,  and  if  it  is  forci- 
ble the  anaesthesia  will  be  persistent,  as  has  been  shown  by  M. 
Laborde. 

In  cases  where  the  anaesthesia  is  of  only  short  duration,  it  is 
not  uncommon  to  see  produced  a  hyperaesthesia,  either  direct  or 
in  the  region  of  a  distant  nerve. 

Moreover,  after  the  operation,  there  always  exists  a  certain 
degree  of  paresis  ;  the  posterior  member,  for  example,  drags  as  if 
the  cord  had  been  divided,  thanks  to  the  crural  nerve,  which  in- 
nervates a  larger  part  of  the  muscles  of  the  hind  limb. 

Finally,  when,  after  having  caused  an  experimental  neuritis  or 
even  a  perineuritis,  we  stretch  the  nerve,  we  produce  anaesthesia  ; 
but  this  quickly  disappears,  so  that  in  these  conditions  a  much 
more  forcible  elongation  of  the  nerve  is  required  to  produce  a 
lasting  anaesthesia  than  is  the  case  with  a  healthy  nerve. 

M.  Quinquaud  has  likewise  observed  various  trophic  disorders 
following  this  operation.  All  these  facts  have  their  clinical  bear- 
ings, which  he  will  dilate  upon  in  a  future  communication. 


The  following  are  the  titles  of  some  of  the  recently  published 
papers  on  the  therapeutics  of  the  nervous  system  and  mind  : 

Kane,  H.  H.:  Chloral  hydrate,  part  iii,  continued,  N.  V.  Med. 
Record,  March  19th.  Blackwood,  W.  R.  D.  :  On  the  treatment 
of  neuralgia  by  static  electricity,  Med.  (St*  Surg.  Reporter.,  March 


690  PERISCOPE. 

12th.  Kane:  Chloral  in  tetanus,  Chicago  Med.  ymirn.  & 
Examr.,  March.  Chancellok,  E.  A.  :  Remarks  on  the  treatment 
of  delirium  tremens,  St.  Louis  Med.  c^  Surg,  yourn.,  March. 
Althaus,  J.  :  On  some  points  in  the  diagnosis  and  treatment 
of  brain  disease,  Brai?t,  April,  1881.  Kane:  Chloral  hydrate, 
N.  V.  Med.  Record.,  April  23d.  Mickle  :  Morphia  in  melan- 
cholia;  its  influence  on  temperature,  Practitioner,  June,  1881. 
Poole  :  Fallacies  of  experiments  with  curare  ;  its  effect  on  the 
motor  nerve  endings,  N.  Y.  Med.  Rec,  May  28,  1881.  Rock- 
well :  The  interrupted  galvanic  current  in  the  treatment  of 
sciatica,  N.  Y.  Med.  Rec,  June  4,  1881.  Rockwell  :  A  case  of 
exophthalmic  goitre  ;  recovery  under  electrical  treatment,  N'.  Y. 
Med.  yourn.,  June,  18S1.  Reichert  :  Hydrobromic  acid  ;  its 
action  on  the  circulatory  and  nervous  systems,  Bost.  Med.  cr^  Surg, 
yourn.,  June  2,  1881.  Charcot:  Hysteria;  applications  of 
static  electricity  in  its  treatment,  A/ed.  &=  Surg.  Rep.,  July  2,  x88i. 


BOOKS  AND  PAMPHLETS  RECEIVED. 


Hygiene  and  Treatment  of  Catarrh.  Therapeutic  and  Opera- 
tive Measures  for  Chronic  Catarrhal  Inflammation  of  the  Xose, 
Throat,  and  Ears,  by  Thomas  F.  Rumbold,  M.D.  St.  Louis: 
George  O.  Rumbold  &  Co.,  1881. 

A  Practical  Treatise  on  Impotence,  Sterility,  and  Allied  Disor- 
ders of  the  Male  Sexual  Organs,  by  Samuel  W.  Gross,  M.D. 
Philadelphia  :  Henry  C.  Lea's  Son  &  Co.,  1881. 

Transactions  of  the  Thirtieth  Annual  Meeting  of  the  Illinois 
State  Medical  Society,  held  at  Belleville,  May  18,  19,  and  20, 
1881. 

A  Medical  Formulary,  based  on  the  United  States  and  British 
Pharmacopoeias,  Together  with  Numerous  French,  German,  and 
Unoflicinal  Preparations,  by  Laurence  Johnson,  M.D.  (Wood's 
Librarv  of  Standard  Medical  Authors,  No.  5.)  New  York  : 
William  Wood  &  Co.,  188 1. 

Index  Catalogue  of  the  Library  of  the  Surgeon-General's  Office, 
L'nited  States  .A.rmy.  Authors  and  Subjects.  Vol.  ii.  Berlioz- 
Cholas.     Washington,  1881. 

Das  Hirngewicht  des  Menschen.  Eine  Studie  von  Dr.  L.  W.  v. 
Bischoff.     Bonn,   1880. 


BOOKS  RECEIVED.  69  I 

Deutsche  Chirurgie,  mit  zahlreichen  Holzschnitten  und  Lithog. 
Tafeln.  Herau>gegeben  von  Frof.  Dr.  Billroth  in  Wien  und 
Prof.  Dr.  Luecke  in  Strassbourg.  Lieferung  30.  Prof.  Dr.  E.  v. 
Bergmann  :  Die  Lehre  den  Kopferletzungen  ;  mit  55  Holzschnit- 
ten und  2  Lithographirten  Tafeln.     Stuttgart,  1880. 

Lehrbuch  der  Gehirnkrankheiten,  fiir  Aerzte  und  Studirende, 
von  Dr.  C.  Wernicke.  Mit  96  Abbildungen.  Band  I.  Kassel, 
1881. 

Wiener  Klinik,  Vortrage  aus  der  gesammten  praktischen  Heil- 
kunde.  Herausgegeben  und  Redigirt  von  Prof.  Dr.  Joh.  Schnitz- 
ler.  Inhalt  :  Frulich  :  Ueber  Meningitis  cerebro-spinalis.  Aus- 
gegeben  in  Marz,  1881.     Wien,  1881. 

Real-Encyclopadie  der  gesammten  Heilkunde.  Medicinisch- 
Chirurgisches  Handworterbuch.  fiir  praktische  Aerzte.  Heraus- 
gegeben von  Dr.  Albert  Eulenberg.  Mit  zahlreichen  Illustra- 
tionen  in  Holzschnitt.     Wien  und  Leipzig,  i88r. 

A  New  Form  of  Nervous  Disease.  Together  with  an  Essay  on 
Erythroxolon  Coca,  by  W.  S.  Searle,  M.D.,  New  York  City,  N.  Y. 
New  York  :  Fords,  Howard,  and  Hulbert,  1881. 

Die  Dr.  Erlenmeyer'schen  Anstalten  fiir  Gemuths-  und  Nerven- 
kranke  zu  Bendorf  bei  Coblenz.  Bericht  iiber  Einrichtung,  Or- 
ganisation, und  Leistungen  derselben,  in  dem  Decennium  i  Jan- 
uar,  187 1,  bis  31  December,  1880.  Mit  3  Chromolithographien 
und  2  Planen.      Leipzig,  1881. 

Haemophilia.  Scurvy.  Morbus  Maculosus  Werlhofii,  by  H.  AL 
Bannister,  M.D.,  of  Chicago. 

The  Functional  and  Morphological  Relations  of  the  Cerebellum, 
by  E.  C.  Spitzka,  M.D.,  New  York  City,  N.  Y.  (Reprint  from 
the  Chicago  Aledical  Revieiv,  July  5,   1881.) 

On  the  Metastases  of  Inflammations  from  the  Ear  to  the  Brain, 
by  J.  A.  Andrews,  ALD.,  Clifton,  S.  L  (Reprint  from  the  New 
York  Medical  y^our/ial,  February  and  March,    i88r.) 

The  Quality  of  Mental  Operations  Debased  by  the  LTse  of  Al- 
cohol, by  T.  L.  Wright,  M.D.  (Reprint  from  the  Alienist  and 
Neurologist^  ]Vi\)',  1881.) 

Report  to  the  Illinois  State  Medical  Society  on  Laryngeal  Tu- 
mors, by  E.  Fletcher  Ingalls,  A.M.,  M.D.  (Reprint  from  the 
Chicago  Aledical  Journal  and  Examiner,  July,  1881.) 

Transactions  of  the  American  Medical  College  Association, 
Fifth  Annual  Meeting,  held  at  Richmond,  Va.,  May  2  and  4,  1881. 

Ether  Death  :  A  Personal  Experience  in  Four  Cases  of  Death 
from  Anaesthetics,  by  John  B.  Roberts,  M.D.,  Philadelphia,  Pa. 
(Reprinted  from  the  Philadelphia  Medical  Times,  June  4,  1881,) 

Un  Caso  di  Microcefalia  Presentazione  del  Prof.  Augusto  Tam- 
burini,  al  Congresso  Freniatrico  di  Reggio-Emilia,  1881. 


692  BOOKS  RECEIVED. 

Ueber  das  Verschwinden  und  die  Localisation  des  Kniephano- 
mens  von  Prof.  C.  Westphal.  Separat-Abdruck  aus  der  Berliner 
Klinische  IVoc/ienschrift,  1881,  No.  i. 

The  College  Story,  by  the  Dean,  Rachel  L.  Bodley,  M.D. 
Woman's  Medical  College  of  Pennsylvania,  Commencement  Day, 
March  17,  1881. 

Report  of  the  Pennsylvania  Hos]:)ital  for  the  Insane,  for  the 
year  1S80,  by  Thomas  S.  Kirkbride,  M.D.,  Physician  and  Su- 
perintendent. Published  by  Order  of  the  Board  of  Managers, 
1881. 

Aus  der  Xervenklinik.  Zur  Frage  von  der  Localisation  der 
unilaterale  Convulsionen  und  Hemianopsie  bedingenden  Hirner- 
krankurgen,  von  Prof.  Dr.  C.  Westphal.  Separat-Abdruck  aus 
den  Charite-Annalen,  VI  Jahrg. 

Annual  Report  of  the  Board  of  Health  of  the  State  of  Louisi- 
ana to  the  General  Assembly,  for  the  Year  1880. 

Contributions  to  Ophthalmology,  by  Dr.  C.  R.  Agnew.  (Re- 
printed from  the  Transactions  of  the  American  Ophthalmological 
Society,  1880.) 

A  New  Cortical  Centre,  by  Graeme  M.  Hammond,  M.D.  (Re- 
printed from  the  Medical  Record,  March  19,  1881.) 

Report  of  the  Trustees,  Resident  Ofificers,  and  Visiting  Com- 
mittee of  the  Maine  Insane  Hospital,  18S0. 

Structure  of  yEsophagus,  Gastrotomy,  by  T.  F.  Prewitt,  ^LD. 
(Reprint  from  the  St.  Louis  Courier  0/  Medicine,  March,  1881.) 

An  Improved  Self-Retaining  Rectal  and  Vaginal  Speculum,  by 
A.  F.  Erich,  ALD.  (Reprinted  from  the  Obstetric  Gazette,  Febru- 
a;-y,  1881.) 

A  Statistical  Report  of  Two  Hundred  and  Fifty-two  Cases  of 
Inebriety  Treated  at  the  Inebriates'  Home,  Fort  Hamilton,  Long 
Island,  by  Lewis  D.  Mason,  M.D.  (Reprint  from  the  Quarterly 
Journal  of  Inebriety,  April,  1 88 1 .) 

Tubercular  Laryngitis,  or  Laryngeal  Phthisis,  by  C.  J.  Lundy, 
M.D.  (Reprinted  from  the  Physician  and  Surgeon,  February, 
1881.) 

Glaucoma,  Caused  by  Mental  Worry.  Illustrated  by  the  Re- 
port of  a  Case,  by  Leartus  Connor,  M.D.  (Reprint  from  the 
Detroit  Lancet,  July,  1881.) 


VOL.  VIII.  OCTOBER,    1881.  No.  4. 

THE 

Journal 

OF 

Nervous  and  Mental  Disease. 


©triglnal  ^xticXts, 


DEFORMITY  OF  THE  HAND  AS  A  SYMPTOM. 

By  R.  W.  AMIDON,  M.  D., 

NEW   YORK. 

IT  was  when  studying  the  bewildering  array  of  chronic 
invalids  under  Prof.  Charcot's  care  at  the  Salpetriere 
that  the  following  article  was  conceived  and  the  material  for 
its  composition,  in  great  part,  collected.  Not  long  after,  the 
writer  met  with  the  excellent  thesis  of  Meillet,'  which  has 
been  of  inestimable  value  as  the  only  book  of  reference  on 
the  same  subject. 

An  article  on  this  subject  may  well  be  preceded  by  a  few 
words  on  the  normal  position  and  appearance  of  the  hand. 
The  normal  position  of  the  hand  depends  on  two  important 
factors  ;  first,  the  extreme  mobility  with  the  force  of  gravity, 
and,  secondly,  the  resultant  of  the  tonicity  of  antagonistic 
muscles.  Each  group  of  muscles  moving  the  hand  and  fin- 
gers has  its  direct  antagonist  in  some  other  group.  Thus, 
flexors  antagonize  extensors ;  pronators  antagonize  supina- 
tors, and  abductors  antagonize  adductors.  Living,  healthy 
muscle  always  has  a  certain  tonus,  which,  together  with  the 

'  Des  Deformations  Permanentes  de  la  Main  au  point  de  vue  de  la  Semeiolo- 
gie  Medicale,  par  H.  Meillet,  TAesg  de  Paris,  1874. 

693 


694  •^-    ^-  AMIDON. 

tonus  of  its  antagonist,  keeps  the  part  moved  by  these  mus- 
cles steady  and  ready  at  the  shortest  notice  to  obey  the  im- 
pulse of  the  will  or  of  reflex  excitation. 

The  best  example  of  this  is  the  head,  which,  during  wak- 
ing hours,  is  balanced  by  the  conjoint  action  of  the  neck 
muscles,  but  the  moment  the  muscles  lose  their  tonicity  at 
the  onset  of  sleep  the  equilibrium  is  destroyed  and  the 
head  obeys  the  laws  of  gravity  and  nods.  As  in  the 
neck,  so  in  the  hand  the  muscles  keep  it  in  a  certain 
attitude. 

The  usual  attitude  of  the  human  hand  at  rest  is  that 
of  pronation  and  slight  flexion  of  the  wrist  and  semi- 
flexion of  the  fingers,  while  the  thumb  is  dependent  and 
slightly  inverted,  so  as  to  make  its  palmar  aspect  face  very 
nearly  the  pulps  of  the  fingers. 

Now,  this  normal  attitude  of  the  hand  may  be  changed 
in  four  ways. 

1.  A  certain  muscle  or  set  of  muscles  may  undergo  atro- 
phy, whereupon  the  antagonists  of  the  same,  which  retain 
their  tonus,  will  distort  the  hand  in  various  ways. 

2.  Nearly  the  same  thing  occurs  when  a  muscle  or  set  of 
muscles  is  paralyzed  without  atrophy. 

3.  A  spasmodic  state  of  certain  muscles  may  distort  the 
hand  by  destroying  the  equilibrium  of  the  muscular 
groups. 

4.  Anatomical,  pathological  changes  may  take  place  in 
the  framework  of  the  hand  itself,  through  which  vicious  at- 
titudes may  arise. 

Thus  deformities  of  the  hand  may  be,  for  convenience, 
divided  into  four  classes. 

1.  Atrophic  deformities. 

2.  Paralytic  deformities. 

3.  Spasmodic  deformities. 

4.  Deformities  of  purely  local  causation. 


DEFORMITY  OF  THE  HAND  AS  A    SYMPTOM.  695 

I. — ATROPHIC   DEFORMITIES. 

Under  this  head  will  be  first  described  the  hand  of  pro- 
gressive muscular  atrophy.  The  fully-developed  muscular 
atrophic  hand  presents  the  deformed  condition  called  com- 
monly "  main  en  griffe,"  or  the  claw-like  hand.  This  de- 
formity is  b}^  no  means  suddenly  acquired,  and  in  many 
cases  of  progressive  muscular  atrophy  is  never  reached.  In 
almost  all  cases,  however,  atrophy  invades  the  hand  some- 
what, and  a  more  or  less  perfect  "  main  en  griffe  "  results. 
When  the  disease  invades  the  hand  the  patient  notices  that 
the  hand  easily  tires  and  its  capacity  for  finer  movements 
is  impaired.  Soon  the  patient  notices  a  falling  away  of  the 
thenar  eminence,  and,  from  this  time  on,  the  atrophy  ex- 
tends, involving  finally  both  thenar  and  hypothenar  emi- 
nences, the  interosseous  and  lumbrical  muscles.  The  atro- 
phy of  the  muscles  of  the  thenar  eminence  and  of  the  first 
interosseous  space  causes  the  thumb  to  separate  from  the 
hand  and  rotate  on  itself  so  as  to  make  its  palmar  surface 
look  in  nearly  the  same  direction  as  that  of  the  fingers  in- 
stead of  in  the  opposite.  This,  together  with  the  loss  of 
the  hypothenar  eminence,  gives  a  flat  look  to  the  hand, 
which  causes  it  to  be  called  "  la  main  de  singe,"  or  the 
monkey  hand.  When  the  atrophy  has  reached  and  de- 
stroyed the  interosseous  muscles  the  typical  "  main  en 
griffe,"  or  claw  hand,  results.  The  trapezium  and  uniform 
processes  of  the  carpus  stand  out  in  relief.  The  normal 
thenar  and  hypothenar  eminences  have  given  way  to  hol- 
lows in  which  the  angular  outlines  of  the  first  and  fifth 
metacarpal  bones  are  readily  made  out.  The  palm  is  hol- 
lowed out  and  very  concave,  and  the  interosseous  spaces, 
instead  of  bulging  as  they  should  in  the  well-formed  hand, 
are  sunken  and  show  the  outlines  of  the  metacarpal  bones 
on  both  the  dorsum  and  in  the  palm. 


696  H.    W.  A  MID  ON. 

The  first  metacarpal  bone  is  drawn  toward  the  same 
level  as  the  others,  and  is  rotated  outward  on  its  longitudi- 
nal axis.  Moreover,  the  antagonists  of  the  thenar  muscles 
cause  the  thumb  to  assume  still  further  a  vicious  attitude. 
The  extensor  ossis  metacarpi  poliicis  draws  the  meta- 
carpal bone  out,  while  the  flexor  longus  poliicis  being 
stronger  than  the  extensor  secundi  internodii  poliicis,  the 
two  phalanges  of  the  thumb,  especially  the  second,  tend 
toward  flexion,  thus  giving  the  thumb  very  much  the  ap- 
pearance of  the  fourth  toe  of  birds. 

The  atrophy  of  the  interosseous  and  lumbrical  muscles 
leaves  no  antagonists  to  the  long  extensors  and  flexors, 
hence  the  former  extend  the  first  phalanges,  while  the  latter 
flex  the  second  and  third. 

Together  with  the  deformity  of  the  hand  its  intrinsic 
movements  are  restricted.  Abduction,  adduction,  and  op- 
position of  the  thumb  are  impossible.  Flexion  of  the  first 
and  extension  of  the  second  and  third  phalanges,  and 
ab-  and  adduction  of  the  fingers  are  impaired  in  proportion 
as  the  atrophy  of  the  interossei  and  lumbricales  is  partial  or 
complete. 

When  these  muscular  changes  have  existed  a  long  time 
there  ensues  a  change  in  the  fibrous  elements  of  the  hand, 
which  seems  to  fasten  it  in  this  unnatural  position  and  to 
prevent,  even  by  the  exercise  of  considerable  force  and  the 
production  of  a  great  deal  of  pain,  even  a  temporary  return 
to  its  normal  shape. 

The  description  of  the  "  main  en  griffe  "  as  above  given 
is  by  no  means  a  constant  sequel  of  progressive  muscular 
atrophy,  and  for  the  following  reasons.  It  is  rare  for  the 
atrophy  to  be  complete  in  the  hands  before  it  invades  other 
parts,  and  if  the  long  extensors  and  flexors  of  the  fingers  in 
the  forearm  are  atrophied  a  typical  claw  hand  cannot 
result. 


DEFORMITY  OF    THE  HAND  AS  A    SYMPTOM.       697 

Again,  the  atrophy  may  commence  in  some  other  part  of 
the  body,  and  the  patient  may  die  with  the  hand  nearly 
normal  or  only  slightly  involved.  Hence  we  more  often 
see  the  "  main  de  singe"  (monkey  hand)  in  progressive  mus- 
cular atrophy,  while  the  typical  "  main  en  griffe  "  is  better 
exemplified  in  some  cases  of  nerve  injury  or  disease,  as  in 
leprosy. 

The  points  in  the  differential  diagnosis  between  this  de- 
formity and  others  resembling  it  are,  first,  the  retention,  to 
the  last  almost,  of  farado-contractility  of  the  muscles ;  sec- 
ondly, the  common  involvement  of  both  hands  ;  thirdly,  the 
existence  of  atrophy  in  some  other  part  of  the  body ; 
fourthly,  the  progressive  tendency ;  fifthly,  the  absence  of 
anaesthesia,  and  also  the  clinical  history.  From  the  atrophy 
following  any  other  spinal  lesion  or  any  cerebral  lesion  it  is 
distinguished  by  the  fact  that  it  is  preceded  and  accom- 
panied by  no  paralysis  or  anaesthesia.  From  the  atrophy 
following  nerve  injury  it  is  distinguished  by  the  facts,  first, 
that  its  atrophy  has  no  regular  distribution,  while  that  fol- 
lowing nerve  injury  is  confined  exclusively  to  the  physiologi- 
cal distribution  of  the  injured  nerve ;  secondly,  because  it 
was  preceded  by  no  paralysis  and  accompanied  by  no 
anaesthesia.  From  the  atrophy  following  neuritis  it  is  told 
by  reason  of  the  absence  of  pain  and  anaesthesia,  and  by  its 
irregular  distribution,  the  atrophy  in  neuritis,  as  in  nerve 
injury,  being  localized.  From  the  occasional  atrophy  fol- 
lowing lead-poisoning  it  is  distinguished  by  the  absence  of 
paralysis,  by  the  electrical  reactions,  and  by  the  absence  of 
a  history  of  plumbism.  From  the  atrophic  hand  of  pachy- 
meningitis cervicalis  and  leprosy  it  is  easily  told  by  its  clini- 
cal history. 

The  history  of  the  patient,  whose  hand  is  represented,  is 
here  inserted,  as  it  is,  in  the  most  important  details,  a  typi- 
cal history. 


698 


R.    W.  AM/DON. 


The  patient  was  Marie  A.  T ,  St.  Alexandre  Ward  of  the  Sal- 

petriere  Infirmary';  40  years  old  ;  a  maker  of  fringes.  Her  occu- 
pation called  for  continual  use  of  the  hands  and  the  pressure  of 
a  round  handle  in  the  palm  of  the  hand  a  good  deal.  About  a 
year  ago  she  noticed  that  when  her  hands  were  a  little  chilled  it 
was  very  hard  work  to  use  them  unless  she  rubbed  them  very 
hard. 

Very  soon  she  noticed  decided  loss  of  power  in  the  hands,  and 
asserts  that  at  this  time  there  was  slight  formication  in  the  parts. 
Next  she  noticed  a  wasting  of  the  thenar  eminence  of  both  hands, 
more  marked  in  the  right.  A  little  later  the  hypothenar  emi- 
nences began  to  fall  away,  and  the  interosseous  spaces  became 
sunken,  and  the  hand  gradually  assumed  a  claw-shaped  appear- 
ance. Of  late  shoulder  movements  have  become  difficult.  She 
denies  ever  having  had  pain. 

May  17,  1880.  Present  condition:  Atrophy  of  muscles  of 
hand,  forearm,  arm,  and  shoulders.  More  marked,  however,  in 
the  hands,  whose  thenar  and  hypothenar  regions  are  very  flat, 
and  whose  interosseous  spaces  are  sunken.  The  left  hand,  in 
particular,  has  assumed  a  partial  "  main  en  griflfe  "  attitude.  (See 
fig.  I.) 


Fig.  I. — Left  hand  of  Marie  A.  T .    A  case  of  common  progressive  muscular  atrophy. 


The  thumb  is  abducted  and  drawn  back  on  a  plane  with  the 
rest  of  the  hand,  while  the  last  phalanx  is  flexed.  The  first 
phalanges  of  the  fingers  are  slightly  extended,  while  the  second 
and  third  are  slightly  flexed. 

Voluntary  movements  of  the  atrophied  parts  are  very  restricted, 
especially  those  of  abduction  and  adduction,  extension  of  the  last 

■  Service  of  Prof.  Charcot. 


DEFORMITY  OF   THE  HAND  AS  A    SYMPTOM.  699 

plialanges  of  the  fingers,  and  opposition  of  thumb.  All  vigorous 
efforts  in  that  direction  result  in  increased  extension  of  the  first 
and  flexion  of  the  two  last  phalanges.  Complete  closure  of  the 
hand  is  also  impossible.  As  yet  no  rigid  fixation  has  taken  place, 
so  passive  movements  can  be  made,  although  they  are  rather  pain- 
ful to  the  patient. 

There  is  no  impairment  of  sensibility,  no  tendon  reflex  in  the 
hands,  and  an  abnormally  marked  one  at  the  knees. 

Lower  extremities  are  intact,  and  all  the  bodily  functions  are 
normal. 

The  next  atrophic  deformity  of  the  hand  described  will 
be  that  of  leprosy — morphoea  alba  or  lepra  anaesthetica. 
The  hand  of  this  disease  when  it  is  fully  developed  is  a 
typical  "  main  en  griffe."  The  hand  is  entirely  deprived  of 
its  fleshy  covering,  and  the  bony  prominences  and  tendons 
everywhere  show  through  the  tightly  drawn  skin.  The 
thenar  and  hypothenar  eminences  have  vanished,  the 
interosseous  spaces  are  sunken,  and  the  palm  is  extremely 
hollow.  The  hand  is  slightly  extended,  the  thumb  is 
rotated  outward,  its  metacarpal  bone  is  extended  and  its 
two  phalanges  flexed.  The  first  phalanges  of  the  fingers 
are  extended,  while  the  second  and  third  are  generally 
flexed,  and  in  an  advanced  stage  completely  and  tightly 
flexed.  The  long  flexor  tendons  in  the  palm  are  very 
prominent  and  extremely  tense.  The  hand  is  held  very 
rigidly  in  this  attitude,  and,  as  might  be  well  imagined,  its 
intrinsic  movements  are  almost,  if  not  entirely,  abolished. 
It  is  in  this  deformity  of  the  hand,  in  particular,  that  some 
change  takes  place  in  the  fibrous  and  articular  apparatus  of 
the  hand  which  renders  a  restoration  to  its  original 
attitude,  even  by  force,  almost  impossible.  With  these 
atrophic  changes  there  are  apt  to  be  ulcerative  or  tuber- 
cular affections  about  the  fingers,  and  an  impairment  or,  in 
many  cases  a  complete  loss  of  general  sensibility  in  the 
parts.     This  form  of  leprosy,  which  receives  its  name  be- 


700  R.    W.    AMIDON. 

cause  when  fully  developed  the  patient  presents  on  various 
parts  of  his  body  patches  of  skin,  large  or  small,  generally 
white,  which  are  entirely  devoid  of  sensibility,  is  endemic 
chiefly  in  Egypt  and  Arabia,  but  is  also  known  in  almost 
all  equatorial  countries  ;  also  in  more  temperate  countries, 
as  Turkey,  Greece,  China,  and  even  in  some  high  latitudes, 
as  in  Norway  and  Sweden.  In  our  country  and  France 
only  imported  cases  are  seen,  and  it  was  from  an  Egyptian 
who  attended  Prof.  Charcot's  clinic  that  the  following 
history  and  sketches  were  taken.  For  the  history  I  depend 
on  my  own  notes  taken  at  the  time  and  a  full  account  of 
the  case  which  appeared  in  the  Progres  Medical,  Dec.  25, 
1880,  reported  by  Ballet,  interne  at  the  Salpetriere. 

The  patient,  H.  F.,  male,  twenty-four  years  old,  was  born  at 
Cairo,  Egypt.  He  had  no  hereditary  taint.  The  disease  com- 
menced at  the  age  of  eighteen.  For  many  years  before  the 
patient  had  led  a  very  dissipated  life.  He  drank  regularly  about 
two  litres  of  raki  a  day,  besides  a  large  quantity  of  wine,  cognac, 
and  absinthe  ;  he  consumed,  besides,  an  enormous  quantity  of 
hashish  ;  he  smoked  about  fifty  cigarettes  a  day,  each  containing 
fifty  centigrammes  of  Indian  hemp,  and  ate  a  pastile  of  the  ex- 
tract, weighing  1.50  ;  he  also  carried  sexual  intercourse  to  a  won- 
derful excess.  The  disease  commenced  by  anaesthesia  of  the 
lower  extremities  ;  then  the  head  and  neck  lost  sensibility,  and 
then  the  neighborhood  of  the  nipples.  Two  years  later  the  hands 
commenced  to  atrophy.  Examination  of  the  patient  reveals  the 
existence  of  large  placques  surrounded  by  a  slightly  elevated 
border,  which  is  strongly  pigmented.  The  skin  in  these  zones  is 
completely  anaesthetic.  One  comprises  the  head  and  neck,  two 
more  each  arm  and  shoulder,  a  small  one  surrounds  each  nipple, 
while  another  comprises  the  external  genital  organs.  A  very  pro- 
nounced atrophy  affects  all  the  muscles  underlying  the  anaesthetic 
areas. 

The  atrophy  is  very  marked  in  the  feet,  legs,  forearms,  and 
hands,  and  also  in  the  face,  particularly  the  orbicularis  palpe- 
brarum, occipito-frontalis,  and  zygomaticus  major. 

This  facial  atrophy  gave  a  peculiar  facies,  as  there  was  inability 
to  close  the  eyes  tight,  and  the  atrophy  of  the  oral  muscles  gave 


DEFORMITY  OF   THE  HAND  AS  A    SYMPTOM.        JO\ 

the  patient  a  particularly  woe-begone  expression.  There  was  an 
ulcerative  keratitis  with  pannus  in  both  eyes.  As  for  the  hands, 
which  concern  us  particularly,  they  had  lost  about  all  their  in- 
trinsic muscular  substance  (see  fig.  2),  the  thenar  and  hypothenar 
eminences  had  disappeared,  and   the    interosseous    spaces  were 


Fig.  2. — Right  hand  of  H.  F.    Case  of  morphoea  alba. 

very  hollow.  The  hand  had  assumed  an  almost  typical  "main  en 
griffe  "  attitude,  and  by  local  changes  was  pretty  tightly  held  in 
this  position.  The  intrinsic  movements  of  the  hand  were  of 
course  impossible.  The  patient  could  write  his  name  by  holding 
the  pencil  stiffly  between  his  index  and  middle  fingers,  and  by 
moving  the  hand  as  a  whole. 

The  results  of  a  careful  electrical  examination  by  Dr. 
Vigouroux  showed  that  there  was  no  response  to  either 
current  where  the  atrophy  was  well  marked,  but  that  in  a 
few  muscles,  as  the  peronei  and  the  pyramidalis  nasi,  there 
was  degeneration  reaction  to  the  galvanic  current. 

This  deformity  of  the  hand  is  easily  distinguished  from 
any  other  by  the  history,  by  the  anaesthetic  patches  on  the 
body,  and  particularly  by  the  anaesthesia  of  the  hands. 

In  myelitis  of  the  anterior  horns  in  the  cervical  region  of 
the  cord  we  have  often  a  condition  of  the  hands  which, 
perhaps  more  nearly  than  any  other,  resembles  the  hands  of 
muscular  atrophy.  Like  it  the  atrophy  is  generally  bilateral, 
and  generally  accompanied  by  no  impairment  of  sensi- 
bility of  the  part;  but  unlike  muscular  atrophy  that  of 
myelitis   is   preceded   by   paralysis,  and    generally   attacks 


702  R.    W.  AM/DON. 

groups  of  muscles  or  whole  extremities,  while  muscular 
atrophy  may  invade  and  destroy  a  part  of  a  muscle  and 
leave  the  rest  intact.  In  the  hand  of  cervical  paraplegia, 
also,  we  get  a  loss  of  farado-contractility  and  a  degeneration 
reaction  to  galvanism. 

The  deformity  resulting  from  myelitis  of  the  anterior 
horns  varies  from  a  simple  atrophy  of  the  larger  groups  of 
muscles  to  a  total  atrophy  of  all  the  hand  muscles.  When 
the  thenar  eminence  is  atrophied  we  get  simply  the  mon- 
key hand,  which  is  quite  common,  and  when  the  other 
intrinsic  muscles  are  involved  there  results  a  more  or  less 
complete  "main  en  griffe,"  modified  in  many  cases  by  a 
paralysis  or  paresis  of  the  long  flexors  or  extensors  in  the 
forearm. 

The  deformity  of  the  hand,  resulting  from  a  common 
myelitis,  differs  in  no  way  from  that  of  myelitis  of  the 
anterior  horns,  except  it  is  accompanied  by  anaesthesia. 
The  man  whose  history  and  a  sketch  of  whose  hand  is 
annexed,  had  a  cervical  myelitis  chiefly  confined  to  the 
anterior  horns,  but  undoubtedly  implicating  the  sensory 
zone  somewhat,  as  evidenced  by  the  sensory  disturbance  in 
one  of  his  arms.     His  history  was  as  follows : 

P.  C,  male,  forty-eight  years  old,*  March  30,  1880,  when  in- 
toxicated, went  to  sleep  on  the  floor  of  a  cold  room,  in  a  draught. 
He  was  perfectly  well  at  12  o'clock,  when  he  fell  asleep.  At 
4  A.  M.,  when  he  awoke,  he  found  his  arms  were  powerless  from 
shoulders  down,  and  that  he  had  no  sensibility  from  just  above 
the  elbows  down  to  the  fingers.  Two  weeks  later  he  could  move 
the  right  index  finger  slightly,  and  at  the  same  time  sensibility  had 
gradually  reappeared  in  the  whole  arm,  last  in  the  right  medius, 
which  was  also  the  last  to  regain  its  power  of  motion.  When 
first  seen,  June  2,  1880,  the  patient  could  use  his  right  hand  a 
little,  but  there  still  remained  a  slight  amount  of  numbness  and 
sense  of  powerlessness.  The  left  arm  was  quite  helpless  from  the 
shoulder  down,  and  there  was  no  sensibility  from  a  little  above 

'  Service  of  Dr.  Seguin,  Manhattan  Hospital. 


DEFORMITY  OF   THE  HAND  ASA    SYMPTOM. 


703 


the  elbow  to  the  finger  tips.  The  muscles  were  flabby  and  degen- 
erated, and  when  asked  to  raise  the  arms  only  the  trapezius  acted 
on  either  side.  There  was  the  reaction  of  degeneration  in  some 
of  the  muscles  of  the  right  upper  extremity  and  in  almost  all  of 
the  left  upper  extremity.  He  was  treated  systematically  with 
electricity  for  months  and  nothing  new  developed,  except  the 
knowledge  that  he  had  been  subject  to  fits  of  psychical  epilepsy 
for  years. 

At  the  time  the  accompanying  sketch  was  made  (see  fig. 
3)  the  right  arm,  forearm,  and  hand  had  entirely  recovered, 


Fig.  3. — Left  hand  of  P.  C.    Case  of  cervical  paraplegia. 

and  the  condition  of  the  left  was  as  follows  :  There  still 
remained  some  atrophy  in  the  suprascapular  muscles.  The 
arm  muscles  were  nearly  normal,  but  the  forearm  muscles 
responded  poorly  to  faradism,  and  with  a  slight  degenera- 
tion reaction  to  galvanism.  Voluntary  motion  was  possible 
in  all  parts  above  the  wrist.  There  was  no  voluntary  con- 
traction of  the  intrinsic  muscles  of  the  hand,  and  in  fact  lit- 
tle of  these  muscles  remained.  Thenar  and  hypothenar 
eminences  were  gone,  and  the  interosseous  spaces  were 
sunken.  The  extensor  tendons  stood  out  on  the  back  of  the 
hand,  while  in  the  palm  the  long  flexor  tendons  were  very 
salient.  The  position  assumed  was  rather  that  of  the 
"  main  de  singe  "  than  the  "  main  en  griffe."  The  thumb 
had  receded  to  the  plane  of  the  fingers,  but  the  first 
phalanges,  except  those  of  the  ring  and  little  fingers,  were 
not  so  much  extended  as  is  usual  in  the  claw  hand.  The 
joints  were  still  mobile.  Whatever  reaction  is  present  at 
all  in  the  hand  is  a  well-marked  degeneration  reaction  to  a 


704  Ji.    W.  AMIDON. 

Strong  galvanic  current,  although  at  times  a  slight  response 
has  been  noticed  to  a  very  strong  faradic  current  in  the 
first  interosseous  muscle. 

Sensibility  is  still  poor  in  the  forearm  and  almost  nil  in 
the  hand,  only  the  strongest  faradic  current  being  felt.  Very 
often   the  galvanic  application  he  now  has  (negative  pole, 


Fig.  4.— Right  hand  of  case  of  cervical  paraplegia  in  the  service  of  Prof.  Charcot  at  the 

Salpetn^re. 

labile)  will  bring  out  on  the  left  arm  and  forearm  a  beauti- 
ful urticaria  rash  which  lasts  only  a  few  minutes.  At  other 
times  a  fine,  red,  papular  eruption  follows  the  same  appli- 
cation. 

In  amyotrophic  lateral  sclerosis  there  is  generally  first  a 
spasmodic  and  then  an  atrophic  deformity  of  the  hand,  but 
as  the  atrophic  deformity  is  most  often  seen  and  more  per- 
manent it  will  be  introduced  here.  The  course  of  the  dis- 
ease is  so  typical  that  only  a  resume  of  its  symptomatology 
need  be  given.  The  patient  complains  of  weakness,  formi- 
cation, numbness,  or  perhaps  muscular  pains  of  the  upper 
extremities.  Fibrillary  twitchings,  atrophy,  and  progres- 
sive paralysis  soon  follow.  There  may  be,  and  generally  is, 
before  the  paralysis  and  atrophy  have  advanced  far,  a  con- 
tracture of  the  hand  and  fingers  due  partially  to  unopposed 
action  of  muscle  still  remaining  healthy,  but  also  to  a  true 
spasm  of  some  muscular  groups.  There  is  adduction  of  the 
arm,  semiflexion  and  pronation  of  the  forearm,  semiflex- 
ion of  the  wrist  and  fingers.     Later  in  the  course  of  the  dis- 


DEFORMITY  OF   THE  HAND  AS  A    SYMPTOM.        705 

ease,  after  the  atrophy  and  paralysis  have  progressed,  this 
spastic  condition  generally  relaxes,  sometimes  completely, 
and  there  remains  the  "  main  en  griffe  "  or  "  main  de  singe." 
At  a  variable  length  of  time  after  the  onset  of  symptoms 
in  the  upper  extremities  walking  becomes  difificult.  The 
legs  feel  heavy,  the  feet  drag,  and  the  patient  frequently 


Fig.  5. — Right  hand  of  Louisa  . 

Case  of  amyotrophic  lateral  sclerosis. 


Fig.  55 — Forearm  and  hand  of  Charcot's 
case' of  amyotrophic  lateral  sclerosis. 


falls.  There  exists,  particularly  in  the  legs,  a  muscular  hy- 
peraesthesia,  and  the  patient  has  attacks  of  "  spinal  epilep- 
sy," brought  on  by  movements  or  contact,  and  consisting 
of  jerkings,  adduction  of  the  thighs,  and  crossing  of  the  feet 
and  legs.  Soon  now  the  patient  becomes  bed-ridden,  and 
the  stiffness  of  the  legs  becomes  permanent.  Paralysis  and 
muscular  atrophy  soon  set  in  but  are  never  so  marked  as  in 
the  arms.  The  head  is  bent  forward,  often  so  that  the  chin 
touches  the  sternum,  and  the  spine  is  very  rigid.  At  last 
labio-glosso-laryngeal  paralysis  sets  in  and  death  soon  results. 

The  patient  from  whom  fig.  5  was  taken  had  entered  the 
third  and  last  stage  of  the  disease,  and  her  hand,  as  figured, 
was  more  atrophic  than  spastic.  She  was  an  embroiderer, 
aet.  49,  and  entered  the  St,  Luke  ward  at  the  Infirmary  of 
the  Salpetriere  Nov.  13,  1878.'     This  case  had  followed  the 

'  Service  of  Prof.  Charcot. 


706  Ji.    W.  AMIDON. 

typical  course,  and  her  condition  when  the  hand  was  figured 
was  as  follows : 

She  was  bedridden.  The  face  had  a  grinning  demented  look. 
Eyes  staring,  brows  elevated,  corrugators  contracted,  mouth  half 
open,  lips  drawn  and  stiff ;  saliva  dropped  almost  constantly  from 
the  mouth.  Tongue  was  incapable  of  protrusion,  thick  and 
rough  ;  articulation  was  impossible,  deglutition  was  difficult,  re- 
gurgitation through  nose,  and  frequent  choking  fits  occurred.  The 
head  was  pretty  rigidly  flexed  on  the  chest.  The  upper  extremi- 
ties were  not  very  rigid,  but  helpless  ;  the  lower  extremities  were 
rigidly  extended,  adducted,  with  the  feet  in  extreme  talipes  equi- 
nus.  The  sensibility  was  good,  voluntary  motion  was  almost  nil, 
and  the  reflexes  enormously  exaggerated  all  over  the  body.  The 
patient  was  very  emotional,  and  simpers  and  cries  easily.  The 
atrophy  was  chiefly  confined  to  the  upper  extremities.  The  hands, 
especially  the  right  (fig.  5),  were  very  much  atrophied.  All  the 
fleshy  eminences  were  gone,  the  palm  was  very  hollow,  and  the 
fingers  were  spasmodically  flexed  into  the  palm.  The  hand  itself, 
unlike  Charcot's  case,  was  about  on  a  line  with  the  forearm. 

The  only  hand  that  amyotrophic  lateral  sclerosis  could  be 
confounded  with,  is  that  of  progressive  muscular  atrophy  or 
cervical  paraplegia.  The  rapid  progress  of  the  disease  and 
the  existence  of  a  spasmodic  element  would  exclude  the 
former,  while  the  absence  of  complete  paralysis  and  the 
preservation  of  farado-contractility  of  the  muscles  would 
exclude  the  latter  disease. 

The  clinical  history  of  the  disease  is  so  typical  that  a  mis- 
take is  scarcely  possible. 

To  exemplify  the  deformity  of  the  hand  which  results 
when  the  spasmodic  element  predominates,  there  is  in- 
serted a  figure  5^  from  Charcot,'  which  he  describes  (p.  235) 
thus:  "  The  arm  is  adducted  and  the  shoulder  muscles  re- 
sist abduction.  The  forearm  is  semiflexed  and  pronated  ; 
supination  and  extension  are  difficult  and  painful.  The  hand 
is  semiflexed  and  the  fingers  are  flexed  on  the  palm." 

'  Legons  sur  les  Localisations  dans  les  Maladies  du  Cerveau,  etc.,  Paris,  1876, 
p.  234- 


DEFORMITY  OF   THE  HAND  AS  A    SYMPTOM.        70J 

In  the  hypertrophic  cervical  pachymeningitis  of  Charcot 
a  pecuHar  deformity  of  the  hand  results,  a  description  of 
which,  as  the  writer  has  never  seen  a  case,  will  be  presented 
as  given  in  the  writings  of  Charcot,  Jeoffroy,  and  Hallo- 
peau. 

The  disease  is  generally  divisible  into  two  stages — the 
painful  period  and  the  paralytic  and  atrophic  period.  The 
disease  commences  by  severe  pains  in  the  occiput  and  back 
of  the  neck,  much  aggravated  by  pressure  on  the  spinous 
processes.  These  pains  often  radiate  over  the  head,  down 
the  back,  and  down  the  arms,  and  there  are,  besides,  fre- 
quent rheumatoid  pains  in  the  shoulders  and  elbows.  The 
neck  is  kept  rigid  as  in  Pott's  disease. 

With  these  pains  the  patient  complains  of  formication, 
numbness,  and  perhaps  of  some  anaesthesia  in  patches,  in 
the  hands  particularly.  Bullous  or  pemphigus  eruptions 
are  sometimes  seen.  There  are  cases,  however,  in  which 
the  pain  is  chiefly  peripheral,  and  confined  almost  en- 
tirely to  the  articulations.  Sometimes  a  true  remission  in- 
tervenes between  the  two  periods.  This  remission  is  not 
constant,  however,  and  the  two  periods  merge  one  into  the 
other. 

After  a  longer  or  shorter  painful  stage,  two  to  three 
months,  the  patient  notices  a  weakness  and  uselessness  of  one 
or  both  upper  extremities.  Very  soon  an  atrophy  com- 
mences in  the  hands  and  extends  to  the  forearms.  The 
muscles  often  more  paralyzed  and  atrophied  are  the  in- 
trinsic hand  muscles  and  the  flexors  of  the  fingers  and  hand. 
The  pronators  of  the  forearm  generally  suffer  with  the  flex- 
ors. This  leaves  the  extensors  and  supinators  the  only 
healthy  muscles,  and  their  unopposed  action  produces  the 
deformity  of  the  hand  named  by  Charcot  "la  main  du 
predicateur  emphatique,"  which  presents  the  following 
characteristics :   The  hand  is  extended  and  supinated.     At 


708  H.    W.   A  MID  ON. 

times  all  the  phalanges  are  somewhat  flexed.  At  other 
times  the  fingers  are  extended.  The  thumb  is  applied  to 
the  side  of  the  hand  and  slightly  flexed.  The  hand  itself  is 
almost  devoid  of  muscular  covering.  This  atrophy  and  par- 
esis generally  soon  invade  the  thoracic  muscles,  and  in  this 
way  sometimes  causes  death.  Of  course  when  the  second- 
ary descending  changes  invade  the  lower  cord,  the  lower 
extremities  may  become  paraplegic  with  vesical  and  rectal 
complications,  or  tetanoid  symptoms  will  develop  as  in 
descending  degeneration  from  other  causes. 

This  disease  can  be  hardly  confounded  with  any  other, 
and  may  with  certainty  be  distinguished  from  amyotrophic 
lateral  sclerosis  by  the  history  of  the  painful  stage,  by  the 
disseminated  patches  of  anaesthesia  and  the  occasional 
eruptions,  and  also  by  the  entire  absence  of  bulbar  symp- 
toms. The  accompanying  figures  are  copied  from  the 
works  of  Charcot,  Jeoffroy,  and  Meillet. 

The  following  is  a  r^suin^  of  the  case  whose  hand  is  de- 
picted, taken  from  the  monograph  of  Jeoffroy.     (See  fig.  6.) 


Fig.  6.— Right  hand  of  Charcot  and  JeofEroy's   case  of  hypertrophic  cervical  pachy- 
meningitis. 

On  Aug.  6,  1865,  this  woman,  29  years  old,  was  exposed  to  cold 
and  wet.     During  the  next  48  hours  she  had  repeated  chills.     At 


DEFORMITY  OF   THE  HAND  AS  A    SYMPTOM.        709 

that  time  sharp  pains  commenced  in  both  right  extremities, 
chiefly  in  the  course  of  nerves  and  in  the  joints. 

In  the  middle  of  September  the  pains  invaded  the  left  side. 
At  this  time  fibrillary  movements  were  noticed  in  the  right  upper 
extremity. 

Two  weeks  later  there  was  noticed  a  difficulty  in  raising  the 
right  arm,  in  opposing  the  thumb  and  in  ad-  and  abduction 
of  the  fingers.  Atrophy  had  already  set  in  in  the  region  of  the 
deltoid  and  in  the  intrinsic  muscles  of  the  hand. 

In  April,  1866,  the  right  elbow  was  semiflexed,  the  forearm 
semipronated,  the  wrist  semiflexed,  and  the  fingers  flexed  in  on 
the  palm.  This  contracture  could  be  voluntarily  overcome  by  an 
effort  of  the  will. 

A  month  later  contracture  appeared  on  the  left  side.  There 
were  diminished  electro-contractility  and  lowered  temperature  in 
the  affected  parts.  The  12th  of  December  all  contracture  had 
disappeared,  and  paralysis  of  the  previously  contracted  muscles 
was  marked. 


Fig.  7. — Left  hand  of  another  case  of  hypertrophic  cervical  pachymeningitis  under  Prof. 
Charcot's  care.    Taken  from  Meillet's  monograph. 

Early  in  1868  the  patient  came  under  the  care  of  Prof.  Charcot 
at  the  Salpetriere.     She  was  very  emaciated  and  bed-ridden  from 


7IO  R.    W.  AMIDON. 

weakness  and  contracture  of  the  legs.  The  left  upper  extremity 
was  atrophied  and  flaccid,  the  right  hand  was  extended  at  a  right 
angle  to  the  forearm,  and  the  thumb  was  also  extended,  except 
the  terminal  phalanx,  which  was  semiflexed.  The  fingers  which 
could  still  be  extended  are  flexed  on  the  palm.  The  forearm  was 
flexed  on  the  arm  and  the  arm  was  adducted.  All  voluntary 
movements  were  abolished.  There  were  some  fibrillary  contrac- 
tions in  the  left  hand.  There  was  much  anaesthesia,  more  marked 
on  the  right  side.  Electro-contractility  was  preserved,  but  quan- 
titatively changed. 

As  deformities  of  the  hand  resulting  from  disease  or  in- 
jury of  a  peripheral  nerve  present  many  of  the  same  charac- 
teristics a  few  words  will  be  said  about  them  together,  and 
then  special  mention  will  be  made  about  each  variety. 

Whether  the  nerve  be  injured  by  a  neuritis,  a  neoplasm, 
by  prolonged  pressure,  by  bruising,  laceration,  or  section, 
and  the  injury  result  in  a  local  disorganization,  or  any 
change  which  completely  destroys  the  conductibility  of  the 
nerve  fibres,  the  same  results  ensue.  First,  of  course,  there 
is  a  paralysis'  and  anaesthesia  in  the  peripheral  distribution 
of  the  injured  nerve  bundle.  Next  the  muscles  supplied 
by  the  nerve,  being  cut  off  both  from  their  motor  and 
trophic  centres,  atrophy,  if  the  separation  be  complete, 
entirely ;  and,  lastly,  changes  take  place  in  the  skin  of  the 
affected  part,  due  to  the  anaesthesia  and  the  cutting  off  of 
the  trophic  supply. 

The  limitation  of  all  these  changes  to  the  exact  distribu- 
tion of  the  nerve  injured,  distinguishes  the  deformities  due 
to  changes  in  a  peripheral  nerve  from  any  other.  If  re- 
generation of  the  nerve  take  place  soon,  the  part  may  re- 
turn to  its  normal  condition,  but  when  regeneration  is 
slow  or  absent,  degeneration  of  the  muscular  substance 
ensues,  and  we  find  they  respond  in  an  abnormal  manner  to 

'The  temporary  deformities  caused  by  the  paralysis  of  the  first  stage  of  nerve 
section,  etc.,  will  be  mentioned  when  speaking  of  paralytic  deformities  of  the 
hand. 


DEFORMITY  OF   THE  HAND  AS  A   SYMPTOM.        711 

galvanism.  The  trophic  changes  occurring  after  nerve  in- 
jury are  various.  The  skin  is  thin  and  smooth.  The  fingers 
are  often  clubbed,  and  the  nails  curved  and  frequently  rough 
and  brittle. 

If  there  be  much  anaesthesia,  as  there  usually  is,  the 
patient  will  frequently  mechanically  hurt  the  anaesthetic 
parts  in  various  ways,  or  burn  or  freeze  them,  and  trouble- 
some indolent  ulcers  will  result. 

The  distribution  of  the  affected  nerve  is  often  the  seat  of 
sharp,  tearing  or  burning  pains,  which  are  excessively  har- 
assing to  the  patient.  One  of  the  most  common  atrophic 
deformities  of  the  hand  due  to  nerve  injury  is  that  caused 
by  contusion  at  the  elbow,  or  by  section  of  the  ulnar  nerve 
at  the  wrist.  The  ulnar  supplies,  in  the  forearm,  the  flexor 
carpi  ulnaris  and  the  two  internal  portions  of  the  flexor  pro- 
fundus digitorum ;  in  the  hand,  all  the  muscles  of  the  hypo- 
thenar  eminence,  the  adductor  pollicis,  the  inner  head  of  the 
flexor  brevis  pollicis,  the  two  inner  lumbricales,  the  two 
inner  interosseous  spaces  entirely,  and  the  others  either 
alone  or  in  conjunction  with  the  median  nerve.  Variations 
from  this  distribution  are  uncommon  but  not  unknown. 

The  deformity  resulting  from  a  destructive  lesion  of  the 
ulnar  nerve  at  the  elbow,  or  above  is  called  the  ulnar  griffe 
(griffe  cubitale  of  the  French).  The  griffe  consists,  first,  in 
marked  prominence  of  the  unciform,  pisiform,  and  third  and 
fourth  metacarpal  bones,  owing  to  an  atrophy  of  the  muscles 
of  the  hypothenar  eminence,  the  interosseii,  and  two  inner 
lumbricales.  Secondly,  in  some  want  of  fulness  about  the 
first  interosseous  space  and  thenar  eminence,  owing  to  the 
atrophy  of  the  adductor  pollicis  and  the  inner  head  of  the 
flexor  brevis  pollicis.  The  vicious  attitude  the  hand  as- 
sumes is  first,  perhaps,  a  slight  extension  of  the  hand  on 
the  forearm,  with  a  slight  depression  over  the  site  of  the 
flexor  carpi  ulnaris  and  that  of  the  outer  half  of  the  flexor 


712  R.    W.    AM  WON. 

profundus  digitorum  in  the  forearm.  The  first  phalanges 
of  the  ring  and  little  fingers  are  slightly  extended,  because 
the  long  extensors  of  the  fingers  are  no  longer  resisted  by 
the  lumbrical  muscles. 


Fig  8.— Left  hand  of  patient  E.  H.,  with  section  of  the  ulnar  nerve  at  wrist. 

Their  third  and  second  phalanges  are  flexed  by  the  flexor 
sublimis  digitorum,  there  being  no  antagonists  where  the 
third  and  fourth  interossei  are  paralyzed  and  atrophied. 

The  medius  has  generally  much  the  same  deformity  as  the 
annulus,  but  the  index  often  has  its  normal  position  and 
motion,  because  its  intrinsic  muscles  are,  in  most  hands, 
supplied  by  the  median  nerve.  The  thumb  retains  its 
power  of  opposition  while  it  has  lost  that  of  adduction  and 
partially  that  of  flexion. 

After  injury  to  the  ulnar  at  the  wrist  the  same  state  of 
things  exists  except  there  is  no  paralysis  of  the  flexor  carpi 
ulnaris,  or  of  the  outer  half  of  the  flexor  profundus  digi- 
torum. The  presence  or  absence  of  this  paralysis  has  little 
effect  on  the  resulting  deformity,  and  so  we  see  in  all  cases 
of  ulnar  injury  a  sort  of  "  main  en  griffe,"  with  contracture 
more  marked  in  the  ring  and  little  fingers. 

The  following  case  came  to  the  clinic  of  Dr.  Seguin  at 
the  Manhattan  Hospital,  March  2,  1881.     (See  fig.  8.) 

E.  H.,  a  janitress,  forty-nine  years  old.  Nine  months  before, 
while  washing  windows,  she  pushed  her  left  hand  through  a  thick 
pane  of  glass,  and  on  the  sharp,  fractured  edge   cut  the  flexor 


DEFORMITY  OF   THE  HAND  ASA   SYMPTOM.        /1 3 

ulnar  side  of  her  forearm,  near  the  wrist,  to  the  bone.  Imme- 
diately after  the  injury  she  noticed  a  prickling  sensation  in  the 
ring  and  little  fingers.  Later  they  became  swollen  and  painful. 
The  cut  healed  in  two  weeks.  At  the  expiration  of  that  time, 
when  the  hand  was  taken  off  the  splint,  the  patient  asserts  that 
the  hand  was  flat  and  the  fingers  crooked.  On  examination  it 
was  seen  that  the  eminences  were  flat.  The  tw'o  distal  phalanges 
were  flexed.  The  thumb  was  abducted  and  semiflexed.  The  hand 
was  somewhat  swollen  and  the  skin  in  great  part  smooth.  The 
finger  tips,  particularly  that  of  the  annulus,  were  clubbed  and  the 
nails  curved.  There  was  almost  complete  paralysis  of  the  in- 
trinsic muscles  of  the  hand.  There  was  fair  sensibility  to  painful 
impressions  in  the  distribution  of  the  ulnar  nerve,  but  tactile  sen- 
sibility was  very  poor.  There  was  no  reaction  in  any  of  the  hand 
muscles  to  faradism,  and  degeneration  reaction  in  all  except,  per- 
haps, in  those  of  the  second  interosseous  space,  where  An  C  C 
and  Ca  C  C  were  about  equal. 

Injury  to  the  median  nerve  at  the  wrist  results  in  a  de- 
formity of  the  hand,  of  which  the  following  case  is  so 
perfect  an  example  that  it  will  be  immediately  introduced. 
(See  fig.  9.) 


Fig.  9. — Right  hand  of  C*  K.,  with  section  of  median  nerve  at  the  wrist. 

C.  K.,  a  laundress,  twenty- two  years  old,  came  to  the  clinic  of 
Dr.  Seguin  at  Manhattan  Hospital,  May  11,  1881.  Three  months 
before,  while  washing,  she  pierced  her  right  palm  with  a  needle. 
Suppuration  followed,  and  on  the  fifth  day  two  incisions  were 
made,  the  one  on  the  anterior  surface  of  the  wrist  without  question 
severing  the  median  nerve.  Three  weeks  later  she  first  noticed 
anaesthesia  in  the  index  and  middle  fingers  and  on  the  pulp  of  the 
thumb. 

At  the  time  of  examination  there  were  anaesthesia,  smoothness 
of  the  skin,  and  marks  of  burns  and  injuries  in  the  median  distri- 


714 


R.    W.    AMIDON. 


bution.  There  was  some  falling  away  of  the  thenar  eminence,  a 
tendency  toward  extension  of  the  first  phalanges  of  the  index  and 
medius,  and  flexion  of  their  last  two  phalanges.  The  intrinsic 
movements  of  these  fingers  are  limited,  if  at  all  present.  The 
thumb  is  adducted  and  has  lost  its  power  of  opposition.  The 
ring  and  little  fingers  are  in  normal  position  and  of  normal 
appearance. 

The  deformity  resulting  from  musculo-spiral  nerve  injury 
will  be  mentioned  under  the  head  of  paralytic  deformities. 

In  injury  to  the  brachial  or  axillary  plexus  (see  figs.  lo 
and  1 1)  hand  deformities  result,  varying  of  course  accord- 
ing as  all  or  only  few  of  the  cords  of  the  plexus  are  injured. 
The  manifestations  are  not  apt  to  be  restricted  to  the 
distribution  of  any  one  nerve,  and  the  more  common 
result  of  such  injury  is  a  general  wasting  and  a  common 
"main  en  griffe,"  as  in  the  following  case: 


Fig.  io.— Left  hand  of  Dr.  Serin's  case  of  injury  to  the  brachial  plexus.    Ulnar  fila- 
ments chiefly  involved. 

A  woman,  forty  years  old,  in  the  St.  Jacques  ward  of  the  In- 
firmary of  the  Salpetriere,'  a  tailoress  by  occupation,  when  twelve 
years  old  dislocated  her  right  shoulder.  Since  then  it  has  been 
dislocated  six  times.  The  last  dislocation  occurred  two  and  a  half 
years  ago,  and  was  treated  at  Lariboisiere.  Then  the  patient  no- 
ticed for  the  first  time  that  her  hand  was  getting  thin  and  that 
there  was  a  very  pronounced  atrophy  of  that  side.  When  exam- 
ined, May  15,  1880,  there  was  some  rigidity  of  the  right  shoulder. 
No  atrophy  of  the  shoulder,  arm,  or  forearm  muscles.     Apparently 

'  Service  of  Prof.  Charcot. 


DEFORMITY  OF   THE  HAND  AS  A   SYMPTOM.        7^S 

complete  atrophy  of  all  the  intrinsic  hand  muscles.  The  thenar 
and  hypothenar  eminences  were  wanting,  the  interosseous  spaces 
sunken,  and  the  palm  hollow. 

The  thumb  was  extended  and  rotated  inward,  the  first  pha- 
langes were  extended,  the  second  were  flexed,  and  the  third 
about  straight. 


Fig.  II. — Right  hand  of  Prof.  Charcot's  case  of  injury  to  the  brachial  plexus. 

This  case  is  not  a  typical  one  of  nerve  injury,  as  its 
course  was  not  marked  by  pain  or  much  impairment  of 
sensibility. 

The  deformity  resulting  from  neuritis  differs  in  no  way 
from  that  of  nerve  injury,  but  the  clinical  history  is  differ- 
ent, the  severe  pain  particularly  characterizing  the  first 
stage  of  neuritis. 

The  electrical  reactions  are  the  same  as  in  nerve  injury, 
and  there  commonly  is  anaesthesia. 

K,  G.,  a  domestic,  thirty-two  years  old,  came  to  the  clinic  of 
Dr.  Seguin  at  the  Manhattan  Hospital,  Aug.  4,  1880. 

For  two  years  she  had  had  occasional  pain  over  brachial  plexus 
(right  side).  She  had  had  no  injury  to  shoulder.  May  11,  1880, 
she  cut  her  right  thumb.  It  bled  little,  but  that  night  the  thumb 
was  the  seat  of  much  pain,  which  by  the  next  night  had  extended 
to  the  palm  of  the  same  hand.  Later  the  pain  ran  from  the  thumb 
up  the  flexor  surface  of  the  forearm,  and  then  the  fingers  began  to 
flex  until  they  acquired  the  position  now  occupied  by  them,  they 
never  having  relaxed.  The  severe  pain  lasted  about  three  weeks, 
but  ever  since  there  have  been  occasional  twinges  in  the  hand. 
There  was  at  one  time  considerable  swelling  of  the  palm,  but  there 
were  no  indications  that  any  suppuration  took  place. 


7i6 


R.    W.   AM  WON. 


On  examination  it  was  seen  that  the  fingers  of  the  right  hand 
were  semiflexed,  fixed,  small,  smooth,  and  provided  with  new 
nails.  There  was  some  atrophy  of  the  eminences,  and  move- 
ments of  fingers  were  restricted.     (See  fig.  12.) 


Fig.  12. — Right  hand  of  K.  G.,  a  case  of  neuritis. 


2. — SPASMODIC   DEFORMITIES. 


We  now  come  to  speak  of  spasmodic  deformities  of  the 
hand,  and  of  these  the  most  common  and  well  known  is  the 
permanent  contracture  of  hemiplegics. 

In  a  large  proportion  of  cases  of  hemiplegia  of  cerebral 
origin,  at  the  expiration  of  from  one  to  three  months,  a  va- 
riable degree  of  descending  degeneration  in  the  lateral  col- 
umns of  the  cord  has  taken  place.  This  lateral  sclerosis  is 
a  lesion  which  irritates  the  cells  in  the  anterior  horns  of  the 
spinal  corn,  and  in  this  way  greatly  heightens  the  reflex 
irritability  of  the  spinal  cord  and  increases  muscular  tonus 
on  the  paralyzed  side.     As  a  result  of  this  certain  muscular 


Fig.  13.— Right  hand  of  a  patient  with  common  hemiplegia  in  the  service  of  Prof.  Charcot. 


DEFORMITY  OF    THE   HAND  AS  A    SYMPTOM. 


717 


groups  on  the  heretofore  relaxed  and  paralyzed  side,  gen- 
erally the  flexors,  pronators,  and  adductors  in  the  upper  ex- 
tremity, and  the  extensors  and  adductors  in  the  lower  ex- 
trennity,  take  on  a  spasmodic  action  which  results  in  the 
condition  called  permanent  hemiplegic  contracture. 

That  it  is  a  purely  reflex  condition  is  proven  in  many 
ways,  but  principally  by  the  fact  that  the  contracture  is  in- 
creased by  the  application  of  any  local  irritation  to  the  part, 
cold,  electricity,  a  rapidly  vibrating  body,  pressure,  pain,  etc., 
etc.,  and  by  any  effort  to  use  the  part,  and  that  when  the 
part  is  quiet  and  warm,  as  during  sleep,  the  contracture  may 
disappear,  or  at  all  events  become  less. 

This  contracture  is,  as  a  general  thing,  accompanied  by 
no  atrophy,  and  by  only  slight  trophic  changes  in  the  part. 
As  a  rule  it  is  permanent,  but  it  sometimes  spontaneously 
disappears  and  leaves  the  part  flaccid. 

Hemiplegic  contracture  of  the  hand  varies  considerably, 
but  it  generally  consists  in  flexion  of  the  hand,  inversion  and 
flexion  of  the  thumb,  and  flexion  of  the  fingers  into  the 
palm  (see  figs.  13,  14,   15).     This  contracture  may  vary  in 


fS*^ 


Fig.  14.— Right  hand,  and  Fig.  15,  left  hand  of  common  hemiplegias  under  Professor  Charcot's  care. 


severity  from  a  gentle  shutting  of  the  hand  to  the  closure 
of  the  fist  like  a  vice,  and  a  deep  indentation  or  puncture  of 
the  palm  by  the  nails  of  the  flexed  fingers  (see  fig.  i6). 
This  spasmodic  condition  of  the  flexors  can  be  overcome  by 
the  exercise  of  considerable  force  which  gives  the  patient  a 


7i8 


J?.    W.    AM/DON. 


good  deal  of  pain.  Many  hemiplegic  contractures,  as  before 
said,  relax  of  themselves  when  external  irritations  are  re- 
duced to  a  minimum,  as  during  sleep.  There  is  no  atrophy 
or  even  emaciation.  The  hand  is,  as  a  general  thing,  well 
nourished,  but,  more  from  disuse  than  any  thing  else,  the 
skin  is  generally  smooth  and  thin ;  sensibility  is,  as  a  gen- 
eral thing,  preserved,  and  reaction  to  faradic  electricity  is 
retained  ;  there  may  or  may  not  be  complete  paralysis  in 
the  contractured  part. 

As  said  above,  a  voluntary  effort  to  use  the  part  increases 
the  contracture.  Not  only  this,  vigorous  voluntary  move- 
ments of  the  opposite  hand,  particularly  flexion,  also  in- 
crease the  contracture. 


Fig.  i6. — Left  hand  of  a  demented  hemiplegic  under  Professor  Charcot's  care. 

This  constitutes  the  phenomenon  known  under  the  name 
of  "  associated  movements,"  and  is  present  in  many  cases 
of  hemiplegia  where  no  contracture  exists.  Hemiplegic 
contractures  are  so  common  that  no  time  will  be  given  to 
the  narration  of  a  case,  but  several  figures  will  be  introduced 
to  demonstrate  their  different  phases. 

When  a  destructive  cerebral  lesion  causing  hemiplegia 
occurs  in  very  early  childhood,  the  limbs  on  the  paralyzed 
side  seldom,  if  ever,  attain  the  same  development  as  those 
on  the  other  side.  There  may  also  be  left  a  spasmodic  or  a 
paralytic  deformity.     Of  the  latter  we  will  speak  later  on. 


DEFORMITY  OF   THE  HAND  AS  A    SYMPTOM.        Jig 

of  the  former  now.     This  peculiar  deformity  is  designated 
as  that  produced  by  cerebral  atrophy. 

In  the  infant,  as  in  the  adult,  hemiplegia  generally  de- 
velops contracture.  The  position  is  also  generally  that  of 
pronation  and  flexion  of  the  hand  and  flexion  of  the  fingers. 
In  young  children  the  osseous,  cartilaginous,  and  ligamen- 
tous structures  of  the  wrist  joint  are  soft  and  malleable,  so 
to  speak,  and  the  result  of  a  long  continuance  in  a  vicious 
position  is  a  permanent  change  in  the  articular  structures, 
rendering  a  normal  attitude  and  movement  of  the  hand  al- 
most impossible.  The  deformity  of  the  hand  resulting  is 
generally  as  follows  (see  fig.  17).     The  forearm  is  semiflexed 


Fig.  17.— Right  hand  of  John  M ,  Dr.  Seguin's  case  of  infantile  hemiplegia  and  cere- 
bral atrophy. 

and  partly  pronated,  the  hand  is  strongly  flexed  on  the  fore- 
arm and  is  generally  inclined  more  to  the  ulnar  side,  while 
the  fingers  are  generally  slightly,  if  at  all,  flexed  on  the  palm. 


720  R.    W.  AMIDON. 

Extension  of  the  wrist  is  almost  impossible,  the  palmar 
edge  of  the  carpal  bones  having  become  thin,  and  very  like- 
ly the  articular  end  of  the  radius  being  also  bevelled  off  on 
its  palmar  aspect.  The  hand  is  smaller  than  its  fellow,  and 
may  or  may  not  show  some  general  atrophy.  Voluntary 
movements  will  be  very  restricted,  while  there  may  be  athe- 
toid  movements  and  very  surely  associated  movements  in 
the  deformed  hand.  Sensibility  is  generally  preserved  and 
electro-contractility  (unless  there  be  atrophy)  normal. 

The  following  case  is  typical : 

John  M.,  21  years  old,  came  to  the  clinic  of  Dr.  Seguin,  at  the 
Manhattan  Hospital,  Aug.  9,  1881. 

The  mother  states  that  soon  after  the  birth  of  the  child  she 
noticed  he  had  strabismus.  When  the  child  was  about  four  months 
old  she  began  to  notice  a  weakness  of  the  right  arm  and  leg. 

When  three  years  old  the  child  had  two  fits  in  rapid  succes- 
sion. Three  years  later  he  had  another  fit,  and  since  then  he  has 
had  typical  epileptic  attacks  at  intervals  of  six  or  eight  weeks  to 
the  present  time.    The  hand  has  been  contractured  for  many  years. 

Examination  revealed  that  there  was  a  slight  ptosis  of  the 
right  eye,  which  was  in  external  strabismus.  The  pupils  were 
equal  and  optic  nerves  normal.  The  tongue  deviated  toward  the 
right  side,  and  the  right  face  was  weak.  The  walk  was  pretty 
good,  but  hemiparetic.  There  was  no  talipes.  There  was  marked 
atrophy  in  the  extensor  region  of  the  right  forearm,  and  when 
the  forearm  was  flexed  the  hand  and  fingers  were  in  the  attitude 
called  "cou  de  cygne,"  which  has  been  already  described.  An 
attempt  to  extend  the  wrist  causes  flexion  of  the  fingers,  and  vice 
versa.  There  are  the  usual  hemiplegic  reactions  to  electricity,  and 
there  is  no  an?esthesia.  The  hand  is  much  smaller  than  its  fellow 
and  is  very  weak. 

The  next  spasmodic  deformity  considered  will  be  hysteri- 
cal contracture.  Like  all  other  hysterical  manifestations  it 
conforms  to  no  regular  laws.  The  more  common  form  re- 
sembles, in  a  great  many  particulars,  a  hemiplegic  contracture. 
The  forearm  is  generally  firmly  flexed  and  supinated.  The 
hand  is  sharply  flexed,  more  toward  the  ulnar  side  of  the 


DEFORMITY  OF    THE  HAND  AS  A    SYMPTOM.        721 

forearm.  The  thumb  is  inverted  and  the  fingers  tightly 
clenched  into  the  palm  of  the  hand. 

Forced  extension  of  the  fingers  is  accomplished  with  great 
difficulty  and  with  apparent  pain  to  the  patient,  and  when 
they  are  released  they  instantaneously  return  to  their  former 
position.  The  contracture  can  also  be  reduced  by  very 
strong  faradization  of  the  extensors,  by  static  electricity,  and 
by  the  magnet,  as  shown  in  the  case  submitted  later.  There 
is  no  atrophy,  no  trophic  change,  no  loss  of  electro-contrac- 
tility in  the  hand  or  forearm.  There  is,  however,  often  a 
local  or  hemi-anaesthesia,  achromatopsy,  and  loss  of  the 
senses  of  smell  and  taste  on  the  same  side  with  the  con- 
tracture. 

The  history  often  reveals  other  hysterical  manifestations, 
as  convulsions,  ovarian  symptoms,  globus,  etc.,  etc.,  which, 
together  with  the  other  symptoms,  will  serve  to  distinguish 
an  hysterical  contracture  from  any  other. 

Sometimes  there  is  contracture  of  one  finger  or  the 
thumb  only,  as  in  a  case  reported  by  Dr.  Adam.  The  case 
occurring  in  Charcot's  service  at  the  Salpetiere,  and  so  ably 
treated  and  reported  by  Dr.  Vigouroux,  will  be  given  in  de- 
tail, as  it  is  typical. 


Fig.  i8.— Lefi  hand  of  Pauline  J.,  Professor  Charcot's  case  of  hysterical  contracture. 


722  R.    W.    AMIDON. 

The  patient  was  Pauline  J.,'  twenty-six  years  old,  of  large 
frame,  ruddy  complexion,  muscular,  and  rather  masculine  in  build, 
and  left-handed.  There  were  no  antecedents.  She  began  to  men- 
struate at  seventeen.  The  menses  were  always  regular,  but  pre- 
ceded by  lumbar  and  hypogastric  pains.  July  17,  1874,  while 
menstruating,  sat  in  a  cold  place  when  overheated,  and  had  a  vio- 
lent chill,  accompanied  by  general  hypersesthesia.  She  was  put 
to  bed,  when  a  violent  headache  came  on.  The  chill  lasted  two 
hours,  but  the  sensation  of  cold  continued  till  a  fever,  with  delir- 
ium, came  on,  which  lasted  eight  days.  The  headache  lasted 
fourteen  days.  After  the  headaches  came  hypogastric  pains,  with 
a  sense  of  constriction,  accompanied  by  retention  of  urine.  The 
first  attack  lasted  forty-eight  hours,  and  these  attacks  occurred  fre- 
quently in  the  next  three  years,  four  or  five  times.  This  attack 
was  replaced  by  attacks  of  incessant  vomiting.  In  November, 
1877,  one  evening,  she  felt  a  numbness  of  the  left  hand,  and  on 
trying  to  raise  it  it  fell  inert.  That  night  a  sort  of  coma  came  on 
and  lasted  three  days,  preceded  by  intense  headache.  Nine  days 
of  somnolence,  with  headache,  followed.  The  flaccid  left  hand 
soon  began  to  grow  rigid,  and  in  three  weeks  it  was  closely  shut. 
The  patient  had  noticed  a  feebleness  of  the  left  leg,  also  ;  she  had 
become  emotional  and  had  acquired  a  globus.  She  never,  how- 
ever, had  any  regular  hysterical  attacks. 

On  admission,*  June  3,  1878,  the  left  hand  was  flexed  at  a  right 
angle,  and  the  fingers  were  tightly  flexed  on  a  roll  of  linen  held  in 
the  palm.  The  elbow  and  shoulder  joints  were  mobile,  but  could 
not  be  voluntarily  moved.  There  was  no  atrophy,  and  farado- 
contractility  was  retained.  There  was  complete  anaesthesia  of  the 
entire  left  upper  extremity.  The  left  half  of  the  face  was  anal- 
gesic. The  left  ear,  affected  with  tinnitus,  was  deaf.  The  left 
eye  perceived  colors,  but  had  diminished  acuity  of  vision.  Smell 
was  diminished  and  taste  abolished  on  the  left  side.  Pressure  on 
the  vertex  and  all  down  the  spine  was  very  painful.  There  was 
pain — made  worse  by  pressure — in  both  ovarian  regions. 

Suffice  it  to  say  that  various  experiments  were  tried  with  the 
electro-magnet,  solenoid,  common  magnet,  galvanic,  faradic,  and 
static  electricity,  and  finally  a  course  of  treatment  was  commenced 
by  repeatedly  producing  a  contracture  on  the  right  side  with  a 

'  Contracture  hysterique  du  poignet  gauche.  Traitement  par  la  production 
artificielle  repetee  d'  une  contracture  du  poignet  droit.  Disparition  de  la  con- 
tracture primitive.  Applications  varices  de  1'  electricite.  Par  le  Dr.  Romain 
Vigouroux.     Prog.  Med.,  31  aout,  1878,  p.  679,  et  seq. 

'  Service  of  Professor  Charcot. 


DEFORMITY  OF    THE  HAND  AS  A    SYMPTOM.        723 

Strong  magnet,  which  finally  left  the  patient,  July  23d,  with  no 
contracture,  no  anaesthesia,  and  with  slight  voluntary  movements 
of  the  left  fingers  and  wrist. 

The  ultimate  recovery  of  the  left  upper  extremity  was  appar- 
ently perfect.  In  the  spring  of  1880,  however,  the  contracture 
and  anaesthesia  reappeared,  and  the  patient  returned  to  the  clinic 
of  Professor  Charcot  for  treatment,  and  it  was  at  that  time  (May 
10,  1880)  that  the  accompanying  drawing  was  made.  There  was 
anaesthesia  of  the  left  upper  extremity,  no  voluntary  movements 
below  the  elbow,  no  atrophy,  flexion  of  wrist  to  about  a  right 
angle,  and  tight  flexion  of  the  fingers  and  thumb  on  a  linen  com- 
press in  the  hand.  This  contracture  could  not  be  overcome  by 
any  force  safely  applied  to  the  fingers,  but  could  be  readily  over- 
come by  strong  faradization  to  the  extensors  of  the  hand  and 
fingers  in  the  forearm.  When  last  seen  this  case  was  under  treat- 
ment by  faradic  and  static  electricity,  and  the  occasional  applica- 
tion of  the  magnet,  but  had  not  yielded,  as  before,  to  any  treat- 
ment. 


Figs.  19  and  20.— Right  hands  of  two  patients  of  Professor  Charcot's,  with  athetosis. 

Athetosis  is  another  condition  which  can  be  classed  with 
contractures  as  a  spasmodic  deformity  of  the  hand.  Athe- 
tosis is  not  always  a  sequel  to  hemiplegia.  It  is  confined 
to  the  extremities  of  one  side,  however,  and  appears  gen- 


724 


A".    IV.    AMIDON. 


erally  after  an  apoplectic  attack,  a  hemi-  or  general  spasm,  a 
severe  headache,  an  aphasia,  a  vertigo,  or  some  other  mani- 
festation of  serious  cerebral  disturbance.  Some  weeks  or 
months  after  such  manifestations,  which  generally  are  hemi- 
plegic,  it  is  noticed  by  the  patient  that  he  is  unable  to  keep 
his  fingers  or  toes  still,  and  that  when  left  to  themselves, 
and  sometimes  in  spite  of  him,  they  are  continually  in 
motion.  These  movements  are  slow  and  vermicular,  re- 
semble in  no  particular  any  other  spasm  or  any  voluntary 
movement.  They  consist  in  alternate  flexion  and  exagger- 
ated extension,  abduction  and  adduction  of  the  fingers  and 
thumb,  all  usually  being  meanwhile  kept  straight,  the  move- 
ment chiefly  occurring  at  the  metacarpo-phalangeal  articu- 
lation. The  more  common  attitude  is  extension  and  wide 
separation  of  the  fingers  and  thumb.  These  movements  are 
continuous,  and  only  in  a  few  cases  can  be  entirely  stopped 
by  an  effort  of  the  will.    The  movements  are  aggravated  by 


Fig.  21. — Right  hand  of  a  peculiar  case  of  hemiplegia,  followed  by  athetosis  in  the  adult. 
Service  of  Professor  Charcot. 


DEFORMITY  OF    THE  HAND  AS  A   SYMPTOM.        725 

an  attempt  to  use  the  part  or  the  opposite  hand,  and  are 
accompanied  by  a  good  deal  of  pain.  There  may  or  may 
not  be  impairment  of  sensibility  in  the  part,  generally  none. 

Continual  exercise  often  causes  an  hypertrophy  of  the 
affected  muscles,  so  that  the  arm  and  leg  of  the  affected 
side  are  often  larger  than  the  opposite,  and  of  great  hard- 
ness. There  is,  however,  a  real  loss  of  voluntary  power  in 
the  part.  In  many  cases  there  occur  occasional  epileptic 
paroxysms,  and  there  is  generally  considerable  failure  of  the 
mental  powers.  There  are  seen  no  trophic  changes  in  the 
parts,  and  no  change  in  the  electrical  reactions  of  the 
muscles. 

The  above  remarks  sufficiently  cover  the  clinical  aspects 
of  the  disease,  so  it  will  suffice  to  say  that  the  patients  from 
whom  two  of  the  accompanying  sketches  were  taken  were 
idiots  about  thirteen  years  old,  affected  with  infantile  hemi- 
plegia and  partial  epilepsy,  in  the  service  of  Prof.  Charcot, 
at  the  Salpetriere  (see  figs.  19  and  20). 

A  peculiar  deformity  of  the  hand  occurs  in  the  course  of 
the  disease  known  as  paralysis  agitans.  This  disease,  rarely 
seen,  except  in  adults  past  forty,  begins  by  a  slight  rythmical 
tremor  generally  in  the  hand,  or  the  fingers  of  one  hand. 
This  tremor  gradually  increases,  becomes  more  general  in 
the  extremity  first  attacked,  and  then  invades  the  other  ex- 
tremity on  the  same  side,  and  perhaps  later  the  correspond- 
ing extremity  on  the  opposite  side,  and  even  toward  the  last, 
though  rarely,  all  four  extremities.  The  exciting  cause  of 
the  disease  appears  in  many  cases  to  be  a  mental  shock  of 
some  kind.  The  movement  is  generally  continuous  during 
waking  hours  and  absent  during  sleep  ;  is  made  worse  by 
excitement  of  any  kind,  and  is  aggravated  by  a  depressed 
mental  or  physical  condition.  In  almost  all  cases  it  can  be 
temporarily  stopped  by  a  strong  effort  of  the  will.  The  con- 
tinual  motion  causes  no  such  hypertrophy  as  athetosis,  and 


T26  R.    w.   AMIDOAT. 

is  very  tiring  to  the  patient,  who  often  complains  of  severe 
pains  in  the  muscles,  which  are  the  seat  of  tremor.  The 
movement  which  is  characteristic  of  the  disease  when  fully- 
developed  is  this :  the  arm  is  slightly  abducted  and  the 
shoulder  has  a  tendency  to  fall  forward  and  inward  on  the 
chest,  the  forearm  is  flexed  to  nearly  a  right  angle,  thus 
bringing  the  hand  in  the  neighborhood  of  the  pubes,  the 
most  natural  attitude  for  the  patient.  The  hand  is  not 
generally  flexed,  but  the  fingers  are  semiflexed  in  a  nearly 
straight  condition,  and  the  thumb  is  generally  nearly  op- 
posed to  them  ;  the  more  common  attitude  then  being  that 
in  which  we  hold  a  pen  when  writing.    The  fingers  generally 


Fig.  22. — Left  hand  of  a  case  of  paralysis  agitans  under  Professor  Charcot's  care. 

have  the  deviation  toward  the  ulnar  border  of  the  hand,  as 
in  chronic  rheumatism.  Such  being  the  position  of  the 
hand,  now  for  the  movements. 

Often  there  are  slight  flexions  and  extensions  of  the  fore- 
arm and  wrist.  The  fingers  continually  oscillate  in  move- 
ments of  slight  flexion  and  extension,  which  give  the  hand 
a  pawing  motion,  and  which,  with  opposition  of  the  thumb, 
give  the  hand  the  appearance  as  if  rolling  a  thread  or  paper 
ball  between  the  fingers  and  thumb. 

Later  in  the  disease  distortions  like  those  in  rheumatism 
may  still  further  deform  the  hand,  and  atrophy  may  super- 
vene from  prolonged  disease,  and  the  electrical  reactions  may 
be  modified,  but  in  the  uncomplicated  disease  they  remain 
unchanged. 


DEFORMITY  OF    THE  HAND  AS  A    SYMPTOM. 


727 


Late  in  the  disease  there  comes  on  a  marked  rigidity  of 
the  spine,  with  flexion  and  projection  forward  of  the  head 
and  neck,  a  fixed,  stooping  attitude,  and  a  marked  shorten- 
ing of  the  stature.  Slowness  of  speech  and  mental  impair- 
ment often  are  present,  and  a  symptom  common  to  almost 
all  is  an  unnatural  subjective  warmth  of  the  body  at  night, 
or  whenever  they  are  in  bed,  leading  them  to  require  much 
less  covering  than  other  patients  in  the  same  ward,  or  than 
they  themselves  did  before  their  sickness.  The  following  is 
the  history'  of  a  typical  case  in  which  the  tremor  was  very 
general : 

The  patient  was  a  woman  in  the  St.  Alexandre  ward  of  the  In- 
firmary at  the  Salpetriere  under  Prof.  Charcot's  care.  She  was  60 
years  old.  Twelve  years  before  she  had  a  crying  spell,  brought 
on  by  some  intense  emotional  disturbance.  She  noticed  imme- 
diately afterward  a  weakness  of  the  arms,  first  the  right.  Soon 
after  the  legs  became  weak,  the  right  first.  At  the  same  time 
there  were  some  cramps.     Tremors  appeared  first  in  1873. 

The  following  notes  were  taken  July  8,  1874: 

The  mouth  is  open  about  a  centimetre  ;  the  lower  lip  falls. 
There  is  some  difficulty  in  deglutition.  Her  sleep  is  often  broken 
by  pains  in  the  fingers  ;  she  is  always  hot.     The  legs  are  adducted 


Fig.  23. — Right  hand  of  a  second  case  of  paralysis  agitans  under  Professor  Charcot's 
care. 


*  Taken  partly  from  the  hospital  records. 


728  R.    W.   AMIDON. 

and  the  trunk  strongly  bent  forward.  The  arms  are  slightly  ab- 
ducted and  flexed,  so  as  to  bring  the  hands  into  the  subumbilical 
region.  The  thumb  is  slightly  flexed,  and  the  index  is  semiflexed, 
and  the  other  fingers  are  semiflexed  together.  The  head  is  fixed 
and  rigid. 

At  the  time  the  sketch  (fig.  22)  was  made,  June  19,  1880,  the 
condition  of  the  patient  was  little  changed.  She  had  not  walked 
for  several  years,  and  could  not  raise  herself  in  bed.  She  is  taken 
out  of  bed  and  sits  doubled  up  in  a  chair.  The  head  is  inclined 
to  the  left  shoulder  and  slightly  forward,  and  is  fixed.  There  is 
some  tremor  of  the  lower  lip  and  tongue  when  protruded.  Her 
arms  are  slightly  abducted,  the  elbows  are  flexed,  and  both  hands 
rest  in  the  lap  near  the  pubes,  and  are  in  continual  motion,  of  the 
ordinary  pawing  variety.  There  is  ulnar  deviation  of  the  fingers 
and  a  contracture  of  the  hand,  which  can  be  overcome  by  force. 
There  is  considerable  atrophy  of  the  first  interosseous  muscle. 
There  is  considerable  tremor  of  the  left  foot.  The  parts  which 
are  the  seat  of  spasm  are  also  painful,  and  not  only  is  sensibility 
retained,  but  there  appears  to  be  some  hyperesthesia  of  the  legs. 

3. — PARALYTIC   DEFORMITIES. 

Under  the  head  of  paralytic  deformities,  of  course,  is 
included  the  temporary  condition  of  the  hand  immediately 
after  various  nerve  injuries.  This  is  especially  true  of  the 
deformity  produced  by  injury  to  the  musculo-spiral  nerve. 
This  deformity  is  simply  a  drop  wrist,  and  this  is  to  be 
spoken  of  immediately  under  lead  paralysis,  where  all  the 
points  in  differential  diagnosis  will  be  fully  brought  out. 

A  person  after  exposure  to  lead  in  various  ways,  by  in- 
halation, by  swallowing,  and  in  all  probability  sometimes 
endermically,  and  commonly  after  some  other  toxic  man- 
ifestations of  the  poison,  as  colics,  constipation,  cachexia, 
etc.,  rather  suddenly  notices  an  inability  to  extend  the 
wrist  and  fingers,  generally  on  both  sides.  Examination 
reveals  the  existence  of  drop  wrist.  There  is  partial  or 
complete  paralysis  of  the  extensors  of  the  hand  and 
fingers. 


DEFORMITY  OF   THE  HAND  AS  A   SYMPTOM. 


729 


Unlike  the  drop  wrist  from  injury  to  the  musculo-spiral 
nerve  the  supinator  longus  escapes  in  saturnine  paralysis. 
The  electrical  reactions  are,  however,  much  the  same,  very 
soon  showing  the  degeneration  reaction  to  galvanism  and 
a  loss  of  farado-contractility. 


Fig.  24.— Right  hand  of  case  of  plumbism,  characterized  by  ''  drop  wrist"  and  atrophy 
under  Dr.  Seguin's  care. 

There  is  very  apt  to  be  a  tumefaction  on  the  back  of 
the  hand  in  these  cases  at  first.  If  the  paralysis  remain 
long  without  treatment,  atrophy  may  take  place  in  the 
paralyzed  area.  There  are  no  trophic  changes,  and  there 
is  generally  only  slight  impairment  of  sensibility.  As  in 
the  case  here  presented  the  paralysis  is  not  always  lim- 
ited to  the  extensors. 


Male,  aged  42,  first  seen  at  the  clinic  of  Dr.  Seguin  in  the  fall 
of  1878.'  In  July  of  that  year,  while  he  was  occupied  as  cook 
on  a  freshly  painted  yacht,  he  woke  up  one  morning  with  loss 
of  power  in  both  arms.  He  said  he  was  in  the  habit  of  drinking 
water  just  from  the  tap  every  morning,  and  that  this  water  was 
conducted  through  a  lead  pipe  from  the  tank. 

'  Part  of  the  history  was  taken  from  the  records  at  the  College  of  Physicians 
and  Surgeons. 


730 


R.    W.  A  MID  ON. 


On  Sept.  2oth,  when  first  examined,  he  had  double  drop  wrist, 
some  flattening  of  the  thenar  and  hypothenar  eminences,  and  pres- 
ervation of  the  supinator  longus.  He  had  had  no  colic,  and 
there  was  now  no  blue  line  on  the  gums. 

Oct.  1 2th  there  was  noticed  for  the  first  time  a  swelling  on  the 
back  of  the  wrists. 

Three  years  later  he  again  came  under  observation.  The  drop 
wrist  still  persisted.  There  was  much  atrophy  of  the  thenar  emi- 
nences and  of  the  first  interosseous  space.  The  grasp  was  good. 
Extension  of  the  two  last  phalanges  was  possible  in  all  fingers  ex- 
cept the  right  index.  There  was  some  adduction  but  no  opposi- 
tion of  the  thumb  possible.  They  were  inverted  and  their  distal 
phalanges  were  flexed.  There  was  some  impairment  of  sensibility 
in  this  case,  and  degeneration  reaction  in  all  the  paralyzed  and 
atrophic  area. 

A  deformity  of  the  hand  which  may  supervene  after  an 
infantile  hemiplegia,  besides  the  permanent  contracture 
already  spoken  of,  is  that  which  is  called  retarded  devel- 
opment. This  hand,  which  has  little  of  the  element  of 
spasm  or  contracture  about  it,  is  essentially  a  paralytic  de- 
formity. The  hand  is  simply  smaller  and  less  developed 
than  its  fellow.  It  is  well  nourished,  mobile,  properly 
shaped,  has  no  atrophy,  and  generally  no  anaesthesia.  It  is 
very  weak,  and  perhaps  the  occasional  seat  of  associated  or 
athetoid  movements.  Its  electrical  reactions  are  normal. 
Sometimes,  as  in  the  case  furnishing  the  subject  for  the  ac- 
companying sketch,  there  is  a  slight  tendency  toward  con- 
tracture, but  it  offers  no  resistance  and  the  part  is  generally 
very  limp. 


Fig.  25.— Left  hand  of  K.  B.,  patient  of  Dr.  Seguin.    Old  hemiplegia  and  retarded  devel- 
opment. 


DEFORMITY  OF    THE  HAND  AS  A    SYMPTOM.        731 

K.  B./  a  girl  of  fourteen  years,  had  a  hemiplegic  attack  at  the 
age  of  three.  She  never  fully  regained  power  on  the  left 
side,  though  at  the  time  the  sketch  was  made,  June  8,  1881,  the 
walk  was  hardly  hemiplegic.  The  most  noticeable  feature  in  her 
case  is  the  weakness  and  small  size  of  her  left  upper  extremity. 
The  hand  is  perfectly  shaped,  and  there  is  no  atrophy,  but  it  is 
very  much  smaller,  as  the  following  measurements  will  show  : 


HEALTHY 

SIDE. 

PARALYZED  SIDE. 

Circumference  of  the  the  wrist  . 

16.        cm. 

12.5       cm. 

Circumference  of  the  hand   below  the  first 

phalanx  of  the  thumb 

27-5 

" 

17. 

Circumference  of   the  hand   at   the  head  of 

the  metacarpal  bones,  excluding  the  thumb 

19. 

" 

15- 

Length  of  medius       ..... 

ID. 

" 

8.5          " 

Circumference  of  its  first  phalanx    . 

5-75 

" 

5- 

Circumference  of  the  thumb 

6.25 

" 

5-25     " 

At  times,  as  for  instance  when  this  sketch  was  made,  there  is  a 
slight  tendency  to  contracture  in  the  hand  of  this  patient. 

4.      DEFORMITIES   OF   LOCAL   CAUSATION. 

An  exhaustive  description  of  hand  deformities  of  local 
causation  would  hardly  be  in  place  in  a  journal  devoted  to 
neurology,  however  important  they  might  be.  Brief  men- 
tion, therefore,  of  a  few  will  be  made,  illustrated  as  well  as 
may  be  by  sketches.  Arthritis  deformans  (the  chronic  pro- 
gressive articular  rheumatism  of  Charcot),  as  a  disease  by 
itself,  is  seen  chiefly  in  people  of  adult  life.  It  quite  often 
begins  in  peripheral  parts  and  tends  in  a  centripetal  direc- 
tion. It  is  very  slow  in  its  progress,  and  its  course  is 
marked  by  very  many  intermissions.  It  often  commences 
by  a  painful  swelling  of  one  or  more  finger  or  toe  joints. 
The  swelling  is  not  accompanied  by  much  heat,  redness, 
and  no  subsequent  desquamation,  as  in  gout.  The  joints 
implicated  are  apt  to  be  symmetrical,  and  the  inflammatory 
process  leaves  them  more  or  less  anchylosed  and  distorted. 

'  Service  of  Dr.  Seguin  at  the  Manhattan  Hospital. 


732 


R.    W.  A  MID  ON. 


Successive  attacks  recur  in  the  same  joints  and  implicate 
new  ones,  until  a  more  or  less  complete  anchylosis  and 
marked  deformity  result.  The  disease,  when  advanced,  im- 
plicates the  larger  joints  of  the  body,  even  those  of  the 
spinal  column,  everywhere  causing  anchylosis  and  deform- 
ity.    There  are  not  always  marked  bony  deposits  about  the 


Fig.  26.— Left  hand  of  a  patient  with    arthritis  deformans  under  Professor  Charcot's 
care. 

diseased  joints  and  nerve  deposits  outside  the  joints,  as  in 
gout.  In  most  all  cases,  as  a  result  of  combined  muscular 
action  and  bony  deposit  in  the  joints,  there  is  a  deviation 
of  the  fingers  toward  the  ulnar  side  of  the  hand.  Beyond 
that  there  are  no  very  typical  deformities.  There  is  often 
seen  an  extension  of  the  first  phalanges,  a  flexion  of  the 
second,  and  an  extension  of  the  third.  (See  fig.  26.)  In 
others  all  the  phalanges  are  more  or  less  flexed.  (See  fig.  27.) 
The  thumbs  generally  escape.  The  course  of  the  disease 
is  frequently  marked  by  cedematous  swellings  of  the  hands. 
From  disuse  and  possibly  from  some  spreading  of  the 
disease  to  the  nerves  or  muscles  very  marked  atrophy  of 


Fig.  27.— Right  hand  of  a  case  of  arthritis  deformans  under  Dr.  Seguin's  care. 


DEFORMITY  OF   THE  HAND  AS  A   SYMPTOM.        733 

the  intrinsic  muscles  of  the  hand  ultimately  ensues.  Sub- 
luxation of  the  phalangeal  joints  sometimes  occurs,  and  re- 
markable thinning  and  smoothness  of  the  skin  often  ensue. 
In  rheumatic  arthritis  and  sometimes  accompanying  acute 
articular  rheumatism  deformities  of  the  hand  are  found,  but 
they  are  not  very  typical.  The  disease  is  not  always  sym- 
metrical ;  a  single  joint  may  be  affected  for  years  and  a  cure 
sometimes  results.  The  inflamed  joint  is  swollen,  hot,  and 
red,  and  very  tender  and  painful.  In  almost  all  these  par- 
ticulars the  disease  differs  from  arthritis  deformans. 


Fig.  28. — Left  hand  in  cases  of  rheumatic  arthritis  under  Prof.  Charcot's  care. 

The  deformity  it  leaves  resembles  that  of  arthritis  defor- 
mans (see  fig.  28)  by  presenting  generally  an  ulnar  devia- 
tion of  the  fingers  and  more  or  less  osseous  deposit  about 
the  joints.  It  differs  again  by  often  invading  the  thumb, 
which  it  leaves  with  extension  of  the  last  phalanx,  giving  it 
a  curved  appearance  represented  in  fig.  29. 


Fig.  29.— Left  thumb  in  cases  of  rheumatic  arthritis  under  Prof.  Charcot's  care. 


734 


K.    W.   AM  WON. 


The  gouty  might  easily  be  mistaken  for  the  rheumatic 
hand,  particularly  that  form  consisting  simply  of  articular 
enlargements,  anchylosis,  and  ulnar  deviation  of  the  fingers, 


Fig.  30.  —Gouty  hand  with  tophi.    Taken  from  Meillet. 

were  it  not  for  the  typical  history  the  gouty  case  presents. 
When,  however,  the  hand  presents  also  the  characteristic 
collections  of  urate  of  soda,  or  tophi,  the  deformity  can  be 
confounded  with  no  other.  These  tophi  present  globular 
swellings,  situated  on  various  joints,  varying  in  size  from  a 


ogry 


Fig.  31.— Hand  with  syphilitic  dactylitis.  Taken  from  Bumstead  and  Taylor's  "  Pathol- 
ry  and  Treatment  of  Venereal  Diseases."    Phila.,  1879. 


DEFORMITY  OF    THE  HAND  AS  A   SYMPTOM. 


735 


pea  to  a  pigeon's  egg,  covered  by  a  thin  bluish  skin,  often 
surrounded  by  tortuous,  hardened  veins.  The  indolent  ul- 
cers into  which  these  concretions  often  break  down  would 
also  be  a  mark  of  diagnostic  value.     (See  fig.  30.) 

The  deformities  produced  by  syphilitic  dactylitis  resem- 
ble in  some  features  those  of  gout  or  rheumatism,  but  the 
clinical  history,  with  the  anatomical  characteristics,  will  serve 
to  distinguish  them. 

The  deformity  resulting  from  contraction  of  the  palmar 
fascia  cannot  possibly  be  mistaken  for  any  thing  else,  and 
all  that  is  necessary  is  to  introduce  a  cut  copied  from 
Meillet. 


Fig.  35. — That  of  contraction  of  the  palmar  fascia,  all  taken  from  Meillet. 

The    bulbous    finger    tips   and   curved    nails  of  cyanosis 
and  phthisis  need  only  figures  borrowed  also  from  Meillet. 


Fig.  33. — That  of  cyanosis. 


Fig.  34. — That  of  phthisis,  and 


736 


/?.    IV.    AM/DON. 


The  writer  having  seen  but  one  case  of  scleroderma,  and 
not  having  at  command  a  sketch  of  her  hands,  borrows 
another  illustration  from  Meillet,  and  regrets  that  space 
does  not  allow  a  brief  r^suni^  of  that  interesting  disease. 


Fig.  32.— The  hand  of  scleroderma. 

At  some  future  date  a  separate  monograph  may  be  made  to 
treat  more  exhaustively  of  deformities  of  the  hand  of  local 
causation,  and  perhaps  those  of  a  surgical  nature,  all  of 
which  are  necessarily  crowded  out  of  an  article  like  this, 
which  treats  simply  of  "  medical "  deformities. 


DESTRUCTIVE  LESION  OF  THE  LEFT  CEREBRAL 
HEMISPHERE,  WITH  GENERAL  PACHYMENIN- 
GITIS, AND  A  LARGE  HEMORRHAGIC  CYST 
PRESSING  UPON  THE  RIGHT  HEMISPHERE,  OF 
THIRTEEN  YEARS'  STANDING* 

By  H.  D.  SCHMIDT,  M.  D.. 

PATHOLOGIST   OF   THE   CHARITY   HOSPITAL  OF   NEW   ORLEANS. 

THE  following  case  of  cerebral  lesion  is  worthy  of  being 
recorded,  not  only  for  the  extent  of  the  lesions  them- 
selves, but  also  for  the  long  period  of  time  through  which 
they  existed.  It  illustrates  the  ability  of  the  brain  to  bear 
a  considerable  amount  of  injury  without  causing  a  serious 
disturbance  of  the  general  health,  or  even  of  the  mental 
faculties  of  the  patient.  As  regards  the  history  of  the  case, 
I  regret  to  have  failed  in  obtaining  an  official  or  otherwise 
more  reliable  account  of  the  accompanying  circumstances 
of  the  injury  when  first  inflicted  upon  the  patient  than  that 
furnished  by  the  latter  himself,  as  such  a  knowledge  would 
have  much  facilitated  the  explanation  of  a  certain  phenom- 
enon revealed  by  the  autopsy.  But  as  the  patient  was  an  in- 
mate of  the  Charity  Hospital  for  nearly  fourteen  years,  he 
frequently  told  his  story  to  the  nurses  and  patients  of  the 
institution,  and,  from  what  I  have  learned,  also  without 
variation,  which  renders  his  account  quite  credible.  The 
story  runs  as  follows  : 

In  the  years  1865  and  1866,  Edward  Farley,  of  Irish  na- 

*  The  plates  illustrating  this  article  will  be  furnished  with  the  next  volume 
and  mailed  to  subscribers. 

737 


738  H.    D.    SCHMIDT. 

tionality,  worked  at  Memphis,  Tenn.,  and  was  in  the  pos- 
session of  some  money,  which  he  had  lent  to  one  of  his 
friends.  When  asking  one  evening  for  the  return  of  this 
money,  his  friend,  who  was  performing  the  function  of  a 
watchman,  answered  the  demand  with  a  blow  of  his  club  upon 
Farley's  head,  felling  him  senseless  to  the  ground.  When 
recovering  his  consciousness,  the  latter  found  himself  at  the 
Memphis  City  Hospital,  to  which  he  had  been  taken,  and 
where  he  had  lived  in  an  unconscious  state  for  a  number  of 
weeks.  He  then  found  himself  paralyzed  on  both  sides, 
though  at  the  time  of  leaving  this  hospital,  to  start  for  New 
Orleans,  the  left  extremities  had  recovered  their  functions. 
Thus,  when  entering  the  Charity  Hospital  of  this  city,  in 
1877,  he  was  only  affected  with  right  hemiplegia,  which, 
however,  did  not  prevent  him  from  making  his  v/ay  to  this 
institution  a-foot.  It  is  to  be  regretted  that  the  physician 
of  the  particular  ward  to  which  he  was  assigned  when  enter- 
ing the  hospital  is  now  dead  for  several  years,  as  otherwise 
more  accurate  data  concerning  the  patient's  condition  at 
that  time  might  have  been  obtained.  Through  one  of  the 
older  Sisters  of  Charity,  who  was  then  supervising  this  ward, 
however,  I  learned  that  the  hemiplegia  interfered  but  little 
with  his  movements,  and  that  he  had  rather  come  to  the 
hospital  on  account  of  his  eyes,  though  in  later  years  his 
sight  appears  to  have  been  unaffected.  In  the  course  of 
some  time,  as  it  frequently  happens  with  incurable  cases, 
all  special  treatment  was  abandoned,  and  he  became  a  per- 
manent inmate  of  the  institution,  enjoying  the  privilege  of 
roaming  at  his  leisure  about  the  place.  As  such  I  have  met 
him  about  the  hospital  for  a  number  of  years  until  a  few 
months  before  his  death. 

According  to  the  statements  of  three  old  nurses,  who 
knew  him  since  1869,  and  to  what  I  observed  myself,  Farley 
was  paralyzed  in  both   extremities  of  the  right  side,  with 


LESION  OF  THE  LEFT  CEREBRAL  HEMISPHERE.      739 

contracture  of  the  flexors  of  the  forearm,  wrist,  and  fingers. 
In  walking  he  dragged  the  paralyzed  lower  extremity  along, 
and  as  the  large  toe,  in  consequence  of  the  paralysis  of  the 
flexors  of  the  foot,  frequently  struck  the  ground,  he  some- 
times stumbled  and  fell.  His  general  health,  including  his 
appetite,  was  always  good.  He  had  no  convulsions,  no 
pains  in  the  head,  nor  anywhere  else.  His  mind  was  clear, 
and  he  was  able  to  express  his  ideas  at  all  times  without 
difficulty,  and  intelligently  refer  back  to  things  that  had 
happened  many  years  before.  His  disposition  was  very  ir- 
ritable, and  a  fit  of  anger  appeared  to  render  him  somewhat 
stupid  for  a  day.  As  I  learned  from  one  of  the  Sisters  of 
Charity,  he  was  very  pious,  and  a  regular  visitor  of  the  little 
chapel  in  the  hospital,  where,  only  during  the  last  years 
of  his  life,  he  had  some  trouble  in  kneeling.  A  few 
months  before  his  death  he  became  more  dull  and  peevish  ; 
he  would  roam  about  in  a  listless  manner,  and  frequently  be 
unable  to  find  his  way  back  to  his  ward  ;  he  would  leave 
things  behind  him  without  being  able  to  render  an  account 
of  them,  nor  knowing  where  he  had  last  been.  During  this 
time  also  he  became  unable  to  express  his  wishes  or  wants  ; 
he  would  apply  to  the  nurse  of  the  ward  for  one  thing  or 
the  other,  but,  unable  to  tell  what  he  wanted,  he  would 
come  to  a  "  halt,"  and  mutter  some  incomprehensible  words 
to  himself ;  if,  however,  somebody  would  mention  the  thing 
he  wanted,  he  would  say  "yes"  in  a  startled  manner;  his 
sight  also  commenced  to  fail.  About  three  weeks  before 
his  death  his  mind  became  completely  clouded  ;  he  was  un- 
conscious of  what  he  did,  and  on  some  occasions  fell  into  a 
quiet  swoon  without  convulsive  movements.  In  such  a  con- 
dition he  died. 

Before  dismissing  the  clinical  history  of  this  case,  it  re- 
mains to  be  mentioned  that  there  was  a  deep  depression  of 
an  oval  shape,  and  soft  to  the  touch,  upon  the  left  side  of 


740  H.  D.  SCHMIDT. 

Farley's  head,  corresponding  to  the  place  upon  which  the 
blow  of  the  club  had  been  applied.  It  was  by  this  depres- 
sion that  the  patient  was  known  to  most  of  the  inmates  of 
the  hospital ;  though  he  himself  always  asserted  that,  to 
the  extent  of  his  knowledge,  there  had  never  been  an  open 
sore  or  wound  upon  tJiis  place. 

The  autopsy  made  in  this  case  was  limited  to  the  exami- 
nation of  the  head  and  brain.  In  the  left  parietal  region 
of  the  former,  the  above-mentioned  depression  was  noticed. 
There  was  Tio  defect  or  cicatrix  of  the  scalp  observed  over 
this  area ;  the  skin  appeared  healthy  and  was  covered  with 
hair  as  abundantly  as  upon  the  rest  of  the  head ;  nor  was 
there  any  difficulty  in  dissecting  the  scalp  from  the  surface 
of  the  depression,  it  being  attached  to  the  subjacent  struc- 
ture by  a  soft  connective  tissue.  When  the  cranium  was 
exposed  by  the  removal  of  the  scalp,  the  depression  was 
found  to  be  due  to  a  deficiency,  or  large  hole,  in  the  bony 
vault,  filled  and  closed  by  a  membrane  of  a  dense  structure, 
presenting  a  white,  almost  glistening,  appearance.  The 
orifice  formed  by  the  absence  of  bony  tissue  was  perfectly 
oval  in  form,  measuring  9^^  cm.  in  a  horizontal,  and  5  cm. 
in  a  vertical  direction ;  the  space  between  the  superior 
border  of  the  orifice  and  the  median  line  of  the  vertex  being 
about  3  cm.  During  the  operation  of  removing  the  cal- 
varium,  it  was  found  that  the  membrane  filling  up  the 
orifice  in  the  bone  closely  adhered  to  the  dura  mater,  and, 
to  accomplish  the  object  in  view,  it  became  necessary  to 
dissect  the  membrane  from  the  bony  margin  without  de- 
taching it  from  the  dura  mater,  after  which  proceeding  the 
calvarium  was  removed  without  difficulty.  In  removing 
the  dura  mater,  by  cutting  it  at  a  level  with  the  cranial 
bones  left,  another  phenomenon  was  met  with  on  the  inner 
surface  of  the  right  half  of  this  membrane,  consisting  in  a 
large,  so-called  hemorrhagic  cyst  with  comparatively  thick 


LESION  OF  THE  LEFT  CEREBRAL  HEMISPHERE.      74 1 

walls,  indicating  that  it  had  existed  for  a  long  time.  The 
upper  border  of  this  cyst  ran  parallel  with  the  longitudinal 
fissure  at  a  distance  of  i8  mm.  The  cyst  itself  measured 
in  a  downward  direction  6^  cm.,  while  horizontally  its 
length  amounted  to  lo  cm.;  it  was  ovoid  in  shape,  and  its 
thickness  or  transverse  diameter  amounted  to  2  cm.  As 
the  result  of  the  pressure  of  this  cyst  upon  the  underlying 
right  cerebral  hemisphere,  the  latter,  instead  of  its  normal 
convexity,  presented  a  slightly  concave  surface,  correspond- 
ing to  the  size  and  form  of  the  cyst.  As  will  be  seen  from 
the  above  description,  the  orifice  in  the  bony  vault  on  the 
left,  and  the  cyst  on  the  right  side,  were  situated  very 
nearly  opposite  to  each  other.  The  condition  of  the  dura 
mater,  and  the  structure  of  the  cyst  and  the  membrane, 
filling  up  the  orifice  in  the  bone,  will  be  discussed  further 
on. 

The  condition  of  the  pia  mater  was  that  of  chronic  hy- 
peraemia,  the  minute  and  larger  vessels  filled  with  blood ; 
there  was  opacity  of  the  arachnoid  membrane  almost  over 
the  whole  convexity  of  the  cerebrum  ;  in  some  places  even 
it  was  thickened. 

In  the  left  hemisphere  of  the  cerebrum  a  large  cavity 
was  found,  extending  through  the  posterior  third  of  the 
middle  frontal  convolution,  directly  in  front  of  the  sulcus 
praecentralis,  through  the  two  inferior  thirds  of  the  anterior 
and  posterior  central  convolutions,  the  entire  supramar- 
ginal  and  the  anterior  portion  of  the  angular  convolution, 
and,  furthermore,  through  the  superior  third  of  the  superior 
temporal  convolution.  The  orifice  of  this  cavity,  that  is, 
the  area  in  which  the  cortex  cerebri  was  entirely  destroyed, 
embraced  the  root  of  the  middle  frontal,  the  middle  of  the 
anterior  and  posterior  central,  and  the  greater  part  of  the 
supramarginal  convolutions.  The  destruction  was  entirely 
confined   to  the  white  substance  of  the  cerebrum,  leaving 


742  H.  D.  SCHMIDT. 

the  gray  substance  of  the  cortex  in  the  form  of  a  shell  with 
a  perfectly  smooth  inner  surface,  and  passing  around  the 
larger  and  smaller  sulci  in  the  depth  of  the  hemisphere. 
The  thickness  of  the  wall  left  between  this  cavity  and  the 
upper  part  of  the  left  lateral  ventricle  amounted  to  about 
I  mm.  The  pia  mater  extending  over  the  orifice  of  the 
cavity  was  not  attached  to  the  dura  mater,  but  had  fallen 
into  the  cavity,  occupying  about  one  third  of  the  latter, 
and  forming,  so  to  say,  a  separate  compartment  of  it. 

Let  us  now  consider  the  different  lesions  individually, 
commencing  with  the  calvarium.  The  orifice  in  this  bony 
vault  was  situated  in  the  parietal  and  frontal  bones,  while 
its  lower  border  slightly  encroached  upon  the  squamous 
portion  of  the  temporal  bone,  its  upper  border  being  37  mm. 
distant  from  the  sagittal  suture.  The  margin  of  this  patho- 
logical fenestra  in  the  bone  was  thinned,  or  bevelled,  upon 
the  outer  surface,  quite  smooth,  and  presented  the  appear- 
ance of  the  outer  table  bent  down  by  the  disappearance  of 
the  diploe,  while  at  the  inside  the  border  was  even  with  the 
inner  surface  of  the  calvarium.  In  some  places  here  the 
surface  of  the  inner  table  appeared  eroded,  or  roughened 
by  the  absorption  of  bony  tissue.  Directly  in  front  of  the 
coronal  suture  a  small  protuberance,  or  thickening  of  the 
bony  margin,  was  observed.  In  the  rest  both  the  parietal 
and  frontal  bones  appeared  in  a  healthy  condition. 

The  dura  mater  throughout,  but  particularly  over  and  to 
some  distance  beyond  the  seat  of  the  lesion,  presented  the 
appearance  of  inflammation,  with  all  the  characters  of 
chronic  pachymeningitis.  Its  inner  surface  was  covered 
with  a  pseudo-membrane,  upon  the  surface  of  which  numer- 
ous minute  red  spots,  resembling  small  extravasations  of 
blood,  were  exhibited.  On  the  right  side  the  pseudo-mem- 
brane had  developed  into  the  cyst  already  mentioned.  On 
the  left  side  the  dura  mater  was  attached  to,  or  rather  con- 


LESION  OF  THE  LEFT  CEREBRAL  HEMISPHERE.      743 

tinued  into,  the  fibrous  membrane,  which,  filling  up  the 
artificial  foramen  in  the  parietal  and  frontal  bones,  was 
closely  attached  to  the  bony  margin  and  loosely  to  the 
scalp  (fig.  i).  A  thin  microscopical  section  of  this  part  of 
the  dura  mater  showed  that  the  fibrous  structure  filling  up 
the  orifice  differed  in  no  respect  from  the  former,  adjacent 
to  the  arachnoid,  but  consisted  of  the  same  coarse  bundles 
of  connective  tissue ;  nor  were  there  any  pathological 
changes  observed  in  the  newly  formed  portion.  The  fibrous 
structure,  found  in  the  place  of  the  absent  bony  tissue, 
therefore,  cannot  be  considered  but  a  part,  or  thickening,  of 
the  dura  mater.  The  inner  or  arachnoidal  surface  of  the 
latter,  on  this  side,  was  covered,  as  already  mentioned,  by 
the  well-known  pseudo-membrane. 

Before  proceeding  to  the  description  of  the  cyst,  a  few 
remarks  regarding  the  particular  pathological  process  con- 
cerned in  the  disappearance  of  the  bony  structure  may  be 
appropriate.  My  first  idea  as  to  the  loss  of  bone  in  the 
cranial  vault  was  that  the  bones  might  have  been  fractured 
by  the  weight  of  the  blow  into  small  fragments,  and  been 
subsequently  removed  by  necrosis  through  an  open  wound, — 
a  view  which  I,  however,  found  incorrect  when  learning  the 
patient's  repeated  assertions  that  there  never  had  been  a  loss 
of  continuity  in  the  skin  of  this  locality,  and  when,  further- 
more, no  traces  of  a  loss  of  tissue  were  detected  at  the 
autopsy.  If  the  patient's  statements  were  founded  upon 
truth,  then  the  disappearance  of  the  bony  tissue  could 
only  be  explained  by  referring  it  to  the  effects  of  the  blow 
having  caused  a  disturbance  in  the  nutrition  of  the  bone, 
leading  eventually  to  atrophy  of  the  osseous  tissue.  There 
have  been  and  perhaps  always  are  a  limited  number  of  cases 
observed  in  which  small  portions  of  the  cranial  bones  are 
found  atrophied  ;  but  in  these  instances  the  absorption  of 
the  bone  is  caused  by  the  pressure  of  tumors  against  the 


744  H-  D.  SCHMIDT. 

inner  table,  or  by  deficient  nutrition  concomitant  to  old  age 
or  depending  upon  diseased  arteries.  In  the  case  under 
discussion,  also,  the  blood-vessels  of  that  portion  of  bone 
injured  by  the  blow  may  have  been  diseased  and  induced  a 
process  of  atrophy,  though  it  will  still  remain  an  open  ques- 
tion as  to  whether  the  fibrous  membrane  filling  up  the  ori- 
fice left  represented  the  bone  itself,  minus  the  earthy  con- 
stituents, or  whether  it  arose  from  the  inflamed  dura  mater 
to  simply  replace  the  atrophied  bony  tissue, 

A  vertical  transverse  section  of  the  cyst  on  the  right  half 
of  the  dura  mater  (fig.  i)  showed  that  this  tumor  was  ellip- 
soidal in  form,  and  contained  two  cavities  greatly  differing 
in  size  and  separated  by  a  thick  partition  formed  by  the 
inner  strata  of  the  cyst.  While  the  vertical  diameter  of 
the  upper  cavity,  or  compartment,  only  measured  from  ii 
to  12  mm.,  that  of  the  lower  amounted  to  42  mm.  The 
walls  of  this  cyst  were  entirely  formed  by  the  successive 
layers  of  the  pseudo-membrane,  the  dura  mater  itself  form- 
ing no  integral  part  of  them.  Their  thickness  measured  in 
the  average  about  i  mm.,  which,  in  the  upper  half  of  the 
cyst,  increased  to  nearly  2  mm.  Thin,  microscopical,  trans- 
verse sections  of  the  walls  of  the  upper  part  of  the  cyst, 
including  the  partition  or  septum,  showed  that  they  con- 
sisted of  numerous  strata,  or  membranes,  measuring  in 
thickness  from  ^-^^  to  yfg-g-  mm.,  and  which,  microscopi- 
cally, could  be  separated  from  each  other  with  a  little  care. 
In  the  same  manner  a  separation  could  be  effected — rather 
more  easily — of  the  layers  composing  the  thinner  portion 
of  the  pseudo-membrane  covering  the  inner  surface  of  the 
dura  mater  beyond  the  cyst,  both  on  the  right  and  left  side. 

Stretched  throughout  the  cavities  of  the  cyst,  a  net  or 
framework  similar  in  form  to  the  stroma  of  a  sarcoma  or 
cancer,  and  consisting  of  coagulated  fibrin,  was  met  with ; 
the  larger  or  smaller  areolar  spaces  into  which  the  cavities 


LESION  OF  THE  LEFT  CEREBRAL  HEMISPHERE.      745 

were  divided  by  this  network,  and  which  communicated 
with  each  other,  were  filled  up  by  a  yellow,  slightly  reddish, 
gelatinous  fluid.  A  microscopical  examination  of  the  anas- 
tomosing branches  of  this  framework  showed  the  character- 
istic structure  of  coagulated  fibrin,  viz.,  the  minute  network 
of  fine  granular  fibrillae. 

Reserving  some  additional  remarks  upon  the  fibrinous 
framework  extending  throughout  the  cavities  of  the  cyst 
for  hereafter,  I  now  pass  to  the  description  of  the  minute 
structure  of  the  pseudo-membrane. 

As  may  be  supposed,  and  as  has  been  known  for  some 
time,  the  mode  of  formation  and  development,  as  well  as 
the  structure  of  this  membrane,  whether  forming  the  walls 
of  a  cyst,  or  whether  simply  covering  the  inner  surface  of 
the  inflamed  dura  mater,  presents  everywhere  the  same  pe- 
culiarities and  characters.  According  to  the  prevailing 
theory,  established  by  Virchow,  the  pseudo-membrane  orig- 
inally represents  an  efflorescence,  or  exudate,  of  the  in- 
flamed dura  mater.  The  newly  formed  blood-vessels,  extend- 
ing through  and  forming  a  considerable  portion  of  the  neo- 
membrane,  are  regarded  as  derived  from  the  adjacent  dura 
mater,  while  the  delicate  connective  tissue  forming  its  sub- 
stratum is  supposed  to  originate  from  emigrated  colorless 
blood  corpuscles.  Let  us  examine  how  far  this  theory  cor- 
responds with  the  results  of  my  own  examinations  in  re- 
viewing the  structure  of  a  thin  portion  of  the  pseudo-mem- 
brane detached  from  the  dura  mater  beyond  the  cyst.  In 
doing  so  it  will  be  observed  that  this  membrane  is  very 
loosely  attached  to  the  dura  mater,  a  circumstance  which 
has  been  explained  by  the  mutual  connection  between  these 
membranes  being  solely  affected  through  the  minute  blood- 
vessels passing  from  the  latter  to  the  former,  as  seen  with 
the  aid  of  a  loupe,  or  even  by  the  naked  eye.  This,  how- 
ever, is  not  altogether  the  case,  for  in  examining  thin  sec- 


74^  H.  D.   SCHMIDT. 

tions,  including  the  dura  mater  and  pseudo-membrane,  it 
will  be  found  that  the  first  stratum  of  the  latter  is  generally 
closely  attached  to  the  former,  and  the  separation  actually 
takes  place  between  this  stratum  and  the  next  one.  In 
these  sections  it  will  furthermore  be  observed  that  the  in- 
dividual strata  or  layers  composing  the  membrane  are  not 
placed  exactly  parallel  to  each  other  throughout  the  whole 
membrane,  but  in  many  places  run  into  each  other  by  means 
of  the  network  of  blood-vessels,  of  which  they  are  chiefly 
composed.  And  it  is  these  blood-vessels,  surrounded  by 
bundles  of  delicate  connective  tissue,  which  are  seen  pass- 
ing from  the  first  to  the  second  stratum  when  the  membrane 
is  carefully  pulled  off  from  the  dura  mater. 

If  one  of  the  thin  layers  of  which  the  membrane  consists 
is  separated  from  the  rest,  properly  prepared,  and  examined 
under  the  microscope,  it  will  be  found  that  it  is  almost  en- 
tirely composed  of  small  blood-vessels,  with  a  diameter 
ranging  from  yTyVc  ^^  looo  rnr"-)  ^nd  presenting  themselves 
in  very  different  conditions.  Those  among  them  approach- 
ing most  closely  the  normal  type  show  a  single  wall,  distin- 
guished by  a  distinct  double  contour,  and  lodge,  the  same 
as  normal  capillaries,  a  number  of  oval  nuclei.  These  ves- 
sels, like  all  others  forming  the  membrane,  divide  at  short 
distances  dicho-  or  tricho-tomously,  and,  closely  anastomos- 
ing with  each  other,  form  an  intricate  vascular  network ; 
they  contain  blood  corpuscles  in  larger  or  smaller  numbers. 
There  are,  however,  a  considerable  number  of  other  vessels 
exhibiting  the  same  characters  as  just  described,  but  pre- 
senting a  second  layer  or  coat  formed  around  their  original 
wall  by  a  rather  extraordinary  process  (figs.  2  and  3).  Along 
the  walls  of  these  vessels,  and  surrounding  them,  namely, 
numerous  larger  or  smaller  masses  of  so-called  haematin 
globules  are  observed.  In  the  angles  formed  by  the  divisions 
of  the  vessels,   particularly,  entire  accumulations  of  these 


LESION  OF  THE  LEFT  CEREBRAL  HEMISPHERE.      747 

masses  are  met  with.  The  masses  themselves  consist  of  a 
number  of  larger  or  smaller  globules — the  larger  ones  of  the 
size  of  colored  blood  corpuscles, — and  present  the  yellow 
color  and  lustrous  appearance  of  crystalline  haematin,  or 
haematoidin  ;  they  are  enclosed  in  a  finely  granular  proto- 
plasm, exhibiting  a  distinct  border,  and  containing  one  or 
two  nuclei,  the  whole  mass  thus  bearing  the  general  char- 
acter of  an  organic  cell.  The  largest  of  these  bodies  present, 
when  round,  a  diameter  of  about  -^\^  mm.  A  number  of 
these  masses,  or  haematin  containing  cells,  especially  when 
placed  in  the  angles  of  the  dividing  vessels,  appear  round, 
while  those  placed  alongside  of  the  vessels  present  a  more 
or  less  elongated  form.  From  the  protoplasm  of  the  latter 
processes  are  observed  to  arise,  which,  blending  with  others 
proceeding  from  the  protoplasm  of  neighboring  masses, 
finally  form  a  protoplasmatic  layer  around  the  vessel,  which, 
itself,  is  eventually  transformed  into  a  delicate  neoplastic 
connective  tissue.  The  general  tendency  of  these  masses 
of  protoplasm  and  haematin  globules,  therefore,  is  toward 
organization. 

A  larger  or  smaller  number  of  colored  blood  corpuscles 
are  observed  in  the  interior  of  the  blood-vessels,  though 
many  of  the  latter,  especially  those  of  small  diameter,  are 
found  empty.  These  blood-corpuscles,  however,  do  not  ap- 
pear with  smooth  surfaces,  as  ordinary  normal  colored  cor- 
puscles present,  but,  like  nuclei,  show  a  distinct  double  con- 
tour, and  contain  from  four  to  six  distinct  granules.  It 
might  be  supposed  that  this  appearance  was  due  to  these 
corpuscles  having  assumed  the  mulberry-form  ;  but  from 
my  close  and  careful  examinations  I  feel  satisfied  that  this  is 
not  the  case,  though  I  am  unable  to  explain  the  phenome- 
non. A  number  of  years  ago,  I  had  met  with  nuclei  re- 
sembling colored  blood  corpuscles  in  the  newly  formed 
minute    blood-vessels    of    the  chorion  of    a  very  small  hu- 


748  H.  D.  SCHMIDT. 

man  embryo,  from  which  observation  I  am  inclined  to 
regard  the  above  blood  corpuscles,  also,  as  newly  formed. 
From  the  observation  made  on  the  blood-vessels  above 
described,  the  whole  process  concerned  in  the  formation  of 
the  new  layer  around  their  original  walls  may  be  presumed 
to  commence  with  an  escape  of  blood  corpuscles,  either  by 
capillary  hemorrhage,  or  even  by  diapedesis,  from  the  in- 
terior of  the  delicate  vessels.  The  same  may  be  said  of 
numerous  other  colored  blood  corpuscles  not  collected  in 
masses,  but  irregularly  lying  in  the  meshes  of  the  vascular 
network  ;  though  it  appears  to  me  that  these  may  rather 
have  escaped  from  the  vessels  by  capillary  hemorrhage.  At 
any  rate,  the  morphological  elements  of  the  blood,  the  col- 
orless, as  well  as  the  colored  corpuscles,  escape  from  the 
vessels  by  one  or  the  other  mode,  and  give  rise  to  the  for- 
mation of  those  well-known  cells  containing  a  larger  or 
smaller  number  of  colored  blood  corpuscles.  For  a  number 
of  years  now  these  cells  have  been  frequently  observed  in 
hemorrhagic  effusions,  and  their  formation  was  at  one  time 
attributed  to  the  gluing  together  of  a  number  of  colored 
corpuscles  by  coagulated  fibrin  ;  but  in  more  recent  times, 
since  it  was  discovered  that  the  protoplasm  of  the  colorless 
blood  corpuscles  has  a  tendency  to  embrace  foreign  bodies, 
such  as  the  granules  of  insoluble  coloring  matter,  etc.,  it  be- 
came obvious  that  these  compound  cells,  in  reality,  repre- 
sented colorless  blood  cells  which  had  swallowed  their  col- 
ored brethren.  I  have  become  convinced  of  this  fact  on 
different  occasions,  but  particularly  about  thirteen  months 
ago,  when  examining  some  serous  fluid  drawn  by  tapping 
from  a  cyst  situated  in  the  recto-uterine  pouch,  very  prob- 
ably ovarian  in  nature.  This  fluid  contained  a  limited 
amount  of  blood,  with  an  apparent  excess  of  colorless 
blood  corpuscles ;  they  mostly  represented  the  larger  kind, 
and  many  of  them  had  assumed  still  greater  dimensions  by 


LESION  OF  THE  LEFT  CEREBRAL  HEMISPHERE.      749 

their  protoplasm  having  embraced  a  number,  in  some  in- 
stances as  many  as  a  dozen  of  colored  blood  corpuscles.  In 
this  instance  there  remained  no  doubt  that  these  cellular 
forms  represented,  in  reality,  colorless  blood  corpuscles,  the 
nuclei  of  which  could  be  distinctly  observed  between  the 
colored  corpuscles  enclosed  by  the  protoplasm  ;  the  minute 
granules  of  the  latter  also  were  still  in  motion. 

As  soon  as  the  blood,  therefore,  has  escaped  from  the 
vessels  of  the  pseudo-membrane,  the  colorless  blood  cor- 
puscles seize  upon  as  many  of  the  colored  ones  as  their  pro- 
toplasm is  able  to  hold,  and,  with  their  prey  enclosed,  ar- 
range themselves  around  the  walls  of  the  blood-vessels  for 
the  purpose  of  forming  an  additional  layer  around  them 
from  the  building  material  they  previously  swallowed  in  the 
form  of  colored  blood  corpuscles.  As  the  formation  of  the 
layer  proceeds,  the  colored  corpuscles  contained  within  the 
protoplasm  are  diminishing  in  size,  until  nothing  is  left  of 
them  but  a  few  small  haematin  granules,  which  finally  also 
disappear.  The  regular  arrangement  of  the  haematin  cells 
around  the  walls  of  these  vessels  seems  to  indicate  that 
here  the  escape  of  the  corpuscles  probably  takes  place  by 
the  process  of  diapedesis. 

The  above-described  mode  in  which  the  formation  of  an 
additional  coat  around  a  newly  formed  blood-vessel  is  ac- 
complished in  the  pseudo-membrane  of  the  dura  mater,  is 
very  interesting,  and,  from  all  I  know,  appears  to  have  been 
observed  only  in  this  membrane,  though  it  may  be  pre- 
sumed that  it  also  takes  place  in  other  localities  where  ca- 
pillary hemorrhages  occur.  But,  besides  this,  there  is 
another  phenomenon  observed,  consisting  in  a  number  of 
spindle-shaped  cells,  which  not  only  adhere  to  each  other 
by  the  poles  of  their  spindles,  but,  moreover,  appear  con- 
nected with  certain  processes  arising  from  such  haematin 
cells  as  do  not  lie  in  the  immediate  vicinity  of  blood-vessels, 


750  H.  D.   SCHMIDT. 

and  from  which  it  may  be  presumed  that  these  cells  are  also 
capable  of  forming  the  latter  themselves  (fig.  4). 

But,  interesting  as  it  may  be  to  behold  the  wonderful  and 
original  ways  and  means  to  which  Nature  resorts  to  accom- 
plish a  certain  object,  in  this  case,  at  least,  her  efforts  appear 
to  be  fruitless  ;  for  scarcely  has  she  succeeded  in  strength- 
ening the  vessel,  when  its  further  development  is  arrested, 
and  a  retrogressive  process  commences,  by  which  it  is  trans- 
formed into  a  connective  tissue,  forming  a  part  of  the  mem- 
brane. It  is  thus  that  in  the  strata  of  the  pseudo-membrane 
we  meet  with  vessels  which,  like  those  above  described, 
exhibit  in  many  places  a  second  layer,  or  coat,  and  a  num- 
ber of  nuclei  still  embedded  in  their  walls,  but  without  a 
single  haematin  cell  to  be  seen  along  the  latter  (fig.  5,  a). 
That  these  cells,  or  compound  blood  corpuscles,  containing 
the  material  for  the  construction  of  the  additional  coat, 
have  likewise  once  existed  here,  is  proved  by  the  presence 
of  the  latter  around  the  vessel.  But  the  material  which 
they  had  accumulated  was  insufficient  for  the  work  to  be 
accomplished,  and  the  laborers,  after  sacrificing  their  own 
substance,  left  their  work  unfinished,  to  be  transformed  into 
an  inferior  structure. 

The  next  step  in  the  retrogressive  process  of  these  ves- 
sels, therefore,  is  the  disappearance  of  the  nuclei,  and  the 
fusion  or  melting  of  the  walls  into  a  finely  fibrillar  connec- 
tive tissue.  The  different  stages  of  the  whole  process  may 
be  distinctly  traced  from  one  vessel  through  its  anastomos- 
ing branches  to  others  (fig.  5,  c  and  U),  and  the  gradual 
transformation  of  the  vessels  be  distinguished  by  the  more 
or  less  defined  outlines,  or  paler  appearance,  which  they 
exhibit. 

These  transformed  vessels,  however,  do  not  form  the  only 
basis  of  the  pseudo-membrane,  for  throughout  their  meshes 
another  extremely  delicate  connective  tissue,  consisting  of 


LESION  OF  THE  LEFT  CEREBRAL  HEMISPHERE.      75  I 

very  fine,  pale,  but  granular  fibrillae,  is  observed  to  extend. 
The  origin  of  this  tissue  is  quite  obscure,  though  the  idea 
has  been  advanced  that  it  owed  its  origin  to  a  secretion  of 
the  spindle-shaped  nuclei,  or  emigrated  colorless  blood 
corpuscles  which  it  contained.  It  is  true  that  there  are 
many  haematin  cells,  which  took  no  part  in  the  formation  of 
the  additional  layer  around  the  blood-vessels,  or  in  the 
original  formation  of  the  latter,  left  distributed  throughout 
the  strata  of  the  membrane,  which  seem  to  gradually  melt 
away,  as  indicated  by  the  haematin  globules  appearing  now 
in  the  form  of  very  small  granules,  or  by  the  faint  outlines 
and  general  appearance  of  their  protoplasm  (fig.  6).  The 
number  of  these  cells,  however,  appears  too  small  to  account 
for  the  quantity  of  the  connective  element.  I  am,  there- 
fore, inclined  to  think,  that  while  they  may  be  instrumental 
in  the  process  of  formation  of  the  latter,  an  additional 
amount  of  formative  material  is  furnished  by  the  blood- 
vessels in  the  form  of  an  exudate.  This  exudate  appears 
at  first  finely  granular,  its  organization  taking  place  by  the 
minute  granules  arranging  themselves  into  rows,  in  order  to 
become  finally  fused  into  fibrils,  of  which  the  granular,  or, 
at  least,  finely  knotted  appearance  can  be  distinctly  seen 
under  the  microscope.  The  same  mode  of  development  of 
the  fibrillar  connective  tissue  I  have  observed,  a  number  of 
years  ago  in  the  pia  mater  of  the  spinal  marrow  of  very 
small  human  embryos,  and  in  other  instances  afterward. 
But  independent  of  this  mode  of  formation  of  the  delicate 
connective  element,  the  latter  is  also  derived  from  the  con- 
nective tissue  of  the  transformed  blood-vessels  above  de- 
scribed, the  bundles  of  which,  after  gradually  becoming 
much  thinner  and  broader,  eventually  fuse  with  each  other 
to  a  certain  extent,  and  assume  a  more  homogeneous  ap- 
pearance. This  process,  I  may  safely  assert  to  take  place, 
as  I  have  distinctly  observed  a  connection  existing  in  this 


752  H.  D.  SCHMIDT. 

manner  between  the  connective  tissue  representing  the 
substratum  of  the  membrane  and  the  transformed  blood- 
vessels. 

Let  us  now  return  to  the  cyst,  which,  in  its  formation  and 
development,  also  offers  some  points  of  interest.  There 
were  in  reality,  as  already  stated,  two  distinct  cysts  or  cav- 
ities forming  the  hemorrhagic  tumor,  the  origin  of  which 
may  be  traced  back  to  hemorrhages,  occurring,  not  from  the 
vessels  of  the  dura  mater,  but  from  those  newly  formed  ves- 
sels of  the  pseudo-membrane,  and  into  or  between  the  strata 
of  the  latter.  It  will  be  observed  (fig.  l)  that  the  upper 
and  smaller  cavity  is  triangular  in  shape,  while  the  larger 
and  inferior  one  presents  an  oval  form.  From  this,  it  may 
be  presumed  that  the  smaller  cavity,  which  I  suppose  to 
have  been  formed  before  the  other,  could  not  have  pre- 
sented this  triangular  form  directly  after  the  effusion  of 
blood  took  place  into  the  layers  of  the  membrane,  but  was, 
very  probably,  at  first  ellipsoidal  in  its  outlines.  But,  when 
a  second,  and  more  considerable  effusion  of  blood,  causing 
a  much  larger  cavity,  subsequently  occurred,  the  partition, 
or  septum,  left  between  the  two  cavities,  was,  by  the 
gradual  extent  in  the  dimensions  of  the  latter,  stretched 
and  pressed  upward,  rendering  thus  the  upper  cavity  more 
triangular.  At  the  same  time  the  superposition  of  new 
pseudo-membrane  strata,  which,  before  the  formation  of  the 
cavities,  had  only  proceeded  from  the  direction  of  the  dura 
mater,  now,  very  probably,  chiefly  proceeded  from  the 
internal  surfaces  of  the  cavities,  and  thus  the  septum  be- 
tween the  latter  gradually  assumed  the  shape  in  which  we 
behold  it,  though  new  strata  may  likewise  have  been  formed 
upon  the  outer  surface  of  the  inner  wall  of  the  tumor. 

In  connection  with  the  new  strata  upon  the  cavernous 
surface  of  the  pseudo-membrane,  it  may  be  asked,  how  far 
the  fibrin  of  the  effused  blood  took  part  in  the  formation  of 


LESION  OF  THE  LEFT  CEREBRAL  HEMISPHERE.      753 

these  layers.  The  question  whether  coagulated  fibrin  is 
capable  of  becoming  organized  into  connective  tissue  has 
always  been  an  interesting  one  to  me,  though  I  never 
formed  a  definite  opinion  regarding  this  subject  when  ex- 
amining old  fibrinous  exudates.  For  this  reason  I  examined 
very  closely  the  fibrinous  framework  already  described  as 
extending  throughout  the  cavities.  The  result  was  that, 
while  the  greater  part  of  it  exhibited  the  general  character 
of  coagulated  fibrin,  there  were,  nevertheless,  a  considerable 
number  of  bundles  observed,  in  which  the  meshes  of  the 
fibrinous  network  had  much  increased  in  size,  and  its  fibril- 
lae  assumed  the  appearance  of  crossing  each  other,  like 
those  of  connective  tissue.  In  other  parts  of  the  frame- 
work, especially  in  those  adjacent  to  the  wall  of  the  cavity, 
bundles  of  fine,  straight  fibrillae,  running  parallel  to  each 
other,  were  even  observed.  In  the  sections  of  the  walls  of 
the  cavities  it  was  observed  that  in  many  places  the  fibrin 
passed  gradually  into  the  innermost  layer  of  the  walls  with- 
out any  distinct,  defined  border.  This  observation  has 
inclined  me  to  the  view  that,  under  certain  conditions, 
coagulated  fibrin,  when  in  close  and  intimate  contact  with 
living  structure,  may  be  transformed  into  connective  tissue  ; 
or,  as  in  the  case  before  us,  furnish,  at  least,  the  material 
for  the  formation  of  such  tissue  under  the  influence  of  the 
wandering  cells.  In  the  fibrinous  framework  itself  numer- 
ous colored  blood  corpuscles  and  a  few  colorless  ones,  but 
no  haematin  cells,  were  observed. 

Before  closing  the  discussion  of  the  hemorrhagic  cyst  of 
the  dura  mater,  it  remains  to  be  mentioned  that  in  the  sec- 
tions a  number  of  haematin  cells  were  observed  between  the 
dura  mater  and  the  first  layer  of  the  pseudo-membrane, 
from  which  fact  the  deduction  may  be  made  that,  while  the 
first  neoplastic  stratum  represents  an  exudate  from  the  in- 
flamed vessels  of  the  dura  mater,  capillary  hemorrhages  do, 


754  H.  D.  SCHMIDT. 

at  the  same  time,  occur  between  the  two  membranes,  giving 
rise  to  the  formation  and  development  of  haematin  cells, 
through  the  activity  of  which  the  new  blood-vessels  and 
other  elements  of  the  pseudo-membrane  are  called  into  ex- 
istence. 

As  regards  the  cavity  in  the  left  hemisphere  of  the  cere- 
brum, it  has  already  been  mentioned  that  the  destructive 
process  had  been  limited  to  the  white  substance,  the  gray 
matter  of  the  cortex  cerebri,  with  the  exception  of  that  por- 
tion lost  by  the  formation  of  the  orifice,  being  left  in  the 
form  of  a  shell.  The  microscopical  examination  of  a  thin 
section  of  the  entire  walls  of  the  cavity  showed  that  the  de- 
struction had  been  exactly  limited  to  the  fibres  of  the 
corona  radiata,  but  that  the  entire  cortex,  and  the  commis- 
sural fibres  connecting  the  neighboring  convolutions,  had 
been  left.  But,  while  in  the  anatomical  elements  of  the 
cortex,  with  the  exception  of  vacuoles  around  the  ganglion- 
cells,  no  pathological  changes  were  observed,  the  commis- 
sural nerve  fibres  had  undergone  a  degenerative  process. 
This  process  appeared  to  consist  in  an  atrophy,  or  gradual 
wasting  of  the  medullary  sheath  and  also  the  axis  cylin- 
der, a  breaking  up  into  small  granules  or  anatomical  mole- 
cules. In  some  places  the  nerve  fibres  had  entirely  disap- 
peared, and  nothing  was  left  but  the  naked  neuroglia,  of 
which  here  I  was  able  to  thoroughly  convince  myself  that 
it  does  not  represent  a  continuous  network,  but  consists,  as 
I  have  elsewhere  stated,  of  fine  and  straight  fibrillae  cross- 
ing each  other  obliquely.  In  other  places  the  nerve  fibres 
were  still  represented  by  mere  shadows  without  definite 
outlines,  though  colored  by  carmine,  a  phenomenon  which 
may  be  explained  in  presuming  that,  while  the  medullary 
sheath  and  the  axis  cylinder  had  undergone  this  granular 
degeneration,  the  tubular  sheath  of  Schwann  was  left  to  ab- 
sorb the  carmine.     In  some  places,  however,  a  few  varicose 


LESION  OF  THE  LEFT  CEREBRAL  HEMISPHERE.      755 

fibres  with  double  contour,  or  single  axis  cylinders,  were 
also  observed.  The  numerous  nuclei,  lodged  between  the 
fibres,  were  all  left,  and  colored  by  haematoxylin.  In  some 
parts  of  the  walls  of  the  cavity  extravasated  colored  blood 
corpuscles  and  haematin  globules  were  met  with,  but  no 
trace  of  organization  could  be  discovered.  As  already 
stated,  the  internal  surface  of  the  cavity  presented,  micro- 
scopically, a  perfectly  smooth  appearance,  resembling  a 
living  pseudo-membrane.  Upon  a  section  of  the  walls,  also, 
the  portion  bordering  the  cavity  presented  a  denser  appear- 
ance, as  if  some  organization  had  here  been  attempted. 
But,  when  examined  microscopically,  it  was  found  that, 
though  the  structure  of  this  border  appeared  denser  than 
the  rest  of  the  wall,  the  appearance  depended  on  no  special 
organization,  but  was  merely  caused  by  an  additional  num- 
ber of  round  and  also  spindle-shaped  nuclei,  which, 
nevertheless,  might  indicate  that  a  fuller  attempt  had  been 
made  by  nature  to  limit  the  progress  of  the  disease. 

The  chief  interest,  which  the  above-described  case  of  de- 
structive lesions  of  the  cerebrum  offers,  consists  in  the  ex- 
tent of  the  lesions  and  the  length  of  time  during  which  they 
existed  without  much  disturbing  the  general  health,  or  even 
the  mental  faculties  of  the  patient.  Some  other  interest- 
ing points,  relating  to  the  physiological  psychology  of  the 
case  might,  besides,  be  discussed,  if  the  extent  of  our 
knowledge  of  the  true  mechanism  of  the  cerebrum  and  its 
cortex  was  not  so  limited.  I  shall,  therefore,  postpone  this 
part  of  the  subject  until  the  time  will  have  arrived  when  I 
may  turn  to  this  case  for  the  purpose  of  illustrating  some 
special  views. 


75^  11.  D.   SCHMIDT. 

Explanation  of  the  Illustrations. 

Fig.  I. — Represents  the  anterior  view  of  a  section  of  the  cal- 
varium,  with  dura  mater  and  pseudo-membrane.  Upon  the  inner 
surface  of  the  right  half  of  the  dura  mater,  the  hemorrhagic  cyst 
with  its  two  cavities,  and  the  fibrinous  network  extending  through 
the  latter,  is  seen  ;  on  the  left  side,  the  orifice  in  the  calvarium, 
filled  up  by  the  fibrous  structure  arising  from  the  dura  mater,  is 
observed  ;  a,  calvarium  ;  b,  dura  mater  ;  c,  pseudo-membrane  ;  d, 
fibrous  membrane,  filling  up  the  artificial  foramen  in  the  bone 
(natural  size). 

Fig.  2. — Represents  a  small  blood-vessel  of  the  pseudo-mem- 
brane, showing  the  additional  layer,  formed  by  the  haematin  cells 
around  its  walls  (375  diameters). 

Fig.  3. — Represents  a  blood-vessel  of  the  same  kind,  but  of  a 
larger  diameter,  and  with  larger  haematin  globules  lying  along  its 
walls  (375  diameters). 

Fig.  4. — Free  haematin  cells,  distributed  throughout  the  meshes 
of  the  vascular  network  of  the  pseudo-membrane.  Some  of  them 
are  sending  out  processes,  which,  as  it  appears,  form  a  connec- 
tion with  certain  long  spindle-shaped  cells,  resulting,  probably,  in 
the  development  of  blood-vessels  (375  diameters). 

Fig.  5. — Represents  the  network  of  retrograding  blood-vessels 
of  the  pseudo-membrane  ;  a,  blood-vessels  during  the  first  stage 
of  the  retrogressive  process,  still  exhibiting  the  additional  neo- 
plastic coat,  and  also  a  number  of  nuclei  ;  b,  blood-vessels  al- 
ready transformed  into  connective  tissue,  the  nuclei  have  disap- 
peared ;  c,  vessel,  showing  the  connection  with  the  latter,  and  the 
gradual  transformation  ;  d,  delicate  connective  tissue  of  the  sub- 
stratum of  the  membrane  (375  diameters). 

Fig.  6. — Minute  haematin  granules,  representing  the  remains  of 
haematin  globules  in  the  substratum  of  the  membrane  (375  diame- 
ters). 


CILIO-SPINAL   CENTRES. 

By   ISAAC   OTT,    M.D. 

THE  existence  of  cilio-spinal  centres  has  been  lately 
the  subject  of  discussion.  Budge's  discoveries  were 
first  called  in  question  by  Salkowski,  who  believed  that 
cilio-spinal  centres  did  not  exist,  but  that  cilio-spinal  fibres 
arose  in  the  medulla  oblongata  or  higher.  Frangois-Frank 
has,  however,  after  the  method  of  Budge  shown  that  spinal 
centres  influencing  the  movements  of  the  iris  exist.  Luch- 
singer  by  means  of  sensory  irritations  has  shown  that  cilio- 
spinal  centres  exist.  Tuwim,  however,  has  thrown  doubt 
on  these  experiments  of  Luchsinger,  stating  that  after  sec- 
tion of  the  spinal  cord  sensory  irritations  did  not  dilate  the 
pupil.  I  have  made  a  number  of  experiments  upon  this 
subject.  Method:  Cats  were  chloroformed,  bound  down, 
the  cord  divided  just  below  the  medulla  oblongata,  and  ar- 
tificial respiration  kept  up  by  a  respiration  apparatus  al- 
ready described.  After  a  rest  of  some  time  the  sciatic 
was  irritated  by  induction  currents  of  a  Du  Bois  apparatus, 
which  was  run  by  a  Daniell  cell.  The  external  palpebral 
commissure  was  slit  up,  and  the  nictitating  membrane  and 
lower  lid  held  away  by  weighted  hooks.  If  now  the  sciatic 
was  irritated  the  pupil  was  seen  to  dilate  about  two  milli- 
metres. When  the  cord  centres  wer^  excited  by  another 
irritant  acting  on  them  through  the  blood,  carbonic  acid, 
then  the  pupil  was  also  dilated.     The  cilio-spinal  centres 

757 


758  ISAAC   OTT. 

may  be  demonstrated  to  exist,  I  think,  in  another  manner. 
If  in  a  cat  the  left  cervical  sympathetic  is  cut  and  the  cord 
divided  high  up,  then  if  no  spinal  centres  acting  on  the 
iris  existed,  the  diameters  of  the  pupils  should  be  equal, 
but  experiment  proves  that  the  pupil  with  the  sympathetic 
intact  is  more  dilated  than  the  other.  Here  some  influ- 
ence through  the  cervical  sympathetic  from  the  cord  is 
acting.  It  might  be  objected  that  the  tonic  influence  of 
the  stellate  -ganglion,  or  fibres,  still  coming  from  the  medulla 
oblongata  caused  the  right  pupil  to  be  larger,  but  the  left 
pupil  was  still  under  the  influence  of  the  superior  cervical 
ganglion.  I  think  that  it  is  fair  to  draw  the  conclusion 
that  the  right  pupil  is  kept  larger  by  the  influence  of  the 
cilio-spinal  centres.  I  have  also  made  experiments  to  deter- 
mine the  path  of  dilating  fibres  of  the  pupil  by  sensory  irri- 
tation. When  in  a  cat  I  had  cut  both  cervical  sympathetics, 
and  the  sciatic  was  irritated,  the  pupil  was  dilated.  When 
the  first  thoracic  and  superior  cervical  sympathetic  ganglia 
were  extirpated  and  the  sciatic  irritated,  the  pupil  still  di- 
lated. When  the  gray  matter  on  the  surface  of  one  of  the 
cerebral  hemispheres  had  been  broken  up  and  the  cervical 
sympathetic  cut,  then  irritation  of  the  sciatic  dilated  the 
pupil.  When  the  gray  matter  of  both  cerebral  hemispheres 
was  broken  up  and  both  sympathetics  in  the  neck  divided, 
sensory  irritation  still  dilated  the  pupil.  When,  however, 
the  cerebrum  was  broken  up  down  to  the  base  of  the  brain 
and  the  cervical  sympathetics  cut,  the  sciatic  irritation  was 
powerless.  These  experiments  lead  to  the  conclusion  that 
fibres  dilating  the  iris  run  in  the  trigeminus,  and  that  the 
seat  of  the  dilation  is  here,  and  not  in  the  yeat  of  conscious- 
ness, as  held  by  Schiff.  The  sympathetic  ganglia  also  have 
an  influence  on  the  diameter  of  the  pupil.  Francois-Frank 
and  Tuwim  have  made  experiments  upon  this  point.  I  have 
also  exsected  these  g-ancrlia.     When  in  a  cat  the   right  first 


CILIO-SPINAL    CENTRES.  759 

thoracic  ganglion  is  cut  away  from  all  spinal  connection 
and  the  trunk  of  the  sympathetic  below  it  cut  and  the  op- 
posite sympathetic  divided  in  the  neck,  then  the  right  pupil 
will  be  found  to  be  larger  than  the  left.  If  now  a  section 
in  the  same  animal  experimented  upon  be  made  above  the 
first  thoracic  ganglion,  the  diameter  of  the  pupils  will  be 
the  same.  If  the  superio-cervical  ganglion  on  the  right 
side  is  extirpated,  then  the  right  pupil  is  smaller  than  the 
left.  If  in  young  cats  the  right  superior  cervical  ganglion 
is  extirpated  and  the  left  sympathetic  below  the  ganglion 
divided,  then  when  the  animal  is  coming  out  of  the  chloro- 
form the  left  pupil  is  at  the  time  larger  than  the  right,  but 
shortly  afterward  it  is  smaller  than  the  right,  and  remains 
so  for  several  days.  If  atropia  is  given  it  does  not  change 
the  result.  These  experiments  demonstrate,  that  in  the 
ganglia  of  the  sympathetic  resides  a  tonic  influence  for  a 
short  period  over  the  pupil  after  they  have  no  anatomical 
connection  with  the  cilio-spinal  centres  in  the  spinal  cord. 
I  have  already  shown  by  experiments  upon  rabbits  that 
after  section  of  a  lateral  column  the  pupil  on  that  side  con- 
tracted, showing  that  cilio-spinal  fibres  run  in  these  col- 
umns and  that  section  removes  part  of  the  spinal  influence 
on  the  pupil. 


SPINAL    IRRITATION.* 

By  J.  S.  JEWELL,   M.D. 

IT  is  no  part  of  my  intention  in  this  brief  paper  to  enter 
upon  a  history  of  the  literature  of  this  disorder,  begin- 
ning, as  it  does,  in  various  more  or  less  vague  descriptions  in 
the  works  of  older  writers,  and  from  them  advancing  down  to 
the  present  rather  abundant,  but  seldom  practically  valu- 
able literature. 

My  intent  is  rather  to  give  the  results  of  a  rather  pro- 
longed experience  with  and  study  of  this  disorder. 

Several  classes  of  affections  have  been  confounded  to- 
gether in  descriptions  of  spinal  irritation. 

In  the  first  place,  various  diseases  of  the  vertebral  column 
itself,  such  as  spondylitis,  more  especially  its  subacute  and 
chronic  non-suppurative  forms,  with  or  without  enlargement 
or  deformity.  Then,  again,  it  would  appear,  in  some  in- 
stances, to  have  included  disease  of  the  muscles  themselves, 
or  of  the  abundant  ligamentous  tissue  of  the  spinal  column, 
such  as  myalgias,  rheumatic  irritation  of  the  external  fibrous 
and  muscular  structures  of  the  spinal  column,  chronic  syph- 
ilitic affections,  attended  with  pain  and  soreness,  affecting 
the  periosteum,  of  the  vertebrae,  and  chronic  affections  of 
the  dura,  more  particularly  subacute  congestions  and  in- 
flammatory affections  of  this  membrane,  attended  with  local 

*  Prepared  to  read  before  the  Tri-State  Medical  Society,  at  St.  Louis,  at  the 
session  of  October  last. 

760 


SPINAL  IRRITATION.  7^1 

pain  and  tenderness  ;  also  recent  subacute  affections  of  the 
sensitive  tract  of  the  spinal  cord.  These  disorders,  not  to 
mention  those  of  so-called  hysterical  origin,  have  either  one 
or  all  been  by  various  writers  included  under  the  term 
spinal  irritation. 

Setting  these  various  classes  of  affections  to  one  side,  and 
directing  attention  to  the  spinal  cord  itself,  we  find  wide 
diversities  in  opinion  as  regards  the  nature  or  pathology  of 
the  disorder  in  question. 

It  has  been  considered  as  due  to  congestion,  or,  on  the 
other  hand,  as  due  to  anaemia  even  of  limited  tracts  of  the 
cord,  such  as  its  posterior  columns  ;  or  in  other  cases  no 
positive  opinions  have  been  emitted  as  to  the  nature  of  the 
affection,  the  task  of  working  out  a  pathology  having  been 
resigned  as  impracticable  in  the  present  condition  of  our 
knowledge. 

It  will  be  impossible,  in  the  time  and  space  to  which  I 
have  limited  myself  in  this  paper,  to  discuss  all  these  ques- 
tions. I  shall,  therefore,  as  already  intimated,  content  my- 
self with  a  statement  of  the  views  I  have  finally  adopted  as 
to  the  nature  and  treatment  of  spinal  irritation.  I  will 
begin,  therefore,  by  citing  its  more  prominent  characteris- 
tics. Thus,  in  the  first  place,  pure  spinal  irritation  includes 
exaltation  of  the  pain-sense,  in  the  nerves  which  enter  the 
horizons  of  the  spinal  cord,  which  are  the  real  seats  of  the 
affection.  As  a  rule,  except  for  short  periods  in  time,  there 
are  no  paraesthesias,  such  as  numbness,  tingling,  prickling, 
and  other  similar  morbid  subjective  sensations,  in  the  sphere 
of  distribution  of  the  nerves  in  question.  As  a  rule,  marked 
anaesthesia  of  the  tact-sense  is  not  present.  But  there  is  a 
true  hyperalgesia,  or  exaltation  of  the  pain-sense,  which  is 
the  m.ore  marked  as  the  sensitive  nerve  trunks  involved  are 
shorter.  In  other  words,  the  nerve  twigs  which  supply  the 
skin  over  the  spinal  column  itself  are  known,  of  course,  to 


7^2  y.    s.    JEWELL. 

be  shorter  than  those  which  proceed  from  the  front  of  the 
body  or  from  the  limbs.  The  longer  the  nerve  trunk  the 
less  irritable  it  seems  to  be ;  the  shorter  its  course  is  before 
it  terminates  in  the  gray  matter  of  the  spinal  cord  the  more 
irritable  it  seems  to  be.  Hence,  the  chief  external  seat  of 
morbid  nerve  sensibility  is,  as  might  have  been  expected  (in 
view  of  the  apparent  fact  just  stated),  greatest  over  the 
spinal  column  itself. 

In  the  second  place,  the  augmentation  of  pain  sensibility, 
which  belongs  to  spinal  irritation,  is  more  marked,  as  a  rule, 
in  response  to  a  slight  touch  than  to  a  heavier  touch,  es- 
pecially if  the  latter  is  made  gradually.  The  morbid  sensi- 
bility, therefore,  which  belongs  to  spinal  irritation  is  not  of 
the  same  nature  as  that  which  belongs  to  the  inflammatory 
soreness,  which,  as  a  rule,  is  more  painful  as  the  pressure  is 
more  firm  or  forcible. 

Then,  again,  in  spinal  irritation  there  is  no  regular  increase 
of  temperature,  or  disturbance  of  the  circulation,  or  swell- 
ing either  in  or  beneath  the  skin  of  the  morbidly  sensitive 
region,  that  can  be  determined  by  the  most  careful  exami- 
nation. Then,  true  spinal  irritation  can  seldom  be  traced, 
with  certainty,  to  physical  injury  of  the  spinal  column. 
Then,  again,  reflex  excitability  of  the  affected  zones  of  the 
cord  is  seldom  diminished,  but  much  more  frequently  than 
otherwise  increased. 

Spinal  irritation  seldom  or  never  includes  paralysis  either 
of  sensibility  or  motion,  in  uncomplicated  cases,  either  in 
the  parts  which  receive  their  nerves  from  the  affected  zones 
of  the  cord,  or  from  parts  which  are  below  or  behind 
them. 

Spinal  irritation  seldom  ever  affects  in  any  given  case  the 
entire  length  of  the  spinal  cord,  but,  as  a  rule,  only  certain 
horizons  or  zones  of  the  same,  especially  the  lumbar,  brachial, 
and  cervical  zones.     It  usually  occurs  in  persons  having  a 


SPINAL   IRRITATION.  7^1 

nervous  temperament  and  presenting  more  or  less  marked 
symptoms  of  nerve  exhaustion. 

The  pain  of  spinal  irritation,  though  frequently  sponta- 
neous, is  nearly  always  a  fatigue  pain,  or  one  which  the  pa- 
tient describes  as  being  a  "  tired  pain,"  which  is  relieved,  in 
a  measure,  by  rest  in  an  easy  posture,  made  worse  by  exer- 
cise, and  though  aggravated  by  movements  or  motions,  is 
not  to  the  same  extent  so  as  in  cases  of  disease  of  the 
spinal  column  or  of  the  dura. 

These  latter  disorders  are,  as  a  rule,  clearly  localized  and 
present  a  variety  of  symptoms,  some  of  which,  more  or 
less,  agree  with  those  of  spinal  irritation,  but  others  offer  a 
wide  difference,  sufficient  to  enable  the  careful  observer  to 
distinguish  between  them,  or,  at  least,  to  enable  him  to  de- 
termine the  presence,  in  complicated  cases,  not  only  of  true 
spinal  irritation,  but  of  the  other  disorders  with  which  it  is 
so  often  confounded. 

Without  undertaking  at  present  to  state  all  the  reasons 
in  view  of  which  I  have  arrived  at  my  conclusions  as  to-  the 
intimate  nature  of  spinal  irritation,  I  will  state  them  briefly. 
In  every  case  of  true  spinal  irritation  the  chief  seat  of 
disease  is  in  the  spinal  cord,  in  its  sensitive  tract.  It  in- 
cludes, first  of  all,  a  nutritive  lesion  in  which,  to  use  a 
favorite  phrase  of  mine,  there  is  a  more  or  less  marked  loss 
of  balance  between  waste  and  repair,  the  former  having  out- 
run the  latter.  In  my  view  of  the  case  there  is  positive- 
leanness,  or  substantial  interstitial  loss  of  the  ultimate 
nerve  elements.  It  is  believed  that,  as  in  the  case  of  the 
wasted  muscle,  or  like  leanness  or  loss  of  volume  and 
weight  in  any  given  part,  or  even  of  the  whole  body,  ac- 
companied by  a  corresponding  loss  of  energy  or  power, 
the  same  condition  occurs  in  the  exceedingly  active  and 
frequently  overworked  nerve  mechanisms,  especially  those  of 
the  spinal  cord.     It  is  true  these  things  have  not  been  made 


764  7-    S-    JEW- ELL. 

the  subjects  of  ocular  demonstration,  but  the  course  of 
reasoning  is  so  direct  and  cogent,  based  upon  well-known 
facts  ascertained  by  observation  in  relation  to  more  accessi- 
ble parts  of  the  body,  as  to  compel  the  acknowledgment 
of  the  position  taken  as  subtantially  correct.  Any  part  of 
the  spinal  cord  which  is  habitually  over-excited  or  over- 
worked, and  the  consequent  wear  of  which  has  gone  on 
faster  than  the  reparative  work  of  nutrition  for  the  same 
part,  sooner  or  later  may  suffer  not  only  a  loss  in  volume 
and  in  power,  but  the  process  of  wear  and  tear,  when  it  has 
advanced  to  an  extreme  degree,  even  in  a  muscle,  gives  rise 
to  irritation,  the  expression  of  which  is  at  first  a  mere  feel- 
ing of  fatigue,  but  if  the  process  of  wear  is  carried  farther, 
fatigue  graduates  into  pain. 

If  repair  of  the  nerve  waste  out  of  which  these  symp- 
toms arise  is  accomplished  by  rest  and  nourishment,  not 
only  the  pain  but  the  fatigue  disappear.  But  if  the  degree 
of  waste  is  great,  and  if  the  circumstances  of  the  case  are 
such  as  to  retard  or  prevent  the  process  of  repair  from  be- 
ing carried  forward,  so  that  the  part  in  question  remains,  as 
regards  its  nutrition,  constantly  in  that  state  which  gives 
rise  to  fatigue  and  pain,  then  these  latter  symptoms,  like 
the  lesion  of  nutrition,  of  which  they  are  the  common 
signs,  become  permanent,  more  especially  if  the  seat  of 
lesion  is  in  the  aesthesodic  or  sensitive  tract  of  the  central 
nervous  system. 

In  spinal  irritation,  therefore,  the  first  thing  to  be  recog- 
nized is  the  lesion  of  nutrition  just  described,  in  which 
there  is  a  more  or  less  permanent  and  marked  preponder- 
ance of  waste  over  repair,  the  process  of  destruction  or 
waste  having  been  carried  to  such  a  degree  as  to  threaten 
the  integrity  of  the  parts,  the  inarticulate  protest  against 
the  farther  progress  of  wear  being  the  constant  fatigue 
pain  which  marks  uncomplicated  cases  of  spinal  irritation. 


SPINAL   IRRITATION.  765 

With  this  view,  so  far  as  I  am  aware,  do  all  the  phenomena 
of  spinal  irritation  agree.  Rest,  the  moderate,  judicious 
use  of  anodynes,  tonics,  good  feeding,  include  the  methods 
most  approved  by  experience.  Nothing  is  better  known 
than  that  persons  affected  with  spinal  irritation  are  often  in 
a  chronic  manner  fatigued,  in  some  instances  bed-ridden. 
Nothing  is  better  known  about  such  cases  than  that  exer- 
cise, unless  of  the  most  moderate  character,  aggravates  the 
spinal  pain  and  exhaustion. 

Having  got  firmly  in  view  the  nature  and  the  immediate 
relations  of  the  lesion  of  nutrition  just  described,  I  would 
next  call  attention  to  the  circulatory  disorders  which,  it 
seems  probable,  follow  in  the  wake  and  occur  in  the  place 
of  the  lesion  of  nutrition  described.  For  my  own  part,  I 
am  clearly  of  the  opinion  that  within  the  areas  of  exhaustion 
and  irritation  in  the  spinal  cord  there  is  a  fluctuating  blood 
circulation.  It  may  be  normal,  or  there  may  be  a  conges- 
tion, or  there  may  be  anaemia.  But  this  latter  condition  I 
conceive  to  be  a  rare  occurrence  and  by  no  means  a  neces- 
sary factor  in  spinal  irritation.  Spinal  irritation  is,  there- 
fore, not  due  to  either  congestion  or  anaemia,  whether 
in  the  posterior  columns  or  other  parts  of  the  cord.  But  I 
can  readily  understand  that  departures  from  the  normal 
state  of  blood  circulation  in  the  disordered  areas  are  ^en- 
erally  toward  congestion.  Both  congestion  and  anaemia  are 
mere  incidents  in  the  course  of  the  disorder  under  discus- 
sion. The  fundamental  factor  is  the  lesion  of  nutrition 
already  described.  It  is  important  to  admit  this,  not  only 
because  it  agrees  with  all  the  facts,  but  once  fully  under- 
stood, it  points  imperatively  to  the  path  of  recovery,  which 
happily  harmonizes  in  every  particular  with  the  results  of 
experience. 

Having  said  thus  much  concerning  the  symptoms  and 
nature  of  spinal  irritation,  I  would  next  direct  attention  to 


766  J.    S.    JEWELL. 

its  chief  clinical  varieties.  If  what  has  been  said  is  true  of 
the  nature  and  pathology  of  the  disorder,  we  may,  a  priori, 
designate  certain  altitudes  of  the  cord  which  would  be 
more  likely  than  others  to  be  the  seats  of  the  disease.  I 
would  point  out  two  great  classes  of  cases:  First,  those  due 
to  over-action,  chiefly  muscular  in  character.  Second,  those 
cases  due  to  over-exciiatioji,  or  in  which  the  spinal  cord  is 
not  disturbed  on  account  of  its  share  in  the  production  of 
muscular  activity,  but  rather  on  account  of  the  excitations 
that  play  into  it  from  different  regions  to  be  later  specified. 
I.  Then,  first  of  all,  those  cases  which  depend  upon 
over-action.  The  altitudes  of  the  cord  most  likely  to  be 
affected  in  this  way  are  the  lumbar;  that  is,  the  altitude 
corresponding  to  the  lower  members,  or  to  the  levels  of 
central  implantation  of  the  sacral  and  lumbar  plexuses  of 
nerves.  Second,  the  brachial  zone  of  the  cord,  which  cor- 
responds to  the  upper  members  in  the  same  manner  as  does 
the  lumbar  to  the  lower  members ;  and,  finally,  the  sub- 
occipital zone,  including  the  muscles  by  which  more  particu- 
larly the  upper  part  of  the  cervical  region  of  the  spine  is 
maintained  erect  and  the  head  balanced  upon  the  spinal 
column.  I  am  not  able  of  course  to  speak  for  others,  but 
in  my  own  experience  I  have  found  a  large  number  of 
cases  of  spinal  irritation  to  be  due  to  over-use  of  the  legs  in 
standing,  walking,  and  in  other  occupations  in  which  they 
are  strenuously  or  persistently  used  for  long  periods  in  time  ; 
or  at  other  times  due  to  over-use  of  the  arms,  as  in  sewing, 
embroidery,  painting,  piano  practice,  and  in  hundreds  of 
other  occupations,  in  which  the  upper  members  are  habitu- 
ally over-used  ;  or,  finally,  the  same  condition  is  seen  in  cases, 
where  the  head  is  bent  forward  so  as  to  put  the  muscles  of 
the  neck  in  a  state  of  all  but  unremitting  tension.  The 
conditions  of  action  described  imply,  of  course,  a  constant 
tide   of  innervation  to  the  related  muscles,  and  this  again 


SPINAL  IRRITATION.  J^J 

implies  continuous  fatiguing  activity  on  the  part  of  the 
spinal  cord ;  and  at  last  the  decisive  irritation  of  extreme  de- 
nutrition  of  those  tracts  of  the  cord  which  are  entered  by 
the  motor  and  sensitive  nerves  of  the  muscles  can  hardly  be 
mistaken,  when  I  say  that  these  three  great  zones  of  the 
cord  are  brought  with  exceeding  frequency,  into  that  worn, 
fatigued,  painful  state  which  is  called  spinal  irritation. 
How  over-use  of  the  cord,  especially  in  persons  of  nervous 
and  feeble  constitution,  in  whose  cases  nutrition  or  repara- 
tive power  is  not  vigorous,  may  produce  the  lesion  of 
nutrition  already  described,  does  not  seem  to  me  difficult  to 
understand. 

II.  I  would  next  call  attention  to  that  exceedingly  im- 
portant and,  thus  far,  not  very  well-defined  group  of  cases 
which  depend  upon  over-excitation.  The  horizons  of  the 
cord  which  may  be  the  seats  of  irritation  in  this  group  of 
cases  are  almost  unlimited.  In  this  paper  it  will  be  practi- 
cally impossible  to  describe  all  the  particular  forms  met 
with  in  clinical  experience.  I  may,  however,  call  attention 
first  of  all  to  two  principal  levels  of  the  cord  which  are 
frequently  the  seats  of  "  spinal  irritation."  They  are  the 
pelvic  and  gastric  zones  of  the  cord.  In  this  class  of  cases 
the  supposition  is,  that  some  peripheral  organ  is  the  seat  of 
irritative  disease.  It  is  supposed  that  the  sensory  nerves 
which  ramify  in  the  diseased  organ  are,  like  its  other  struc- 
tures, involved.  It  is  farther  supposed  that,  so  long  as  the 
irritative  disease  exists  in  the  organ,  a  more  or  less  con- 
tinuous tide  of  irritative  "  influence "  is  directed  by  way 
of  its  nerves  into  the  corresponding  altitudes  of  the  spinal 
cord. 

Night  and  day,  whether  asleep  or  awake,  an  irritative  in- 
fluence enters  the  cord  and  contributes  to  the  exhaustion 
and  irritation  of  its  related  mechanisms.  In  this  way  it 
comes    to   pass   that  inflammatory   or  other  irrritative  dis- 


768  y.  s.  JEWELL. 

eases,  let  us  suppose,  of  the  uterus,  its  fundus  or  its  neck, 
or  disease  of  the  ovaries,  or  of  the  rectum,  or  bladder,  or, 
in  the  male,  its  prostatic  zone  or  the  urethra,  lead  sooner  or 
later,  if  persistent,  to  exhaustion  and  irritation  of  corres- 
ponding horizons  of  the  cord.  Hence  the  all  but  uni- 
form tenderness,  exhaustion,  pain,  etc.,  in  the  lumbar  and 
sacral  regions  of  the  spine  in  cases  of  irritative  disease 
of  the  pelvic  viscera.  Then,  again,  no  part  of  the  aliment- 
ary tract  is  so  often  the  seat  of  important  irritative  disease 
as  that  which  lies  in  what  may  be  called  the  gastric  zone. 
This  includes  the  stomach,  more  especially  its  mucous  mem- 
brane, the  liver,  and  the  duodenum.  Irritative  disease, 
especially  chronic  subacute  affections  of  these  organs,  in- 
volve their  nerves,  and  these  become  the  channels  of  a 
disturbing  influence,  which  sooner  or  later  exhausts  and 
irritates  the  corresponding  horizons  of  the  spinal  marrow. 
These  horizons  for  the  stomach,  etc.,  lie  between  the  third 
and  the  eighth  dorsal  vertebrae,  or  in  the  interscapular  region. 
Spinal  irritation  situated  within  these  limits,  I  have  found, 
points,  with  almost  unerring  certainty,  to  irritative  disease 
in  the  gastric  zone. 

The  spinal  horizons  which  appear,  clinically  speaking,  to 
stand  in  connection  with  the  small  intestine,  are  included 
between  the  eighth  and  eleventh  dorsal  vertebrae.  The 
horizon  which,  in  like  manner,  I  have  found  to  correspond 
to  the  colon,  especially  its  descending  portion  and  its  sig- 
moid flexure,  lies  between  the  eleventh  dorsal  and  the 
second  or  third  lumbar  vertebrae,  whereas  the  spinal  region, 
tenderness  of  which  appears  to  stand  in  connection  with 
disease  within  the  pelvic  zone,  extends  from  the  lower  dor- 
sal down  to  the  limits  of  the  lumbar  part  of  the  spine  or  even 
beyond,  while  disease  of  the  rectum,  especially  about  the 
anus,  and  of  the  neck  of  the  womb,  finds  its  tender  zone 
from  the  lower  lumbar  region  down  to  the  coccyx.     Chronic 


SPINAL   IRRITATION.  7^9 

irritative  affections  of  the  lungs  and  the  pleura  give  rise,  if 
at  all,  to  tenderness  from  about  the  middle  dorsal  up  to  the 
altitude  on  a  level  with  the  middle  cervical  region. 

Chronic  painful  affections  of  the  pharyngeal  zone,  includ- 
ing subacute  nasal  and  pharyngeal  catarrh,  give  rise  in  some 
cases  to  tenderness  in  the  region  extending  from  the  sub- 
occipital to  the  middle  cervical  region.  These  are  under- 
stood to  be  approximations  to  the  truth,  as  determined 
from  a  clinical  standpoint. 

Such  are  the  two  principal  groups  into  which  cases  of 
true  spinal  irritation  may  be  divided,  according  to  my  obser- 
vation,— all  cases  including,  as  already  described,  a  lesion  of 
nutrition  with  certain  symptoms  to  which  that  lesion  gives 
rise,  chief  among  which  are  more  or  less  persistent  fatigue, 
pain,  and  hyperalgesia  in  the  nerves  of  the  affected  zone, 
especially  those  that  run  the  shortest  course  from  the  in- 
tegument over  the  affected  region  of  the  spine  to  the  spinal 
cord.  If  the  remarks  made  as  to  the  nature  and  conditions 
ot  spinal  irritation  are  correct,  they  point  out  plainly  the 
general  line  along  which  treatment,  if  successful,  must  be 
conducted. 

Granting  the  existence  of  the  nutritive  lesion  insisted 
upon,  it  is  plain  that  the  first  and  most  imperative  condi- 
tion to  be  complied  with  is  that  of  rest.  If  the  spinal  irri- 
tation can  be  traced  either  to  over-use  or  to  over-excitation, 
a  first  duty  is  to  remove  the  cause  by  stopping  the  action, 
or  by  appropriate  treatment  of  the  irritative  disease,  which 
may  be  a  morbid  feature  in  spinal  irritation,  whether  it  be 
in  the  alimentary  canal,  or  the  genito-urinary  tract,  or  else- 
where. The  recognition  of  spinal  irritation  as  having  the 
nature  and  causes  already  specified,  directs  the  observer 
intelligently  to  its  causes.  But,  as  already  said,  the  first 
condition  to  be  complied  with  is  rest.  In  this  way  waste  in 
the  play  of  nutritive  activities  is  diminished. 


TJO  y.    S.    JEWELL. 

The  second  condition  to  be  complied  with  is  to  give,  by 
every  means  at  command,  a  full  supply  of  materials  for  a 
fresh  impulse  to  nerve  nutrition.  Under  this  head  is  in- 
cluded, not  only  good  feeding,  but  whatever  is  adapted  to 
such  cases  in  general,  and  to  these  cases  in  particular,  in  the 
way  of  tonics. 

As  respects  irritative  visceral  disease,  it  need  be  scarcely 
said,  after  its  existence  and  nature  have  been  determined, 
that  it  calls  for  careful,  effectual  treatment.  Gastric  and 
gastro-duodenal  catarrhs,  irritative  disease  of  the  mucous 
membrane  of  the  small  intestine  lower  down,  or  of  particu- 
lar segments  of  the  colon,  the  irritation  produced  by  habit- 
ual constipation  and  consequent  colic  impactions,  persis- 
tent disease  of  the  rectum,  or  of  the  uterus,  vagina,  bladder, 
or  other  parts  of  the  genito-urinary  tract, — all  should  receive 
special  attention.  In  this  paper  it  is  impracticable  for  me 
to  describe  the  treatment  adapted  to  each  case.  But  it 
may  be  laid  down  as  a  law  in  the  treatment  of  such  cases, 
that  unless  the  particular  mode  or  kind  of  over-action  or 
morbid  excitation  is  not  determined  and  rationally  met, 
many  of  the  cases  are  likely  to  remain,  as  they  have  always 
been,  among  the  opprobria  of  practical  medicine. 

There  are  two  special  points  in  the  treatment  of  this  class 
of  cases  to  which  I  desire  to  direct  attention.  The  first  of 
these  relates  to  the  persistent  use  of  small  doses  of  opium, 
either  the  watery  extract,  or  the  muriate  or  bimeconate  of 
morphia,  antagonized  in  either  case  by  correspondingly 
small  doses  of  a  reliable  preparation  of  belladonna,  usually 
associated  with  the  tonics  given.  The  opium  or  prepara- 
tions of  its  salts  indicated  are  usually  given  by  me  without 
the  knowledge  of  the  patient,  though  not  always  so,  and 
uniformly  in  small  doses.  Of  the  watery  extract  of  opium, 
the  doses  given  range  from  the  twelfth  to  the  sixth  of  a 
grain  at  a  dose,  twice  daily  or  oftener.     Of  the  morphia,  the 


SPINAL  IRRITATION.  771 

dose  is  from  a  thirtieth  to  a  tenth,  twice  or  thrice  daily, 
in  connection  with  other  remedies,  also  antagonized  by 
moderate  doses  of  belladonna,  in  doses  ranging  from  the 
eighth  to  the  twentieth  of  a  grain  of  the  solid  extract.  I 
am  persuaded  that  but  few  members  of  the  profession  can  be 
fully  aware  of  the  very  great  benefit  to  be  derived  from  the 
use  of  opium,  as  just  indicated,  in  painful  affections  of  the 
nervous  system.  If  it  is  properly  employed  I  am  convinced 
there  is  no  danger  of  forming  an  "opium  habit."  In  a 
large  experience  in  its  use  by  the  mouth,  I  have  not  yet 
seen  a  case  of  the  "  opium  habit "  produced  in  the  use  of 
opium  as  just  indicated.  While  its  use  does  not  entirely 
banish  pain,  it  blunts  the  edge  and  usually  inspires  the 
patient  (where  it  agrees)  with  a  feeling  of  positive  comfort, 
and,  in  many  instances,  actually  improves  nutrition. 

The  second  point  in  treatment  consists  in  the  use  of  elec- 
tricity, especially  the  electrical  wire  brush,  generally  using 
it  at  the  positive  electrode,  the  negative  pole  being  at  one 
or  both  feet  of  the  patient.  In  connection  with  the  local 
use  of  electricity,  beginning  in  a  very  mild  manner  I  have 
employed  it  at  each  sitting  in  a  more  general  manner,  the 
descending  spinal  current  from  the  nape  of  the  neck 
downward  to  the  feet.  In  some  instances,  in  using  the  elec- 
trical metallic  brush,  I  have  reversed  the  poles,  using  a  mild 
current,  thoroughly  pencilled  by  rather  rapid  movements  of 
the  brush,  at  first,  and  making  the  movements  of  the  brush 
slower  as  the  sitting  advances,  directing  attention  chiefly, 
though  not  exclusively,  to  the  sensitive  zones  of  the  spine. 
These  sittings  have  been  not  oftener  than  once  a  day,  usu- 
ally, when  practicable,  in  the  afternoon.  Sometimes  I  have 
used  the  galvanic,  at  other  times  a  fine  induced  current  from 
the  second  coil  of  a  good  induction  machine.  Combined 
with  the  bodily  and  mental  rest  I  have  uniformly  directed 
more  or  less  thorough  careful  massage,  according  to  the 
case. 


TJ2  J.    S.    JEWELL. 

Such  is  a  simple  statement  of  the  views  at  which  I  have 
arrived  in  regard  to  the  nature  and  general  modes  of  treat- 
ment of  spinal  irritation.  I  do  not  for  a  moment  claim  for 
them  the  merit  of  novelty.  But  they  are  fruits,  in  no  unim- 
portant sense,  of  personal  observation  and  experience. 


'^tvUxos  attjd  glMi0j9ira|rlxij:aI  Notices, 


American  nervousness  :  its  causes  and  consequences. 

A  supplement  to  Nervous  Exhaustion  (Neurasthenia).  By 
George  M.  Beard,  A.M.,  M.D.  New  York  :  G.  P.  Putnam's 
Sons,  1881. 

This  latest  volume  of  its  prolific  author  takes  up  one  aspect  of 
an  idea  that  has  been  the  subject  with  which  many  previous  au- 
thors have  occupied  themselves  to  a  greater  or  less  extent.  The 
notion  that  the  special  physical  and  social  conditions  existing  or 
supposed  to  exist  in  this  country  have  been  and  are  now  modi- 
fying the  race,  is  a  popular,  or,  at  least,  is  a  common  one  in  the 
popular  mind.  As  a  rule,  it  has  been  the  popularizers  of  medical 
and  ethnological  subjects  that  have  broached  this  opinion.  It 
cannot  be  said  to  have  a  confirmed  status  as  a  scientific  truth, 
certainly  not  when  stated  as  broadly  as  is  done  by  most  of  its 
advocates.  It  is  generally  assumed  by  these,  that  the  change  is 
one  of  degeneration  to  a  certain  degree,  and  that  the  modern 
American  white  man  is,  in  his  physique,  at  least,  inferior  to  his 
European  progenitors.  It  is  not  exactly  satisfactory  to  a  patri- 
otic citizen  to  accept  these  views,  but  they  are  so  frequently 
dinned  into  our  ears  by  native  alarmists  and  superficial  foreign 
observers  that,  with  the  natural  tendency  to  accept  whatever  ill 
is  said  as  true,  they  have  become  almost  matters  of  faith  with  a 
large  proportion  of  our  population.  And  now  comes  Dr.  Beard 
with  a  work  on  American  nervousness  to  show  that  a  very  in- 
convenient form  of  physical  evil  is  almost  peculiar  to  our  country 
and  people,  and  gives  it  all  the  weight  that  his  name  and  reputa- 
tion can  command.  It  is  worth  while,  therefore,  to  look  over  the 
arguments  he  brings  forward  in  support  of  his  opinions,  and  to 
see  whether  they  are  sufficiently  convincing  to  establish  American 
nervousness  as  a  fact. 

773 


774  REVIEWS. 

Dr.  Beard  begins  his  volume  with  a  preface,  in  which  he 
states,  as  an  epitome  of  the  philosophy  of  this  work,  eight  proposi- 
tions, which  we  reproduce,  slightly  condensed,  as  follows  : 

First. — Nervousness  is  strictly  deficiency  or  lack  of  nerve  force. 
This  condition,  with  all  its  symptoms,  has  developed  mainly 
within  the  nineteenth  century,  and  is  especially  severe  in  the 
northern  and  eastern  United  States.  It  is  to  be  distinguished  in 
the  sense  here  used  from  mere  excess  of  emotion  and  from  organic 
disease. 

Second. — The  chief  primary  cause  of  the  development  and  rapid 
increase  of  nervousness  is  modern  civilization,  distinguished  from 
the  ancient  by  five  characteristics  ;  steam  power,  the  periodical 
press,  the  telegraph,  the  sciences,  and  the  mental  activity  of 
women. 

There  can  be  little  or  no  nervousness  without  civilization,  and 
under  its  modern  forms  nervousness  in  its  many  varieties  is  in- 
evitable. Among  the  secondary  and  tertiary  causes  of  nervousness 
are  climate,  personal  habits,  indulgence  of  appetites  and  passions. 

Third. — These  secondary  and  tertiary  causes  are  of  themselves 
powerless  to  produce  nervousness,  except  as  they  exist  and  are 
interwoven  with  modern  civilization. 

Fourth. — The  type  of  functional  nervous  diseases  is  neuras- 
thenia, which  is  closely  related  to  certain  functional  nervous 
disorders,  such  as  hay  fever,  sick  headache,  inebriety,  and  certain 
forms  of  hysteria  and  insanity. 

Fifth. — The  greater  prevalence  of  nervousness  in  America  is  a 
complex  resultant  of  numerous  influences,  the  chief  of  which  are 
dryness  of  the  air,  extremes  of  heat  and  cold,  civil  and  religious 
liberty,  and  the  great  mental  activity  necessary  and  possible  in  a 
new  and  productive  country  under  such  climatic  conditions. 

Sixth. — Among  the  signs  of  American  nervousness  specially 
worthy  of  attention  are  the  following  :  the  nervous  diathesis  ; 
susceptibility  to  stimulants  and  narcotics  and  various  drugs,  and 
consequent  necessity  of  temperance  ;  increase  of  the  nervous  dis- 
eases, inebriety  and  neurasthenia,  hay  fever,  nervous  dyspepsia, 
asthenopia,  and  allied  diseases  and  symptoms  ;  early  and  rapid  de- 
cay of  teeth  ;  premature  baldness  ;  sensitiveness  to  heat  and  cold  ; 
increase  of  diseases  not  exclusively  nervous,  as  diabetes  and  cer- 
tain forms  of  Bright's  disease  and  chronic  catarrhs  ;  unprece- 
dented beauty  of  American  women  ;  frequency  of  trance  and 
muscle-reading  ;  the  strain  of  dentition,  puberty,  and  the  change 
of  life  ;  American  oratory,  humor,  speech,  and  language  ;  change 


AMERICAN  NERVOUSNESS.  77S 

in  type  of  disease  during  the  past  half  century  ;  and  the  greater 
intensity  of  animal  life  on  this  continent. 

Seventh. — Side  by  side  with  this  increase  of  nervousness,  and 
partly  as  a  result  of  it,  longevity  has  increased,  and  in  all  ages 
brain-workers  have,  on  the  average,  been  long-lived,  the  very 
greatest  geniuses  being  the  longest  lived  of  all.  In  connection 
with  this  fact  of  the  longevity  of  brain-workers  is  to  be  noted  also 
the  law  of  the  relation  of  age  to  work,  by  which  it  is  shown  that 
original  brain-work  is  done  mostly  in  youth  and  early  and  middle 
life,  the  latter  decades  being  reserved  for  work  requiring  simply 
experience  and  routine. 

Eighth. — The  evil  of  American  nervousness,  like  all  other  evils, 
tends,  within  certain  limits,  to  correct  itself  ;  and  the  physical 
future  of  the  American  people  has  a  bright  as  well  as  a  dark  side  ; 
increasing  wealth  will  bring  increasing  calm  and  repose  ;  the  fric- 
tion of  nervousness  shall  be  diminished  by  various  inventions  ; 
social  customs,  with  the  needs  of  the  times,  shall  be  modified  ; 
and,  as  a  consequence,  strength  and  vigor  shall  be  developed 
at  the  same  time  with,  and  by  the  side  of  debility  and  ner- 
vousness. 

So  much  for  the  author's  own  summary  of  his  views  here 
stated.  It  will  be  unnecessary  to  attempt  to  notice  each  and 
every  particular  in  a  review  like  the  present  one,  but  we  can  well 
spare  the  space  to  examine  a  few  of  these  leading  propositions, 
which,  in  fact,  form  the  subjects  of  the  several  chapters  that  make 
up  the  volume. 

First  of  all  is  Dr.  Beard's  definition  of  nervousness,  and  why 
American  nervousness.  He  tells  us  that  it  is  strictly  deficiency 
or  lack  of  nerve  force.  This  requires  to  fulfil  the  conditions  of 
a  satisfactory  definition,  a  statement  or  at  least  an  understanding 
of  what  is  meant  by  nerve  force,  and  lacking  this  it  is  deficient  in 
every  essential  particular.  Perhaps  Dr.  Beard  has  a  clear  idea  of 
what  he  means  by  "  nerve  force,"  but  he  seems  to  assume  that 
that  is  a  term  that  requires  no  further  definition,  whereas  it  is,  in 
fact,  as  vague  and  uncertain  as  vitality  or  neurility  or  any  other 
phrase  that  indicates  the  limit  of  our  knowledge.  We  cannot  say 
with  strict  accuracy  that  a  tendency  to  become  quickly  exhausted 
by  mental  exertion,  or  to  succumb  to  minor  nervous  ailments,  such 
as  hay  fever,  etc.,  implies  deficiency  in  any  special  force  pertain- 
ing to  the  nerves,  for  the  conditions  are  too  complex  and,  so  far, 
too  little  understood.  Even  the  so-called  neurasthenia  is  not  to 
be  defined   simply  by  its  other  name,  "  nervous  exhaustion,"  for 


7/6  J?  E  VIEWS. 

it  has  as  causal  factors  an  indefinite  number  of  pathological  con- 
ditions that  can  affect  nutrition,  and  especially  that  of  the  nerve 
centres,  and  any  such  general  term  is  misleading  when  employed 
to  cover  the  whole  condition. 

But  admitting  Dr.  Beard's  definition  of  nervousness  as  a  defi- 
ciency of  endurance  for  exertions  requiring  what  is  called  ner- 
vous strain  and  a  particular  liability  to  functional  nervous  dis- 
ease, which  is  its  signification  from  the  context,  it  is  a  question 
whether  it  is  properly  any  more  American  than  it  is  cosmopolitan. 
It  is  not  flattering  to  our  national  feeling  to  presume  that,  as  a 
people,  we  are  preeminently  nervously  weak  and  irritable,  yet,  if 
such  is  the  case,  it  is  a  fact  that  will  have  to  be  endured.  Dr. 
Beard  rejects  all  statistics  in  regard  to  the  increase  of  nervous  dis- 
orders in  this  country,  for  the  very  good  reason  that  there  are 
none  of  any  value,  and  relies  upon  general  observation.  He  sees 
the  signs  of  American  nervousness  in  the  long  list  of  disorders, 
etc.,  enumerated  in  his  sixth  proposition,  some  of  which  are  dubi- 
ous supports  to  any  theory  of  an  especially  "American"  nervousness. 
It  is  a  question,  to  say  the  least,  whether  many  of  these  exist  as 
peculiarly  American  characteristics,  and  whether,  indeed,  more 
than  a  very  few  of  them  are  justly  to  be  considered  as  such.  We 
have  never  observed  or  been  satisfactorily  assured  that  Americans 
are  more  subject  to  nervous  dyspepsia,  myopia,  baldness,  to  dia- 
betes or  kidney  disease,  or  to  trance,  or  more  sensitive  to  heat  and 
cold  than  the  people  of  other  parts  of  the  world,  certainly  not 
more  so  than  Europeans.  The  differences  in  our  climate,  and  per- 
haps also  those  in  our  social  conditions,  from  the  analogous  condi- 
tions in  Europe,  may  be  accountable  for  some  of  the  items  in  the 
list,  but  these,  among  which  we  may  perhaps  include  the  alleged 
early  decay  of  the  teeth,  and  the  chronic  catarrhs  of  Americans, 
are  not  necessarily  indicative  of  "nervousness,"  Others  of  these 
peculiarities  are  no  more  than  could  be  expected  from  such  a  dif- 
ference in  latitude  and  longitude,  and  still  others  we  do  not  believe 
exist  as  American  characteristics  to  any  such  general  extent  as  is 
here  assumed.  It  is  a  little  surprising  to  one  who  judges  from 
general  observation,  as  does  Dr.  Beard,  to  hear  that  thirstlessness  is 
such  a  prominent  peculiarity  of  our  people  ;  and  how  to  refer  "  the 
intensity  of  animal  life  in  America  "  to  a  lack  of  "nerve  force"  is 
still  less  easily  to  be  understood.  Indeed,  Dr.  Beard  admits  in 
one  place  that  his-  remarks  apply  to  only  a  small  fraction  of  the 
American  people,  and  we  presume  that  his  observations  on  even 
this  fraction  have  been  influenced  by  his  preconceptions. 


AMERICAN  NERVOUSNESS.  777 

The  "Causes  of  American  Nervousness  "  are  discussed  in  a 
chapter  of  nearly  one  hundred  pages,  in  which  the  author  dilates  on 
the  topics  indicated  in  his  fifth  proposition.  He  states  here  a  cer- 
tain amount  of  truth,  but  says  much  that  in  our  opinion  is  of  little 
value,  and  would  have  been  fully  as  well  left  unsaid.  The  next 
longest  chapter  in  the  volume  is  an  expansion  of  an  earlier  essay 
by  Dr.  Beard,  its  subject  being  the  longevity  of  brain-workers  and 
the  relation  of  age  to  work.  The  former  paper  was  duly  noticed 
in  this  journal,  and  we  need  only  say  that  the  opinions  there  ex- 
pressed are  still  held  by  us.  The  essay  has  been  rewritten  and 
enlarged,  but  the  main  ideas  are  here  the  same  as  in  the  earlier 
article. 

The  concluding  chapter,  on  the  physical  future  of  Americans, 
contains  Dr.  Beard's  ideas  of  what  we  are  coming  to,  and  is,  in  a 
measure,  encouraging.  But,  like  all  prophecy,  it  requires  some 
faith  for  its  acceptance,  and  as  we  do  not  fully  admit  all  that  he 
says  in  regard  to  our  present  condition,  we  may  not  accept  his 
conclusions  for  the  future.  The  chapter  also  contains  the  author's 
views  on  the  subject  of  education,  which  are  certainly  extreme 
when  judged  by  those  practically  applied  at  the  present  time.  His 
expressions  here  seem  to  us  frequently  unfortunate,  whatever  he 
may  mean  by  them.  For  example,  such  statements  as  "Ignorance 
is  power  as  well  as  joy,"  "  Even  our  sciences  would  seem  to 
flourish  best  in  the  soil  of  ignorance  and  non-expertness,"  have  a 
rather  curious  sound,  but  they  occur  here  and  are  matched  by 
others  in  the  volume. 

In  conclusion  we  would  state  that  the  work  is  a  popular  rather 
than  a  scientific  one,  and,  as  the  author  states,  it  is  a  very  proper 
sequel  to  his  semi-medical  treatise  on  nervous  exhaustion.  It 
gives  what  we  think  is  an  exaggerated  view  of  some  phases  of 
American  life,  and  makes  wholesale  generalizations  from  facts 
that  exist  to  only  a  very  limited  extent  in  our  population.  We 
have  not  had,  perhaps,  all  the  advantages  of  observation  in 
foreign  countries  that  Dr.  Beard  may  have  had,  but  with  a  rather 
extensive  acquaintance  with  our  foreign-born  population  here,  and 
some  slight  observation  of  the  people  of  certain  other  political 
divisions  of  the  globe  on  their  own  soil,  we  are  far  from  being  con- 
vinced that  nervousness  is  so  characteristically  American  as  this 
work  would  make  it  appear. 

The  literary  style  of  the  work,  as  might  be  expected,  is  very 
good  ;  it  is  very  readable  and  entertaining.  Its  typographical 
appearance  is  also  very  good. 


7/8  RE  VIE  WS. 

The  mother's  guide  in  the  management  and  feeding 
of  infants.  By  John  M.  Keating,  M.D.,  Lecturer  on  the 
Diseases  of  Children  at  the  University  of  Pennsylvania,  etc. 
Philadelphia  :  1881,  H.  C.  Lea's  Sons  &  Co.  Chicago  :  Jansen, 
McClurg  &  Co. 

The  most  perilous  period  of  every  individual's  life  is  the  first 
year  of  his  or  her  existence.  It  is  not  a  matter  for  wonder,  there- 
fore, that  there  should  be  an  extensive  literature  on  the  hygiene 
of  that  period,  and  that  it  should  be  enlarged  by  very  frequent 
additions.  The  one  standard  text-book  on  infant  hygiene  and 
medicine  can  scarcely  be  said  to  exist ;  there  are  so  many  trea- 
tises of  more  or  less  merit  on  the  subject.  This  latest  volupne  is 
intended  for  the  use  of  mothers  and  nurses  who  have  the  prac- 
tical care  and  management  of  infants,  and  should,  therefore,  be  a 
popular  rather  than  a  medical  work.  So  far  as  we  can  see,  its 
advice  is  safe  and  sensible.  It  does  not,  however,  give  all  the 
information  that  may  be  needed  at  times,  and,  like  all  these  little 
books,  it  is  no  substitute  for  a  physician  in  cases  of  actual  danger. 
It  deserves  a  large  circulation. 

The  wilderness  cure.  By  Marc  Cook.  New  York  :  Wm. 
Wood  &  Co.,  1881. 

This  little  book  gives  the  experience  of  a  consumptive  benefited 
by  a  residence  in  the  northern  wilderness  of  New  York,  the  Adi- 
rondack region,  together  with  a  large  amount  of  valuable  informa- 
tion in  regard  to  that  region,  and  the  cost  and  methods  of  the 
plans  of  obtaining  the  benefit  of  the  camp-cure  for  invalids.  It  is 
very  entertainingly  written,  and  will  doubtless  be  widely  read  and 
help  to  build  up  summer  (and  winter,  according  to  the  author's 
recommendations)  health-camps  in  John  Brown's  tract  and  the 
St.  Regis  region.  Such  are  of  great  value  to  many  invalids,  not 
consumptives,  though  this  book  is  addressed  especially  to  that 
class,  and  in  showing  how,  and  how  cheaply,  it  can  be  managed, 
provided  the  author's  figures  are  correct,  it  may  be  of  consider- 
able service. 

A  treatise  on  albuminuria.  By  W.  Howship  Dickinson, 
M.D.,  Cantab.  Second  edition.  New  York  :  Wm.  Wood  &  Co., 
1881. 

Messrs.  Wm.  Wood  &  Co.  have  reproduced  in  their  series  for 
this  year,  Dickinson  on  albuminuria.  As  this  is  a  second  edition, 
and  the  former  edition  may  be  known  to  our  readers,  it  is  not  nec- 
essary to  say  very  much  in  regard  to  its  contents.     It  treats  solely 


FOREIGN  PSYCHIATRICAL   LITERATURE.  779 

of  pathological  albuminuria  connected  with  the  various  forms  of 
nephritis  commonly  classed  together  under  the  name  of  Bright's 
disease,  and  is  therefore  not  a  complete  treatise  on  all  the  condi- 
tions in  which  albumen  appears  in  the  urine.  Every  physician 
who  makes  a  common  practice  of  urine  examination  in  his  cases 
is  aware  that  albumen  often  is  met  with  when  there  is  no  reason  to 
diagnose  any  serious  kidney  disease,  and  therefore  the  general 
assertion  that,  save  in  physiological  alimentary  albuminuria  and 
that  connected  with  certain  hepatic  disorders,  when  the  urine 
contains  albumen  the  kidneys  are  abnormal,  if  taken  as  meaning 
notably  diseased,  is  misleading.  The  book  does  not  contain  all 
the  results  of  the  most  recent  investigations  on  the  subject,  but  it 
is  well  written  and  a  valuable  treatise. 


REVIEW  OF  FOREIGN  PSYCHIATRICAL  LITERATURE 

FOR    1881. 

I. — Archiv  fur  Psychiatrie  und  Nervenkrankheiten. 
II. — Jahrbucher  fur  Psychiatrie. 
III. — Allgemeine    Zeitschrift     fur    Psychiatrie    und 

Psyschisch-Gerichtliche  Medicin. 
IV. — Centralblatt  fur  Nervenheilkunde,  Psychiatrie, 

UND  Gerichtliche  Psychopathologie. 
V. — Annales  Medico-Psychologiques.    ' 
VI. — Archives  de  Neurologie. 
VII. — L'  Encephale. 

VIII. — Archivio    Italiano   per   le   Malattie   Nervose   e 
Piu  Particolarmente  per  le  Alienazioni  Men- 
tali. 
IX. — RivisTA  Sperimentale  di  Freniatria  e  di  Medicina 

Legale. 
X. — Brain. 

XL — The  Journal  of  Mental  Science. 
XII. — The    Journal    of    Psychological    Medicine    and 
Mental  Pathology. 

That  psychiatry  has  made  any  very  great  advance  during  the 
semi-annual  period  embraced  in  this  review  cannot  be  said. 
While  some  points  in  its  clinical  and  forensic  relations  have  been 
more  clearly  defined,  while  some  new  methods  of  treatment  have 
received  extended  trial  and  commendation,  it  must  be  confessed 


78o  RE  VIE  WS. 

that  in  certain  points  the  tendency  has  been  apparently  toward 
a  retrograde  rather  than  an  advance.  In  the  present  review  we 
shall  attempt  a  survey  of  a  portion  of  American,  English,  French, 
German,  Austrian,  and  Italian  periodical  psychiatrical  literature 
from  a  purely  critical  standpoint.  The  subjects  set  apart  for 
particular  treatment  cannot  be  said  to  be  clearly  demarcated. 
The  topics  to  which  special  attention  will  be  given  are,  first,  the 
general  clinical  aspect  of  psychiatry  ;  second,  the  therapeutic 
aspect  of  psychiatry;  third,  the  special  psychoses ;  and  finally,  the 
general  pathology. 

The  subject  of  hallucinations  is  always  one  of  great  interest 
insomuch  as  it  has  important  forensic  prognostic  and  diagnostic 
relations.  Hallucinations,  or  to  speak  more  properly,  hallucina- 
tory delusions  are  the  deus  ex  machina  of  many  of  the  acts  of  the 
insane.  They  therefore  usually  attract  attention,  and  few  col- 
lections of  psychiatrical  works  are  destitute  of  extended  treatises 
on  this  subject.  The  literature  before  us  is  by  no  means  poor  in 
this  respect.  Tamburini,'  for  example,  raises  the  question  as 
to  the  seat  of  hallucinations,  and  decides,  in  contradistinction  to 
the  opinions  of  Hammond'  and  Luys,'  that  the  optic  thalamus  is 
not  the  seat  of  lesion,  but  regards  excitation  of  the  cerebral  cor- 
tex as  their  fundamental  cause,  at  least  of  hallucinations  which  are 
unilateral.  Tamburini  could  not  have  read  a  discussion  in  the 
New  York  Neuroliogical  Society,  March,  1877,*  or  he  would  not 
have  set  forth  his  conclusions  as  so  purely  original.  In  the  es- 
sential part  of  his  conclusions  he  has  been  anticipated  by  Spitzka, 
as  witness  the  following  quotation  :  "  The  true  explanation  of  a 
hallucination  would  therefore  be  that  in  an  intact  cortical  terri- 
tory, through  anomalies  in  its  vascular  supply,  an  old  impression 
is  awakened  with  life-like  vigor,  that  an  electro-negative  oscilla- 
tion takes  place  analogous  to  the  one  occurring  when  the  actual 
impression  was  first  registered."  This  states  Tamburini's  theory 
with  even  more  clearness  than  he  himself  has  done.  Kaudensky* 
has  described  a  well-marked  case  of  monomania  (primare  Ver- 
rucktheit)  with  systematized  delusions  and  hallucinations,  the 
pathological  basis  of  which  is  described  as  being  a  "  loss  of  ca- 
pacity on  the  part  of  the  frontal  lobes,  with  increased  excitability, 

^  Rivisti  Sperimentale ,  Fasciculus  one  and  two,   1880. 

*  Journal  of  Nervous  and  Mental  Disease,  vol.  iv,  p.  321. 
^  Gazette  des  Hdpitaux,  No.  142,  1880. 

*  Journal  OF  NerVous  and  Mental  Disease,  April,  1877,  p.  321. 

*  Archiv  fiir  Psychiatric,  Band  xi,  Heft  3. 


FOREIGN  PSYCHIATRICAL   LITERATURE.  78 1 

at  the  same  time,  of  the  cortical  or  infracortical  sensory  centres." 
While  the  first  part  of  this  opinion  cannot  be  sustained,  the  sec- 
ond is  in  full  accord  with  the  views  of  Tamburini  an-d  Spitzka 
just  quoted.  Pick'  describes  a  case  of  a  patient  who  to  the  eti- 
ological influence  of  marked  heredity  added  syphilitic  infection. 
The  patient,  although  having  some  optimistic  delusions,  exhibited, 
in  addition,  marked  hallucinations  of  touch,  hearing,  and  sight. 
He  complained  of  being  subjected  to  an  electric  machine  and 
being  burnt  on  his  feet.  These  hallucinations  of  general  sensi- 
bility evidently  arose  in  a  manner  indicated  in  a  commu- 
nication to  this  Journal,'^  namely,  by  the  intense  mental  concen- 
tration of  the  patient  on  sensations  produced  by  his  luetic  con- 
dition. The  patient  had,  besides  these,  hallucinations  of  hearing 
and  "  partial  "  hallucinations  of  sight  ;  the  patient  had  a  defect 
in  the  visual  field,  and  saw  but  half  the  hallucinatory  object. 
These  hallucinations  of  sight  were  confined  to  the  right  side  of 
the  field  of  vision,  and  evidently  originated  in  a  similar  manner 
to  the  hallucinations  of  touch.  Pick  referred  the  affection  to  a 
lesion  affecting  the  posterior  portion  of  the  internal  capsule  ;  a 
pathological  localization  difficult  or  impossible  to  justify.  In 
marked  contrast  with  the  views  of  Tamburini  are  those  of  Bail- 
larger,  who  reports  the  case  of  a  man,  aged  83,  who,  although 
blind,  had  for  two  years  (subsequent  to  two  unsuccessful  opera- 
tions for  cataract,  and  following  these  an  attack  of  cerebral  con- 
gestion) periodical  hallucinations  of  sight  which  lasted  thirty-six 
hours.  Baillarger  claims  that  the  patient  fully  recognized  the  de- 
lusive nature  of  his  hallucinations,  and  from  this  and  the  fact 
that  hallucinations  were  confined  to  one  sense  concludes  that  in 
the  production  of  hallucinations  both  a  sensorial  and  a  psychical 
element  are  required.  This  conclusion  does  not  logically  follow 
from  the  facts  given.  That  the  patient  had  not  had  hallucinations 
of  touch,  and  that  the  hallucinations  did  not  become  delusions, 
simply  shows  that  a  psychical  element  was  wanting,  and  no  more. 
Of  similar  nature  to  this  is  the  reasoning  of  Regis, ^  who  cites 
five  cases  in  which  the  hallucinations  were  persistently  unilateral, 
which  Regis  claims  demonstrate  the  proposition  already  quoted 
from  Baillarger,  that  for  the  production  of  hallucinations  a 
sensorial  and  a  psychical  element  are  required.  His  cases  prove 
that  sensorial  defects  may  exert  an   influence   in    the  production 

'  Jahrbucher  fiir  Psychiatrie,  Band  ii,  Heft  3. 

^Journal  of  Nervous  and  Mental  Disease,  vol.  viii,  p.  458. 

'^  L'Encephale,  vol.  i,  Xo.  i. 


782  RE  VIE  WS. 

of  hallucinations,  but  nothing  more,  and  more  especially  not,  that 
hallucinations  always  require  sensorial  defect  for  their  produc- 
tion. As  an  example  of  Regis'  reasoning,  the  following  may  be 
given  :  "  Even  if  it  be  admitted  that  the  faculties  of  imagina- 
tion and  memory  may  reproduce  an  idea  or  a  remembrance  with 
the  characteristic  phenomena  of  a  normal  sensation,  so  that  the 
individual  attacked  regards  himself  as  having  received  a  true  sen- 
sorial impression,  no  reason  could  be  assigned  why  in  certain 
cases  an  individual  would  constantly  refer  to  a  sense  organ  of 
one  side  a  phenomenon  of  purely  intellectual  nature." 

This  reasoning  can  be  said  to  lead  only  to  the  conclusion,  to 
which  reference  has  been  already  made,  that  in  certain  cases  the 
sensorial  defect  enters  into  the  formation  of  a  hallucination.  I 
have,  however,  seen  cases  of  unilateral  hallucinations  in  which  a 
defect  of  the  sense-organs  could  not  be  detected  by  the  most  ex- 
tended examination.  While  the  views  of  Dr.  Regis  are  entitled 
to  all  respect,  and  while  no  considerations  other  than  those  of 
scientific  truth  are  of  any  weight  in  deciding  the  matter,  still  the 
serious  consequences  attending  the  acceptance  of  this  sensorial 
doctrine  should  impose  a  rigid  examination  of  the  facts  on  which 
it  is  based.  It  certainly  shows  the  influence  of  the  "reflex" 
school  of  neurologists  so  numerous  in  France.  It  is  safe  to  pre- 
dict that  not  a  few  murders  will  be  committed  by  lunatics,  "  whose 
sensorial  basis  of  hallucinations  "  has  been  removed  by  devotees  of 
the  Regis  theory.  Regis  is  a  disciple  of  Ball,  and  the  latter  is  a 
full-fledged  alienist,  without  previous  training,  on  being  elevated 
to  a  position  for  which  his  previous  studies  by  no  means  fitted 
him.  Another  disciple  of  the  Ball  school,  Semon,'  endeavors  to 
show  that  a  conception  which  an  insane  patient  has  thought 
aloud  is  a  "  psychic  hallucination."  The  attempt  is  by  no  means 
a  success,  and  exhibits  but  little  psychological  knowledge.  The 
endeavor  bears  the  impress  of  diletantism.  In  regard  to  the  liter- 
ature of  hallucinations  it  cannot  be  said  that  it  exhibits  any  thing 
but  a  retrograde  tendency,  Tamburini,  Pick,  and  Laseque  ex- 
cepted, who  have  endeavored  to  maintain  what  is  certainly  the 
scientific  view  of  the  subject.  Needham^  and  Savage  report  under 
the  head  of  "  contagiousness  of  delusion,"  cases  which  are  evi- 
dently folic  a  deux,  and  which  certainly  add  force  to  the  opinion,' 
elsewhere  expressed,  that  asylum  treatment,  by  reason  of  bringing 

'  Lyon  Me'Jicale,  November  25  and  December  5,  1S80. 
"  Journal  of  Mental  Science,  January  and  April,  1881. 
*  Journal  of  Nervous  and  Mental  Disease,  vol.  vii,  p.  643. 


FOREIGN  PSYCHIATRICAL   LITERATURE.  783 

insane  patients  into  close  relations  with  each  other,  exerts,  at  times, 
an  injurious  influence.  The  cases  cited  in  Needham's  article  were 
two  brothers,  the  younger  of  whom  was  the  recipient  of  the  delu- 
sion, being  the  weaker  intellect.  The  originator  of  the  delusion 
died,  but  the  recipient  still  continued  to  accept  it  as  true. 

Savage's  cases  are  very  similar,  except  that  in  one,  the  delusions 
have  extended  from  the  father  to  his  son,  and  then  to  the  latter's 
wife,  who  is  sane  but  stupid. 

Psychiatrists  who  have  approached  the  subject  of  psychiatry 
from  the  standpoint  of  the  study  of  alcohol  exhibit  very  curiously 
the  influence  of  a  bias  of  this  kind  in  whatever  else  they  attempt. 
Magnan,'  for  example,  claims  that  varied  psychoses  may  exist  in 
the  same  individual,  a  claim  that  is  strictly  correct,  but  he  adds  to 
this  a  bizarre  attempt  to  show  that  these  varied  psychoses  are 
directly  inherited.  Thus,  the  father  in  one  case,  at  once  epileptic 
and  melancholic,  having  been  an  alcoholist,  the  patient  inherits 
from  him  epilepsy,  as,  according  to  Magnan,  alcoholism  in  the 
parent  produces  epilepsy  in  the  offspring  ;  at  the  same  time  the 
patient's  mother  being  a  melancholiac,  he  inherits  from  her  his 
melancholia.  This  is  certainly  bolstering  up  one  hypothesis  by 
another,  and  what  little  influence  for  good  the  article  is  likely  to 
have  is  destroyed  by  this  vague  method  of  reasoning.  Another 
curious  attempt  at  explaining  certain  morbid  psychological  phe- 
nomena is  that  of  Des  Courtis,^  who  tries  to  show,  by  the  citation 
of  certain  cases,  that  the  two  cerebral  hemispheres  can  act  inde- 
pendently of  each  other.  The  cases,  who  are  paretics  principally, 
if  nor  entirely,  carry  on  conversations  in  two  persons,  and  this 
phenomenon,  which  Ball,  who  is  at  the  bottom  of  much  of  this 
fanciful  but  not  ingenious  psychiatry  has  dubbed  des-equilibra- 
tion,  is  frequently  found  in  cases  of  progressive  paresis.  Many 
cases  of  the  same  kind  have  come  under  observation  on  this  side 
of  the  Atlantic,  but  admit  of  a  more  prosaic  explanation  than  that 
given  by  Des  Courtis.  The  great  psychological  phenomenon  pre- 
sented by  the  paretic  is,  as  Spitzka'  has  pointed  out,  a  loss  of  his 
proper  self-consciousness.  Now,  it  is  noteworthy  that  many  of 
the  paretic's  delusions  originate  as  gasconading,  but,  owing  to  his 
imperfect  associating  mechanism,  are  accepted  finally  as  healthy. 
Children  often  indulge  in  this  habit  of  speaking  in  two  persons  to 
placate  some  one  they  have  offended,  or  to  give  a  support  to  some 

'  Archives  de  Neurologic,  vol.  i,  No.  i. 

*  L' Encephale,  vol.  i,  No.  i. 

*  Journal  of  Nervous  and  Me.ntal  Disease,  vol.  iv,  p.  273. 


784  REVIEWS. 

pretension.  The  child  whose  associating  mechanism  has  not 
been  trained,  and  the  paretic  whose  associating  mechanism  has 
been  impaired,  are  on  the  same  plane.  A  formula  of  speaking 
in  two  persons,  which  the  paretic  adopts  in  a  spirit  of  gasconading, 
is  continued  as  a  matter  of  fact,  and  for  lack  of  correction  by  the 
proper  associating  mechanism.  To  some  such  mental  operation 
as  this  can  be  safely  referred  the  phenomenon  that  seems  to  Des 
Courtis  to  require  the  action  of  both  cerebral  hemispheres.  Suf- 
ficient clinical  evidence  can  be  found  to  support  this  view  at  a 
fitting  tirrie  and  place. 

A  similar  evidence  of  this  fanciful  psychiatry  is  to  be  found  in 
Ball's'  article  on  cerebral  impulses,  in  which  he  endeavors  to  show 
that  an  impulse  which  seizes  men  ordinarily  healthy  as  regards 
mentality  to  wander  from  the  subject  in  which  they  are  supposed 
to  be  interested,  is  of  a  morbid  type.  Any  medical  society  will 
furnish  numerous  examples  of  the  phenomenon  in  question,  but 
the  pathological  element  of  it  is  not  at  all  clear,  and  Ball's  at- 
tempts at  reducing  it  to  this  basis  are  not  successful. 

Dagonet,^  in  an  article  considerably  tinctured  by  a  sacerdotal 
spirit,  attempts  to  consider  conscience  from  a  psychiatrical  point 
of  view,  but  the  article  is  of  little  interest  from  either  a  psycho- 
logical or  psychiatrical  standpoint.  In  many  respects  far  superior 
to  this  is  Lasegue's  "evolution  of  delusions  of  persecution." 
According  to  him  ^  this  class  of  delusions  are  the  most  subjective 
of  all  delusions,  and  have  nothing  concrete  at  their  inception. 
Lasegue,  however,  is  not  sufficiently  definitive  here,  as  he  is  evi- 
dently speaking,  not  of  the  delusions  of  persecution  pure  and 
simple,  but  of  these  delusions  as  found  in  melancholia.  Sadness 
precedes  the  delusions  of  persecution  in  melancholia,  but  the 
reverse  is  the  case  in  many  of  the  delusions  of  persecution  as 
found  in  other  psychoses.  A  man  claims  to  be  a  king,  and  is 
incarcerated  in  an  asylum.  From  this  a  delusion  of  conspiracy 
results,  and  he  becomes  sad.  It  cannot  be  said  that  in  this  latter 
delusion  there  is  nothing  concrete,  nor  can  it  be  said  to  be  purely 
subjective  ;  yet  it  may  be,  and  often  is,  a  well-marked  delusion  of 
persecution.  Lasegue  has  fallen  into  an  error  common  to  many 
superintendents  of  insane  asylums,  considering  delusions  of  per- 
secution and  melancholia  as  almost  synonymous.  Lasegue  differs, 
as  most  psychiatrists  are  likely  to  differ,  from  the  Ball  school,  in 

'  L' Encephale,  vol.  i,  No.  i. 

*  Annales  Medico-Psychologiqiies,  May,  l88r. 

^  Ibid.,  January  and  March,  1881. 


FOREIGN  PSYCHIATRICAL  LITERATURE.  785 

believing  that  hallucinations  may  be  of  purely  psychic  origin.  He 
classifies  the  hallucinations  occurring  among  the  insane  of  this 
class  as  of  two  great  types,  one  initial  or  casual,  the  other  con- 
secutive or  terminal.  Among  the  English-speaking  psychiatrists 
the  first  is  usually  called  an  illusion  arising  from  the  misinterpre- 
tation of  an  actual  perception.  The  evolution  of  the  other  type 
of  hallucination  is,  according  to  Lasegue,  as  follows  :  ''  The 
patient  reasons  that  among  the  numerous  ideas  which  strike  him 
there  are  some  the  origin  of  which  he  recognizes,  and  some  which 
he  does  not.  There  are  for  him,  then,  two  individualities,  one  of 
which  is  himself  and  the  other  is  a  he  which  is  not  and  is  himself, 
a  species  of  parasitic  being  which  has  taken  control  over  him.  It 
is  he  who  commands,  maintains,  and  ordains,  and  the  patient  is 
unable  to  detach  himself  from  this  parasite.  How  has  this  new 
'ego  '  obtained  control  over  his  thoughts  and  imposed  on  him  his 
will  ?  By  the  ordinary  process  of  thought  ?  No,  but  by  some- 
thing or  some  one  which  speaks  to  him.  When  the  patient  has 
obtained  this  formula,  he  has  the  explanation  of  his  condition. 
The  auditory  hallucinations  form  as  a  means  of  communication 
between  his  thought  and  that  of  the  parasite,  which  interferes  in 
his  existence.  It  is  an  elaborated  transition  between  the  ideas  of 
self  and  the  idea  of  another."  The  great  defect  of  this  article  is 
the  absence  of  a  distinction  between  systematized  and  unsystema- 
tized delusions. 

Roth,'  in  an  elaborate  article,  attempts  to  trace  a  relation  be- 
tween temperament  and  insanity,  which  he  regards  as  well  estab- 
lished, but  which  is  so  illy  defined  as  scarcely  to  be  of  value. 

A  case^  illustrating  how  long  certain  cases  of  monomania  may 
live  has  been  recently  reported  from  England.  A  patient  devel- 
oped marked  symptoms  of  insanity  at  eighteen,  and  died  after 
an  asylum  sojourn  of  sixty-six  years.  A  somewhat  similar  case 
occurred  at  the  New  York  City  Asylum  for  the  Insane.  A  patient 
entered  the  asylum  in  his  seventeenth  year  and  remained  till  his 
death,  which  occurred  at  the  age  of  eighty-three. 

A  paper'  which  has  attracted  some  little  attention  in  the  United 
States,  and  which  is  founded  on  an  English  paper  on  the  same 
subject,  is  one  on  certain  facial  hairy  growths  among  insane 
women,  by   Dr.  Allan  McL.   Hamilton.     The  conclusion  of  this 

'  Zeitschrift  fUr  Psychiatrie,  Band  xxxvii,  Heft  3. 
*  Medical  Times  and  Gazette,  February  ig,  1881. 

'  Significance  of  facial  hairy  growths  in  insane  women.  Medical  Record, 
March  12,  1881. 


786  REVIEWS. 

paper,  that  facial  hairy  growths  among  young  insane  women  have 
a  bearing  on  prognosis,  is  vitiated  by  the  fact  that  social  peculiari- 
ties have  been  disregarded.  The  paper,  curiously  enough,  con- 
tains an  admission  that  asylum  histories  are  very  imperfect, — a 
matter  strenuously  denied  by  its  author  on  several  occasions. 
The  paper  is  certainly  a  contribution  of  value  to  the  much- 
neglected  study  of  trophic  conditions  in  the  insane. 

The  mental  condition  of  Martin  Luther  has  been  frequently 
discussed,  but  the  subject  seems  to  be  ever  attractmg  new  investi- 
gators. Berkhard'  considers  Luther's  mental  and  nervous  condi- 
tion. He  regards  him  as  suffering  from  the  effects  of  overwork, 
and  while  many  well-known  facts  in  connection  with  Luther's  life 
are  quoted,  the  hallucinations  of  Luther  after  marriage  with  Kathe- 
rine  von  Bora  seem  unknown  to  Berkhard.  After  all,  had  Luther 
lived  in  the  nineteenth  century,  his  vigorous  intellect  would  not 
have  failed  to  demarcate  between  subjective  and  objective  sensa- 
tions, even  though  he  were  suffering  from  overwork. 

Passing  from  the  subjects  already  quoted,  which  are  capable 
only  of  being  included  in  general  psychiatry,  we  come  to  ques- 
tions of  etiology,  and  of  cases  bearing  on  this  point  the  present 
literature  is  quite  full.  Siemens^  has  had  the  opportunity  of 
examining  cases  of  insanity  due  to  ergot.  A  six-year-old  boy 
and  a  woman  exhibited  optimistic,  auditory,  and  visual  hallucina- 
tions. One  of  the  remaining  cases  exhibited  symptoms  of  melan- 
cholia ;  the  others  dementia,  with  maniacal  exacerbations.  The 
general  intellectual  condition  was  that  of  depression,  with  the 
exceptions  mentioned.  Even  the  so-called  maniacal  outbursts 
were  really  melancholia,  with  frenzy.  All  the  patients  recovered. 
Siemens'  terms  are  somewhat  indefinite.  The  article  would  be 
more  valuable  if  the  psychoses  were  properly  classified. 

Kraepilin,  in  an  interesting  article  on  the  relations  of  acute  dis- 
eases to  the  psychoses,  discusses,  first,  the  relations  of  intermittent 
fever,  which  he  finds  produces,  as  a  rule,  an  active  melancholia,  but 
in  a  quarter  of  the  cases  mental  conditions  varied  from  apathetic 
melancholia  to  maniacal  exaltation.  At  times  these  psychoses  are 
of  a  periodic  type,  and  the  prognosis  is,  as  a  rule,  favorable. 
The  existence  of  a  predisposition  is  of  course  necessary.  He 
next  takes  up  the  question  ot  rheumatism,  and  claims  that  at  cer- 
tain seasons  rheumatism  is  more  frequent  than  at  others,  so  that 
at  times  a  number  of  cases  may  appear  together.       He  quotes 

^  Archiv  fiir  Psychiatrie,  Band  xi,  Heft  3. 

'  Archiv  fur  Psychiatric,  Band  xi,  Heft  1  and  2. 


FOREIGN  PSYCHIATRICAL  LITERATURE.  787 

Rigler  as  saying  that  rheumatic  cerebral  complications  are  most 
frequent  in  Turkey. 

He  divides  insanity  as  produced  by  rheumatism  into  the  follow- 
ing classes  :  First,  the  hyperpyretic  form,  the  most  acute  variety, 
the  initial  symptoms  of  which  are  insomnia,  talking  in  sleep,  slight 
delirium,  followed  by  severe  delirium  later  ;  after  a  rise  in  the 
temperature  death  results  ;  with  continued  rise  in  the  temperature 
the  prognosis  is  bad,  only  18  per  cent,  recovering  ;  the  disease  is 
sometimes  complicated  by  facial  spasm.  Second,  less  acute  de- 
lirious cases  occurring  during  the  first  week  of  the  disease,  rarely 
during  the  second  week  ;  usually  comes  on  with  maniacal 
excitement  at  times,  though  rarely  with  melancholic  frenzy  ;  col- 
lapse or  deatli  occurs  in  over  one  half  the  cases.  Choreic  compli- 
cations occurred  in  a  few  cases.  Three  cases  recovered  after 
spontaneous  epistaxis.  Third,  a  form  which  requires  for  its  pro- 
duction, in  addition  to  the  exciting  cause — rheumatism, — certain 
predisposing  causes — anaemia,  alcohol,  or  heredity.  This  form  is 
divisible  into  two  great  symptomatological  groups.  I.  Active 
melancholia,  with  fright  and  suicidal  tendencies,  sometimes  ac- 
companied with  choreic  movements  and  vertigo.  The  prognosis 
is  not  very  favorable.  II.  The  other  symptomatological  group 
lasts  three  or  four  months,  presenting  symptoms  of  confusion  with 
depression,  sometimes  chorea  and  sitophobia,  always  with  hallu- 
cinations.    Four  cases  recovered  ;  one  died. 

While  this  system  of  classification  seems  very  thorough  it  can- 
not be  so  regarded,  as  the  influence  of  rheumatism  on  already  ex- 
istent psychoses  is  not  considered.  In  the  third  division  of  his 
article  he  considers  the  influence  of  pneumonia  and  pleiirisy  in 
the  production  of  the  psychoses,  but  these  two  latter  influences  ex- 
ercise a  slight  effect,  except  indirectly,  through  producing  fever  or 
asthenia.  The  whole  article  is  a  valuable  one.  The  relations  of 
syphilis  to  the  production  of  insanity  is  always  an  interesting 
question,  and  to  its  discussion  Ripping*  devotes  a  somewhat 
lengthy  article,  and  regards  the  direct  and  solitary  influence  of 
syphilis  in  the  production  of  insanity  as  being  of  rare  occurrence, 
syphilis  being  aided  by  other  causes.  The  article  is  rather  preten- 
tious and  somewhat  authoritative.  He  has  not  met  with  the  form 
occurring  during  the  second  period.  Schaefer^  agrees  to  a  great 
extent  with  Skene,*  but  his  article  is  much  more  scientific,  consid- 

'  Zeitschtifl  fur  Psychiatrie,  Band  xxxvii,  Heft  6. 
''  Zeitschrift  fiir  Psychiatric,  Band  xxxvii,  Heft  I, 
*  American  yournal  of  Obstetrics,  January,  188 1. 


788  RE  VIE  ws. 

ered  from  the  standpoint  of  psychiatry,  than  that  of  Skene.  He 
finds  that  five  principal  classes  of  morbid  mental  plienomena  are 
produced  by  sexual  disorders  in  women.  Simple  insanity,  insan- 
ity developed  from  hypochondria,  sudden  insanity  with  numerous 
hallucinations,  primary  insanity,  an  abortive  type  of  insanity  with 
fixed  conception.  The  terms  adopted  are  not  very  well  suited  to 
demarcate  clinical  forms.  The  simple  forms  are  those  like  pure 
melancholia  and  mania.  The  sudden  insanity  is  a  species  of 
mania  transitoria  or  melancholia  furibunda  ;  the  remaining  terms 
fully  explain  themselves.  Skene,  in  his  article,  traces  too  much 
to  the  influence  of  the  ovaries  in  the  production  of  insanity,  and 
adopts  the  ovarian  theory  of  hysteria,  a  theory  that  has  pretty  well 
received  its  coup  de  grace. 

The  subject  of  the  influence  of  saturnism  has  been  discussed 
at  some  length  by  Bartens,'  who  claims  that  the  psychoses  pro- 
duced by  lead  are  both  of  an  acute  and  chronic  type.  The  acute 
type  is  a  species  of  mania  transitoria,  or  more  properly  melancho- 
lia furibunda,  with  great  incoherence  and  very  vivid  hallucinations 
of  sight  and  hearing.  In  a  few  cases  the  type  presented  is  that 
of  melancholia  attonita.  The  chronic  type  presents  hallucina- 
tions of  taste,  touch,  sight,  and  hearing.  The  patients  are  sus- 
picious and  have  delusions  of  persecution.  Some  present  the 
physical  phenomena  of  progressive  paresis.  The  prognosis  in 
the  acute  type,  Bartens  claims,  is  by  no  means  unfavorable,  two 
thirds  of  the  cases  having  recovered.  Paralytic  and  choreic  com- 
plications are  not  rare,  and  the  maniacal  furor  is  at  times  not  un- 
likely to  lead  to  death  from  exhaustion.  The  prognosis  of  the 
chronic  type  is,  of  course,  unfavorable  as  regards  both  life  and 
recovery.  To  Bartens'  use  of  the  term  mania  transitoria  the  ob- 
jection exists  that  the  term  has  been  applied  to  a  distinct  form  of 
insanity,  and  its  use  in  this  relation  tends  to  create  confusion. 
The  chronic  types  of  lead  insanity  have  exhibited  a  tendency  to 
end  in  progressive  paresis,  according  to  some  observations  else- 
were  reported.^  Verga '  attempts,  in  an  extended  article,  to  draw 
a  relation  between  meteorological  perturbation  and  agitation  of 
the  insane.  While  his  general  conclusion  that  such  a  relation  exists 
is  probably  correct,  it  cannot  be  said  that  his  arguments  and  cases 
are  so  free  from  elements  of  error  as  to  be  even  relative  proof 
of  it. 

'  Zeitschrift  fiir  Psychiatric,  Band  xxxvii,  Heft  2. 

'  Journal  of  Nervous   and  Mental   Disease,  July,    1881.     Psychoses 
from  lead. 

*  ArcAivio  Italiano  per  la  Malatiie  Ncrvosc,  May,  1881. 


FOREIGN  PSYCHIATRICAL  LITERATURE.  789 

The  therapeusis  of  insanity  is  like  therapeusis  in  other  branches 
of  medicine — a  rather  unsatisfactory  subject.  Friedmann'  takes 
up  the  question  of  hydrotherapy.  He  uses,  in  torpid  atonic  cases, 
the  douche  to  such  an  extent  as  to  be  stimulating,  and  generally 
washing  of  the  body  is  also  used.  Hip  and  sitz  baths  are  given  in 
cases  of  an  anomistic  tendency.  Wet  packing  is  used  with  good 
effect  in  the  more  acute  types  unless  contra-indicated  by  heart 
failure,  tuberculosis,  etc.  The  extreme  douche  is  used  by  him  with 
favorable  results  in  the  irritable,  noisy,  and  sleepless.  This  sub- 
ject is  one  to  which  too  little  attention  is  paid  in  the  United  States 
and  extended  trial  of  hydrotherapy  could  not  fail  to  be  rewarded. 

The  use  of  hyoscyamine  seems  to  be  spreading.  Savage,^  Se- 
guin,'  Seppili  and  Riva,*  and  Reinhardt^  have  been  all  investiga- 
ting. The  conclusions  of  Seppili  and  Riva,  Reinhardt  and  Savage, 
are,  to  a  considerable  extent,  the  same,  and  simply  amount  to  the 
expression  of  conclusions  that  hyoscyamine  is  of  value  as  an 
hypnotic.  Seguin's  conclusions  cover  more  ground  and,  therefore, 
deserve  more  extended  notice.     These  conclusions  are  as  follows  : 

1.  Hyoscyamine  acts  as  a  mydriatic,  but  whether  more  fully  or 
larger  than  atropia,  remains  to  be  settled. 

2.  When  given  in  small  doses  it  reduces  the  cardiac  pulsations, 
increases  arterial  tension,  and  checks  the  loss  of  body  heat.  It 
also  produces  hallucinations  and  delirium.  It  may  cause  a  fall  of 
axillary  temperature,  and  also  produces  a  rash. 

3.  In  large  doses  it  immediately  increases  the  pulse  rate,  pro- 
duces a  seeming  paralysis  or  motor  debility,  and  sleep. 

4.  Hyoscyamia  is  indicated  in  mania,  restlessness,  delusions 
of  persecution,  dementia  with  agitation  and  destructiveness,  epi- 
leptic mania,  insomnia,  rapid  action  of  the  heart,  epilepsy  (?), 
status  epilepticus,  chorea,  paralysis  agitans,  hysterical  spasms, 
tremor,  neuralgia,  rapid  pulse,  etc. 

5.  In  mania  and  allied  states  it  produces  sleep  as  certainly,  or 
even  more  certainly  than  chloral,  without  any  evil  after-effect,  un- 
less it  be  an  occasional  gastric  disorder. 

6.  In  cases  of  delusion  of  persecution  or  suspicions  it  has  pro- 
duced an  absolute  cure. 

7.  In  paralysis  agitans  it  achieves  what  no  other  remedy  ever 

*  Mittheil.  der  Verein  der  Aerzte  in  Neider-Oesterreich,  one  and  two,  1881. 
'  Journal  of  Mental  Science,  April,  1881. 

*  Archives  of  Medicine,  April  and  June,  1881. 

*  Rivista  Sperimentale ,  1881. 

*  Archiv  fiir  Psychiatrie,  Band  xi,  Heft  2. 


790  REVIEWS. 

has  done,  viz.,  arrests  the  movements  for  four  hours  or  more 
without  insensibility. 

8.  In  the  status  epilepticus  it  shortens  the  attack  materially, 
perhaps  better  than  any  other  single  remedy. 

9.  It  is  a  diuretic  of  no  mean  power. 

10.  The  curative  power  of  hyoscyamia  does  not  appear  to  be 
great.  In  some  cases  of  insanity  its  use  has  been  followed  by  re- 
covery, but  as  a  rule  we  must  look  upon  it  as  a  good  narcotic, 
often  speedier,  more  complete,  and  less  objectionable  than  mor- 
phia and  chloral  hydrate.  In  spasmodic  diseases  we  can  speak  of 
hyoscyamia  only  as  an  ameliorating  agent  or  as  a  palliative. 

The  conclusions  that  are  most  striking  in  the  above  are  the 
third  and  sixth.  Leaving  aside  the  question  of  psychiatrical  classi- 
fication, of  which  the  crudeness  is  somewhat  remarkable,  the  as- 
sertion in  regard  to  delusions  of  persecution  certainly  calls  for 
comment.  Which  type  of  delusions  of  persecution  is  meant  ?  The 
one  found  in  monomania  resulting  from  incarceration  in  a  lunatic 
asylum,  or  some  similar  logical  reason  ?  The  one  found  in  mel- 
ancholia, or  the  one  found  in  progressive  paresis  ?  The  delusion 
in  monomania  is  a  somewhat  complicated  process  of  thought, 
and  can  any  one  claim  that  this  can  be  swept  away  by  a  single 
drug?  The  idea  is  absurd.  As  well  might  one  have  attempted  to 
remove  the  "  terror  "  of  the  French  during  the  first  revolution  by 
doses  of  hyoscyamine.  Melancholia  is  a  condition  in  which  bella- 
donna and  the  other  mydriatics  are  strongly  contra-indicated,  and 
on  it  hyoscyamine  could  have  but  a  depressing  effect.  The  de- 
lusions in  progressive  paresis  shift  and  vary  so  much  that  it  would 
be  difficult,  nay,  impossible,  to  prove  that  their  disappearance  was 
due  to  any  one  drug.  It  may,  therefore,  be  safely  said  that  this 
alleged  action  of  hyoscyamine  has  been  rather  too  hastily  ac- 
cepted. In  point  of  fact,  the  tenth  and  sixth  conclusions  are 
somewhat  contradictory  on  this  point.  The  same  criticism  ap- 
plies to  the  conclusion  in  regard  to  epilepsy,  for  some  of  the  re- 
searches on  which  it  has  been  based  have  been  shown  in  a  court 
of  justice  to  be  valueless.  While  hyoscyamine  is  undeniably  valua- 
ble, it  certainly  owes  its  present  great  prominence  in  psychiatrical 
therapeutics  chiefly  to  fashion. 

Baillarger'  reports  a  case  of  hallucinations  of  alcoholic  origin 
which  recovered  by  the  use  of  wine  of  aloes.  The  case  is,  how- 
ever, very  imperfectly  reported,  and  if  any  benefit  was  attained  by 
the  use  of  aloes,  it  could  be  only  from  its  derivative  action.     The 

'  Annates  Medico- Psychologiques,  May,  1881. 


FOREIGN  PSYCHIATRICAL  LITERATURE.  791 

results  in  the  case  scarcely  merited  the  prominence  which  has  been 
given  it.  Baillarger  seems  to  have  an  ability  in  the  production  of 
good  results  by  medical  treatment,  for  he  reports  a  case  in  which 
hallucinations  made  their  appearance  during  the  night,  vanishing 
during  the  day,  developing  into  violent  mania,  which  was  treated 
by  sequestration  and  sulphate  of  quinine  in  large  doses,  which 
measures  were  followed  by  recovery.  He  pronounced  the  hallu- 
cinations intermittent,  and  acting  on  this  idea,  poured  in  quinine 
in  fifteen-grain  doses.  While  this  treatment,  considered  from  the 
principle  on  which  Baillarger  based  it,  is  absurd,  there  can  be  but 
little  doubt  that  in  conditions  where  hallucinations  of  the  ear  are 
present,  apparently  produced  by  vaso-motor  spasm,  quinine  in  large 
doses  might  be  of  benefit.  The  principle  of  treatment  is  what  is 
objectionable  in  this  case,  not  the  treatment  itself.  The  proced- 
ure of  Baillarger  in  this  case  reminds  one  very  forcibly  of  the 
scenes  at  the  death  of  Charles  II,  where  the  physicians,  after 
quarrelling  as  to  whether  his  disease  was  epilepsy  or  apoplexy, 
finally  decided  to  call  it  a  fever  and  throw  in  bark. 

Voisin*  has  recently  described  many  cases  of  melancholia 
treated  with  remarkable  success  by  means  of  chlorhydrate  of 
morphia.  While  the  results  he  has  given  seem  very  brilliant,  it  is 
obvious  his  enthusiasm  has  carried  him  away,  and  that  many  of 
his  alleged  cures  were  temporary  ameliorations,  and  his  results 
will  certainly  do  harm  by  encouraging  amateur  alienists  to  call 
hypochondriasic  conditions  melancholia,  and  treat  the  same  with 
chlorhydrate  of  morphia.  Morphia  well  used  in  psychiatry  is  an 
agent  of  great  value,  but  clinical  demarcation  of  the  psychoses  is 
necessary  before  the  remedy  can  be  tried.  Depression  exists  in 
melancholia ;  here  morphia  is  of  advantage.  But  depression 
also  exists  in  progressive  paresis  and  epileptic  conditions,  not  to 
speak  of  monomania  ;  here  morphia  is  worse  than  useless.  The 
article  is  of  much  value  when  used  with  a  little  caution.  Winn,* 
who  is  one  of  those  very  conservative  superintendents  not  yet 
reformed  away  in  England,  discusses  the  prophylaxis  of  insanity 
in  a  manner  strongly  suggestive  of  the  Utica  sages,  and  cites,  in 
support  of  his  ideas,  which  are  neither  very  luminous  nor  original, 
authorities  of  more  than  doubtful  value.  The  article  seems  to  be 
made  up  after  the  fashion  of  the  famous  Pickwickian  Chinese 
metaphysics.  The  author  has  read  up  for  prophylaxis  under  the 
letter  P,  and  insanity  under  the  letter  /,  and  combined  his  infor- 

*  Bulletin  Generale  de  Thirapeutique  Aledicale  et  Chirurgicale,  May  30,  1881. 

*  Journal  of  Psychological  Medicine,  January,  1881. 


792  RE  VIE  WS. 

mation  with  wonderful  results.  That  such  articles  emanate  from 
superintendents  speaks  strongly  as  to  the  necessity  for  prophylaxis, 
not  for  the  benefit  of  the  patient  but  for  the  benefit  of  the  super- 
intendent. 

Regis/  Lailler,'  and  Erckhardt'  discuss  the  question  of  forced 
alimentation  of  the  insane  with  clearness,  but  add  nothing  new  to 
the  subject. 

The  French'  have  been  discussing  non-restraint  in  the  treat- 
ment of  the  insane,  and,  like  Conolly  himself,  but  unlike  certain 
American  pseudo-reformers  who  have  made  canting  promises  and 
pretenses,  believe  that  in  certain  cases  a  limited  amount  of  restraint 
is  of  undoubtedly  great  value.  It  is  interesting  in  this  connection, 
however,  to  read  that  the  famous  Utica  crib,  which  originated  in 
its  first  crude  form  in  France,  is  thus  disposed  of  by  the  Annales 
Me'dico-Psychologiques :  *'  The  crib  originated  by  Aubanel  has  been 
long  since  abandoned  in  France,  and  is  there  regarded  as  a  useless 
and  dangerous  appliance." 

Schiile*  proposes  to  treat  the  unclean  insane  by  a  carefully 
regulated  system  of  baths,  and  proposes  to  inaugurate  for  them 
certain  regular  habits  of  defaecalion,  etc.  The  ideas  proposed 
are  certainly  practicable,  but  have  suggested  themselves  to  the 
majority  of  even  the  laymen  who  are  employed  about  the  insane. 

Stenger,^  Lelut,^  and  Mabille'  deal  with  the  question  of  the 
treatment  of  insanity  by  extended  antiphlogistic  or  counterirri- 
tant  treatment  by  producing  profuse  suppuration.  In  progressive 
paresis  the  apparent  good  effects  ascribed  by  them  to  the  treat- 
ment might  be  due  simply  to  remissions,  and  the  treatment,  to  say 
the  best,  useless.  In  monomania  (primare  verriicktheit)  there  is 
no  good  to  be  anticipated  from  this  species  of  treatment.  It  is 
possible  that  certain  cases  of  insanity  have  been  benefited,  but 
the  laissez  alter  system  is  certainly  preferable  to  these  active 
therapeutic  measures. 

Curwen,'  whose  malfeasance  in  office  led  to  the  loss  of  his  posi- 
tion, discusses  the  propositions  of  the  Asylum  Association,  as  if 
these  constituted  the  summum  bonum  of  all  human  medical  wis- 
dom.    This  contains  the  usual  hypocrisy  of  the  Association.     He 

'  Annales  Alddico-Psychologiques,  January,  l8Si. 
'  Zeitschrift  fiir  Psychiatrie,  Band  xxxvii,  Heft  2. 

*  Annales  M^dico-Psychologiques,  November,  l88o. 

*  Zeitschrift  fur  Psychiatrie,  Band  xxxvii,  Heft. 

'  Annales  Me'dico-Psychologiques,  November,  iSSo. 

*  Alienist  &"  Neurologist,  January,  1881. 


FOREIGN  PSYCHIATRICAL  LITERATURE.  793 

declares,  in  discussing  the  first  proposition,  that  a  knowledge  of 
general  medicine  is  not  necessary.  His  premises  would  lead,  and 
lead  very  surely,  to  the  one  conclusion,  that  a  layman  at  the  head 
of  an  insane  asylum  would  be  of  equal  value  with  a  medical  man, 
and  taking  himself  and  most  of  his  colleagues  only  into  comparison 
he  is  certainly  right.  He,  of  course,  opposes  the  cottage  system  of 
treatment,  to  whose  value  his  colleagues.  Dr.  Catlett,  of  Missouri, 
and  Dr.  Bucke,  of  Toronto,  have  borne  such  striking  testimony. 
In  many  points  this  total  ignoring  of  the  spirit  of  the  age  and  of 
all  progress  is  an  interesting  psychological  problem,  showing  the 
evil  influence  of  asylum  incarceration  on  a  mind  incapable  of 
rising  above  the  petty  details  of  building,  cooking,  etc.  The  article 
illustrates  the  fact  that  whatever  evil  the  removal  of  a  public  offi- 
cer occasions,  these  evils  were  at  their  minimum  when  Dr.  Cur- 
wen  lost  his  position.  From  treatment  we  pass  to  the  subject  of 
the  special  psychoses. 

Dr.  Clouston,'  in  an  interesting  article,  discusses  the  relations 
of  puberty  and  adolescence,  and  considers  the  influence  of  diet  on 
the  sexual  impulses.  The  article  is  rather  a  hint  as  to  the  proph- 
ylaxis of  puberty,  and  certainly  deserves  widely  extended  repub- 
lication, as  the  period  of  puberty,  psychologically  speaking,  is  one 
of  the  critical  epochs  in  human  life.  Buch^  and  Scholtz'  analyze 
primare  Verrucktheit,  monomania  of  Spitzka,  primary  intellectual 
insanity  of  other  authors,  but  beyond  exhibiting  the  symptoms  of 
this  psychosis  in  a  somewhat  clearer  light  than  usual,  add  noth- 
ing of  value  to  the  general  literature  of  the  subject.  Monomania 
is  a  subject  always  of  great  interest,  more  especially  at  the  present 
time  when  a  patient  afflicted  with  this  type  of  disease  has  at- 
tempted homicide.  The  history  of  that  attempt  is  only  a  repeti- 
tion of  many  similar  cases,  and  shows  that  asylum  isolation  is  most 
needed  and  most  difficult  to  apply  to  a  certain  class  of  very  dan- 
gerous patients.  Russel*  discusses  melancholia  in  a  manner  that 
very  fully  indicates  he  has  no  clear  conceptions  on  the  subject. 
He  has  confounded,  like  most  asylum  superintendents,  melan- 
cholia and  depressing  delusions,  and  cases  are  described  by  him  as 
melancholia  which  are  hypochondriacal  monomania,  a  condition 
clinically  and  pathologically  distinct  from  melancholia.  Russel  is, 
however,  very  sound  on  the  suicidal  tendencies  of  melancholiacs, 

'  Edinburgh  Medical  Journal,  January,  1881. 
'  Archiv  fUr  Psychiatric,  Band  xi,  Heft  2. 
^  Berliner  Klinische  Wochenschrifl,  No.  33,  1880. 
*  Alienist  ^  Neurologist,  April,  1881. 


794  REVIEWS. 

and  if  his  suggestions  were  heeded  by  his  colleagues  many  lives 
would  be  saved. 

Bourneville  and  D'Olier'  quote  from  Delasiauve  the  following  as 
expressive  of  their  views  of  the  psychology  of  epileptic  dementia, 
or  rather  of  dementia  generally,  of  which  epilepsy  is  a  very  fre- 
quent cause:  "  Varying  with  the  gravity  of  the  mental  condition  the 
attention  is  enfeebled  and  null  ;  memory  is  confused,  untrustwor- 
thy, and  at  times  entirely  lost  ;  conceptions  are  obscure,  abortive, 
or  false  ;  following  a  train  of  thought  is  painful,  incorrect,  and 
impossible  ;  imagination  is  not  markedly  developed.  From  this  in- 
tellectual mutilation  results,  as  a  matter  of  course,  moral  enfeeble- 
ment."  The  observations  forming  the  basis  of  this  are  believed 
by  the  authors  to  justify  the  conclusion,  that  at  times  epileptic  de- 
mentia is  not  characterized  by  any  marked  lesion,  though  in  other 
cases  very  decided  lesions  exist.  These  latter  lesions  are  very 
similar  to  those  encountered  in  progressive  paresis.  They  differ 
however,  in  many  important  points  ;  thus,  Brissaud  has  not  found 
miliary  aneurisms  in  three  cases  which  he  studied  with  much  care. 

Witkowski'  makes  general  criticisms  of  the  subject  of  epilepsy, 
characterized  by  the  rather  authoritative  air  with  which  the  author 
disposes  of  many  vexed  questions.  He  claims,  and  a  negative 
statement  of  this  kind  seems  of  no  value,  that  no  one  who  has 
had  large  experience  can  come  to  any  other  conclusion  than 
that  pure  psychic  equivalence  of  epilepsy  is  an  occurrence 
not  established  on  a  very  firm  basis.  Were  Dr.  Witkovvski 
an  interne  of  the  New  York  City  Asylum  for  the  Insane, 
he  would  be  soon  convinced  from  his  personal  observations  that 
there  is  such  a  thing  as  a  pure  psychical  equivalent  of  epilepsy 
without  any  motor  phenomena  whatever.  This  author,  like 
one  of  the  editors  of  the  Archives  de  Neurologie  (No.  2,  page 
320),  has  a  very  imperfect  knowledge  of  the  psychology  of  epi- 
lepsy, and  both  seem  unacquainted  with  the  labors  of  Falret  and 
Samt,  Sommer'  classifies  the  postepileptic  psychoses  into  :  Doubt- 
ful mental  conditions,  hallucinatory  delirium  :  i.  With  depressing 
delusions.  2.  Delusions  of  persecution.  3.  Anxious  and  impul- 
sive delusions.  4.  With  expansive  delusions.  Many  of  the  cases 
reported  are  cases  of  monomania  complicated  by  epilepsy,  and  a 
fairly  valuable  critical  analysis  has  not  been  made.  Sommer 
could  teach  Witkowski  and  a  few  French  psychiatrists,  however, 

'  Archives  de  Neurologic,  No.  2,  1880. 

"  Allgcmeine  Zeitschrift  fur  Psychiatric,  Band  xxxviii,  Heft  2. 

'  Archiv  fur  Psychiatric,  Band  xi,  Heft  2. 


FOREIGN  PSYCHIATRICAL  LITERATURE. 


795 


the  exact  meaning  of  terms,  as  the  words  psychical  equivalent  are 
used,  and  used  properly  in  the  whole  paper,  as  witness  the  follow- 
ing table. 


MALE. 

FEMALE. 

TOTAL. 

Pre-epileptic  psychic  disturbance  occurred  in 
Postepileptic  psychic  disturbance  occurred  in 
Pre-  and  postepileptic    psychic  disturbance    in 

Equivalent  alone 

Equivalent  pre-  and  postepileptic  psychic  dis- 
turbance occurred  in         ...          . 

2 

27 

I 

7 

3 

7 
2 

I 

2 

5 
34 
13 

2 

9 

48 

15 

63 

The  table  illustrates  a  fact  which  has  been  observed  by  other 
authors,  that  postepileptic  psychical  disturbances  are  of  greater 
rarity  than  the  other  types  of  epileptic  psychoses.  His  observa- 
tions do  not  tend  to  confirm  the  opinion  generally  expressed,  even 
by  neurologists  of  some  note,  that  the  percentage  of  epileptics  be- 
coming insane  is  relatively  small.  Pick'  narrates  a  very  interest- 
ing case  of  psychic  equivalence  of  epilepsy,  and  comes  to  much 
the  same  general  conclusions  as  Samt,  Falret,  Krafft-Ebing,  and 
Spitzka,  that  this  condition  is  a  clearly  demarcated  one,  the 
patient  presenting  the  type  of  the  grand  tnal  intellectual  of  Falret. 
With  this  concurrent  testimony  to  the  value  of  the  conclusions  of 
Falret,  it  is  a  little  difficult  to  understand  why  they  have  been  so 
much  ignored.  Heimann'  takes  up  the  epileptic  question  from  an 
interesting  standpoint,  a  casuistical  discussion  of  the  history  of 
six  insane  criminals,  in  which  the  relationship  between  criminality 
and  early  epilepsy  is  traced  in  a  very  clear  and  convincing  man- 
ner. Heimann  like  a  thorough  clinician,  makes  the  term  epilepsy 
a  very  comprehensive  one.  All  the  patients  described  by  Heimann 
had  marked  hereditary  defects,  and  of  the  early  history  of  these 
patients  he  gives  the  following  table  : 

Case  one  was  epileptic  as  a  child,  and  became  a  criminal  pX  the 
age  of  twenty-six  years,  after  displaying  the  usual  moral  phe- 
nomena of  insane  epileptics.  Case  two  was  also  an  epileptic  in 
early  childhood,  and  became  a  criminal  at  the  age  of  fifteen. 
Case  three  had  a  similar  history,  becoming  a  criminal  at  the  age 
of  sixteen.  Case  four  became  epileptic  at  fourteen,  and  criminal 
at  sixteen.     Case  five  became  a  criminal  at  the  age  of  thirty-four, 

'  Archiv  fiir  Psychiatric,  Band  xi.  Heft  i. 

'  Zeitschrift  fiir  Psychiatric,  Band  xxxvii,  Heft  5 . 


79^  REVIEWS. 

and  was  epileptic  from  childhood.  Case  six  was  epileptic  in  child- 
hood, and  criminal  at  twenty-one.  Insanity  and  irresponsibility 
were  judicially  recognized  in  the  first  case  at  the  age  of  twenty- 
eight,  two  years  after  the  first  crime  ;  while  in  case  two  irrespon- 
sibility was  recognized  half  a  year  after  the  first  crime  ;  in  case 
three,  at  the  age  of  forty-seven,  thirty-one  years  after  the  first 
crime  ;  in  case  four,  at  the  age  of  thirty-one,  seven  years  after  the 
first  crime  ;  in  case  five,  at  the  age  of  thirty-nine,  five  years  after 
the  first  crime  ;  in  case  six,  at  the  age  of  twenty-one,  three  months 
after  the  first  crime.  The  mental  phenomena  presented  by  these 
patients  were  :  Case  first,  slight  degree  of  incoherence,  weak  judg- 
ment, defective  memory,  abnormal  sensibility.  The  second  case, 
whose  irresponsibility  was  soon  recognized,  presented,  according 
to  Heimann,  that  much  disputed  psychosis,  moral  insanity.  The 
third  case  was  simple  weakmindedness  ;  the  fourth,  diminished 
intellectual  power  ;  the  fifth,  imbecility  and  dementia  ;  and  the 
sixth,  imbecility. 

The  first  symptoms  of  insanity  were  recognized  in  the  first  case 
one  year  after  the  first  crime,  one  month  before  an  epileptic  attack. 
The  symptoms  in  the  second  case  were  recognized  one  month 
after  the  first  crime,  one  year  after  an  epileptic  attack.  No  evi- 
dences of  insanity  were  discovered  in  the  third  case  until  twenty- 
nine  years -after  the  first  crime,  two  years  before  an  epileptic  attack. 
The  fourth  case  was  not  considered  as  insane  until  six  years  after 
the  first  crime,  one  year  after  an  epileptic  attack.  In  the  fifth  case 
no  symptoms  were  discovered  until  five  years  after*  the  first  crime, 
one  month  before  an  epileptic  attack.  In  the  sixth  case  the  symp- 
toms were  noticed  one  month  after  the  first  crime,  shortly  before 
an  epileptic  attack.  Plaxton'  discusses  the  question  of  the  crimi- 
nal insane,  but,  after  all,  adds  nothing  new  to  the  subject.  His 
conclusions  are  sound,  and  oppose  the  treatment  of  insane  as 
criminals  simply  because  they  have  committed  a  criminal  act. 
The  criminals  who  a  priori  are  such,  but  become  insane,  certainly 
should  be  treated  in  a  criminal  asylum  ;  but  the  patient  who, 
through  insanity,  commits  a  criminal  act  most  assuredly  should 
not.  If  his  responsibility  be  complete,  to  commit  such  a  patient 
to  a  criminal  asylum  would  be  to  punish  for  a  crime  of  which  he 
has  been  declared  not  guilty  through  insanity.  Cognate  to  this 
question  is  the  subject  of  the  treatment  of  criminals  who  have  be- 
come insane.  Perhaps  it  would  be  as  well  this  class  of  the  insane 
should  be  treated  in  an  asylum  placed  as  much  as  possible  under 

^  Journal  of  Mental  Science,  April,  i88l. 


FOREIGN  PSYCHIATRICAL  LITERATURE.  797 

prison  auspices,  as  the  moral  effect  would  certainly  do  much  to 
restrain  the  mischievous  tendencies  which  many  of  these  patients 
develop. 

Channing'  has  also  discussed  this  subject,  but  rather  in  the 
spirit  of  the  Asylum  Association  and  permeated  by  their  prejudices. 
Apart  from  these  prejudices  the  position  taken  in  the  article  is 
relatively  sound,  and  fully  in  accord  with  the  opinions  already 
expressed.  Karrer^  discusses  circular  insanity.  He  has  had 
under  observation  ten  cases,  of  whom  four  were  male  and  six 
female.  The  cases  reported  by  Dittmar,  Krafft-Ebing,  Flemming, 
Kelp,  and  others  quoted,  amount  to  about  equal  proportions  of  the 
sexes.  L.  Meyer  believes  that  the  proportion  of  males  and  females 
is  about  the  same.  The  experience  of  the  city  asylums  of  New 
York  would  lead  to  the  conclusion  that  more  males  than  females 
are  attacked  by  this  psychosis,  but  that  the  figures  on  which  such 
a  conclusion  would  be  based  cannot  be  said  to  be  beyond  im- 
peachment. The  classification  of  the  psychoses  adopted  by 
Karrer  is  much  the  same  as  that  of  Spitzka  :^  i.  Mania,  melan- 
cholia, mania.  2.  Mania,  melancholia,  free  interval.  3.  Mania, 
free  interval,  melancholia.  But  the  differences  are  not  as  clearly 
outlined.  The  article  is  a  contribution  to  the  clinical  history 
rather  than  the  casuistry  of  the  disease. 

Reich*  has  had  under  observation  four  boys,  six  to  ten  years 
old,  who  had  developed  a  transitory  form  of  insanity  under  the 
following  circumstances  :  They  had  been  skating  on  the  ice  at  a 
temperature  below  zero,  when,  on  re-entering  the  house,  which  was 
heated  to  a  high  temperature,  they  were  seized  an  hour  after  by  a 
maniacal  furor,  with  hallucinations,  after  which  came  a  slumber, 
on  waking  from  which  they  were  perfectly  lucid.  These  cases 
resemble  somewhat  others  elsewhere  described  in  this  Journal^  in 
their  etiology.  Grille'  considers  the  subject  of  moral  insanity, 
but  does  not  add  any  thing  new  to  the  subject,  or  place  it  in  any 
clearer  light.  Of  Bini's^  article  much  may  be  said.  Were  these 
two  articles  written  in  the  United  States  many  of  the  hypercriti- 
cal Italians  would  sneer  at  the  primitive  ideas  of  the  United 
States.     Moral  insanity   is    now,  fortunately,  on    a    pretty  firmly 

'  Boston  Medical  and  Surgical  Journal,  Feb.  24,  1881. 
*  Zeitschrift  fUr  Psychiatric,  Band  xxxvii,  Heft  6. 
^  New  York  Medical  Gazette,  May  15  and  29,  1880. 
^  Berliner  Klmisc he  Wochenschrift,  No.  8,  1881. 
'  Journal  of  Mental  and  Nervous  Disease,  Oct.,  1880. 
Archivio per  la  Malattie  Nervose,  vi,  1881.  '  Ibid.,  May,  1881. 


79^  RE  VIE  WS. 

established  basis,  and  such  efforts  as  those  of  the  two  authors  last 
quoted  can  scarcely  add  much  to  the  subject.  The  influence  of 
certain  social  conditions  in  the  production  of  insanity  appears  to 
have  attracted  much  attention.  Recently  Lochner'  has  been 
studying  the  influence  of  military  campaigns  on  the  production  of 
insanity.  Thirty-three  cases  came  under  his  observation  during 
the  period  between,  and  inclusive  of,  1870  to  1878.  Of  these,  ten 
were  cases  of  melancholia,  eight  cases  of  mania,  nine  secondary 
dementia,  and  six  progressive  paresis.  Of  these,  fourteen  were 
discharged  recovered,  two  improved,  five  died,  and  ten  still  remain 
under  treatment.  Of  those  who  recovered  one  had  been  less  than 
a  month  ill,  six  between  one  and  three  months,  four  between  three 
and  six  months,  and  three  between  six  and  twelve  months.  Of 
the  five  who  died  one  was  a  case  of  melancholia,  two  of  secondary 
dementia,  and  two  of  progressive  paresis.  The  first  case  presented, 
on  the  autopsy,  pulmonary  gangrene  and  chronic  leptomeningitis. 
The  two  dements  exhibited  evidences  of  pulmonary  tuberculosis 
and  cerebral  atrophy.  The  two  paretics  exhibited  pachymenin- 
gitis haemorrhagica  and  chronic  peri-encephalitis.  Bartels"  takes 
up  the  subject  of  psychoses  from  lead-poisoning,  but  he  has  been 
elsewhere  quoted  in  the  present  number.  The  article  contains  a 
very  fair  resume  of  the  literature  of  the  subject.  His  general 
conclusions  are  correct. 

Schmidt'  makes  a  very  interesting  contribution  to  the  puer- 
peral psychoses.  He  cites  from  Liibben,  Fiirtsner,  and  Ripping 
the  following  figures.  Liibben  found  that  fifteen  and  three  tenths 
per  cent,  of  the  insanity  of  his  female  patients  was  of  the  puer- 
peral variety.  Fiirtsner  gave  a  higher  percentage,  about  sixteen 
and  eight  tenths  ;  while  Ripping's  percentage  greatly  exceeded 
either,  reaching  twenty-one  and  six  tenths.  Schmidt  found  that 
of  the  fifteen  hundred  and  twenty  female  insane  coming  under 
his  observation  the  insanity  of  two  hundred  and  sixty-four,  or 
seventeen  and  three  tenths  per  cent.,  was  due  to  the  puerperal 
condition.  The  percentage  given  by  him  is  nearly  equal  to  the 
average  percentage  given  by  Ripping,  Fiirstner,  and  Liibben. 
Of  the  two  hundred  and  sixty-four,  forty-seven  arose  during  preg- 
nancy, one  hundred  and  thirty  during  the  lying-in  period,  and 
eighty-seven  during  the  period  of  lactation.  Schmidt  finds  that 
the  greatest  number  of  cases  of  puerperal  insanity  occur  between 

'  Zeitschrift  fur  Psychiatric,  Band  xxxvii,  Heft  I. 
"  Zeitschrift  fiir  Psychiatric,  Band  xxxvii,  Heft  I. 
'  Archiv  fUr  Psychiatric,  Band  xi,  Heft  I. 


FOREIGN  PSYCHIATRICAL   LITERATURE.  799 

the  ages  of  twenty-six  and  thirty-five  ;  the  least  between  fifty  and 
fifty-five,  and  between  fifteen  and  twenty.  The  greatest  number 
of  cases  of  puerperal  insanity  during  pregnancy  occurred  be- 
tween twenty-six  and  thirty-five  ;  during  the  lying-in  period,  be- 
tween thirty  and  thirty-five,  which  is  still  more  markedly  true  of 
the  period  of  lactation.  Schmidt  finds  rather  absurdly  that 
twenty  cases  of  chronic  mania,  fourteen  dementia,  six  progressive 
paresis,  and  two  circular  insanity,  were  due  to  puerperium.  This 
does  not  speak  highly  for  Schmidt's  logic.  About  forty-three  per 
cent,  were  cases  of  mania,  and  forty-one  melancholia. 

Liibben,  Fiirstner,  Ripping,  and  Emminghaus,  of  course,  failed 
to  detect  paresis  among  this  class  of  the  insane,  whereat  Schmidt 
rather  naively  expresses  his  wonder.  Krafft-Ebing  and  Liibben 
find  a  greater  percentage  of  mania  than  the  author,  Ripping,  Em- 
minghaus, and  Schule  a  greater  percentage  of  melancholia.  What 
renders  Schmidt's  figures  suspicious  is  the  small  percentage  of 
recoveries — thirty-six  per  cent.  This  shows  that  Schmidt's  power 
of  observation  or  of  analysis  is  somewhat  deficient.  He  has  cer- 
tainly mixed  up  coincidence  and  cause  in  a  marvelous  manner. 
Fliigge'  reports,  somewhat  in  detail,  a  case  of  self-mutilation  in 
what  was  evidently  hebephrenia,  and  the  mutilation  was  due,  like 
many  such  cases,  to  an  aberrant  expression  of  eroticism.  This  ten- 
dency has  received  but  very  little  attention,  but  is  one  deserving 
some  consideration. 

Foville'  reports  a  case  of  monomania  (primare  Verriicktheit) 
with  marked  delusions  of  grandeur.  The  case  is  well  described 
and  well  demarcated  from  progressive  paresis,  but  an  objection- 
able feature  is  found  in  the  use  of  the  term  omegalomania  other 
than  as  descriptive  of  a  condition.  The  patient's  delusions  in 
this  case  were  markedly  systematized.  Cotard^  describes  a  case 
of  monomania  with  predominant  depressing  delusions.  Brunet* 
describes  a  case  of  chronic  mania  which  developed  into  progres- 
sive paresis  after  an  apoplectiform  attack.  Cases  of  this  kind  are 
by  no  m.eans  rare,  and  frequently  cases  of  chronic  mania,  mono- 
mania, etc.,  make  their  exit  under  this  type.  Christian^  describes 
a  case  of  paresis  coming  on  in  an  imbecile  ;  it  was  preceded  by 
delusions  of  persecution,  and  it  is  not  improbable  that  some  cause 
like  traumatism  was  at  the  bottom  of  the  origin  of  the  progressive 

'  Archiv  fiir  Fsychiatrie,  Band  xi,  Heft  i. 

'  Annales  Me'dico-Psyckologiqttes ,  November,  l88o.  '  Ibid. 

*  Annales  AI edico- P sychologiques ,  November,  1880. 

'  Ibid.,  January,  1881. 


800  HE  VIEWS. 

paresis.  Foville  has  reported  a  similar  case.  Bevan  Lewis'  dis- 
cusses the  use  of  the  sphygomograph  in  progressive  paresis,  and 
finds  that  the  percussion  impulse  is  extremely  shallow  and  di- 
rected obliquely  upward  ;  the  shallow  up-stroke  ends  in  a  convex 
summit.  The  concavity  of  the  tidal  wave  looks  directly  down- 
ward. The  dicrotic  wave  is  frequently  absent,  or  if  present,  is 
very  feebly  developed.  There  were  some  variations  from  these 
obtained.  Billod^  reports  a  man  who,  after  a  violent  fall  on  the 
head,  became  demented,  which  was  followed  by  melancholia,  and 
at  length  by  hypochondriacal  delusions,  the  latter  appearing  co- 
incident with  a  slight  eczema.  The  case  is  well  reported,  and 
appears  to  be  one  of  those  cases  occurring  from  traumatism 
which  are  the  result  of  insidious  meningeal  inflammation,  and 
frequently  end  in  the  evolution  of  progressive  paresis  and  the  pa- 
tient's death.  The  relation  to  the  eczema  was  probable  only 
a  trophic  one. 

Lamaestre'  and  Regis'  describe  several  cases  of  congestive 
mania,  an  affection  which  has  received  much  attention  in 
France,  but  relatively  little  in  Germany,  England,  or  the 
United  States.  Frankly  speaking  the  affection  appears  to  be  a 
form  of  progressive  paresis  which  temporarily  yields  to  treatment, 
the  patient  subsequently  being  lost  sight  of.  The  treatment 
adopted  by  both  Lamaestre  and  Regis  has  been  aloes,  the  idea 
being  to  produce  by  this  means  a  derivation  which  would  prove 
beneficial  to  the  patient. 

Fiirstner*  gives  a  fairly  complete  account  of  acute  delirium, 
claiming  that  in  it  alterations  of  the  muscles,  as  also  convulsions, 
are  frequent.  He  does  not  regard  it  as  so  very  clearly  defined  an 
affection  as  Schiile  and  others  do.  His  description  is  much  more 
valuable  than  that  of  Ball,'  who  draws  much  on  his  imagination, 
and  is  so  little  versed  in  psychiatry  as  to  regard  the  changes  found 
post  mortem  as  primary,  and  not  the  result  of  fluxions  produced  in 
the  course  of  the  disease. 

Jenn'  comes  to  much  the  same  general  conclusions  as 
Fiirstner.  He  gives  an  interesting  casuistical  description  of  the 
disease.      Some  of  his  cases  strongly  resemble  and  are  evidently 

'  yournal of  Mental  Science,  April,  l88l. 

*  Annates  Midico-Psychologiques,  May,  1881. 

^  Annates  Mddico-Psychologiques,  March,   1881. 

*  Archiv  fiir  Psychiatrie,  Band  x,  Heft  2. 
'  La  France  Midicale,  June  12,  1880. 

'  Zeitschrift  fiir  Psychiatrie,  Band  xxxvii,  Heft  i. 


FOREIGN  PSYCHIATRICAL   LITERATURE.  80I 

imperfectly  diagnosticated  cases  of  katatonia.  Schaefer'  dis- 
cusses very  fully  the  psychoses  arising  from  disturbances  of  the 
female  sexual  organs.  Many  of  these,  Schaefer  points  out,  are  due 
to  periods  of  life  when  changes  in  the  sexual  condition  are  going 
on.  At  the  period  of  puberty,  for  example,  both  hebephrenia  and 
katatonia  occur. 

Binecker'  discusses  the  subject  of  hebephrenia,  adding  little 
that  is  new  to  the  subject,  but  adducing  fresh  reasons  for  con- 
sidering this  type  of  disease  well  established. 

Kiernan'  discusses  the  general  subject  of  insanity,  of  which  he 
gives  the  following  classification :  Mania  acute,  melancholia 
(lypemania),  acute  periodical  insanity,  circular  insanity,  epilep- 
tic insanity,  hebephrenia,  katatonia,  monomania,  chronic  mania 
with  confusions,  chronic  mania  with  imbecility,  progressive  pare- 
sis, and  senile  dementia.  Spitzka*  had  before  given  the  same 
classification.  The  monomania  of  this  classification  is  not  that 
ordinarily  meant  by  the  term,  but  corresponds  to  the  monomania 
of  Ray,  the  primary  intellectual  insanity  of  other  authors,  and  the 
primare  Verrucktheit  of  the  Germans.  Kiernan  defines  insanity  as 
being  a  morbid  condition  produced  by  disease  of  the  brain,  which 
perverts  the  mental  relations  of  an  individual  to  his  surroundings, 
or  to  what  from  his  birth,  education,  and  circumstances  might 
be  anticipated  to  be  such  surroundings.  Baillarger^  discusses'  a 
case  of  demonomania  manifesting  itself  in  a  progressive  paretic. 
Other  than  as  evidence  of  how  many  psychical  phenomena  pro- 
gressive paresis  may  present  the  case  is  of  no  importance.  He 
also  gives  instances  where  certain  cerebral  and  spinal  diseases 
have  produced  psychic  symptoms  at  times  resembling  those  of 
progressive  paresis.  Locomotor  ataxia  is  remarkable  in  this  re- 
spect. 

Foville'  reports  an  interesting  case  of  fleeting  delirium  in  an  old 
hemiplegic.  Cases  of  this  kind  are  by  no  means  infrequent,  but 
pass  unobserved.  In  a  not  very  clear  article  Melendez^  discusses  the 
subject  of  mixed  delirium,  adding  nothing  that  is  of  value.  Verga* 
reports  one  case  of  what  he  calls  rupophobia,  which  is  a  useless 

» Ibid. 

'  Zeitschrift  fiir  Psyckiatrie,  Band  xxxvii.  Heft  2. 

*  Gaillaras  Medical  Journal,  Nov.,  1880. 

*  Medical  Gazette,  May  15,  1880. 

*  Annales  Mddico-Psychologiques,  Jan.  and  May,  1881. 

*  Annates  Midico-Psychologiques,  May,  1881. 

''  Revista  Medico-Quirurgica,  Buenos  Ayres,  May  8,  1881. 
'  Rivista  Sperimentale  de  Frematrie,  Tome  vi. 


802  RE  VIE  WS. 

name  added  to  psychiatry,  as  Hammond  has  already  described  the 
same  condition  under  the  name  of  mysophobia. 

Kirn'  discusses  the  psychoses  found  in  prisons.  His  etiological 
remarks  are  of  no  value,  except  as  to  the  influence  of  heredity, 
which,  of  course,  is  strong.  The  types  of  insanity  presented 
were,  out  of  forty  cases,  seventeen  of  melancholia,  thirteen  of 
mania,  two  alcoholic  insanity,  three  epileptics,  two  idiots  of  irrita- 
ble type,  one  impulsive  insanity,  one  secondary  dementia,  and  one 
case  of  senile  dementia.  Aside  from  his  classification  his  article 
is  of  much  value. 

Echeverria,*  in  an  article  on  feigned  epilepsy,  does  not  add 
much  that  is  of  value  to  the  subject, — in  point  of  fact  his  article 
would  lead  to  the  impression  that  in  a  neurotic  subject  epilepsy 
would  be  a  somewhat  difficult  matter  to  detect.  None  of  the 
signs  given  by  him  are  positively  pathognomonic,  nor  are  they 
even  relatively  so.  The  relations  between  epilepsy  and  certain 
psychoses  are  not  sufficiently  taken  into  account. 

Moraudon  de  Monteyel'  considers  folic  a  deux  as  presenting 
three  great  types  :  folie  impose'e,  where  a  patient  of  greater  intel- 
lect imposes  his  delusion  on  another  ;  folie  simultane'e,  where  two 
patients  brought  up  under  the  same  circumstance  develop  similar 
delusions.  There  is  a  great  objection  to  placing  this  with  folie  a 
deux.  There  is  no  relation  between  the  delusion  of  the  two 
patients,  and  it  certainly  tends  to  lead  to  confusion  to  apply  the 
X&xvci  folie  a  deux  to  this  class  of  cases.  The  last  division  adopted 
by  Monteyel  is  folie  communiqu^e,  where  the  delusions  are  inter- 
communicated by  two  insane  individuals.  Apart  from  the  folie 
simultanie  idea  the  article  is  a  broad  and  philosophical  one. 

We  now  come  to  the  last  division  of  our  subject, — the  relation 
of  insanity  to  jurisprudence. 

Snell,*  in  a  valuable  article  on  the  simulation  of  insanity,  alludes 
to  the  great  difificulty  in  settling,  at  times,  the  exact  responsibility 
of  certain  neurotic  individuals  who  have  committed  crimes. 

Waller'  discusses  the  responsibility  of  epileptics,  leaning  rather 
to  the  sentimental  aspect  of  the  question,  holding,  however,  the 
very  sound  view  that  during  a  short  period  antecedent  and  subse- 
quent to  an  epileptic  attack,  the  responsibility  for  a   criminal    act 

'  Zeitschrift  Jur  Psychiatrie,  Band  xxxvii,  Heft  6. 
^  fournal  of  Insanity,  Jan.,  l88i. 

*  Annates  Mddico-Psychologiques,  Jan.,  i88l. 

*  Zeitschrift  fur  Psychiatrie,  Band  xxxvii,  Heft  3, 

*  Zeitschrift  fiir  Psychiatrie,  Band  xxxvii,  Heft  3. 


FOREIGN  PSYCHIATRICAL   LITERATURE.  803 

is  very  doubtful.  The  article,  despite  its  sentimental  tinge,  is  of 
considerable  value. 

Hughes,*  in  a  somewhat  rambling  article,  proclaims  his  belief  in 
moral  insanity, — a  position  on  which  he  is  certainly  to  be  con- 
gratulated,— denounces  the  lawyers,  forgetting  that  the  lawyer's 
first  duty  is  to  his  client.  He  objects  to  the  "hypothetical  case," 
which  certainly  in  the  hands  of  a  good  lawyer  is  the  best  means 
of  eliciting  truth,  for  medical  experts  will  disagree  on  as  plain  a 
disease  as  progressive  paresis,  even  after  a  personal  examination  ; 
and  this  being  the  fact  the  hypothetical  case  does  much  to  elimi- 
nate the  personal  equation.  Hughes  objects  to  the  lawyers  com- 
pounding several  psychoses,  a  tendency  not  confined  to  the  law- 
yers, but  also  present  in  many  of  his  colleagues  of  the  Asylum 
Association,  and  of  which  the  Journal  of  Insanity  gives  a  great 
many  instances. 

In  connection  with  the  subject  of  the  pathology  of  insanity  a 
wonderful  specimen  of  literature  has  recently  made  its  appearance 
from  the  pen  of  Deecke.''  Thirty-two  pages  of  singularly  involved 
and  incoherent  English  are  strung  out  on  the  subject  of  the  condi- 
tion of  "The  Brain  in  Insanity,"  without  a  single  literary  refer- 
ence. The  impression  conveyed  to  the  uninitiated  is  naturally 
that  the  propositions  advanced  are  the  results  of  original  labor 
and  thought.  The  same  writer  has  on  a  previous  occasion  been 
convicted  of  making  short  abstracts  from  Rindfleisch,  at  a  salary 
of  fifteen  hundred  dollars  a  year,  paid  by  the  State  of  New  York 
for  such  work,  and  has  remained  true  to  the  principle  with  which 
he  opened  his  career  as  a  medical  writer,  merely  varying  the  pro- 
gramme to  the  extent  of  abstracting  not  from  one  writer  but 
from  several,  and  notably  from  the  severest  critic  of  the  pretended 
scientific  work  done  at  Utica  and  Oshkosh.  It  is  to  be  noticed 
that  the  writer  has  not  been  uniformly  fortunate  in  assimilating 
the  essence  of  the  writings  which  he  has  dovetailed  into  his 
paper.  He  is  under  the  impression  (p.  3)  that  Ferrier's  localiza- 
tions refer  to  the  white  matter  of  the  cerebrum  ;  that  "leucocy- 
thsemia,  oligocythaemia,  hydraemia,  anhydraemia,  progressive  per- 
nicious anaemia,  pyaemia,  and  septicaemia"  produce  local  hyper- 
aemia,  serous  exudations,  local  inflammations,  and  hemorrhages 
in  the  brain  (p.  6)  ;  that  in  delirium  the  temporal  convolutions,  in 
melancholiac  and  maniacal  excitement  (!)  the  parietal  and  central, 
and  in  their  sequences  (whatever  these  may  be)  the  frontal  lobe 
and  base  of  the  brain,  are  chiefly  affected,  etc.  The  following 
^  Alienist  and  Neurologist.  ^  Journal  of  Insanity,  A.t^x\\,  1881. 


804  REVIEWS. 

features  may  be  original,  or  are  such  profound  misinterpretations 
of  standard  writers  that  these  would  hesitate  to  acknowledge 
them  as  their  own.  Perhaps,  as  in  the  case  of  the  Utica  crib,  the 
original  inventor  will  blush  for  the  uses  to  which  his  invention  has 
been  put.  Congenital  mental  weakness  is  reckoned  as  a  "  pri- 
mary affection  of  the  psychical  tracts,  of  physical  origin  "  ;  nerve 
fibres  terminate  in  the  gray  matter  "  with  their  specific  energies," 
which,  according  to  every  modern  writer,  do  not  exist ;  the  Syl- 
vian or  temporal  lobe  is  found  on  page  i6  ;  the  gray  commissures, 
or  tracts,  conduct  nerve  force  (p.  22)  ;  and  finally,  in  "  acute  pri- 
mary insanity  "  the  basal  processes  of  nerve  cells  undergo  "  coagu- 
lation or  gradual  contraction,"  shrink  down  to  little  knobs,  and 
the  mental  continuity  is  interrupted.  Can  this  writer  have  had  an 
intuitive  perception  of  the  actual  value  of  his  own  balderdash 
when,  on  page  20  of  his  essay,  he  says  :  "Language  may  be  called 
the  image  of  reason,  and  the  facts  of  its  evolution,  as  presented 
in  the  various  modes  of  human  speech,  are  the  reflex  of  the  his- 
tory of  reason  in  the  history  of  mankind  from  the  loftiest  revela- 
tions down  to  absurd  developments  of  morbid  human  thought  and 
imagination"?  This  last  seems  to  be  strongly  suggestive  of  the 
influence  of  Kussmaul. 

In  conclusion  it  may  be  not  amiss  to  allude  to  a  criticism  passed 
on  American  psychiatrical  work.  In  a  review  of  Dr.  Jewell's* 
article  on  the  influence  of  civilization  in  the  production  of  nerv- 
ous and  mental  disorders,  Signor  Biffi,'  in  a  way  indicative  of  the 
fact  that  the  asylum  psychosis  has  not  been  without  its  victims  in 
Italy,  assumes  that  Dr.  Jewell  has  said  that  our  race  has  in  it  the 
elements  of  its  own  destruction,  and  proceeds  to  demolish  that 
figment  of  bis  own  creation.  The  doctor  expressed  the  fear  that 
our  civilization,  like  other  civilizations,  had  in  it  the  elements  Of 
its  own  destruction  ;  and  that  there  are  sufficient  grounds  for  this 
cannot  be  denied,  except  by  those  who  have  passed  their  lives 
immured  in  institutions  having  but  little  contact  with  the  outside 
world.  The  same  gentleman  totally  misapprehends  the  object  of 
certain  propositions  laid  down  in  this  Journal  for  January,  1880, 
as  being  the  ultima  thule  of  what  is  to  be  desired  in  asylum  man- 
agement in  the  United  States.  Here,  unlike  the  Latin  races,  the 
practicable  is  aimed  at,  not  an  unseen  ideal,  but,  for  all  that,  it  is 
doubtful  if  even  the  moderate  degree  of  reform  alluded  to  in  the 
propositions  quoted  has  been  attained  in  Italy,  despite  the  great 

'Journal  of  Nervous  and  Mental  Disease,  Jan.,  188 1. 
*  Archivio  Italiano per  la  Malattie  Nervose,  May,  1881. 


GENERAL  PARALYSIS  OF   THE  INSANE.  805 

advances  made  under  the  stimulus  of  imported  German  thought. 
Some  Italian  writers  are  beginning  to  display  the  superciliousness 
of  certain  German  writers  without  their  ability,  and  it  is  safe  to 
recommend  to  Signor  Bififi  that  he  have  an  understanding  of  what 
he  is  to  criticise  before  making  a  criticism.  While,  as  has  been 
shown,  there  has  not  been  any  great  recent  advance  in  psychiatry, 
still  there  has  been  steady  progress  during  the  last  semi-annual 
period. 

General  paralysis  of  the  insane.  By  Wm.  Julius  Mickle, 
M.D.,  M.R.C.P.,  London,  Member  of  the  Medico-Psychological 
Society  of  Great  Britain  and  Ireland  ;  Member  of  the  Clinical 
Society,  London  ;  Medical  Superintendent,  Grove  Hall  Asylum, 
London.     London:  H.  K.  Lewis,  1880. 

During  the  past  decade  there  has  been  no  psychosis  more 
studied  than  general  paresis.  Voisin  has  written  an  excellent 
work ;  Mendel,  a  somewhat  extended  one,  valuable  chiefly  for  its 
statistics;  while  perhaps  one  of  the  best  is  the  pithy  monograph  of 
Simon.  The  present  work  is  an  extension  of  articles,  by  the  same 
author,  which  have  from  time  to  time  appeared  in  the  Journal  of 
Mental  Science.  The  first  chapter  is  devoted  to  a  consideration  of 
the  various  names  of  the  disease  ;  to  its  definition,  its  prodromata 
very  affectedly  called  prodromes,  the  history  of  its  discovery,  and 
its  stages.  The  author  very  properly  objects  to  the  use  of  the 
term  dementia  paralytica,  which  is  such  a  favorite  name  for  the 
disease  among  the  Germans.  The  term  is  certainly  misleading, 
but  in  choosing  the  term  the  author  has  not  done  much  better. 
Perhaps  the  best  term  is  progressive  paresis.  The  portion  of  the 
chapter  devoted  to  the  prodromata  gives  a  pretty  extensive  but 
not  well-analyzed  account  of  these.  In  his  discussion  of  the 
symptoms,  in  the  second  chapter,  the  author  divides  tlie  disease 
into  stages,  the  first  period  preceding  recognized  mental  aliena- 
tion. That  this  is  objectionable  is  shown  by  the  fact  mentioned 
by  him,  that  morbid  moral  phenomena  are  often  prodromata  of 
the  disease.  The  second  period  given  by  him  is  called  also  the 
first  stage  of  the  confirmed  disease  ;  the  third  period  of  general, 
or  the  second  period  of  the  confirmed  disease ;  and,  finally,  the 
fourth  period.  It  is  obvious  that  all  these  periods  are  very  arti- 
ficial divisions,  evidences  rather  of  an  attempt  at  mathematical 
exactness  rather  than  the  expression  of  true  clinical  features.  In 
the  discussion  of  the  symptoms  in  the  third  chapter  a  fair  r^sum/ 
of  the  subject  of  epileptiform  and  apoplectiform  attacks  is  given. 
This  chapter  taken  together  is  a  not  well-digested  summary  of 


8o6  HE  VIE  IV s. 

the  views  of  various  authors,  sandwiched  among  which  are  a  few 
views  of  the  author.  The  doctor  considers  that  recovery  is  possi- 
ble in  a  few  cases  of  the  less  advanced  degrees  of  the  disease. 
The  average  given  by  him  has  been  much  the  same  as  that  of 
other  authors.  He  has  seen  cases  last  as  long  as  ten  years,  a 
duration  which  has  sometimes  been  met  with  on  this  side  of  the 
water.  Chapter  five,  on  diagnosis,  gives  a  good  summary  of  the 
points  of  differential  diagnosis,  without  adding  any  thing  new. 
The  discussion  of  the  causes  in  the  sixth  chapter  is  not  clear. 
The  author  objects,  and  on  very  good  ground,  to  the  sexual  ex- 
cess theory.  He  very  properly  lays  great  stress  on  mental  over- 
strain and  emotional  disturbance.  Taking  the  latter  in  its  widest 
sense  it  may  be  said  to  be  the  great  cause  of  progressive  paresis. 
The  morbid  anatomy  given  by  the  author  in  the  seventh  chapter  is 
chiefly  coincidental,  but  not  characteristic  of  progressive  paresis. 
He,  however,  mentions  the  hemorrhagic  condition  of  the  stomach 
and  intestines,  which  is  so  frequently  a  concomitant  of  the  disease. 
The  same  may  be  said  of  the  microscopical  part  of  the  chapter. 
The  sections  on  pathological  physiology  contain  nothing  that  is 
new,  and  but  little  that  is  well  digested.  The  author  says  almost 
nothing,  except  in  an  indirect  way,  about  trophic  changes  in  the 
disease.  The  second  part,  chapters  ten  and  eleven,  chiefly  consist 
of  attempts  at  demarcation  of  varieties  of  progressive  paresis. 
The  histories,  however,  scarcely  seem  complete  enough  to  justify 
these  divisions,  and  the  cases  are  by  no  means  clearly  demarcated 
from  each  other.  Taking  the  book  as  a  whole  it  cannot  be  said 
to  be  well  digested;  the  author  should  have  waited  for  some  years 
before  publishing  it.  The  material  he  has  accumulated  is  valu- 
able, but  with  the  present  specimen  one  may  well  be  inclined  to 
doubt  his  power  of  analysis.  For  one  who  is  able  to  pick  out 
detached  facts  the  book  is  of  value.  It  bears  the  evidence  of 
great  haste,  and  as  the  author's  powers  of  observation  are  such  as 
have  enabled  him  to  secure  much  that  is  very  valuable,  it  will 
serve  as  a  useful  supplement  to  that  of  Voisin  ;  it  is  in  many  re- 
spects superior  to  that  of  Mendel.  J.  G.  Kiernan. 

Processes  of  excitation  and  inhibition  in  the  motor 
brain-centres.  The  above  is  the  title  of  a  paper  of  fundamen- 
tal importance,  by  Bubnoff  and  Prof.  Heidenhain,  in  Ffliigers 
Archiv,  vol.  xxvi,  p.  137. 

It  opens  to  our  view  the  nature  of  some  hitherto  unknown  pro- 
cesses in  nerve  centres,  and  paves  the  way  for  an  explanation  of 
many  cerebral  disorders,  such  as  hysteria  and  hypnotism. 


FJiOCESSES  IN  THE  MOTOR  BRAIN-CENTRES.         807 

The  existence  of  true  cortical  centres  has  been  denied  on  ac- 
count of  the  possibility  of  an  escape  of  the  irritating  electric  cur- 
rent to  the  subjacent  white  fibres,  stimulation  of  which  gives  a 
similar  reaction  as  irritation  of  the  cortical  surface.  But  Heiden- 
hain  argues  that  similarity  is  by  no  means  identity,  and  to  prove 
the  difference  he  attempted  to  record  the  muscular  contraction 
produced  in  either  case.  This  had  been  done  by  Frank  and  Pi- 
tres,  but,  as  shown  by  Heidenhain,  their  results  are  not  quite  con- 
clusive. Heidenhain  operated  on  dogs  under  the  influence  of  mor- 
phia, which,  as  is  well  known,  does  not  affect  all  animals  alike. 
The  two  extremes  of  its  action  are  represented  by  a  deep  sleep  on 
the  one  hand,  and,  on  the  other  hand,  by  a  state  of  exalted  reflex 
irritability  in  which  the  animals,  though  somnolent,  are  startled  by 
the  slightest  irritation.  This  state  cannot  be  removed  by  further 
doses  of  morphia,  but  it  can,  in  some  cases,  by  the  administration 
of  chloral  or  chloroform.  The  former  condition  is  accompanied 
by  anaemia  of  the  brain,  but  the  state  of  irritability  by  congestion. 
The  cortical  centre  of  the  foreleg  was  exposed,  the  leg  rigidly 
maintained  in  a  fixed  position,  and  the  tendon  of  the  long  com- 
mon extensor  of  the  toes  attached  to  the  graphic  apparatus.  The 
exact  beginning  of  the  muscular  contraction  was  indicated,  more- 
over, by  an  automatic  electric  signal.  Some  difficulty  was  expe- 
rienced in  selecting  a  proper  mode  of  stimulation.  A  single  in- 
duction shock  does  not  stimulate  the  cortex,  unless  it  has  an 
undesirable  intensity  ;  while  a  series  of  successive  shocks  pro- 
duces a  result,  even  if  a  very  feeble  current  is  used.  But  in  the 
latter  case,  the  exact  time  of  the  stimulation  cannot  be  deter- 
mined. The  authors  finally  selected  the  breaking  shock  of  a  con- 
stant current,  resorting  to  some  precautionary  devices  which  are 
characterized  by  the  same  ingenuity  that  pervades  the  entire  ar- 
ticle. The  strength  of  the  current  was  regulated  with  a  rheochord. 
It  was  found  necessary  to  use  unpolarizable  electrodes. 

Frank  and  Pitres  arrived  at  the  important  result  that  the  time 
elapsing  between  the  stimulation  and  the  beginning  of  the  muscu- 
lar contraction  is  enormously  shortened  by  slicing  off  the  gray 
surface  of  the  cortex  and  stimulating  the  white  fibres  directly. 
Heidenhain  and  Bubnoff  admit  the  correctness  and  importance  of 
this  experiment,  since  it  is  the  decisive  argument  that  the  cortex 
does  not  merely  conduct  the  electric  current,  but  really  originates 
the  nervous  impulse.  But  they  deny  the  accuracy  of  the  figures  of 
the  French  observers,  for  the  latter  did  not  recognize  that  the  time 
of  reaction  diminishes  with  the  intensity  of  the  stimulation.    Heiden- 


8o8  REVIEWS. 

hain  found  that  with  the  increase  in  the  strength  of  the  exciting 
current  or  the  excitability  of  the  cortex  the  height  of  the  muscu- 
lar contraction  increases,  while  the  time  of  reaction  is  diminished. 
Every  stimulus  leaves  the  cortex  in  a  state  of  exalted  irritability, 
disappearing  in  some  seconds.  Hence  successive  stimuli  can  be 
chosen  feebler  and  feebler,  and  still  be  effective.  Even  those 
shocks  not  intense  enough  to  produce  muscular  response  augment 
the  cortical  excitability  temporarily  ;  hence  a  series  of  faint  shocks 
will  give  a  result  when  a  single  shock  of  that  strength  fails.  In 
fact,  cortical  excitation  of  any  kind  is  followed  by  heightened  ir- 
ritability, so  that  peripheral  irritation  producing  a  reflex  move- 
ment leaves  the  corresponding  cortical  centre  more  irritable. 

On  removing  the  gray  surface  the  time  of  reaction  is  indeed 
shortened,  but  the  height  of  the  contraction  is  also  increased,  at 
least  when  the  animal  is  in  a  state  of  calm  morphia  narcosis. 

But  on  comparing  different  experiments  it  was  found,  after  all, 
that  the  shortening  of  the  time  is  really  greater  than  corresponds  to 
a  similar  augmentation  of  the  contraction  produced  by  more  intense 
cortical  stimulation.  Moreover,  the  recorded  muscular  course  is 
shorter  when  due  to  irritation  of  the  centrum  ovale  than  when 
produced  by  a  single  shock  applied  to  the  gray  surface.  The  pro- 
cess of  excitation  begins  later  and  lasts  longer  in  the  ner^e  cells  than 
in  the  white  fibres  when  the  latter  are  stimulated  directly.  But 
this  is  true  only  when  the  morphia  narcotizes  the  animal.  When 
the  dog  is  rendered  excitable  by  the  drug  the  retardation  of  the  time 
of  contraction,  due  to  overcofning  the  cortical  inertia,  is  inappreciably 
small.  In  some  instances,  of  which  the  conditions  are  not  fully 
known,  a  large  dose  of  morphia  has  a  contrary  influence.  The 
time  of  contraction  is  immensely  retarded  (once  up  to  0.17  sec- 
ond), and  the  contraction  produced  by  cortical  stimulation  pro- 
longed into  a  persistent  contracture.  In  these  cases  the  role  of 
the  gray  surface  can  be  most  strikingly  shown,  for  on  its  removal 
the  stimulation  of  the  white  fibres  leads  to  a  much  speedier  and 
shorter  contraction.  But  the  most  conclusive  proof  of  the  im- 
portance of  the  cortical  layer  is  obtained  in  the  deepest  narcosis, 
when  the  cortex  is  entirely  inexcitable,  while  the  usual  current 
applied  to  the  subjacent  white  fibres  produces  a  vigorous  re- 
sponse. 

The  authors  introduce  into  the  article  their  experience  on  cor- 
tical epilepsy,  which  is  often  an  undesirable  complication  of  these 
experiments,  especially  when  the  brain  is  hyperaemic.  The 
course  of  the  attack  is  usually  the  following :    The  convulsion 


PROCESSES  IN  THE  MOTOR  BRAIN-CENTRES.         809 

begins  in  the  part  the  centre  of  which  is  irritated,  the  centre 
being,  of  course,  on  the  other  side  of  the  brain.  If  it  does  not 
stop  here,  which  it  may,  it  spreads  to  the  symmetrical  muscles  of 
the  other  side,  then  radiates  to  other  parts  of  the  original  side,  and 
finally  involves  the  entire  body.  As  Munk  has  shown,  the  attack 
can  be  stopped  by  immediate  excision  of  the  irritated  centre,  but 
not  by  its  removal  later  on.  This  the  authors  corroborate,  and 
add  that  by  the  early  extirpation  of  some  other  cortical  centre  at 
the  beginning  of  the  attack,  the  corresponding  muscular  group  re- 
mains exempt.  In  some  cases  they  succeeded  also  in  checking 
the  spasm  of  the  entire  body  by  a  speedy  removal  of  the  whole 
motor  region  of  either  side.  In  other  cases  this  did  not  succeed. 
They  infer  that  the  change-producing  epilepsy  starts  in  the  cor- 
tex, but  involves  later  on  also  the  subcortical  ganglia.  Albertoni 
has  seen  epilepsy  started  by  irritation  of  the  centrum  ovale.  This, 
Heidenhain  confirms,  but  points  out  the  important  difference  that 
in  that  case  the  spasm  begins  on  the  same  side  of  the  body,  and 
not,  as  with  cortical  irritation,  on  the  opposite  half.  In  this  case, 
the  epilepsy  is  really  due  to  irritation  of  the  cortex  of  the  other 
cerebral  hemisphere,  the  irritation  being  conducted  thither 
through  the  association  fibres,  for  after  bilateral  extirpation  of 
the  cortex  no  epilepsy  can  be  produced.  The  authors  compare 
the  origin  of  the  epileptic  convulsions  to  an  increase  of  cortical 
excitability  produced  by  excessive  stimulation. 

Excitability  of  the  cortical  centres  can  be  considerably  influ- 
enced by  stimulation  of  the  peripheral  sensory  nerves.  It  is  some- 
times increased,  sometimes  diminished  thereby.  Merely  touching 
the  pair  decisively  augments  the  excitability  of  the  corresponding 
centre.  In  certain  instances  morphine  causes,  as  above  men- 
tioned, a  condition  of  the  cerebrum  in  which  a  single  stimulation 
is  followed  by  contracture  of  the  corresponding  muscle.  This 
may  now  be  inhibited  by  faint  peripheral  electric  irritation,  and 
more  strikingly  so  by  blowing  on  the  skin.  The  latter  experience 
recalls  vividly  checking  of  the  cataleptic  state  induced  by  hypno- 
tism. A  point  of  special  interest  was  the  observation  that  such 
contractures  could  be  inhibited  likewise  by  following /(?^<J/(fr  stim- 
ulation of  the  cortical  centre  itself,  or  even  other  parts  of  the 
cortex. 

The  authors,  in  discussing  these  results,  explain  them  by  assum- 
ing the  occurrence  of  two  kinds  of  processes  in  the  cortical  cen- 
tres, viz.,  excitation  and  inhibition.  The  predominance  of  the  kind 
of  molecular  change  causing  the  one  or  the  other  accounts  for  the 


8lO  REVIEWS. 

variability  of  the  cortical  excitability.  Sensory  impressions,  as 
well  as  direct  electric  stimulation  of  the  cortex,  influence  both  pro- 
cesses, augmenting,  as  a  rule,  the  one  feeblest  at  the  time.  Thus, 
the  depressed  excitability  in  morphia  narcosis  is  exalted  by  periph- 
eral irritation  or  successive  stimulation  of  the  cortex,  while  inhib- 
itory processes  are  started  by  the  same  procedures  when  morphia 
has  previously  heightened  the  cortical  irritability. 

They  point  out,  finally,  that  the  continuation  of  these  experi- 
ments promises  a  clue  for  the  phenomena  of  hypnotism  in 
man. 


SHORTER     NOTICES. 


I.  Manual  of  Histology.  By  Thomas  E.  Satterthwaite,  M.D., 
in  association  with  Drs.  T.  Dwight,  J.  Collins  Warren,  W.  F.  Whit- 
ney, Clarence  J.  Blake,  C.  H.  Williams,  H.  C.  Simes,  B.  F.  West- 
brook,  E.  C.  Wendt,  A.  Mayer,  R.  W.  Amidon,  H.  R.  Robinson, 
W.  R.  Birdsall,  D.  Bryson  Delavan,  C.  L.  Dana,  and  W.  H.  Por- 
ter.    W.Wood  &  Co.,  1881. 

II.  Lectures  on  the  Diagnosis  and  Treatment  of  Dis- 
eases OF  THE  Chest,  Throat,  and  Nasal  Cavities.  By  E. 
Fletcher  Ingals,  A.M.,  M.D.     W.  Wood  &  Co.,  1881. 

III.  Indigestion  and  Biliousness.  By  J.  Milner  Fothergill, 
M.D.     W.  Wood  &  Co.,  1881. 

IV.  A  Practical  Treatise  on  Impotence,  Sterility,  and 
Allied  Disorders  of  the  Male  Sexual  Organs.  By  S.  Gross, 
A.M.,  M.D.     H.  C.  Lea's  Son  &  Co.,  1881. 

V.  Lectures  ON  Digestion.  An  introduction  to  the  clinical 
studv  of  Diseases  of  the  Digestive  Organs.  Twelve  lectures.  By 
Dr.  C.  A.  Ewald.  Translated  by  Robert  Saundby,  M.D.  W 
Wood  &  Co.,  1881. 

I.  This  handsome  volume  is  intended  to  fill  an  intermediate 
position  between  the  larger  works  like  Strieker's,  and  the  smaller 
guides  for  the  microscope,  designed  for  beginners.  It  is,  we  be- 
lieve, the  first  American  work  of  any  scope  on  histology.  It  is 
well  and  plainly  written,  and  deals  with  the  subject  in  a  commend- 
able manner.  It  is  of  course  but  a  compilation  by  men,  practi- 
cally familiar,  however,  with  the  subject.  We  cannot,  however, 
grant  the  praise  of  absolute  completeness,  since  many  of  the  finer 
points  are  barely,  if  at  all  mentioned,  while  some  important  inves- 


SHORTER  NOTICES.  .'  8ll 

ligations  are  altogether  omitted,  like  those  of  Ebner  on  bone, 
Kiihne  and  his  pupils  on  nerves,  Gaule  on  corpuscles,  and  others. 
Yet  the  work  as  a  whole  gives  considerable  information  on  the 
subject  it  treats,  and  gives  it  in  a  practical  way.  The  plates,  not 
any  too  numerous,  are  sufficiently  instructive  for  their  purpose, 
though  often  useful  rather  than  ornamental. 

II.  This  volume  of  some  four  hundred  pages  differs  from  other 
works  on  these  subjects  (of  which  there  is  an  abundance),  only 
in  grouping  together  such  heterogeneous  topics,  as  diseases  of  the 
lungs,  heart,  throat,  and  nose,  and  considering  them  only  from 
the  standpoint  of  diagnosis  and  treatment.  The  physical  signs 
are  given  pretty  fully,  but  often  the  length  of  the  separate  articles 
will  be  found  to  depend  more  on  the  author's  verbose  style  than 
on  any  special  thoroughness.  Of  course  we  find  thrown  in  gratui- 
tously, as  an  aid  to  diagnosis,  the  cuts  of  all  requisite  instruments, 
familiar  to  the  reader  of  the  oldest  surgical-instrument  catalogues. 
So  far,  so  good  !  But  when  the  author  follows  up  the  physical 
signs  with  the  description  of  the  treatment,  without  pathology, 
course  of  disease,  or  prognosis,  we  stop  to  wonder.  But  no  harm 
is  done.  The  hints  on  treatment  are  so  brief  ''to  wit,  diphtheria, 
14  lines),  so  dictatorial  without  explanation,  and  so  unsatisfactory 
in  general,  that  no  reader  will  be  tempted  to  place  reliance  on 
them  to  the  exclusion  of  more  comprehensive  works. 

III.  Dr.  Fothergill  is  well  known  as  a  prolific  writer,  whose 
productions  deserve  due  attention.  His  present  volume,  some 
300  pages  in  size,  discusses  indigestion  and  biliousness  in  a  pleas- 
ant, chatty  way,  teeming  with  suggestions.  It  does  not  pretend  to 
be  a  rigidly  scientific  work.  It  is  not  characterized  by  systematic 
arrangement,  consecutive  original  research,  nor  are  even  the 
numerous  physiological  allusions  to  be  taken  in  all  cases  without 
some  allowance.  But  it  is  an  agreeably  written  essay  on  practical, 
often  neglected  topics,  showing  much  erudition  and  personal  clinical 
experience.  We  have  no  hesitation  in  recommending  it  for  its 
suggestiveness  to  any  practising  physician. 

IV.  The  title  of  this  monograph,  "  a  practical  treatise,"  etc., 
is  fully  justified  by  the  nature  of  its  contents.  It  is  eminently 
practical.  The  author  shows,  on  the  basis  of  a  large  and  evidently 
satisfactory  experience,  that  routine  prescriptions  are  out  of  place 
in  these  disorders,  and  that  each  case  requires  an  individual  ex- 
amination. There  has  been  but  little  information  accessible  on 
this  topic  hitherto,  and  this  original  and  painstaking  treatise  does 
therefore  really  fill  a  void.     It  may  be  that  the  author  generalizes 


8 12  REVIEWS. 

too  broadly  in  attributing  such  importance  to  stricture  as  the  cause 
of  these  disorders  as  he  does,  but  this  can  only  be  decided  by  an 
experience  of  others  similar  to  his.  At  any  rate  the  book  is  a  re- 
freshing lecture  in  this  time  of  compilatory  book-making. 

V.  This  is  a  well-written  book  containing  a  series  of  twelve 
lectures  delivered  to  practitioners  and  advanced  students  on  the 
physiology  of  digestion.  It  presupposes  some  knowledge  of  chem- 
istry and  physiology,  but  gives,  in  a  simple  and  pleasing  manner, 
the  results  of  the  latest  investigations  in  this  department  of  physi- 
ology. The  experiments,  many  of  which  are  those  performed  by 
the  author,  are  carefully  stated  and  the  conclusions  well  drawn. 
The  book  is  one  which  may  be  read  with  interest  and  profit, 
and  should  find  its  way  into  the  library  of  the  well-informed 
physician. 


%dxtoxml  ^tpnvtmtnt 


"  I  ^HE  present  number  closes  the  eighth  volume  of  this  Jour- 
nal. It  was  at  first  projected  under  the  belief  that  such  a 
periodical  could  be  made  useful.  The  editors  were  willing  to  in- 
cur, and  to  the  end  have  cheerfully  accepted,  any  labor  or  pecuni- 
ary risk  involved  in  its  publication.  Whether  it  has  answered 
reasonable  expectations,  or  has  been  of  any  service  in  the  depart- 
ment of  medicine  the  interests  of  which  it  has  sought  to  advance, 
others  must  judge.  But  the  editors  have  no  reason  for  disap- 
pointment when  they  regard  the  numerous  expressions  of  favor 
with  which  the  Journal  has  been  received,  and  which  have 
reached  them  from  the  most  competent  members  of  the  profes- 
sion both  at  home  and  abroad.  Many  of  these  expressions  have 
been  peculiarly  gratifying. 

The  Journal  has  not  been  of  a  kind  to  commend  itself  to  phy- 
sicians at  large.  It  could  not  be  devoted  to  promoting  the  scien- 
tific interests  of  neurological  medicine,  and  at  the  same  time 
meet  the  direct  practical  spirit  of  the  mass  of  the  profession.  In 
view  of  the  fact  that  the  position  deliberately  chosen  for  the  Jour- 
nal could  not  be  popular,  it  was  begun  and  has  been  continued 
as  a  personal  enterprise  in  the  midst  of  much  care  and  under  the 
pressure  of  other  occupations.  In  justice  to  ourselves  we  may 
be  permitted  to  refer,  in  a  general  way,  to  the  difficulties  which  we 
have  had  to  encounter,  as  excuses  for  the  numerous  literary 
and  other  blemishes  which  have  marred  its  pages  in  spite  of  such 
care  in  its  make-up  as  we  were  able  to  exercise.      Those  persons 

813 


8 14  EDITORIAL  DEPARTMENT. 

only  who  have  had  practical  experience  in  such  matters  can  justly 
estimate  a  situation  in  which  so  much  labor  has  been  performed  by 
the  editors  in  conducting  the  Journal. 

It  may  not  be  amiss  at  this  time  to  state  in  a  few  words  the 
share  in  the  work  which  has  been  taken  by  the  active  editors  re- 
spectively. 

The  periscope  department,  containing  extracts  from  foreign  and 
home  periodicals,  and  which  has  been  so  often  commended  by 
our  readers,  has  been  almost  wholly  made  up  by  Dr.  Bannister. 
In  the  department  of  reviews,  the  majority  of  lengthy  book  no- 
tices have  been  prepared  by  Dr.  Jewell,  who  has  also  written  the 
larger  portion  of  editorial  matter.  In  other  respects  contributions 
from  either  of  the  editors  have  been  signed  with  their  names. 

The  editors  desire  to  express  their  deep  sense  of  obligation  to 
the  gentlemen  who  have  kindly  lent  the  inhuence  of  their  names 
as  associate  editors  to  give  the  Journal  the  stamp  of  authority 
in  the  higher  walks  of  the  profession.  They  wish  at  the  same 
time  to  express  their  obligations  in  no  formal  manner  to  the  gen- 
tlemen who  have  in  every  way  (especially  by  their  contributions) 
aided  the  Journal.  They  would  particularly  mention  the 
names  of  Drs.  Hammond,  Spitzka,  Beard,  Kieman,  Ott,  and 
Mason  among  the  many  who  have  freely  given  of  the  choicest  re- 
sults of  their  labors. 

Since  the  first  year  of  its  existence  the  Journal  has  been  the 
exclusive  property  of  Dr.  Jewell.  During  the  past  year  impaired 
general  health  and  the  pressure  of  other  obligations  on  his  part 
had  led  to  the  determination  to  transfer  the  Journal.  That 
determination  is  now  carried  into  effect.  In  laying  aside  a 
pleasant  responsibility  voluntarily  assumed,  the  editors  wish 
finally  to  express  their  grateful  acknowledgment  to  their  sub- 
scribers and  to  all  friends  of  the  Journal,  wherever  they  may 
be,  for  the  interest  they  have  manifested  in  its  welfare. 

The  Journal  has  been  delayed  in  its  appearance  for  a  month, 
chiefly  with  the  hope  of  presenting  to  our  readers  the  prize  essay  of 
Dr.  E.  C.  Spitzka  on  the  Somatic  Etiology  of  Insanity,  with  which 
to  close  the  present  volume.     But  in  this  hope  we  have  been  dis- 


EDITORIAL  DEPARTMENT.  815 

appointed.  The  above  statement  is  made  that  our  readers  may- 
know  why  the  present  issue  has  been  so  long  delayed. 

The  Journal  has  now  been  transferred  to  Dr.  William  J. 
Morton,  of  New  York  City,  who  is  both  proprietor  and  editor-in- 
chief,  and  who  has  secured  the  cooperation,  as  associate  editors, 
of  several  of  our  first  neurologists,  whose  names  appear  in  the 
accompanying  prospectus  for  the  new  year. 

We  would  heartily  commend  the  new  management  to  our  sub- 
scribers and  friends  everywhere. 


'gtviscopz. 


a. — ANATOMY   AND   PHYSIOLOGY   OF   THE   NERVOUS 
SYSTEM. 

The  Physiology  of  the  Heart  is  enriched  by  a  very  methodic 
paper,  by  Ludwig  and  Luchsinger,  in  Pflugers  Archiv  (vol.  25, 
p.  211).  They  began  by  studying  the  influence  of  temperature 
upon  the  heart.  Contrary  to  the  experience  of  some  previous  ob- 
servers in  mammals,  they  found  that  in  the  frog  decided  lowering 
of  the  temperature  destroyed  the  action  of  the  vagus  nerve,  while 
extreme  warmth  increased  its  irritability.  Since  the  temperature 
is  known  to  influence  also  the  motor  ganglia  of  the  heart,  the 
authors  propose  the  following  view  :  The  effect  of  stimulation  of 
the  vagus  depends  not  only  upon  the  irritability  of  that  nerve,  but 
also  inversely  upon  the  excitability  of  the  motor  ganglia.  Vigorous 
activity  of  the  latter  is  less  easily  inhibited  than  feeble  action. 
Cold  enfeebles  both  vagus  and  motor  ganglia,  but  the  former 
most.  As  the  temperature  increases  beyond  a  mean,  the  irrita- 
bility of  the  motor  ganglia  rises  above  that  of  the  inhibitory  appa- 
ratus, hence  the  weak  action  of  the  vagus  observed  by  previous 
authors  under  these  circumstances.  But  as  the  temperature  ap- 
proaches the  limit  compatible  with  life  the  motor  ganglia  fail  first, 
hence  the  superiority  of  the  inhibitory  fibres.  In  fact,  this  same 
increase  of  vagus  action  just  prior  to  failure  of  the  heart,  can  be 
witnessed  in  natural  death  as  well  as  in  various  forms  of  narcotic 
poisoning. 

Further  experiments  were  made  on  the  bloodless  heart.  Blood 
was  expelled  by  a  current  of  normal  salt  solution  or  neutral  al- 
mond oil.  After  some  minutes  or  hours,  sooner  with  oil  than 
with  salt  water,  the  pulsations  cease  in  the  ventricle,  auricle,  and, 
lastly,  venous  sinus. 

Blood  or  serum  restores  the  irritability  at  once. 

816 


ANATOMY  AND  PHYSIOLOGY.  817 

In  these  experiments  the  effect  of  vagus  irritation  persisted  as 
long  as  the  heart  continued  to  beat  ;  the  feebler  even  the  pulsa- 
tion the  more  easily  could  it  be  checked  by  vagus  stimulation. 

The  effect  of  the  intracardiac  pressure  upon  the  rhythm  was 
studied  by  sending  a  current  of  salt  solution  through  the  bloodless 
heart  under  variable  pressure.  It  was  found  without  exception  that 
the  frequency  rose  with  the  pressure  at  first  in  a  direct  propor- 
tion, subsequently  more  slowly. 

The  same  dependence  of  the  activity  on  the  tension  was  even 
more  strikingly  illustrated  on  the  lower  half  of  the  ventricle, 
which  contained  no  nerve  cells.  Ordinarily  quiescent,  when  filled 
with  a  salt  solution  the  apex  will  beat  only  when  the  pressure  is 
increased,  and  the  frequency  will  rise  with  the  tension.  The 
greater  the  stimulation  of  the  motor  ganglia  by  the  augmented 
tension  the  less  manifest  is  the  action  of  the  vagus  when  irritated, 
because  in  the  struggle  between  inhibitory  and  motor  ganglia 
the  more  active  side  must  win.  If  in  such  experiments  the  auricle 
yields  more  readily  to  the  influence  of  the  vagus  than  the  ven- 
tricle, it  is  due  to  the  fact  that  the  thinner  auricular  musculature 
is  nearly  overcome  by  the  greater  work  imposed  upon  it  by  the 
high  pressure,  which  the  thicker  ventricular  walls  can  yet  accom- 
plish. Occasionally  some  anomalous  results  were  observed  ;  for 
instance,  a  relative  insufficiency  of  the  vagus  even  after  the 
pressure  had  been  reduced.  This  is  referred  to  a  long  persistence 
of  the  stimulant  effect  of  the  previous  pressure  upon  the  motor 
ganglia,  and  not  to  paralysis  of  the  vagus.  For  in  other  instances 
the  vagus  regained  its  superiority  after  a  pressure  equal  to  40  cm. 
of  water  had  distended  the  heart  for  some  time.  .The  authors 
explain  this  by  failure  of  the  motor  ganglia  from  over-stimulation. 
Occasionally  they  even  saw  an  accelerating  influence  of  the  vagus 
upon  a  heart  in  a  state  of  contracture,  for  which  they  give  a  some- 
what forced  explanation. 

The  experiments  of  Merunowicz  have  shown  that  the  apex  of 
the  heart  is  capable  of  pulsating  under  the  influence  of  some 
irrigating  fluids  like  defibrinated  blood.  This  is  not  due  to  the 
tension  alone,  for  the  beats  continue  even  at  a  pressure  of  zero. 
The  action  of  different  fluids  was  examined  in  this  respect.  First 
of  all  the  temperature  was  investigated  and,  as  was  anticipated, 
it  was  found  that  with  increasing  temperature  the  apex  became 
more  irritable. 

The  author's  experiments  with  different  irrigating  fluids  seem 
hardly  numerous  or  varied  enough,  but,  on  the  whole,  confirm  the 


515  PERISCOPE. 

conclusion  previously  arrived  at  by  Merunowicz,  that  the  higher 
percentage  of  blood  in  the  irrigating  fluid  increases  the  irritability 
of  the  muscle,  while  a  lower  proportion  favors  the  muscular  dis- 
charges. 

The  Functions  of  the  Cerebral  Cortex. — We  translate 
the  following  abstract  by  Sigmund  Exner  of  J.  Munk's  recent 
memoir  on  the  functions  of  the  brain,  from  the  Biologische  Cen- 
iralblait,  No.  i,  April  15,  of  this  year. 

The  book  before  us  contains  six  lectures  delivered  from  1877 
to  1880  before  the  Physiological  Society  and  one  before  the 
Academy  of  Sciences,  of  Berlin.  The  earliest  publication  is  a 
historical  introduction,  together  with  a  series  of  critical  remarks, 
with  also  important  suggestions  for  the  experimenter.  It  may  be 
well  to  use  this  opportunity  to  give  a  comprehensive  abstract  of 
the  author's  experimental  results,  although  they  do  not  altogether 
belong  to  the  most  recent  times. 

In  opposition  to  the  view  of  Gall,  chiefly  by  reason  of  the 
experiments  of  Flourens  and  Longet,  the  idea  of  the  unity  of  the 
cortex  of  the  brain  as  the  organ  of  the  mental  functions  had 
become  established  with  physiologists.  Nevertheless,  clinical 
observation  had  afforded  the  proof  that  certain  merital  activities 
were  associated  with  the  integrity  of  limited  localities  of  the  brain 
(speech  centre),  and  anatomical  investigations  had  rendered  it 
probable  that  sensory  and  motor  functions  were  associated  with 
different  portions  of  the  cerebriam.  Fritsch  and  Hitzig  showed  in 
1870  that  electric  excitation  of  limited  tracts  of  the  cortex  pro- 
duced movements  in  definite  muscular  groups  on  the  opposite  side 
of  the  body,  and  that  definite  muscle  groups  belonged  function- 
ally to  definite  regions  of  the  cortex.  For  the  purpose  of  demon- 
strating localized  centres  for  the  separate  sensory  functions, 
Munk  has  the  especial  credit  of  having  made  numerous  and  care- 
ful investigations  in  dogs  and  monkeys. 

In  the  dog  the  larger  portion  of  the  occipital  lobe  has  the 
function  of  a  "  visual  sphere  "  ;  that  is,  in  it  occur  the  central 
changes  on  which  the  function  of  sight  depends.  It  is  the  ulti- 
mate distinction  of  the  optic  fibres,  according  to  the  following 
arrangement.  The  greater  part  of  the  left  retina  is  in  connection 
with  the  right  visual  sphere  ;  only  the  most  lateral  portion,  not 
over  a  quarter  of  the  whole  retina,  measured  horizontally,  is  in 
connection  with  the  visual  sphere  of  the  same  side.  That  of  the 
right  eye  is  correspondingly  connected  with  the  left  side  of  the 
brain.     The  distribution  of  the  fibres  is  so  arranged  that  the  ret- 


ANATOMY  AND  PHYSIOLOGY.  819 

inal  and  the  cortical  terminations  in  the  opposite  hemisphere  are 
inverted,  so  that  what  is  on  the  right  in  the  retina  is  on  the  left  in 
the  cortex,  and  what  is  above  in  the  former  is  below  in  the  latter. 
Extirpation  of  any  one  portion  of  the  cortical  visual  tract  renders 
the  corresponding  part  of  the  retina  insensible  ;  extirpation  of  one 
"visual  sphere"  blinds  the  eye  on  the  opposite  side,  except  its 
outermost  part  ;  extirpation  of  both  cortical  visual  tracts  causes 
complete  and  permanent  blindness.  In  each  visual  tract  is  a  cen- 
tral portion,  characterized  by  the  peculiarity  that  its  extirpation 
produces  a  loss  of  visual  memory  in  the  opposite  eye  ;  that  is,  the 
dog  still  sees,  but  does  not  recognize  its  food,  etc.,  any  more. 
This  visual  appreciation  may  later  become  restored.  The  author 
distinguishes  between  this  kind  of  visual  loss  and  ordinary  loss  of 
sight  from  injury  to  the  cortex,  and  calls  the  former  psychic  blind- 
ness {Seelenblindheit)  and  the  latter  cortical  blindness  {Rinden- 
blindheif).  This  spot,  destruction  of  which  causes  psychic  blind- 
ness, contains  also  the  central  terminations  for  those  parts  of  the 
retina  for  the  fixation  of  vision — corresponding  to  the  fovea  cen- 
tralis in  men.  In  the  temporal  lobe  is  situated  the  auditory 
cortical  tract.  This  also  contains  a  special  spot,  extirpation  of 
which  causes  psychic  deafness  ;  that  is,  the  dog  still  hears,  he 
pricks  up  his  ears  at  a  sound,  but  he  no  longer  comprehends  what 
it  means. 

The  touch  sense  has  also  its  region  in  the  cortex,  and  indeed 
this  "  sensory  sphere  "  involves  nearly  the  whole  of  the  convexity 
that  is  not  occupied  by  the  visual  and  auditory  tracts.  In  this 
can  be  still  further  distinguished  the  subdivisions  corresponding  to 
different  parts  of  the  body,  especially  those  for  the  anterior  and 
posterior  limbs,  the  head,  an  eye,  ear,  neck,  and  back  regions. 
All  these  lie  in  the  anterior  half  of  the  cortex,  and  show  an  ar- 
rangement that  makes  a  relation  between  the  results  of  our 
author  and  those  of  Hitzig  appear  certain. 

In  his  experiments  on  monkeys  Munk  obtained  results  cor- 
responding to  those  obtained  in  experimenting  with  dogs. 


Mechanical  Excitation  of  the  Nerves. — K.  Hallsten, 
Nordiskt  Med.  Arkiv,  Trettonde  Baudet,  Forsta  Haftet,  1881, 
No.  6,  describes  some  physiological  investigations  on  the  excita- 
tion of  nerves  by  the  use  of  a  new  method.  He  so  arranged  a 
Marey's  tambour  that  the  lever  should  strike  against  the  nerve 


820  PERISCOPE. 

when  the  membrane  was  put  in  vibration.  This  tambour  was 
connected  in  the  usual  way  by  an  india-rubber  tube  with  another 
similar  one,  upon  which  an  ivory  ball  fell  from  a  determined 
height.  The  intensity  of  the  excitation  of  the  nerve  was  modi- 
fied by  the  jointed  lever,  which  is  supplied  with  the  more  modern 
models  of  Marey's  apparatus.  To  excite  the  different  parts  of  the 
same  nerve,  the  tripod  which  supports  the  tambour  travels  along 
the  table  of  the  myographion. 

The  author  examined  by  the  graphic  method  the  mode  of  move- 
ment of  the  lever,  and  found  that  in  each  experiment  the  lever 
strikes  twice  against  the  nerve,  and  that  the  last  shock  occupied  a 
considerable  space  of  time,  but  did  not  exert  as  profound  an  influ- 
ence from  above  downward  as  the  first. 

The  researches  were  directed  to  the  modifications  of  irrita- 
bility caused  by  a  transverse  section,  and  also  the  irritability  of 
different  portions  of  the  same  nerve.  As  regards  the  first  of 
these,  Hallsten  has  found  that  the  changes  in  the  irritability  pro- 
duced by  a  transverse  cut  may  also  be  demonstrated  by  me- 
chanical excitation.  Concerning  the  irritability  of  different  parts 
of  the  same  nerve,  his  experiments  show  that  it  reaches  its  maxi- 
mum a  little  below  the  point  where  the  nerve  trunk  leaves  the 
plexus,  and  diminishes  on  each  side  of  this  maximum  point ;  the 
irritability  is  less,  on  the  other  hand,  below  the  point  where  the 
femoral  branch  leaves,  and  from  there  it  increases  in  both  direc- 
tions. 

Finally,  he  shows  also  that  even  with  mechanical  excitation, 
an  irritant  that  is  about  at  its  minimum  produces  a  muscular  con- 
traction in  a  great  range  of  the  charge,  and  that  these  contractions 
diminish  with  the  charge. 

As  to  the  determination  of  the  exact  degree  of  the  minimum 
excitant,  there  exists,  according  to  M.  Hallsten,  no  difficulty  in 
determining  by  his  method  the  limits  between  which  it  is  to  be 
found;  nevertheless  he  considers  all  determinations  of  this  kind  as 
illusory  so  long  as  these  so-called  limits  for  the  calculation  of  the 
minimum  excitant  cannot  be  expressed  in  figures. 


The  Ganglia  of  the  Urinary  Passages  of  Man  and  Cer- 
tain Animals. — The  following  are  the  conclusions  of  a  recent 
memoir  by  Prof.  Rudolf  Maier,  of  Freiburg,  published  in  Vir- 
chow's  Archiv,  Ixxxv,  i  Hft.,  July,  1881. 

I.  Upon  all  portions  of  the  walls  of  the  urinary  passages  ex- 


ANATOMY  AND  PHYSIOLOGY.  821 

ternal  to  the  kidneys,  in  man  and  certain  other  animals,  are 
ganglia  giving  out  nerve  branches,  and  in  the  mucous  as  well  as  in 
the  muscular  layer. 

2.  In  the  mucous  membrane  they  are  situated  either  in  its 
whole  thickness  or  preferably  or  exclusively  in  that  portion  of  it 
adjoining  the  muscular  coats. 

3.  In  the  muscular  coat  itself  the  nerves  form  larger  anastomoses 
between  the  coarser  muscle  bundles  and  smaller  ones  between  the 
finer  bundles  of  this  greater  layer.  Both  contain  ganglia,  the 
first  the  greater  number. 

4.  The  nervous  plexuses  in  the  muscular  and  mucous  coats 
are  in  continuous  connection  with  each  other. 

5.  The  nerve  plexuses  do  not  form  a  continuous  closed  net- 
work over  the  vessels,  but  more  commonly  form,  by  frequent  anas- 
tomoses, connections  between  the  more  superficial  and  deeper 
layers. 

6.  The  ganglia  are  situated  : 

a.  On  the  nerve  branches,  and  so  arranged  that  the  perineurium 
passes  over  them  only  on  one  side,  while  on  the  other  the  cell 
groups  are  margined  directly  by  nerve  fibres. 

b.  They  lie,  not  closely  associated  with  the  nerve  fibre,  in 
rounded  or  spindle-shape  masses,  but  in  larger  masses  and  more 
like  a  bunch  of  grapes  on  a  stem,  surrounded  by  connective  tissue. 

c.  The  ganglia  lie  in  the  middle  of  a  nerve  branch,  and  push 
the  fibres  apart  from  each  other. 

d.  They  are  situated  at  the  points  of  bifurcation  of  the  nerve 
branches. 

e.  The  ganglia  lie  embedded  in  the  course  of  a  single  nerve 
fibre. 

7.  The  ganglion  cells,  where  they  occur  in  large  numbers 
together,  are  enclosed  in  a  meshwork  of  perineurium. 

8.  Where  they  occur  singly  they  are  altogether  or  partly  sur- 
rounded by  a  simple  sheath  of  perineurium,  or  are  naked  ;  they 
are  enclosed  in  neurilemma  when  they  appear  within  nerve  fibres. 

9.  Part  of  the  ganglion  cells  appear  to  be  apolar,  others  are 
unipolar,  and  some  again  bipolar. 

10.  The  processes  divide  themselves  into  true,  that  is,  actual 
continuity  of  the  protoplasm  into  a  nerve  fibre,  and  false,  or  ex- 
tensions of  the  ganglionic  sheath  into  the  connective-tissue  sheath 
of  the  nerves. 

11.  The  ganglion-bearing  nerve  plexuses  consist,  for  the  most 
part,  of  pale  fibres. 


822  PERISCOPE. 

The  Nature  of  Voluntary  Muscular  Contractions. — 
Prof.  Christian  Loven,  in  a  paper  read  at  the  Scandinavian  Nat- 
uralists' Congress,  1880,  and  published  in  the  Nordiskt  Med. 
Arkiv,  xiii,  i,  No.  5,  1881,  after  having  noticed  the  fact  that  the 
very  numerous  investigations  on  the  functions  and  properties  of 
nerves  and  muscles  have  yet  left  only  too  much  to  be  desired  in 
the  way  of  explanation  of  the  most  common  phenomena  man- 
ifested in  the  living  healthy  organism,  and  especially  of  those  rela- 
tive to  voluntary  tonic  contractions,  reviewed  the  various  opin- 
ions on  this  subject,  and  distinguished  three,  essentially  differing 
from  each  other,  viz.  : 

1.  That  which  holds  that  these  contractions  are  truly  continu- 
ous, /.  e.,  engendered  by  a  continuous  excitation  of  the  nervous 
centres. 

2.  The  opinion  admitting  that  the  central  apparatus,  and,  first 
of  all,  those  of  the  spinal  cord,  can  only  transmit  their  excita- 
tions to  the  muscles  by  separate  discharges,  following  in  this  a  def- 
inite rhythm  for  each  species  of  animal  (in  many,  according  to 
Helmholtz,  this  would  be  18-20  per  second,  in  the  frog  16-18  per 
second). 

3.  And  last,  that  of  M.  Briicke,  holding  that  the  apparent  con- 
tinuity of  the  tonic  contraction  is  due  to  the  fact  that  the  dis- 
charges are  not  perfectly  isochronous  in  all  the  nerve  fibres  sup- 
plying a  muscle,  but  resemble  rather  "volley  firing." 

Decisive  proofs  of  all  these  views  are  lacking.  The  first 
is  based  upon  the  generally  admitted  fact,  that  voluntary  con- 
traction, as  well  as  strychnine  tetanus,  never  produces  "  second- 
ary "  or  induced  tetanus  in  the  paw  of  the  galvanoscopic  frog, 
the  nerve  of  which  has  been  applied  to  the  contracted  muscle. 
The  second,  which  may  be  considered  the  predominant  one  at 
the  present  time,  supports  itself  by  the  analogy  with  artificial  teta- 
nus, and  especially  by  the  muscular  sound.  The  third  view, 
finally,  has  scarcely  any  other  .thing  in  its  favor  than  the  desire  to 
show  the  difficulty  presented  by  the  absence  of  induced  tetanus. 

Thanks  to  the  extreme  sensitiveness  of  a  capillary  electrometer 
the  author  was  able  to  show  in  1879  {Nordiskt  Med.  Arkiv, 
xi.  No.  14)  that  the  voluntary  tonic  contractions  in  the  toad, 
also  strychnine  tetanus  in  that  animal  as  well  as  in  the  frog,  are 
accompanied  with  well-marked  and  regular  rhythmic  electric 
variations.  But  the  number  of  these  variations  being  only  about 
eight  per  second  (instead  of  16-18  according  to  the  reigning  opin- 
ion), it  becomes  very  difficult  to  explain  to  one's  self  how  in  volun- 


ANATOMY  AND  PHYSIOLOGY.  823 

tary  contractions  and  strychnine  tetanus  muscular  jerks  so  widely 
separated  in  point  of  time  could  so  fuse  themselves  as  to  form  an 
apparently  continuous  contraction,  especially  when  we  consider 
that  ordinarily  as  many  as  20  excitations,  and  even  more  per  sec- 
ond, are  needed  to  cause  a  perfect  electric  tetanus. 

The  author  thinks  that  the  simplest  method  of  obtaining  a  solu- 
tion of  this  difficulty  Vi^ould  be  to  admit  that  the  physiological 
excitations  sent  to  the  muscles  from  the  motor  centres  differ  in 
some  essential  property  from  those  we  give  to  the  motor  nerves 
in  laboratory  experiments,  and  notably  differ  in  the  fact  that 
they  are  slower.  In  fact,  these  oscillations  provoked  in  the  capil- 
lary electrometer  by  voluntary  and  strychnic  contractions  ap- 
peared to  M.  Loven  to  possess  this  property,  though  naturally  the 
difficulty  of  reaching  perfect  certainty  in  this  regard  ought  to  be 
very  great.  Furthermore,  amongst  the  whole  of  the  facts  ob- 
tained by  experimental  excitation  of  the  motor  nerves,  we  find 
some  that  show,  as  far  as  we  can  judge  by  the  form  of  the  mus- 
cular curve,  that  the  character,  or,  if  we  choose,  the  form  of  the 
motor  excitations  is  not  always  the  same.  It  suffices  to  recall 
the  slow  contractions  that  appear  when  a  part  of  the  nerve  by 
which  the  excitation  should  pass,  is  chilled,  and  also  the  contrac- 
tions which,  in  certain  cases,  are  provoked  by  the  opening  of  a 
continuous  current. 

If  the  physiological  excitations  are  distinguished  by  their 
slowness,  the  inability  of  a  voluntary  contraction  to  produce  an 
induced  contraction  ought  not  to  be  so  difficult  to  comprehend, 
seeing  that  it  is  necessary,  in  order  to  excite  the  nerve  of  the  gal- 
vanoscopic  paw,  that  the  electric  variations  in  the  "  inductor  " 
muscle  should  have  not  only  a  sufficient  intensity  but  a  certain 
celerity  ;  and  therefore  the  fusion  of  these  slow  contractions  into 
a  continuous  tetanus  ought  not  to  appear  strange,  even  if  the  num- 
ber of  the  muscular  jerks  per  second  does  not  exceed  the  eight 
oscillations  above  mentioned. 

The  study,  by  the  aid  of  the  electrometer,  of  the  electric  varia- 
tions that  accompany  voluntary  and  strychnic  contractions  reveals 
still  other  peculiarities  that  appear  to  M.  Loven  to  be  of  capital 
importance,  especially  for  the  explanation  of  certain  pathologi- 
cal conditions  of  the  motor  functions.  These  oscillations  vary, 
not  only  in  their  rhythm,  and  that  in  direct  proportion  to  the 
energy  of  the  contractions,  but  also,  as  the  author  thinks,  very 
notably  in  quickness,  being  sometimes  slower,  sometimes  faster. 

M.  Loven  thinks   that  these   differences  can  hardly  have  any 


824  PERISCOPE. 

Other  cause  than  a  regulator  action  already  exerted  in  the  nerve 
centres.  It  would  evidently  be  very  difficult  and  altogether  un- 
profitable, in  the  present  state  of  our  knowledge,  to  try  to  form- 
ulate hypotheses  in  regard  to  the  organs  that  may  exercise  this 
function,  or  as  to  their  probable  mode  of  action  ;  but  the  cases 
where  this  regulating  influence  is  lacking  are  very  easily  recog- 
nized. 

One  of  these  cases  presents  special  points  of  interest,  inasmuch 
as  it  still  belongs  to  the  physiological  domain  ;  it  is  the  tremor 
that  is  seen  in  strongly  contracted  muscles  when  we  seek  to  over- 
come a  resistance  by  the  greatest  possible  effort.  In  order  to  see 
if  the  oscillations  of  such  a  tremor  follow  any  constant  rhythm, 
Loven  registered  graphically  by  a  very  simple  procedure  the  oscil- 
lations that  occur  in  the  muscles  of  the  arm  when  an  attempt  is 
made  to  flex  a  very  resistant  bar  of  steel,  and  he  found  that  in  a 
number  of  healthy  persons  the  rhythm  of  these  oscillations  was 
very  regular  at  12-13  P^'^  second. 

He  thinks  that  we  may  admit,  without  too  much  assumption,  that 
these  oscillations  are,  in  fact,  nothing  else  than  the  expression  of 
the  simple  muscular  contractions,  which  in  an  excessive  effort  of 
the  motor  centres  cannot  be  sufficiently  blended  to  produce  a 
perfect  continuous  tetanus. 

At  the  end  of  his  paper  M.  Loven  called  attention  to  various 
applications  that  could  be  made  of  these  views  in  the  explanation 
of  certain  characteristic  phenomena  of  some  pathological  con- 
ditions of  the  motor  system. 


Vaso-motors  of  the  Lymphatics. — MM.  Paul  Bert  and 
Laffont  have,  by  opening  the  abdomen  of  an  animal  in  the  full 
process  of  digestion  under  warm  water,  discovered  the  vaso- 
motor nerves  of  the  lymphatics.  In  this  operation,  the  chylifer- 
ous  vessels  appear  as  white  cords,  and  nodosities  are  formed 
along  them  by  excitation  of  the  solar  plexus  or  the  great  splanch- 
nic nerve.  Their  experiments  were  reported  to  the  Societe  de 
Biologie,  April  2,  of  this  year. 


Origin  of  the  Cranial  Nerves. — Duval  {Progrh  Mddical, 
Nos.  15  and  16,  1881),  before  the  Paris  Biological  Society, 
read  a  paper  on  the  subject  of  the  cranial  nerves  originating  as 
spinal  nerves  with  intumescences,  ih  which  he  dealt  more  espe- 
cially with  the  olfactory  and  fifth  pair.  The  ganglion  of  Gasser  is 


ANATOMY  AND  PHYSIOLOGY.  82$ 

easily  recognizable  as  an  intervertebral  ganglion,  and  Duval  is 
evidently  unacquainted  with  the  lengthy  paper  read  at  the  last  Bos- 
ton meeting  of  the  American  Association  for  the  Advancement  of 
Science,  August  28,  1880,  by  Dr.  S.  V.  Clevenger,  of  Chicago,  who 
not  only  brought  the  intervertebral  homology  to  bear  upon  all  the 
cranial  nerves,  but  insisted  that  the  cerebrum,  olivary  body,  mam- 
millary  eminence,  and  tubercular  quadrigemina  were  originally 
swellings  upon  the  roots  of  posterior  sensory  nerves,  and  that  the 
cerebellum  was  formed  from  a  great  number  of  fused  hypertro- 
phied  intervertebral  ganglia  (Journal  of  Nervous  and  Mental 
Disease,  October,  1880).  The  tendency  of  French  and  German 
journals  to  ignore  American  scientific  work  is  not  a  little  remark- 
able.— Chicago  Med.  Review,  June  5. 


Influence  of  Section  of  the  Trigeminus  on  the  Eye. 
— At  the  session  of  the  Soc.  de  Biologic.  Apr.  2  (rep.  in  Le 
Progres  Medical),  M.  Poncet  (of  Cluny)  communicated  the  re- 
sult of  some  investigations  on  the  effects  of  section  of  the  trigemi- 
nus upon  the  eye.  After  having  shown  that  physiologists  dis- 
agree to  a  considerable  extent  in  the  acceptance  of  the  traumatic 
theory  of  the  consecutive  corneal  ulcer,  he  showed  the  part  that 
the  discoveries  of  Franck,  and  Dastre  and  Morat  should  play  in 
the  pathology  of  the  trigeminus  ;  the  former  having  demonstrated 
the  action  of  a  special  sympathetic  filament,  and  the  latter  authors 
having  proved  the  vaso-dilating  action  of  the  sympathetic  on  the 
labial  mucous  membrane.  M.  Poncet  has  been  able  to  determine, 
with  M.  Dastre,  that  vaso-dilatation  by  excitation  of  the  great  sym- 
pathetic extends  to  the  veins  of  the  retina. 

In  the  eyes  of  a  rabbit,  after  section  of  the  trigeminus  performed 
by  M.  Laborde  himself,  and  dating  back  8,  15,  and  30  days,  and 
one  year,  he  found  the  following  conditions  :  i.  As  regards  the 
corneal  nerves,  the  degeneration  of  which  has  been  so  well  de- 
scribed by  M.  Ranvier,  he  also  found,  after  a  year,  the  complete 
regeneration  of  the  corneal  plexus,  in  a  manner  altogether  unlike 
the  normal  type.  In  the  middle  of  the  inextricable  nervous  maze, 
are  found  nerve  sheaths  in  which  the  old  tubes  have  not  been  re- 
generated. 2.  The  keratitis  which  may  accompany  an  exudation 
into  the  interior  chamber  affects  especially  the  superficial  layers 
of  the  cornea.  Neither  iritis,  nor  suppuration  of  the  process,  nor 
posterior  choroiditis,  nor  humoral  disorder,  nor  migration  of  pig- 
ment in  the  retina,  nor  detachment  of  that  membrane,  were  ob- 


826  PERISCOPE. 

served,  but  the  most  internal  layers  of  the  retina  are  the  seat  of 
an  oedema,  characterized  either  by  the  presence  of  oedematous 
masses  between  the  optic  fibres,  or  by  hypertrophic  degenerations 
of  the  ganglion  cells  ;  finally,  by  the  increase  of  the  protoplasm 
of  the  internal  granules.  These  alterations  differ  essentially  from 
those  described  by  the  author  in  a  previous  memoir,  as  following 
optico-ciliary  section. 

Development  of  the  Cranial  Nerves. — M.  Mathias  Duval 
reported  to  the  Societe  de  Biologie,  April  2  (abstr.  in  Le  Frogrh 
Medical),  that  he  had  recently  had  an  opportunity  to  examine  the 
brain  of  a  lamb  foetus  at  term,  which  was  subject  to  an  arrest 
of  development.  It  was  an  otocephale  ;  the  head,  reduced  to  the 
middle  and  inner  ears,  appeared  to  have  been  severed  by  a  liga- 
ture above  the  basilar  process.  In  a  section  of  the  encephalic 
stump,  at  the  level  of  the  floor  of  the  fourth  ventricle,  he  recog- 
nized the  nucleus  of  origin,  the  eminentia  teres,  and  the  exit  of 
the  facial  nerve,  as  well  as  the  origin  of  the  external  motor  oculi. 
The  nucleus  of  origin  of  the  trigeminus,  situated  in  the  same 
plane,  and  the  section  of  which,  in  the  form  of  a  horseshoe,  is 
commonly  easy  to  recognize,  was  absolutely  invisible.  What  is 
the  explanation  of  this  phenomenon  ?  M.  Duval  finds  it  in  the 
study  of  the  development  of  the  spinal  roots. 

We  are  aware,  in  fact,  that  in  the  embryo,  before  the  closure  of 
the  spinal  canal,  we  observe  rising  from  its  anterior  portion  two 
prolongations,  the  origins  of  the  anterior  roots.  Later,  when  the 
canal  is  closed,  we  see  leaving  its  posterior  region  two  lateral 
prolongations  composed  of  nervoso-epithelial  colonies.  These 
diverticula  become  the  spinal  ganglia,  but  they  first  become  pedicu- 
lated,  then  they  separate  themselves  completely  from  the  medul- 
lary canal,  and  it  is  only  still  later  that  it  sends  toward  the  cord 
on  one  side  and  toward  the  periphery  on  the  other  the  prolonga- 
tions that  form  the  sensory  nerve  roots. 

Thus,  as  regards  the  trigeminus,  the  medullary  portion  should 
start  from  the  ganglia  of  Gasser,  thus  explaining  why  no  trace  of 
it  was  found  in  the  medulla. 


Jj^ — PATHOLOGY  OF  THE  NERVOUS  SYSTEM  AND  MIND, 
AND  PATHOLOGICAL  ANATOMY. 


Disorders  of  the  Brain  in  Dyspepsia. — At  the  session  of  the 


PATHOLOGY.  827 

Soc.  de  Biologic,  May  21  (rep.  in  Le  Progrh  Medical,  No.  22), 
M.  Leven  made  a  communication  on  the  brain  troubles  in  dyspep- 
sia. He  had  a  hundred  observations  that  demonstrated  to  him 
the  existence  in  dyspepsia  of  cerebral  symptoms  not,  so  far, 
noticed,  for  example,  cerebral  commotion.  He  had  seen  patients 
struck  suddenly  in  the  street  with  veritable  apoplectic  attacks, 
lasting  ten  minutes  or  a  quarter  of  an  hour  ;  they  were  supposed 
to  be  epileptics,  but  were  in  reality  only  dyspeptics,  in  whom  the 
cerebral  accidents  subsided  completely  as  soon  as  the  digestive 
functions  were  reestablished.  In  the  dyspeptics  the  intelligence 
remains  intact ;  there  is  never  any  mental  alienation  ;  certain 
cerebral  faculties  may  be  altered  or  obscured,  so  to  speak,  but  the 
Ego  remains  entire,  and  the  patient  controls  himself  in  his  disorder. 
The  disorder  of  the  higher  mental  faculties,  the  enfeeblement  of 
the  will,  of  the  activity,  of  the  memory,  of  the  power  of  speech, 
are  easily  observed.  Some  patients  are  incapable  of  determina- 
tion ;  they  need  an  effort  to  perform  even  ordinarily  instinctive 
actions,  such  as  to  recover  an  object  they  have  accidentally 
dropped  ;  in  them  the  memory  is  defective  and  speech  difficult, 
especially  after  eating.  A  general  sadness  overcomes  them,  every 
thing  appears  dark  ;  but,  unlike  the  subjects  of  hysteria,  they  gen- 
erally present  a  cutaneous  hyperaesthesia,  but  never  anaesthesia. 

In  the  discussion  of  M.  Leven's  communication  M.  Laborde 
took  some  exceptions  to  its  conclusions.  Certainly  he  did  not 
deny  the  influence  of  disorders  of  the  stomach  upon  the  brain, 
and  no  one  cares  to  discredit  the  symptoms  of  anaemia  of  dyspep- 
tic origin  ;  but  it  may  be  that  M.  Leven  had  made  a  slightly 
forced  interpretation  of  his  results. 

There  are  many  persons  in  whom  the  digestive  disorder  is  de- 
pendent upon  nervous  disease,  and  it  is  straining  a  point  some- 
what to  seek  to  find  in  the  stomach  the  point  of  departure  of  all 
the  phenomena.  He  had  had  under  his  care  a  dyspeptic  woman, 
who  had  simultaneously  delirious  ideas  of  fear  of  being  bitten  by 
a  mad  dog,  which  soon  increased  to  the  dread  of  contact  with  any 
one  who  had  touched  a  dog  ;  finally  it  extended  to  fear  of  con- 
tamination by  aliments,  and  at  last  the  patient  became  almost  en- 
tirely insane. 

M.  Leven  said,  in  reply,  that  that  case  was  simply  one  of  in- 
sanity, while  he  spoke  only  of  hypochondriacs,  who,  however  they 
are  spoken  of  by  alienists  and  others  who  have  so  far  studied  them 
so  ill,  are  not  demented  ;  they  possess  their  intelligence  and 
ought  not  to  be  ranked  with  lunatics. 


828  PERISCOPE. 

M.  Laborde  asked,  then,  what  proof  could  be  given  that  cer- 
tain hypochondriacs  were  not  insane.  That  a  well-directed 
dietary  course  might  improve  them  is  possible,  but  that  is  no 
reason  for  saying  that  the  stomach  is  the  point  of  departure  for 
all  the  symptoms.  ''It  is  necessary  to  observe  a  patient  a  long 
time  to  see  a  mental  affection,  partial  in  its  beginning,  degenerate 
into  dementia. 


Hydrophobia  and  Septicemia. — At  the  session  of  the 
Acad,  de  Medicine,  May  24th  (reported  in  Le  Progres  Medical) 
M.  Colin  (of  Alfort)  read  a  paper  entitled  :  Some  Experiments  on 
Hydrophobia,  Septicaemia,  and  Charbon.  After  a  preamble  no- 
ticing the  experiments  of  MM.  Raynaud,  Lannelongue,  and  Pas- 
teur, who  had  claimed  to  have  found  a  new  disease  produced  by 
inoculating  rabbits  with  the  saliva  taken  from  the  mouth  of  a 
child  dead  with  rabies,  and  with  whose  views  he  did  not  agree,  he 
stated  his  own  experiments.  He  collected  on  a  lancet  a  certain 
quantity  of  virus  from  the  mouth  of  a  rabid  living  dog,  and  succes- 
sively inoculated  three  rabbits.  The  first  received  one  puncture 
with  the  lancet,  the  second  received  two,  and  the  third  three. 
The  rabbits  exhibited  no  noteworthy  symptoms  till  the  eighteenth 
day,  when  they  began  to  drag  the  foot  in  which  the  puncture  had 
been,  made,  and  six  hours  later  they  fell  over  on  one  side.  The 
same  evening  the  rabbit  that  received  a  single  inoculation  suc- 
cumbed, the  second  was  in  agony,  and  the  third  had  no  abnormal 
symptoms. 

All  three  finally  died  ;  the  first  eighteen  days  after  the  inocula- 
tion, the  second  nineteen,  and  the  third  twenty-two  days  after  the 
punctures  were  made.  The  symptoms  of  the  disease  were  vague, 
and  consisted,  in  the  later  stages,  in  an  extreme  depression  and  a 
stiffness  of  limbs  together  with  tetanic  convulsions.  The  respira- 
tory movements  were  much  diminished  and  attained  only  one 
third  the  normal  frequency.  In  short  the  salient  phenomena  of 
rabies  were  altogether  lacking.  The  autopsy  revealed  the  follow- 
ing lesions  :  on  the  right  flank,  where  the  inoculations  were  made, 
absence  of  oedema,  or  of  pus  or  plastic  deposits  ;  in  the  lymphat- 
ics, which  were  much  tumefied  and  smooth,  the  presence  of  volu- 
minous white  globules,  and  the  complete  absence  of  vibriones  and 
bacilli  ;  and  in  the   skin,  nothing  indicating  any  lesion  whatever. 

These  lesions  show  without  question  that  we  have  to  do  here 
with  septicaemia,  or  purulent  infection,  and  M.  Colin  declares  that 
these  animals  have  succumbed  to  hydrophobia. 


PA  THOLOG  Y.  829 

Alterations  of  the  Nerves  in  Chronic  Rheumatism. — 
At  the  session  of  the  Soc.  de  Biologic,  April  2d  (rep.  in  Le  Pro- 
gres Medical),  MM.  Leloir  and  Dejerine  stated  that  they  had  found 
in  a  case  of  muscular  rheumatism  with  considerable  muscular 
atrophy  and  rapid  eschars,  the  nerves  adjacent  to  the  eschars 
affected  with  atrophic  parenchymatous  neuritis.  They  are  of  the 
opinion  that  the  nervous  alteration  was  antecedent  to  the  eschar, 
and  see  the  proof  of  this  in  the  rapidity  of  the  alteration  of  the 
tissues. 


The  Etiology  of  Lepra. — Dr.  Albert  Neisser,  of  Leipzig, 
concludes  a  paper  on  the  etiology  of  lepra  in  Virchotvs  Archiv, 
Ixxxiv,  3  Heft,  June,  containing  the  results  of  careful  microscopic 
investigation  of  the  disease,  with  the  following  : 

From  all  the  above-described  points  follow,  for  lepra,  these 
hypotheses. 

1.  Lepra  is  a  true  bacteria  disease  produced  by  a  specific 
bacillus  form.  For  this  hypothesis  speak  the  following  :  the  con- 
stancy of  the  unquestionable  microscopic  findings  ;  the  peculiar 
constitution  of  these  bacilli  ;  their  presence  in  abundance  corre- 
sponding to  the  disease,  and  in  all  affected  organs  ;  the  proof  that 
the  si>ecific  peculiarities  of  the  lepra  cells  can  also  be  experimen- 
tally produced  by  invasion  of  the  bacilli. 

2.  These  bacilli  occur  as  such,  or  more  probably  as  spores  in 
the  organism,  and  remain  in  incubation,  varying  in  length  ac- 
cording to  circumstances,  in  depositories,  possibly  in  the  lymph 
glands.  The  duration  of  this  incubation  varies,  like  the  cases  of  le- 
pra themselves,  to  a  remarkable  degree,  especially  in  comparison 
with  other  infectious  diseases.  The  physiological  resistance  of 
the  human  organism  is  also  sometimes  as  great  as  the  energy  of 
growth  of  these  bacilli  is  slight.  Both  the  incubation  and  the 
course  of  the  disorder  appear  to  be  more  rapid  in  the  tropical 
than  in  the  European  regions  where  leprosy  abounds. 

3.  From  the  depositories  the  invasion  of  the  system  takes  place 
and  especially, 

{a)  Into  the  skin  (lepra  tuberculosa)  as  in  variola,  syphilis,  etc. 
In  this,  special  regions,  which  are  otherwise  particularly  exposed 
to  external  injurious  influences,  such  as  the  face,  hand,  elbow, 
knee,  are  points  of  selection  for  its  attacks. 

{b)  Into  the  peripheral  nerves  (lepra  anaesthetica).  The  mus- 
cular phenomena  and  also  the  trophic  disorders  correspond  to 
the  known  symptoms  in  other  disorders  of  the  peripheral  nerves. 


830  PERISCOPE. 

{c)  The  other  organs,  testicles,  spleen,  cornea,  cartilage,  liver, 
are  less  involved. 

4.  Through  the  bacilli,  or  spores,  inflammation  is  produced  in 
the  vascular  organs,  or  by  their  migration  inward  from  the  pe- 
riphery in  case  blood-vessels  are  lacking.  These  lymph  cells  (and 
fixed  cells)  form,  then,  the  material  for  the  leprous  new  forma- 
tion. By  the  specific  action  of  the  bacilli  the  wandering  cells  be- 
come lepra  cells,  characterized  by  their  peculiarities  of  form, 
course,  and  changes. 

5.  With  these  preliminary  propositions  we  can  assert  the  prob- 
ability that  lepra  is  an  infectious  disease,  and,  in  its  specific  prod- 
ucts, contagious.  These  are  tubercle  cells,  tissue  juice,  and  pus, 
with  living  bacilli  or  spores.  Not  every  sample  of  pus  is  infec- 
tious, on  the  other  hand,  in  the  subject  of  leprosy,  since  they  may 
contain  no  bacilli,  no  more  than  the  contents  of  the  pemphigus 
bullae. 

The  disorder  can  not  only  be  directly  contagious,  but  may  be 
transmitted  indirectly  by  external  means,  if  by  these  latter  the  ba- 
cilli or  spores  are  transported.  It  has  been  already  pointed  out 
that  in  lepra,  more  than  other  bacteria  disorders,  the  individual 
sensitiveness  to  infection  is  of  influence. 

On  the  contrary,  lepra,  in  my  opinion,  is  not  transmissible  by 
inheritance. 

I  close,  for  the  present,  with  these  remarks,  but  hope  soon  to 
follow  them  with  a  clinical  memoir,  especially  upon  the  morbid 
nervous  phenomena  of  the  disorder. 


Epilepsy. — At  the  late  session  of  the  International  Medical 
Congress  at  London  (rep.  in  N.  V.  Med.  Record),  epilepsy  was 
the  subject  of  a  demonstration  by  Dr.  Lasegue,  who  described  true 
epilepsy  as  being  due  to  malformation  of  the  skull,  either  idio- 
pathic or  traumatic,  all  other  forms  as  being  spurious  or  epilep- 
toid,  /.  e.,  those  due  to  cerebral  traumatism,  organic  lesion,  and 
toxic  or  hysteric  conditions.  The  true  epilepsy  (excluding  the 
traumatic),  dependent  on  malformation  of  the  skull,  follows  only 
on  its  ossification,  and  invariably  develops  between  the  age  of 
fourteen  and  eighteen  years.  The  head  is  found  on  examination 
and  measurement  to  be  asymmetrical,  either  laterally  or  antero- 
posteriorly,  and  this  is  accompanied  by  asymmetry  of  the  face,  the 
mouth  especially  being  askew  (strabismus  buccalis).  This  form 
is  never  hereditary,  nor  is  it  transmissible  to  offspring.     The   first 


PATHOLOGY.  83 1 

attack  of  epilepsy  is  identical  in  character  with  all  succeeding 
attacks,  therein  differing  markedly  from  the  epileptoid  forms. 
The  attacks  of  epilepsy  occur  between  4  and  7  a.  m.,  during  the 
passage  from  the  sleeping  to  the  waking  state.  These  patients  are 
epileptics  in  every  thing.  Dr.  Motet  stated  that  Dr.  Lasegue's 
views  were  generally  accepted  in  Paris,  but  no  discussion  in  con- 
firmation or  opposition  followed. 


Local  Asphyxia  of  the  Extremities. — Dr.  Momsen,  of  the 
French  Marine,  Arch,  de  Med.  Nervale,y.xx\\\,  340  and  431  (abstr. 
in  L'  Union  Medicate,  July  21).  As  a  result  of  chronic  miasmatic 
infection  there  are  sometimes  observed  nervous  syndromes  not 
without  analogy  to  those  following  the  processes  of  diphtheritic 
intoxication.  In  the  original  observation  and  those  selected  from 
other  quarters,  that  are  discussed  in  this  memoir,  the  patients  were 
affected  with  local  asphyxia  of  the  members,  or  rather  with  ner- 
vous disorders  analogous  to  the  vascular  spasms  of  the  limbs,  and, 
further,  with  regular  intermittent  symptoms  preceded  or  followed 
by  local  asphyxia  or  alternating  with  it.  In  some  the  local 
asphyxia  appeared  with  the  febrile  symptoms,  forming  genuine 
attacks,  followed  by  the  epiphenomenon  of  painful  tumefaction  of 
the  extremities,  that  is,  by  a  paralysis  of  the  vaso-motors.  This 
local  asphyxia  appeared  not  only  after  the  attack  of  intermittent 
fever,  but  it  also  follows  the  malarial  diarrhoea  of  Cochin  China. 

It  follows,  therefore,  from  the  twenty-two  cases  cited  in  this 
paper,  that  local  asphyxia  is  related  etiologically  with  intermittent 
fever,  which  it  may  replace,  and  that  these  nervous  accidents  are 
comparable  to  the  larvated  manifestations  of  malaria. 

The  symptoms  may  be  classed  methodically  ;  in  fact  they  ap- 
pear :  1.  In  thetierves  arising  itt  the  ffiedutta  (epileptiform  and  hys- 
terical symptoms)  ;  2.  in  the  organs  innervated  by  the  pneumogas- 
trics  with  or  without  association  with  the  sympathetic  (pulmonary 
accidents,  congestions,  pneumonias,  etc.,  gastro-intestinal  acci- 
dents, vomiting,  epigastralgia,  intestinal  congestions,  cardiac  ac- 
cidents, irregularity  of  the  cardiac  pulsations,  angina  pectoris, 
etc.)  ;  3.  in  the  sympathetic  (ocular  disorders,  amblyopia,  conges- 
tion, flow  of  tears,  secretory  disorders,  diabetes,  polyuria,  icterus)  ; 
4.  in  the  peripheral  vaso-motor,  sensory,  or  motor  nerves  (herpes, 
urticaria,  pemphigus,  asphyxia  of  the  mammae,  flushing,  local 
chills,  muscular  atrophy,  growth  of  adipose  or  epidemic  tissue, 
anaesthesia,  hyperaesthesia,  temporary  paresis,  tremors). 


832  PERISCOPE. 

These  phenomena  can  be  explained  up  to  a  certain  point  by 
the  theory  which  considers  local  asphyxia  of  the  extremities  as  a 
neurosis,  by  the  exaggeration  of  the  excito-motor  power  of  the 
cord  holding  under  its  dependence  the  vascular  innervation.  It 
is,  perhaps,  not  impossible  to  explain  the  miasmatic  origin  of 
these  phenomena,  by  an  irritation  of  the  vessels  of  the  cord  due 
to  melanaemic  deposits.  This  irritation  would  give  rise  to  spasms 
of  the  extremities.  Other  material  alterations  in  the  cord,  such  as 
congestion  or  inflammation,  could  produce  the  same  symptoms. 

In  his  final  chapter  the  author  demonstrates  the  secondary  r6le 
of  cold  in  the  production  of  local  asphyxia.  He  recalls  also  the 
fact  that  Raynaud  had  observed  a  case  caused  by  insolation. 
This  fact  established  a  relation  with  the  febrile  attacks  following 
sunstroke.  Cold  and  heat  have,  therefore,  the  same  action  in  the 
pathogeny  of  attacks  of  local  asphyxia  and  intermittent  fever.  In 
a  therapeutic  point  of  view,  sulphate  of  quinine,  the  constant  de- 
scending current  to  the  spine,  and  derivative  agents  acting  on  that 
organ,  are  the  medical  agencies  that  have  been  found  effective. 


Gastric  Epilepsy. — H.  Pommay,  Revue  de  Med.,  i,  vi,  June 
10,  describes  and  discusses  a  couple  of  cases  of  epilepsy,  appar- 
ently connected  with  digestive  disorders,  and  ends  his  article  with 
the  following  conclusions  : 

1.  Digestive  disorders  may  give  rise  to  various  nervous  symp- 
toms ;  due  {a)  to  the  paralysis,  and  (^)  to  the  excitation  of  the 
vagus  nerve. 

2.  These  phenomena  are  of  reflex  origin,  and  occur  entirely  in 
the  sphere  of  the  vagus  (irritation  of  its  sensory  gastric  fibres,  ex- 
citation or  reflex  paralysis  of  its  cardiac  branches). 

3.  The  phenomena  of  excitation  betray  themselves  in  epileptic 
attacks,  those  of  paralysis  in  cardiac  crises  (palpitation  of  the 
heart  and  defects  of  rhythm). 

4.  The  age  and  the  habitual  condition  of  health  of  the  sub- 
ject appear  to  play  a  part  in  affecting  the  mode  of  the  response  to 
the  irritation. 

5.  Gastric  epilepsy  differs  from  other  epilepsies  by  {a)  its 
cause — errors  in  diet, — and  in  {b)  its  symptoms — vomiting  of  food, 
in  addition  to  the  usual  symptoms  of  the  attack, — and  in  '\c) 
its  sequels — gastric  embarrassments. 


D^LiRE  AiGU. — Dr.  Marcel  Briaud,  These  de  Paris.,    1881  (an. 


PATHOLOGY.  833 

by  H.  de  Boyer  in  Archives  de  Neurologie,  J^J^y)*  considers  the  dd- 
lire  aigu  to  be  a  morbid  entity,  susceptible  of  precise  definition. 
He  describes,  in  its  pathological  anatomy,  a  lesion  that  he  claims 
is  almost  constant,  though  it  has  not  before  been  noticed.  It  con- 
sists of  an  injection,  of  variable  extent,  of  the  internal  tunic  of 
the  arch  of  the  aorta,  resembling  very  much  the  effect  that 
"would  be  produced  by  a  brush,  two  or  three  centimetres  thick, 
charged  with  red  ink,  carried  from  below  upward  for  five  or  six 
centimetres  from  the  sigmoid  valves."  This  very  marked  color- 
ation, which  is  sometimes  accompanied  with  actual  thickening,  is 
strictly  limited  to  the  internal  tunic  of  the  vessel,  and  is  indepen- 
dent of  the  atheromatous  patches  that  may  exist  there,  and  which 
it  sometimes  envelopes.  It  is  met  with  in  subjects  of  all  ages, 
temperate  or  otherwise.  It  is  sometimes  more  than  a  simple  in- 
jection ;  in  some  cases  there  is  a  genuine  false  membrane  investing 
the  inner  wall  of  the  aorta.  According  to  the  author  this  is  only 
a  more  advanced  stage  of  the  pathological  process.  The  exist- 
ence of  this  lesion  supports  the  view  that  the  cause  of  the  gravity 
of  the  disorder  is  to  be  sought  for  in  a  modification  of  the  blood. 
The  typhoid  aspect  of  the  patients  also  favors  this  view. 

Hereditary  predisposition  and  excesses  are  the  causes  that  pre- 
dominate in  the  etiology  of  the  disorder,  together  with  faulty 
hygienic  conditions. 

The  cases  given  in  illustration  support  the  author's  statements 
very  fully.  Among  them  is  that  of  a  well-known  musical  com- 
poser. Though  death  is  the  usual  termination,  cure  may  occur, 
and  in  these  cases  the  author  attributes  the  favorable  result  mainly 
to  the  disuse  of  all  mechanical  restraint  and  all  causes  of  conten- 
tion. He  also  mentions  good  results  from  the  use  of  salicylate  of 
soda,  and  tonics,  and  the  wet  pack,  in  the  treatment  of  this  dis- 
order. 


Glycosuria  from  Stretching  the  Vagi. — At  the  session  of 
the  Soc.  de  Biologic,  May  14  (rep.  in  Le  Progres  Medical,  No.  21), 
MM.  Marcus  and  Wiet  announced  that  in  carrying  on  their  re- 
searches on  nerve-stretching,  they  had  made  some  experiments  to 
find  out  what  results  followed  the  elongation  of  the  pneumogas- 
tries. 

In  the  first  rabbit  experimented  upon  they  operated  by  stretch- 
ing the  right  pneumogastric  on  its  central  portion.  The  animal, 
who  could  not  be  examined,  died  three  days  after  the  operation. 
The  autopsy  presented  all  the  signs  of  asphyxia.     Its  lungs  were 


834  PERISCOPE. 

covered  with  ecchymoses,  and  the  bronchiae  filled  with  foamy 
sputa. 

A  second  rabbit,  carefully  chosen  and  pure  white  in  color,  was 
experimented  upon  ;  on  this  animal  MM.  Marcus  and  Wiet 
stretched  both  pneumogastrics,  operating  on  the  central  end  and 
carefully  avoiding  any  implication  of  the  sympathetics.  Immedi- 
ately after  the  operation  they  observed  a  considerable  congestion 
of  the  two  ears,  which  was  followed,  a  few  minutes  later,  by  a  not 
less-marked  contraction  of  the  vessels.  This  anaemia  was  of  short 
duration,  and  gave  place  to  an  intense  vaso-dilatation  that  existed 
up  to  the  time  of  making  their  report,  and  a  very  well-marked 
double  myosis.  The  next  day  the  animal  commenced  to  have  dif- 
ficulty in  breathing,  and  this  symptom  became  still  more  promi- 
nent and  led  to  the  presumption  that  the  rabbit  would  ultimately 
die  asphyxiated.  The  analysis  of  the  urine  showed  nothing 
abnormal  the  first  day  after  the  operation,  but  on  the  second  day 
it  revealed  the  presence  of  traces  of  sugar,  well  shown  by  Fehling's 
test  and  that  of  the  subnitrate  of  bismuth. 

The  authors  also  stretched  the  two  vagi  in  another  rabbit  to  as- 
certain whether  the  operation  would  not  produce  glycosuria. 
This,  indeed,  was  the  fact,  as  the  experimenters  easily  demonstrated 
with  the  aid  of  the  above-mentioned  reagents. 

These  facts  appear  to  show  that  stretching  of  the  nerves  pro- 
duces an  effect  on  the  nerve  centres,  and  they  may  throw  some 
light  on  several  physiological  questions  now  the  order  of  the  day. 
The  histological  study  of  the  medullas  of  the  animals  experi- 
mented upon  will  aid  to  complete  the  investigation,  and  may  also 
be  of  some  use  in  the  solution  of  these  problems. 

MM.  Marcus  and  Wiet  also  stretched  the  sympathetic  and  the 
vagus  by  pulling  the  peripheral  portion,  and  their  researches  will 
form  the  subject  of  a  future  communication. 


Calcareous  Deposits  in  the  Spinal  Arachnoid. — Chvostek, 
Wiener  Med.  Fresse,  Nos.  51  and  52,  1880,  and  13  and  15,  1881 
(abstr.  in  Centralbl.  f.  d.  Med.  Wissench.,  No.  27),  reports  a  series 
of  cases  in  which,  with  the  clinical  symptoms  of  a  spinal  affec- 
tion,— severe  neuralgic  pains,  increased  by  attempts  at  movement 
of  the  rigidly  held  lumbar  and  dorsal  vertebrae,  the  ascending  ex- 
tension of  the  process  from  the  lumbar  to  the  dorsal  spine,  the 
late  and  insignificant  involvement  of  the  motor  nerves,  the  ad- 
vanced age  of  the  patients,  the  long  duration  of  the  process,  and. 


PATHOLOGY.  835 

prominently,  the  lack  of  symptoms  that  are  characteristic  of  other 
spinal  diseases,  being  the  principal  points  for  the  diagnosis, — the 
autopsy  revealed  numerous  and  very  large  calcareous  plates  in  the 
spinal  arachnoid,  which  apparently  bore  a  causal  relation  to  the 
above  symptoms. 

The  Coincidence  of  Spinal  Disease  and  Skin  Affections. 
— A.  Jarisch,  Vierteljahrschr.  f.  Dermatol,  u.  Syphilis,  1880,  p.  195, 
(abst.  in  Centralbl.  fUr  Med.  Wissensch.,  No.  27,  1881).  Starting 
with  the  presumption  that  the  advances  in  nerve  pathology  would 
also  assist  in  the  explanation  of  the  connection  between  skin  dis- 
eases and  disorders  of  the  nervous  system,  the  author  undertook 
the  microscopic  examination  of  the  spinal  cord  of  a  patient  who, 
without  developing  motor  or  sensory  disturbances,  had  suffered 
from  an  intense,  in  part  sharply  limited,  febrile  herpes  iris,  and, 
after  the  occurrence  of  an  acute  bedsore  over  the  sacrum  and 
fatal  inflammation  of  the  lungs,  had  afforded,  as  obvious  results  of 
the  autopsy,  a  lobular  pneumonia  associated  with  the  third  stage 
of  Bright's  disease. 

Examination  of  the  cord  hardened  in  a  -j^th  per  cent,  solution 
of  chromic  acid,  revealed  notable  alterations  in  its  gray  axis.  The 
central  and  posterior  portions  of  both  anterior  horns  appeared  in 
part  to  be  spongy  and  in  part  shrunken,  and  in  the  region  of  the 
3-7  and  2-5  cervical  nerves  there  were  symmetrical  lateral  foci  of 
alteration.  The  majority  of  the  ganglion  cells  in  the  anterior 
horns,  from  the  third  cervical  to  the  eighth  dorsal  vertebra,  had 
become  coarsely  granular,  and  their  processes  were  notably  thick- 
ened ;  also  there  had  been  formed  in  the  foci  a  network  of  thick, 
smooth-margined  fibres  made  up  of  irregularly  formed  pieces. 

These  alterations  existed  in  their  greatest  intensity  in  those 
parts  in  which  Charcot  has  located  his  hypothetical  trophic  cen- 
tres for  the  skin. 

The  author  also  extended  his  investigations  into  the  spinal  cord 
in  syphilis,  and  found  in  three  cases  of  inherited  syphilis  circum- 
scribed foci  in  the  central  portion  of  the  anterior  horns  or  in  the 
commissure,  which  were  deeply  colored  and  showed  visible  swell- 
ings of  the  network.  In  two  of  these  cases  the  protoplasm  of  the 
ganglion  cells  was  coarsely  granular  ;  in  the  third  it  appeared 
shrunken  and  penetrated  by  numerous  vacuoles.  The  medulla  in 
a  case  of  acquired  syphilis  was  similarly  pathologically  altered. 

Finally,  Jarisch  discovered  in  the  spinal  cord  of  a  man  who  had 
been  a  sufferer  from  psoriasis  for  the  greater    part  of  his   life, 


836  PERISCOPE. 

sclerosed  and  inflamed  patches  in  the  gray  axis,  and  in  one  case 
of  lupus  erythematosus,  symmetrical  patches,  visible  to  the  naked 
eye,  in  the  central  lateral  portion  of  the  anterior  horns,  the  same 
locality  as  was  affected  in  the  already-mentioned  case  of  herpes 
iris. 


Hydrophobia. — MM.  Bertholle  and  Eloy  send  the  account  of 
a  carefully  observed  and  reported  case  of  hydrophobia  in  the 
human  subject  in  JJ  Union  Medicale,  Aug.  11,  with  the  following 
conclusions  : 

1.  The  existence  of  Hydrophobia  in  our  patient  is  incontesta- 
ble. The  incubation  of  about  forty  days  had  a  duration  confirm- 
able  to  the  statistics  resulting  from  the  observations  collected  by 
the  Conseil  d'  Hygiene  of  1862- 1874.  Death  occurred  rapidly 
about  forty-eight  hours  after  the  beginning  of  the  hydrophobic 
spasms. 

2.  Erections,  ejaculations,  and  dysuria  were  the  first  symptoms 
of  irritation  of  the  nervous  centres.  These  early  phenomena,  in 
the  absence  of  any  other  clinical  indication,  might  lead  to  error, 
since  they  occurred  at  a  period  of  the  disease  in  which  the  exis- 
tence of  genetic  disorders  had  not  been  noticed  by  authors. 
Here  the  excitation  of  the  genito-urinary  organs  was  the  first 
manifestation  of  spinal  irritation,  preceding  thus  the  other  classic 
phenomena  of  hydrophobia. 

3.  The  generalization  of  cadaveric  rigidity,  its  prompt  appear- 
ance, and  the  quickness  with  which  putrefaction  set  in,  are  phe- 
nomena analogous  to  those  observed  in  physiological  experiments. 
They  confirm  the  numerous  observations  made  now  many  months 
in  the  laboratory  of  experimental  medicine  of  the  College  de 
France,  by  which  M.  Brown-Sequard  has  shown  that  cadaveric 
rigidity  and  putrefaction  appear  the  more  quickly  as  the  death 
was  preceded  by  longer  and  more  violent  convulsions.  These 
phenomena  are  therefore  in  relation,  not  with  the  hydrophobic 
intoxication,  but  with  the  duration  of  the  convulsive  spasms. 

4.  The  dark  coloration  and  the  diminution  of  the  fluidity  of 
the  blood  are  proofs  that  in  this  case  death  was  not  due  to  as- 
phyxia. Indeed,  in  cases  of  asphyxia  the  blood  is  fluid  and  pre- 
sents no  increase  in  its  consistency.  Our  observation  therefore 
confirms  the  statement  to  that  effect  made  by  Dr.  Calve,  of  Tou- 
lon {Union  Medicale,  Dec.  30,  1876). 

The  existence  of  pulmonary  ecchymoses  in  hydrophobia  is  also 
in  confirmation  of  a  physiological  phenomenon  observed  by  vari- 


PATHOLOGY.  837 

ous  authors  and  studied  with  care  by  Dr.  Henocque  {Gaz.  Heb- 
dom.,  1880,  Nov.,  I,  2,  and  3).  In  cases  of  lesions  of  the  nervous 
centres,  these  ecchymoses  are  met  with  in  the  tissues  of  various 
organs  (stomach,  intestines,  bladder,  liver,  etc.)  ;  but  they  occur 
habitually  in  the  pulmonary  substance,  as  in  the  present  case. 
The  bloody  appearance  of  the  tracheal  form  is  probably  caused 
by  the  mingling  of  these  extravasations  with  the  bronchial 
mucus. 

The  pulmonary  emphysema  often  observed  in  hydrophobia, 
probably  occurs  subsequent  to  death.  It  is  produced  by  an  anal- 
ogous mechanism  to  that  of  the  post-mortem  emphysema  studied 
some  time  ago  by  M.  Henocque,  especially  in  cases  of  violent 
death  and  lesions  of  the  nerve  centres. 

The  anatomical  dififerences  between  the  contraction  of  the 
right  and  left  halves  of  the  diaphragm  are  similar  to  those  ob- 
served in  animals  following  a  nervous  irritation  on  only  one  side 
of  the  body.  It  was  precisely  this  result  in  certain  previous 
physiological  experiments,  as  yet  unpublished,  of  which  we  were 
witnesses,  that  led  one  of  us  to  seek  for  and  ascertain  these  dif- 
ferences in  the  autopsy  of  our  patient. 

En  resume,  the  excitation  of  the  cord,  localized,  in  the  begin- 
ning, in  the  centres  of  innervation  of  the  genito-urinary  organs, 
was  the  first  act  of  this  pathological  drama.  But,  so  far  as  we  are 
aware,  genesic  disorders  have  never  before  been  observed  in  the 
prodromic  period  of  hydrophobia.  They  have  been  observed  in 
an  advanced  stage  of  the  disease.  Such,  for  example,  was  the 
case  in  the  patient  of  Van  Swieten,  whose  death  was  preceded  by 
ejaculations,  and  of  whom  he  wrote  "  Semen  et  armnam  simul 
efflavity 

The  respiratory  disorders,  the  pulmonary  ecchymoses,  the  dif- 
ferences in  the  state  of  contracture  of  the  two  halves  of  the  dia- 
phragm, the  condition  of  the  blood,  are  signs  of  a  death  by  syn- 
cope, rather  than  by  asphyxia,  and  are  related  to  the  physiologi- 
cal phenomena  observed  in  animals  (guinea-pig,  dog,  rabbit,  ape), 
following  irritations  at  a  distance  or  direct  injuries  of  the  medulla. 
These  facts,  moreover,  appear  to  be  related  to  the  numerous  suc- 
cesses obtained  in  Germany  and  in  France  by  M.  Pasteur  in  the 
inoculations  practised  on  dogs  with  the  tissue  of  the  medulla  it- 
self taken  from  other  rabid  dogs.  Therefore  we  wait  with  some 
impatience  the  result  of  experiments  by  M.  Pasteur  with  inocu- 
lations with  the  bulbar  tissue  of  our  patient.  This  will,  if  suc- 
cessful, be  an  authentic  case,  if  not  the  first  one,  of  the  direct 


838  PERISCOPE. 

transmission  of    rabies   from   men   to  the   lower    animals,  and  a 
great  step  in  the  experimental  study  of  hydrophobia. 


Injuries  of  the  Brain,  with  General  and  with  Local 
Symptoms. — E.  v.  Bergmann,  Volkm.  Klin.  Vortrdge,  No.  190, 
(abstr.  in  Deutsche  Med.  Wochenschr.,  No.  35,  Aug.  27).  The  au- 
thor first,  in  this  valuable  clinical  lecture,  directs  himself  against 
the  former  sharp  distinction  of  cerebral  shock  and  cerebral  com- 
pression. As  he  has  repeatedly  stated  in  former  papers,  the  general 
symptoms  observed  in  both  of  these  traumatic  conditions  are 
referable  to  a  more  or  less  considerable  disturbance  of  nutrition  of 
the  whole  brain,  which,  according  to  the  irritability  of  the  various 
sections  of  the  brain,  reveals  itself  in  paralytic  or  irritative  phe- 
nomena. The  cortex  is  earliest  affected  in  all  cases,  the  centres 
situated  in  the  medulla  (vaso-motor  and  vagus  centres)  are  im- 
plicated later.  Slight  concussion  causes  only  a  transitory  confu- 
sion resulting  from  shock  to  the  nerve  elements,  or  a  vaso-motor 
disturbance  of  the  surface  of  the  brain  ;  a  more  severe  one  has,  as 
a  consequence,  more  lasting  benumbing  of  the  faculties  and  re- 
tardation of  the  pulse,  with  irregularity  of  the  respiration  from  a 
more  pronounced  paralysis  of  the  cortex,  and  with  it  irritation  of 
the  automatic  centres  ip  the  medulla.  A  still  severer  shock  pro- 
duces quickening,  weakening,  and  smallness  of  the  pulse,  together 
with  deep  coma  in  consequence  of  paralysis  of  the  central  organs 
involved.  A  compression  of  the  brain  from  extravasation  of  blood 
between  it  and  thejdura,  when  slight,  may  cause  also  only  a  moder- 
ate, transient  benumbing  of  the  faculties,  but  when  more  extensive, 
causes  more  lasting  unconsciousness,  with  sopor  and  slow  pulse, 
and  later,  coma  with  small,  rapid  pulse.  The  cortical  paralysis 
which  asserts  itself  variously  from  mere  confusion  to  the  most 
profound  coma,  is  in  the  first  case  the  result  of  nutritive  disturb- 
ances in  the  nervous  elements,  accompanied  later  by  vaso-motor 
disorder  or  capillary  hemorrhages  in  the  cortex  ;  in  the  second 
case  the  coma  is  the  result  of  anaemia  caused  by  the  increasing 
pressure  having  a  great  extension  over  the  cortex,  inhibiting  and 
destroying  the  function  of  the  nerve  elements.  The  same  cause 
affects  the  automatic  organs,  first  causing  irritation  and  then  their 
paralysis.  Any  distinction  between  the  phenomena  of  cerebral 
shock  and  cerebral  compression  is  only  afforded  by  the  order  in 
time  and  the  duration  of  the  symptoms.  In  cerebral  shock  the 
symptoms  are  of  early  occurrence,  and,  in  favorable  cases,  early  in 


PATHOLOGY.  839 

disappearing.  In  cerebral  compression  they  increase  slowly  or 
rapidly  but  continuously,  and  they  last  longer  in  favorable  cases, 
even  if  the  extravasation  is  absorbed.  If  after  injury  to  the  skull 
the  cerebral  symptoms  are  steadily  severer,  the  coma  more  profound, 
the  respiration  stertorous,  and  the  pulse  steadily  retarded,  then  in- 
creasing pressure  is  to  be  diagnosed,  caused  by  an  extravasation, 
and  trephining,  for  the  stoppage  of  the  bleeding,  is  needed.  If 
after  rather  quick-appearing,  transient,  severe  cerebral  symptoms, 
there  is  left  a  dulness  with  confusion  and  drowsiness,  while  the 
pulse  and  respiration  are  normal,  then  the  first  symptoms  are  prob- 
ably due  to  a  cerebral  shock  accompanying  the  traumatic  injury  to 
the  nervous  substance,  while  the  later  confusion,  etc.,  are  due  to 
an  extravasation  upon  the  surface  of  the  brain  not  large  enough 
to  cause  serious  compression,  but  yet  sufficient  to  disorder  the 
functions  of  the  sensitive  brain.  If  a  large  extravasation  becomes 
absorbed,  the  disturbances  of  the  pulse  and  respiration  disappear 
first,  the  mental  confusion  last.  Von  Bergmann  found  in  these 
cases  urobilin  in  the  urine  (a  result  of  absorbed  coloring  matter 
of  the  blood).  Stasis  papilla  is  not  necessarily  present  with  an 
intracranial  extravasation.  It  is  often  lacking,  and  may,  moreover, 
occur  (according  to  Berlin)  with  fracture  of  the  basis  cranii  (with- 
out extravasation),  as  when  the  fissure  crosses  the  optic  canal  and 
ruptures  the  nerve-sheath,  blood  from  the  former  enters  the  latter. 
The  brain  injuries  with  local  symptoms  form  a  natural  counter- 
part to  those  with  general  symptoms.  They  occur  when  prefer- 
ably a  more  or  less  circumscribed  portion  of  the  brain  is  injured. 
In  that  case  the  special  symptoms  connected  with  the  injured 
part  are  most  prominent.  But  if  at  the  same  time  the  whole  brain 
is  also  more  or  less  involved,  whether  as  a  consequence  of  shock 
or  through  pressure  from  a  rapidly  increasing  extravasation  of 
blood,  then  they  only  will  require  consideration  together  with  the 
general  phenomena,  whether  the  latter  are  slight  or  retrogressive. 
Localized  brain  symptoms  occur  especially  prominent  with  lesions 
of  the  motor  zone,  and  appear  as  definite  combined  paralytic  and 
irritative  phenomena  on  the  opposite  half  of  the  body.  From 
these  symptoms  the  locality  and  extension  of  the  injury  in  the 
motor  zone  can  be  definitely  known,  and  the  case  treated  accord- 
ingly. Broca  has  given  directions  for  the  orientation  over  the 
motor  region  on  the  skull,  and  these  the  author  copies.  Still 
another  method  is  given  by  Lucas  Champonniere.  Still  the 
author  considers  both  methods,  which  are  given  in  Lucas 
Champonniere's  monograph  on  localized  trepanation,  as  not  al- 


840  PERISCOPE. 

together  satisfactory,  and  the  last  one  is  somewhat  complicated. 
(A  much  simpler  method,  and  one  that  has  been  verified  by 
numerous  experiments  on  the  cadaver,  will  be  published  by  the 
reviewer  (M.  Schiiller)  in  the  Deutsche  Med.  Wochenschr.)  Von 
Bergmann  reports  one  case  in  which  he  successfully  trephined  a 
funnel-formed  depression  of  the  right  temporal  bone  of  some 
3-4  cm.  circumference.  He  takes  the  occasion  to  recommend, 
after  removal  of  fragments  of  bone  and  careful  antiseptic  cleansing 
of  the  wound,  the  utmost  possible  cleanliness  of  the  skin-margin 
of  the  wound  above  the  trephined  place.  The  cutaneous  wound 
is  closed  over  the  opening,  through  which  a  drainage  tube  is  laid 
upon  the  brain.     *     *     * 

The  author  adds  to  this  case  instructive  remarks  upon  the  phe- 
nomena of  cerebral  oedema,  which  occurred  in  the  vicinity  of  the 
wound,  and  with  this  connects  the  paralysis  of  the  left  arm  that 
appeared  some  hours  after  the  operation,  disappearing  again  in  a 
few  days,  to  which  were  added  now  and  then  contractions  in  the 
muscles  supplied  by  the  left  facial  nerve.  From  these  symptoms 
Bergmann  thinks  that  the  spot  of  the  cortical  injury  must  be 
sought  for  in  the  anterior  margin  of  the  anterior  central  gyrus, 
where  it  borders  the  third  frontal. 


Mental  Symptoms  from  Isthmus  Disease. — The  conven- 
tional notion  associates  all  mental  disturbances  with  perversion  of 
the  functions  of  the  cerebral  hemispheres.  This  it  would  be  a 
truism  to  speak  of  as  a  correct  belief,  but  sufficient  stress  is  not 
laid  by  modern  writers  on  the  fact  that  the  converse,  pathologi- 
cally speaking,  of  this  proposition  is  not  of  universal  application, 
namely,  that  only  hemispheric  lesions  are  found  where  mental 
symptoms  have  been  evinced  during  life.  It  is  an  old  observa- 
tion, but  it  has  not  been  sufficiently  commented  on,  that  lesions  of 
the  pons,  the  crura,  and  thalami,  are  accompanied  by  obliteration, 
more  or  less  complete,  of  consciousness,  blurring  of  the  percep- 
tions, confusion  in  the  intellectual  sphere,  and  this  in  cases  where 
the  lesion  was  not  one  of  such  a  character  as  to  disturb  neighbor- 
ing ganglia  by  pressure.  Two  explanations  may  be  offered  for 
this  phenomenon.  Either  the  vaso-motor  centre  for  the  cortical 
vessels  must  be  assumed  to  be  under  the  partial  control  of  isth- 
mus ganglia,  and  hence  that  isthmus  lesions  may  by  irritation  or 
destruction  of  this  centre  excite  or  paralyze  the  vascular  tubes  of 


PATHOLOGY.  84 1 

certain  cortical  districts,  or  it  must  be  concluded  that  the  patho- 
logical interruption  of  the  great  nerve  tracts  involves  a  functional 
disturbance  of  cortical  end  stations.  The  former  explanation 
would  seem  rather  applicable  to  cases  in  which  general  and  wide- 
spread mental  disturbance,  somnolence,  excitement,  or  depression 
are  found  ;  the  latter,  to  those  where  the  disturbances  are  partial 
in  character. 

It  is  a  well-known  fact  that  if  all  the  avenues  of  sensory  percep- 
tion are  closed,  unconsciousness  in  the  way  of  sleep  speedily 
follows.  May  not  the  interruption  of  the  perception  tracts  be 
followed  by  corresponding  phenomena  of  a  less  extensive  nature, 
when  occurring  in  the  isthmus  territory  ?  That  an  irritative 
lesion  in  the  line  of  the  centripetal  tracts  can  influence  cortical 
life,  is  amply  illustrated  by  cases  of  thalamus  lesion,  where  hallu- 
cinations were  present.  Here  the  cause  of  the  hallucination  is  in 
a  lower  centre,  but  from  all,  the  belief  is  justified  that  the  entry 
of  the  hallucination  into  the  intellectual  sphere  can  only  take 
place  in  the  cortical  termination  of  that  tract.  From  this  point, 
through  the  conducting  associating  tracts,  it  becomes  a  part  and 
parcel  of  the  patient's  Ego.  The  study  of  the  pathology  of  the 
great  nerve  tracts  has  been  limited  of  late  almost  exclusively  to 
the  middle  and  posterior  thirds  of  the  internal  capsule.  It  seems 
to  have  been  forgotten  that  Meynert  traced  an  enormous  division 
of  the  crus  directly  to  the  frontal  lobe  and  the  lenticular 
nucleus,  and  that  this  portion,  through  the  transverse  fibres  of  the 
pons  was  of  necessity  connected  with  the  cerebellum,  and  that 
other  functions  are  to  be  located  in  the  cortex,  than  merely 
muscular  innervation  and  visual  and  auditory  perceptions,  to 
whose  study  modern  localizationalists  are  directing  their  attention 
so  exclusively.  The  restiform  columns  derived  from  spinal 
fibres  enter  the  cerebellum,  terminating  chiefly  in  its  hemispheres  ; 
the  cortex  of  the  hemispheres  is  connected  by  radiatory  fibres 
with  the  dentated  nucleus,  which  is  a  recipient  of  fibres  of  the 
auditory  nerve.  In  short,  the  cortex  of  the  cerebellar  hemisphere 
receives  fibres  from  the  sensorial  periphery  of  the  body  as  well  as 
the  semicircular  canals,  and  possibly  of  the  cochlea. 

From  the  primary  reception  area,  the  transverse  fibres  of  the 
pons  originate,  and  enter  the  crus  ;  it  is  these  which,  according 
to  Flechsig's  most  recent  researches,  enter  the  frontal  lobe  and 
lenticular  nucleus.  In  no  respect  does  man  so  much  differ  from 
the  ape  as  in  the  quantitative  development  of  this  tract.  It  is  in- 
timately associated  with  the  map  of  the  frontal  lobe.     There  is 


842  PERISCOPE. 

every  reason  to  consider  it  the  channel  of  information  of  the 
equilibrium,  and  possibly  of  the  senses  of  space  and  time,  on 
which  the  scope  of  the  mind  is  closely  dependent.  It  is  not  at  all 
improbable  that  lesions  in  these  tracts  may  disturb  these  sensa- 
tions, and  that  the  entire  mental  architecture  may  totter  with  the 
withdrawal  of  so  important  pillars.  Probably  the  congenital 
asymmetry  of  the  peduncular  tracts,  observed  in  certain  cases  of 
mental  perversion,  may  not  be  without  a  bearing  in  the  explana- 
tion of  the  symptoms  of  those  cases.  And  this  explanation  would 
be  adjunct  to  the  theory  of  mal-development  of  the  associating 
tracts,  recently  advanced  in  explanation  of  other  symptoms 
of  these  same  states.  The  day  will  come  when  physiologists  will 
not  attempt  any  longer  to  determine  the  seat  of  higher  functions 
in  single  centres  by  special  experiments,  but  rather  seek  to  cor- 
relate the  results  of  different  sets  of  experiments,  and  thus  dem- 
onstrate that  complex  functions  have  a  complex  substratum. 
Nothing  could  be  more  absurd,  for  example,  than  to  speak  of  "  in- 
tellectual cells "  (Denkzellen)  in  the  cerebral  cortex,  as  Schiile 
does  in  Ziemssen's  Cyclopaedia.  Simple  elements  have  simple 
functions,  complex  functions  require  a  union  of  numerous  simpler 
elements  in  a  cc)mplex  combination.  {Chicago  Medical  Review^ 
Sept.  20,  1881.) 

Autographic  Men.  —  Chouel  {Marseilles  Midical,  January, 
1881)  reports  a  class  of  human  beings  whom  he  calls  "autographic 
men,"  who,  from  certain  central  neuroses,  present  a  form  of  urti- 
caria which  shows  itself  when  a  slight  irritation  is  applied  to  the 
skin.  The  cuticle  may  be  written  on  and  retain  the  character 
inscribed  on  it  for  some  time,  through  the  urticaria  so  produced. 
Dujardin-Beaumetz  was  the  first  to  describe  this  phenomenon, 
which  is  by  no  means  rarely  observed. — Chicago  Medical  Review, 
August  5,  1881. 

Eclampsia. — Masino  (Lo  Sperimentale)  has  arrived  at  certain 
conclusions  which,  while  not  entirely  new,  contain  a  fair  rdsum^ 
of  existing  knowledge  on  the  subject.  He  claims,  first,  that  the 
pathogeny  of  eclampsia  is  still  obscure,  but  that  clinical  observa- 
tion is  in  accord  with  experimental  physiology  in  demonstrating 
that  the  seat  of  this  disease  is  in  the  medulla  oblongata.  Second, 
that  the  nature  of  these  unknown  alterations,  whether  they  are  of  a 
toxic  character  or  the  results  of  reflex  irritation,  has  yet  not  been 
settled.     Third,  the  existence  of  sugar  in  the  urine  of  eclamptic 


PATHOLOGY.  843 

patients  may  indicate  a  bio-chemical  change  in  the  medulla  ob- 
longata, but  has  no  pathogenic  value.  Fourth,  there  seems  to  be 
a  relation  between  the  existence  of  sugar  and  the  eclamptic  at- 
tacks, the  glycosuria  ceasing  on  their  cessation.  Fifth,  the  urine 
of  eclamptics  does  not  always  contain  albumen,  nor  is  anasarca 
always  present.  Sixth,  temperature  has  no  essential  relations 
with  it.  Seventh,  tlie  temperature,  however,  does  not  always  re- 
main the  same  ;  sometimes  it  rises  a  few  hours  before  an  eclamptic 
seizure,  but  generally  returns  to  normal.  Eighth,  the  continued 
existence  of  a  high  temperature  indicates  the  existence  of  a  com- 
plication of  the  eclampsia.  From  these  conclusions,  Massin 
draws  the  following  indications  for  treatment.  First,  the  two 
best  indications  for  symptomatic  treatment  are  to  combat  passive 
congestion  and  diminish  nervous  excitability.  Second,  the  methods 
of  procedure  most  capable  of  fulfilling  these  indications  are,  in 
the  first  case,  blood-letting,  in  the  second,  chloroform  and  chloral 
hydrate.  It  might  well  be  asked  whether  the  blood-letting  did 
not  act  on  the  nervous  system  directly. — Chicago  Medical  Review, 
July  5,  1881. 

Hydrophobia  and  Strychnine. — A  case  likely  to  lead  to  in- 
teresting medico-legal  discussions  recently  occurred  at  Tipton, 
Indiana.  A  rabid  dog  bit  an  old  woman  and  her  daughter.  They 
died  two  weeks  after  from  what  was  regarded  as  hydrophobia. 
Suspicion  being  accidentally  awakened,  investigation  led  to  the 
discovery  that  the  son-in-law  of  the  old  woman,  it  is  claimed, 
had  poisoned  her  with  strychnine.  He  evidently  seized  a  fortu- 
nate period  for  the  administration  of  the  drug,  and  a  skilful 
lawyer  could  easily  throw  much  doubt  on  the  forensic  circumstan- 
tial evidence  against  the  accused. — Chic.  Med.  Roj.,  October  5, 
1881. 


Real  and  Simulated  Epilepsy. — Gottardi  {Giomale  di  Medi- 
cina  Militare)  examines  carefully  the  diagnostic  points  given  by 
various  authors,  and  comes  to  the  following  conclusions  :  Tactile 
sensibility,  as  determined  by  Weber's  compass,  immediately  after 
the  epileptic  attack,  is  of  no  value  as  a  means  of  diagnosis.  Per- 
manent alterations  of  the  fundus  of  the  eye  are  most  frequent  in 
cases  presenting  asymmetry  of  the  face  and  skull,  already  recog- 
nized by  Voisin,  Miiller,  Dumas,  and  Hasse.  During  the  attack, 
and  better  still  after  the  attack,  temporary  alterations  occur  in  the 
vascularization  of  the  fundus  of   the  eye,  or,  isolatedly,  of  the 


844  PERISCOPE. 

central  vessels  of  the  retina.  These  alterations  are,  however,  of 
no  value  as  a  means  of  diagnosis  in  cases  of  simulated  epilepsy, 
as  they  occur  under  the  influences  of  other  causes.  The  temper- 
ature, Gottardi  (in  full  accord  with  the  results  of  Charcot,  Bourne- 
ville,  and  Jaccoud)  finds  to  be  markedly  lower  after  an  attack,  a 
conclusion  with  which  other  observers  are  very  likely  not  to 
agree.  The  sphygmographic  traces  obtained  by  Gottardi  corrob- 
orate those  obtained  by  Voisin.  In  epileptics,  after  the  attack, 
the  mean  pulse  is,  according  to  Gottardi,  lower  than  normal,  re- 
maining for  a  time  stationary,  then  rising  to  normal.  He  regards 
this  as  characteristic  of  the  disease.  It  is  obvious,  however,  that 
the  simulation  of  epilepsy  by  a  neurotic  individual  is  a  somewhat 
difficult  matter  to  detect. — Chicago  Medical  Review,  June  20th. 


The  following  are  the  titles  of  some  of  the  recent  papers  on  the 
pathology  of  the  nervous  system  and  mind. 

Lepine,  R.  :  Sur  1'  epilepsie  congestive.  Revue  de  Me'decine,  June. 
Langhans,  T.:  Ueber  Hohlenbildung  im  Riickenmark  als  Folge 
von  Blutstauung,  Virchow's  Archiv,  Ixxxv,  i,  1880.  Israel,  Os- 
car :  Schussverletzung  der  grossen  Armennerven  mit  nachfol- 
gender  Atrophic  der  Extremitat,  Ibid.  Seguin,  E.  C.  :  Clinical 
lecture  on  hemiplegic  epilepsy,  Boston  Med.  and  Surg,  yourn., 
July  2 1  St.  Walton,  Geo.  L.  :  The  reflexes;  notes  from  one 
of  Professor  Erb's  lectures  on  the  diagnosis  of  diseases  of  the 
nervous  system,  Leipzig,  Ibid.,  Aug.  4th.  Bechteren,  W.  :  Ueber 
die  klinischen  Erscheinungen  des  Symptoms  von  combinirter 
Abweichung  der  Augen  und  des  Kopfes  bei  Affectionen  der 
Gehirnrinde.,  Si.  Petersb.  Med.  Wochenschr.,  Nos.  12  and  13  ;  and 
der  Einfluss  der  Hirnrinde  auf  die  Korpertemperatur,  Ibid.,  No. 
25.  LiZE,  D.  :  Sur  quelques  symptomes  laryngobronchiques  de 
r  ataxic  locomoteur  progressive,  etc.,  L' Union  Med.,  No.  100. 
Bertholle  and  Ch.  Eloy  :  Observation  d'  hydrophobic  rabique. 
Ibid.,  No.  III.  De  Jonge,  D.  :  Ueber  einen  Fall  von  sogenanter 
Compressions  myelitis  mit  hochgradiger  Steigerung  des  Tastsinnes 
der  gelahmrten  Unterextremitaten,  Deutsche  Med.  Wochenschr., 
Nb.  35.  Unverricht  :  Beitrag  zur  Lehre  von  partiellen  Epilepsie, 
Ibid.  Bassi,  Ugo  :  Contributo  alio  studio  dei  fenomeni  postemi- 
plegici  ;  emiatassia  postemiplegica,  Lo  Sperimentale,  July.  John- 
son, Anna  H.  :  Neurasthenia,  Phila.  Med.  Times,  Aug.  27th. 
Reichert,  E.  T.  :  Convulsions  due  to  depression  of  spinal  reflex- 
inhibitory  centres,  with   special  reference  to  the  convulsions  of 


THERAPEUTICS.  845 

apomorphine,  atropine,  strychnine,  and  other  poisons,  Ibid.,  Aug. 
13th.  Spamer  :  Ueber  den  Hypnotismus,  seine  Ursachen,  sein 
Wesen  und  die  aus  beiden  sich  ergehenden  Folgerungen,  yahrh. 
f.  Psych..,  iii,  Hft.  i  and  ii.  Seeligmuller  :  Ueber  traumatischen 
Tremor  und  die  Simulation  desselben.  Ibid.  Hollander  :  Ueber 
epileptoide  Zustande  mit  Einschluss  des  transitorischen  Irrseins, 
Ibid.  Greene,  J.  S.  :  Subinvolution  of  the  uterus  and  neurasthe- 
nia, Boston  Med.  and  Surg,  y^ourn.,  Aug.  ivth.  Seguin,  E.  C.  : 
Importance  of  the  early  recognition  of  epilepsy,  N.  V.  Med.  Record., 
Aug.  6th  and  nth. 


-THERAPEUTICS   OF    THE    NERVOUS    SYSTEM   AND    MIND. 


Hoang  Nan.- — Dr.  Barthelemy  {^Bulletin  Ge'nerale  de  Thera- 
peutique  Me'dicale  et  Chirurgicale,  August  15,  1881)  claims  that 
on  man  hoang  nan  produces  the  following  effects  :  In  a  small 
dose,  five  to  ten  centigrammes,  the  result  is  an  augmentation  of 
the  mental  and  physical  activity,  increased  animation  and  flow  of 
ideas.  Given  for  a  long  time  in  this  dose  hoang  nan  has  a  tonic 
effect,  increasing  flesh  and  weight.  In  from  two  to  four  times  the 
dose  just  mentioned,  general  feeling  of  heat,  itching  and  formica- 
tion result  ;  muscular  tonus  and  the  reflexes  are  increased  ;  there 
are  also  pains  over  the  region  of  the  liver,  in  both  temples  ;  and,  at 
the  same  time,  vertigo.  From  a  still  larger  dose,  general  malaise, 
excessive  vertigo,  irregular  involuntary  contractions  of  the  feet 
and  hands  result.  An  excessive  dose  is  attended  by  loss  of  con- 
sciousness and  chills. — Chic.  Med.  Rev.,  Oct.  5,  1881. 


Massage  for  the  Relief  of  Tabetic  Anesthesia. — 
Schreiber  {Medicin,  Chirurgische  Rundschau,  April,  1881)  claims 
very  good  results  from  massage  in  a  case  of  locomotor  ataxia  in 
an  advanced  stage,  with  lancinating  pains,  gastric  crises,  paralysis 
of  the  abducens  nerve,  and  complete  anaesthesia  of  both  gluteal 
regions.  Having  been  convinced  that  massage  is  capable  of 
curing  the  anaesthesia  which  presents  itself  in  the  course  of  neur- 
algia, especially  in  sciatic,  Schreiber  resolved  to  attempt  this 
treatment  in  the  case  under  consideration,  although  it  has  been 
heretofore  claimed  that  mechanical  treatment  is  contra-indicated 
in  locomotor  ataxia.  In  daily  sittings  of  five  minutes'  duration, 
the  affected  parts  were  kneaded  with  the  clenched  fist   in  various 


846  BOOKS  RECEIVED. 

directions.  The  manipulations  were  performed  with  moderate 
force,  and  did  not  cause  pain.  After  twelve  days  the  anaesthesia, 
which  had  existed  five  months  without  any  intermissions,  disap- 
peared entirely.  Tiirck  was  the  first  to  point  out  that  rubbing 
was  sufficient  to  relieve  mild  anaesthesia,  and  he  asserted  that  the 
benefit  derived  from  salves  and  liniments  was  in  a  great  measure 
due  to  the  conjoined  mechanical  manipulations.  What  the 
rationale  of  the  treatment  is  cannot  be  said.  A  single  case  is, 
however,  not  of  much  value  as  evidence  of  the  good  result  of  any 
treatment  in  any  disease  whatever. — Chicago  Med.  Review,  Oct. 
5,  1881. 


BOOKS  AND  PAMPHLETS  RECEIVED. 


Untersuchungen  Ueber  die  Localisation  der  Functionen  in  der 
Grosshirnrinde  des  Menschens  von  Prof.  Sigmund  Exner.  Wien, 
1881.     Pages  180. 

Ueber  Hemianopsie  und  Ihr  Verhaltniss  zur  Topischen  Diag- 
nose der  Gehirnkrankheiten,  von  Dr.  Hermann  Wilbrand.  Ber- 
lin, 1881.     Pages  214. 

Lehrbuch  der  Neurologie,  von  Dr.  G.  Schwalbe.  Erlangen, 
1881.     Pages  1026. 

Real-Encyclopadie  der  gesammten  Heilkunde.  Medicinisch- 
Chirurgisches  Handworterbuch  fiir  praktische  Aerzte.  Heraus- 
gegeben  von  Dr.  Albert  Eulenberg.  Mit  zahlreichen  Illustra- 
tionem  in  Holzschnitt.     Wien  und  Leipzig,  1881. 

Dictionnaire  Encyclopedique  des  Sciences  Aledicales.  Direc- 
teur,  A  Dechambre.     Paris,  1881. 

A  Treatise  on  Diseases  of  the  Nervous  System,  by  James  Ross, 
M.D.,  2  vols.     Wm.  Wood  &  Co.,  1881,  594  and  998  pages. 

A  Treatise  on  Food  and  Dietetics,  Physiologically  and  Thera- 
peutically Considered,  by  T.  W.  Pavy,  M.D.,  F.R.S.  Second 
edition.     Wm.  Wood  &  Co.,  1881,  pages  402. 

A  System  of  Surgery,  Theoretical  and  Practical,  in  Treatises  by 
various  Authors.  Edited  by  T.  Holmes,  M.A.,  Cantab.  First 
American  from  second  English  edition.  Revised  and  enlarged 
by  John  H.  Packard,  A.M.,  M.D.  Vol.  L  H.  C.  Lea's  Son  & 
Co.     Pages  1007. 

Suir  Azione  della  losciamina  e  sul  suo  Valore  Terapeutico 
nelle  Malattie  Mentali,  dei  Dottori  Giuseppe  Seppilli  e  Gaetano 
Riva.     Reggio  nell'  Emilia,  1881. 


BOOKS  RECEIVED.  847 

Osservazioni  sul  Cranio  e  Cervello  di  un  Idrocefalo  di  19  Anni, 
del  Prof.  A.  Tamburini.     Reggio  nell'  Emilia,  i88r. 

Sulla  Legislazione  per  gli  Alienati  ed  i  Maniaci  del  Prof.  A. 
Tamburini.     Milano,  1881. 

Opening  and  Drainage  of  Cavities  in  the  Lungs,  by  Christian 
Fenger,  M.D.,  and  J.  H.  Hollister,  M.D.,  Chicago,  III.  (Ex- 
tracted from  the  American  Journal  of  the  Medical  Sciences  for 
October,  1881.) 

American  Neurological  Association,  Seventh  Annual  Meeting. 
Reported  by  M.  J.  Roberts,  M.D.  (Reprint  from  the  Journal 
OF  Nervous  and  Mental  Disease,  July,  1881. 

Contributions  to  Psychiatry,  by  Jas.  G.  Kiernan,  M.D.  (Re- 
print from  Journal  of  Nervous  and  Mental  Disease,  April, 
1881.) 

Case  of  Paretic  Dementia  :  Intercurrent  Attack  of  Left-sided 
Convulsions,  beginning  in,  and  chiefly  confined  to,  Arm  and  Face  ; 
Lesions  of  Posterior  Extremity  of  Right  Superior  Frontal  Convo- 
lution, by  Ringrose  Atkins,  M.A.,  M.D.  (Reprint  from  Brain, 
Part  xiii.) 

Contributions  to  the  Study  of  the  Toxicology  of  Cardiac  De- 
pressants, by  Edward  T.  Reichert,  M.D.  (Extract  from  the 
American  J^ournal  of  Medical  Sciences,  October,  1881.) 

Convulsions  due  to  Depression  of  Spinal  Reflex  Inhibitory 
Centres  ;  with  special  Reference  to  the  Convulsions  of  Apomor- 
phine,  Atrophine,  Strychnine,  and  other  Poisons,  by  Edward  T. 
Reichert,  M.D.  (Reprint  from  Philadelphia  Medical  Times,  Au- 
gust 13,  1881.) 

The  Dangers  and  the  Duty  of  the  Hour,  by  William  Goodell, 
M.D.  (Reprint  from  the  Transactiofis  of  the  Medical  and  Chi- 
rurgical  Society  of  Maryland,  1881.) 

Hip-Joint  Disease  ;  Death  in  early  Stage  from  Tubercular 
Meningitis,  by  De  Forest  Willard,  M.D.,  and  E.  O.  Shakespeare, 
M.D.     (Reprint  from  Boston  Med.  and  Surg,  j^ourn.) 

Connection  of  Cardiac  and  Renal  Disease,  by  Robert  T.  Edes, 
M.D.  (Reprint  from  Boston  Med.  and  Surg.  Journ.,  May  19, 
1881.) 

Simple  Methods  to  Stanch  Accidental  Hemorrhage,  by  Edward 
Borck,  M.D.  (Reprint  from  Indiana  Medical  Reporter,  April, 
1881.) 

Microscopic  Studies  on  the  Central  Nervous  System  of  Rep- 
tiles and  Batrachians.  Article  III.  By  John  J.  Mason,  M.D. 
(Reprint  from  Journal  of  Nervous  and  Mental  Disease, 
January,  1881.) 

Atresia  of  the  Vagina  and  Uterus,  by  A.  F.  Erich,  M.D.  (Re- 
print from  the  Altanta  Medical  Register,  Nov.,  1881.) 


848  PERIODICALS  RECEIVED. 

Chronic  Pelvic  Abscess,  by  A.  F.  Erich,  M.D, 

Uterine  Massage  as  a  Means  of  Treating  certain  Forms  of  En- 
largement of  the  Womb,  by  A.  Reeves  Jackson,  A.M.,  M.D.  (Re- 
print from  vol.  V,  Gynecological  Transactions^  1881.) 


THE   FOLLOWING   FOREIGN    PERIODICALS   HAVE     BEEN     RE- 
CEIVED  SINCE   OUR   LAST   ISSUE. 


Allgemeine   Zeitschrift    fuer  Psychiatrie  und   Psychisch-Gerichtl. 

Medicin. 
Annales  Medico-Psychologiques. 
Archives  de  Neurologie. 

Archives  de  Physiologie  Normale  et  Pathologique. 
Archiv  fuer  Anatomie  und  Physiologie. 

Archiv  fuer  die  Gesammte  Physiologie  der  Menschen  und  Thiere. 
Archiv  fuer  Path.  Anatomie,  Physiologie,  und  fuer  Klin.  Medicin. 
Archiv  f.  Psychiatrie  u.  Nervenkrankheiten. 
Archivio  Italiano  per  le  Malattie  Nervose. 
Brain. 

British  Medical  Journal. 
Bulletin  Generale  de  Therapeutique. 
Centralblatt  f.  d.  Med.  Wissenschaften. 
Centralblatt  f.  d.  Nervenheilk.,  Psychiatrie,  etc. 
Cronica  Med.  Quirurg.  de  la  Habana. 
Deutsche  Medicinische  Wochenschrift. 
Deutsche  Archiv  f.  Geschichte  der  Medicin. 
Dublin  Journal  of  Medical  Science. 
Edinburgh  Medical  Journal. 
Gazetta  degli  Ospilali. 
Gazetta  del  Frenocomio   di  Reggio. 
Gazetta  Medica  di  Roma. 
Gazette  des  Hopitaux. 
Gazette  Medicale  de  Strasbourg. 
Hospitals-Tidende. 
Hygeia. 

Jahrbiicher  fiir  Psychiatrie. 
Journal  de  Medecine  de  Bordeaux. 
Journal  de  Medecine  et  de  Chirurgie  Pratiques. 
Journal  of  Mental  Science. 
Journal  of  Physiology. 
La  France  Medicale. 
Le  Progres  Medical. 
Lo  Sperimentale. 
L'  Union  Medicale. 
Mind. 


PERIODICALS  RECEIVED.  849 

Nordiskt  Medicinskt  Arkiv. 

Norsk  Magazin  for  Lagensvidenskabens. 

Practitioner. 

Revue  de  Medecine. 

Rivista  Clinica  di  Bologna. 

Rivista  Sperimentale  di  Freniatria  e  di  Medicina  Legale. 

Schmidt's    Jahrbiicher   der    In-  und  Auslandischen    Gesammten 

Medicin. 
St.  Petersburger  Med.  Wochenschrift. 
Upsala  Lakarefornings  Forhandlinger. 


THE      FOLLOWING      DOMESTIC      EXCHANGES      HAVE      BEEN 

RECEIVED. 


Alienist  and  Neurologist. 

American  Journal  of  Insanity. 

American  Journal  of  Medical  Sciences. 

American  Journal  of  Obstetrics. 

American  Journal  of  Pharmacy. 

American  Medical  Journal. 

American  Practitioner. 

Annals  of  Anatomy  and  Surgery. 

Archives  of  Comp.  Med.  and  Surgery. 

Archives  of  Dermatology. 

Archives  of  Medicine. 

Atlanta  Medical  and  Surgical  Journal. 

Boston  Medical  and  Surgical  Journal. 

Buffalo  Medical  Journal. 

Bulletin  National  Board  of  Health. 

Canadian  Journal  of  Medical  Sciences. 

Canada  Medical  and  Surgical  Journal. 

Canada  Medical  Record. 

Chicago  Medical  Journal  and  Examiner. 

Chicago  Medical  Review. 

Chicago  Medical  Times. 

Cincinnati  Lancet  and  Clinic. 

Clinical  News. 

College  and  Clinical  Record. 

Country  Practitioner. 

Detroit  Lancet, 

Dial. 

Gaillard's  Medical  Journal. 

Independent  Practitioner. 

Index  Medicus. 

Indiana  Medical  Reporter. 

Maryland  Medical  Journal. 


850  PERIODICALS  RECEIVED. 

Medical  and  Surgical  Reporter. 

Medical  Annals. 

Medical  Brief. 

Medical  Herald. 

Medical  News  and  Abstract. 

Medical  Record. 

Michigan  Medical  News. 

Monthly  Review. 

Nashville  Journal  of  Medicine. 

Neurological  Contributions. 

New  England  Medical  Monthly. 

New  Orleans  Medical  and  Surgical  Journal. 

New  Remedies. 

New  York  Medical  Journal. 

Northwestern  Lancet. 

Pacific  Medical  and  Surgical  Journal. 

Philadelphia  Medical  Times. 

Physician  and  Bulletin  of  the  Medico-Legal  Society. 

Physician  and  Surgeon. 

Proceedings  of  the  Medical  Society  of  the  County  of  Kings. 

Quarterly  Epitome  of  Braithwaite's  Retrospect. 

Quarterly  Journal  of  Inebriety. 

Rocky  Mountain  Medical  Review. 

Sanitarian. 

Science. 

Southern  Clinic. 

Southern  Practitioner. 

Specialist  and  Intelligencer. 

St.  Joseph  Medical  and  Surgical  Reporter. 

St.  Louis  Clinical  Record. 

St.  Louis  Courier  of  Medicine. 

St.  Louis  Medical  and  Surgical  Journal. 

Therapeutic  Gazette. 

Toledo  Medical  and  Surgical  Journal. 

Veterinary  Gazette. 

Virginia  Medical  Monthly. 

Walsh's  Retrospect. 


THE  JOURNAL  OF 

Nervous  and  Mental  Disease 

EDITED   BY 

WILLIAM  J.  MORTON,  M.D.,  New  York. 

ASSOCIATE   EDITORS  : 

WiLLLAM    A.   Hammond,    M.D.,    Edward  C.    Seguin,    M.D.,    Meredith 

Clymer,  M.D.,  New  York  ;    J.  S.  Jewell,  M.D.,  H.  M. 

Bannister,    M.D.,   Chicago;    and    Isaac 

Ott,    M.D.,    Easton,    Pa. 

PROSPECTUS  FOR    1882. 

The  Journal  of  Nervous  and  Mental  Disease,  with  the  issue  of  Jan- 
uary I,  18S2,  will  pass  into  the  ninth  year  of  its  existence.  It  is  therefore  the 
longest-continued  journal  on  Diseases  of  the  Nervous  System  ever  published  in 
this  country,  and  it  is  speaking  within  bounds  to  say  that  it  has  proved  a  constant 
credit  to  American  medical  literature.  During  its  term  of  life  it  has  won  its 
way  to  the  highest  recognition  as  an  authority  and  guide  in  that  branch  of  med- 
icine of  which  it  is  an  exponent.  To  the  specialist  on  Nervous  Diseases  it  has 
ever  been  an  inviting  field  in  which  to  record  his  observations,  and  an  unfailing 
source  of  information  in  his  studies  ;  to  the  general  practitioner  it  has  proved  the 
readiest  means  of  keeping  himself  informed,  of  the  current  thought  of  the 
times  concerning  a  class  of  diseases  that  pass  daily  before  his  eyes  and  claim  his 
acutest  attention.  To  meet  the  wants  of  both  these  classes  will  still  be  its 
mission. 

Diseases  of  the  Nervous  System  form  probably  the  most  important  part  of 
the  modern  practitioner's  labors.  In  no  branch  of  medicine  is  it  more  difficult 
to  keep  abreast  of  the  times  ;  in  no  branch  are  more  noteworthy  discoveries  be- 
ing made.  The  Journal  offers,  then,  to  the  specialist  a  forum  from  which  to 
address  his  labors  to  the  medical  world,  either  by  original  communications  or 
through  editorial  abstract  and  comment ;  while  to  the  busy  practitioner  it 
presents  a  class  of  special  information  which  cannot  be  obtained  in  the  journals 
of  general  medicine.  Conducted  and  edited  by  men  who  are  engaged  in  special 
practice,  there  will  be  nothing  in  its  pages  which  the  general  practitioner  will 
not  find  of  service  to  him  in  his  every-day  duties,  and  in  this  respect  it  will  be 
found  to  differ  from  special  journals  in  many  other  departments  of  medicine. 

851 


852  PROSPECTUS. 

The  January  number  of  the  Journal  will  go  forth  to  its  subscribers  and 
friends  under  a  new  management.  It  has  become  the  exclusive  property  of  the 
present  editor,  who  has  happily  been  able  to  secure  the  continued  aid  of  those 
who  have  contributed  to  its  previous  success,  and  to  add  to  their  number  distin- 
guished associate  editors  and  an  efficient  corps  of  collaborators  whose  names  and 
reputations  are  well  and  favorably  known  to  the  profession  and  to  the  world. 

The  former  editor,  who  was  also  the  proprietor  of  the  journal  which  he  had 
himself  established,  found  that  increasing  professional  cares  and  impaired 
health  would  no  longer  permit  him  to  give  the  labor  and  attention  required  for 
the  editorial  work,  and  he  has  therefore  transferred  the  Journal  to  the  present 
management.  While  the  Journal  will  no  longer  have  the  benefit  of  Dr. 
Jewell's  editorial  control,  the  editor  takes  pleasure  in  announcing  that  he  has 
received  every  assurance  of  his  continued  hearty  interest  and  the  promise  of 
his  valuable  aid  as  an  associate  editor.  The  editor  is  also  glad  to  be  able 
to  announce  that  Doctors  W.  A.  Hammond  and  Meredith  Clymer,  of  New 
York,  and  Doctor  H.  M.  Bannister,  of  Chicago,  who  have  heretofore  acted  as 
associate  editors,  have  agreed  to  continue  their  active  co-operation  in  the  same 
capacity.  To  this  already  efficient  editorial  staff  are  now  added  the  names 
of  Drs.  E.  C.  Seguin  and  Isaac  Ott.  Having  in  view  the  co-operation  of  the 
gentlemen  named  and  that  of  the  staff  of  collaborators  soon  to  be  announced, 
the  editor  feels  a  just  pride  in  the  prospects  of  the  Journal  of  Nervous 
and  Mental  Disease,  and  may  reasonably  hope  that  it  will  continue  to  main- 
tain the  position  which  it  has  long  held  before  the  medical  profession,  and  may 
continue  to  be  accepted  as  the  exponent  of  thorough  and  capable  work  in  the 
branch  of  diseases  of  which  it  treats. 

On  account  of  inability  to  give  adequate  attention  to  the  work,  Dr.  S.  Weir 
Mitchell  no  longer  continues  as  associate  editor.  He  writes  :  "  I  may  hope, 
however,  although  not  as  editor,  to  aid  your  purposes." 

The  Journal  will  be  both  edited  and  published  in  New  York.  The  distinc- 
tive features  of  its  general  make-up  will  not  be  altered.  Original  contributions 
of  value  are  already  secured  for  its  pages.  Careful  attention  will  be  given  to 
critical  reviews  of  current  literature,  both  domestic  and  foreign,  and  every  effort 
will  be  made  to  maintain,  at  its  present  high  state  of  excellence,  the  Periscope 
or  Abstract  Department. 

It  is  hardly  necessary  to  say  that  the  Journal  represents  no  clique,  school, 
nor  party.  It  will  be  in  the  widest  sense  independent  and  cosmopolitan.  We 
cordially  invite  communications  from  all  interested  in  Neurological  Science,  and 
we  can  promise  an  absolutely  impartial  consideration  to  all. 

Conscious  of  our  obligations  to  our  subscribers  and  to  the  medical  public,  we 
shall  make  every  practicable  endeavor  to  widen  the  range  of  usefulness  of  a 
journal  whose  value  has  already  been  tested. 

Contributions,  books  for  review,  exchanges,  and  communications  pertaining 
to  the  Editorial  Department  should  be  addressed  to  Dr.  William  J.  Morton, 
15  East  45th  Street,  New  York. 

Business  communications  should  be  addressed  to  the  publishers,  Messrs.  G.  P. 
Putnam's  Sons,  27  &  29  West  23d  Street,  New  York. 

All  remittances  should  be  made  by  Post  Office  order  or  by  draft  on  New 
York. 

The  Journal  will  be  issued  quarterly,  at  a  subscription  price  of  $5.00 
per  year,  payable  in  advance.     The  price  per  number  will  be  $1.50. 


INDEX   TO  VOL.  VIII. 


A  case  of  acute  chorea,  by  F.  P  Kinni- 
cutt,  M.D 506 

A  case  of  paralysis  agitaas,  by  E.  C. 
Mann,  M.D 124 

A  case  of  widespread  and  rapid  muscu- 
lar wasting  without  disease  of  the 
spinal  cord,  by  J.  J.  Putnam,  M.D.     .  201 

A  historical  case  of  impulsive  mono- 
mania, by  E.  C.  Spitzka,  M.D.    .        .     87 

A  new  current  of  induced  electricity     .  605 

A  second  contribution  to  the  study  of 
localized  cerebral  lesions,  by  E.  C. 
Seguin,  M.D. 510 

Absinthism 190,  426 

Aconitia 193 

"        Action  of 421 

"        in  sclerosis,  by  E.  C.  Seguin, 
M.D 632 

Action  of  aconitia 421 

"          anaesthetics  on  the  reflexes     .  424 
"         digitaline   on  the  blood-ves- 
"         sels  and  heart  ....  415 
"          an  irritant,  by  I.  Ott,  M.D.    .  581 
"         pressure  on    the  motor  and 
sensory  nerves 162 

Adult,  Cephalic  souffle  in         .        .        .  674 

^sthesiogenic  vibrations        .        .        .  189 

Affections,  Skin  and  spinal  disease,  co- 
incidence of 835 

Aged,  Chorea  in,  by  W.  Sinkler,  M.D.    577 

Aigu  D61ire 832 

Albuminuria  as  a  symptom  of  epilepsy    674 
"  Dickinson.    (Review)       .  778 

Alcohol 426,  686 

Alcoholic  insanity  in  private  practice    .  185 

Alcoholism,  chronic  Gait  in     .        .        .  679 
"  Treatment  of        .        .        .  427 

Alterations  of  the  nerves  in  chronic 
rheumatism 667,  829 

American  Neurological  Association, 
Transactions  of 586 

American  Neurological  Association, 
Hammond  prize  of         ....  153 

American  nervousness  :  its  causes  and 
consequences.     Beard.     (Review)       .  773 

Amidon,  R.  W.,  M.D.,  Deformity  of 
the  hand  as  a  symptom  .        .        .  693 

Anatomy,  Encephalic,  Contributions  to, 
by  E.  C.  Spitzka,  M.D.         .        .        .  317 

Anatomy,  Pathological,  of  hallucina- 
tions          386 

Anatomy  and  physiology  of  the  nervous 
system     ....  158,  375,  643,  816 

Anatomical  nomenclature  of  the  brain     652 

Anaemia,  Use  of  the  cold  pack  followed 
by  massage  in,  Jacobi  and  White. 
(Review; 141 

Anaesthesia,  Tabetic  Massage  for  the 
relief  of, 845 

Anaesthetic  leprosy.  Nerve-stretching 
in,  by  Drs.  Fenger  and  Lee         .        .  300 

Anaesthetics 68s 

"  Action  of,  on  the  reflexes  .  424 

Aneurism,  Relations  of  the  nerves  to     .  171 

Arachnoid ,  Spinal  calcareous  deposits  in  834 


PAGE 

Arnold,  A.  B.,  M.D.,  Tumor  of  the  cen- 
trum ovale 305 

Arsenic  in  tetanus 411 

Arteries  of  the  head  and  the  iris  ; 
physiological  connection  between 
them  and  the  ganglion  cervicale  su- 
premum 647 

Asphyxia,  Local,  symmetrical,  of  the 
extremities 392 

Asphyxia,  Local,  of  the  extremities        .  831 

Association,  American  Neurological, 
Transactions  of 586 

Association  for  the  protection  of  the 
insane 151 

Asthma,  Treatment  of      ...        .  191 

Ataxia,  Diphtheritic,  by  E.  C.  Seguin, 
M.D 634 

Ataxia,  (hemi-).  Posthemiplegic     .        .  402 
"        Locomotor,  elongation  of  the 
sciatic   nerve    in,    by    W.    A.   Ham- 
mond, M.D C53 

Ataxia,  Locomotor  nerve-stretching  in, 
by  Drs.  Fenger  and  Lee       .        .        .  292 

Ataxia,  Locomotor,  nerve-stretching 
in ,        .  189 

Ataxy,  Locomotor  .  .  .  .  .  173 
"  Locomotor  ear  symptoms  in  .  396 
"        Locomotor  zinc  phosphide  in      .  686 

Atlas  of  skin  diseases.  Duhring.  (Re- 
view)         .147 

Auditory  tract,  hypothetical,  by  G.  M. 
Hammond,  M.D.  ....  565 

Autographic  men 842 

B 

Bannister,  H.  M.,  M.D.,  A  note  on  the 
peculiar  effect  of  the  bromides  upon 
certain  insane  epileptics        .        .        .  560 

Bannister,  H.  M.,  M.D.,  Some  points  in 
regard  to  color-blindness      .        .        .49 

Bastian,  H.  C,  M.D.,  The  brain  as  an 
organ  of  mind.     (Review)     .        .        .  145 

Beard,  G.  M.,  M.D.,  Electricity.  (Re- 
view)         364 

Beard,  G.  M.,  M.D.,  How  to  use  the 
bromides 401 

Birdsall,  W.  R.,  M.D.,  Cases  of  polio- 
myelitis anterior,  in  which  the  ab- 
dominal muscles  were  affected    .  482 

Birdsall,  W.  R.,  M.D.,  New  foot  dyna- 
mometer   6«o 

Bischoff,  Brain  weight  of  man.  (Re- 
view)        638 

Bladder,  Paralysis  of       ...        .  178 

Blaise,  Peripheral  or  cerebral  tempera- 
tures.   (Revie\  .'  ....  347 

Blindness,  Color-,  in  diseases  of  the 
optic  nerve 384 

Blindness-Color,  some  points  in  regard 
to,  by  H.  M.  Bannister,  M.D.       .        .     49 

Blindness-Color,  some  points  in  regard 
to,  by  B.  J.  Jeffries,  M.D.     .        .        .433 

Blood,  Increase  of  fibrine  of,in  pericere- 
britis 398 

Blood-vessels  and  heart,  Action  of  digi- 
taline on 415 


11 


INDEX. 


PAGE 

Blood-vessels,  lungs,  and  heart,  Reflex 

connection  between      ....  380 
Book  Reviews  :        .         .         n8,  336,  636,  773 
Albuminuria,  Dickinson  .        .  778 

American  nervousness.  Beard  .  773 

Atlas  of  skin  diseases,  IDuhring  .  147 
Brain   as  an   organ  of  mind,  Bas- 

tian 145 

"    weight  of  man,  Bischoff  .  638 

Catarrh,  Robinson  ....  364 
Cold  pack  and  massage  in  anaemia, 

Jacobi  and  White   ....  141 
Cutaneous     and     venereal    memo- 
randa, Piffard  and  Fox  .        .  148 
Diphtheria,  Jacobi     ....  147 
Diseases  of  the  chest,  throat,  and 

nasal  cavities,  Ingals  .  .  '  810 
Diseases  of  the  nervous    system, 

Mitchell 636 

Diseasesof  the  skin,  Duhring  .        .  363 
Diseases  of  the  throat,  Mackenzie      364 
Disorders  of  the    male  sexual  or- 
gans. Gross 810 

Ear  diseases.  Buck  ....  147 
Electricity,  Beard  and  Rockwell  .  364 
Feeling  of  effort,  James    .        .        .  361 

Fever,  Wood 347 

General   paralysis   of    the    insane, 

Mickle 80s 

Gynecology,  Mund^  .  .  .  164 
Histology,  Satterthwaite  .        .  810 

Hypnotism,  Hammond  .  .  .  356 
Indigestion        and         biliousness, 

Fothergill 810 

Insane  hospitals,  Kirkbride  .  .  336 
Invalid  food,  Fothergill  .  .  .  363 
Lectures  on  digestion,  Ewald  .  810 

Medical  diagnosis.  Da  Costa  .  .  363 
Mother's  guide,  Keating  .        .  778 

Ophthalmic  and   otic  memoranda, 
Roosa  and  Ely        ....  148 

Optic  nerve 128 

Peripheral    or    cerebral    tempera- 
ture, Blaise      .        .        ,        .        .  347 
Practice  of  medicine,  Bartholow     .  147 
Processes   of   excitation    and  inhi- 
bition in  the  motor  brain  centres    806 
Provinzialen-Irren-Anstalten     der 

Rhein  Provinz  ....  363 
Psychiatrical  literature,  1881  .  .  779 
Surgical  diagnosis,  Ranney  .  .  147 
Therapeutics,        Trousseau       and 

Pidoux 147 

Visiting  list,  Medical  Record  .  148 

Wilderness  cure.  Cook     .        .        .  778 
Books  and  pamphlets  received  : 

196,  429,690,  846 
Brain,  Anatomical  nomenclature  of  .  652 
"  Disorders  of,  in  dyspepsia  .  .  826 
"  Electrotherapy  of^  .  .  .683 
"  Functional  ischsemia  of  .  .  175 
"      Injuries   of,  with  general    and 

local  symptoms 838 

Brain,  Tumor  of,  by  C.  K.  Mills,  M.D.  630 
"      centres,  motor.   Processes  of  ex- 
citation and  inhibition  in.     (Review)     806 
Brain  and  nervous  system.  Relation  of 

the  ovaries  to 389 

Brain  weight  of  man,  Bischoff.  (Re- 
view)        638 

Bromide  of  Ethyl 685 

Bromides,  How' to  use,  by  G.  M.  Beard, 

M.D 491 

Bromides,  Influence  of,  on  the  cerebral 

temperature 188 

Bromides,  Peculiar  effects  of,  on  cer- 
tain insane  epileptics,  by  H.  M.  Ban- 
nister, M.D.  560 

Bucco-labial  region,  Vaso-dilators  of    .  164 


PACK 

c 

Case  of  acute  chorea,  by  F.  P.  Kinni- 

cutt,  M.D 506 

Case  of    paralysis  agitans,  by    E.  C. 

Mann,  M.D.  124 

Case  of  widespread  and  rapid  muscu- 
lar wasting  without  disease    of   the 
spinal  cord,  by  J.  J.  Putnam,  M.D.  201 
Cases  of  alcoholic  insanity  in  private 

practice 185 

Cases     of    poliomyelitis    anterior,    in 
which  the  abdominal  muscles  were 
affected,  by  W.  R.  Birdsall,  M.D.      .  482 
Calcareous  deposits  in  the  spinal  arach- 
noid          834 

Catarrh.  Robinson.  (Review)         .        .  364 
Cauterization  of  a   nerve    for  neural- 
gia     190 

Centre,  A  new  cortical  .        .        .  651 

Centres,  Cilio-spinal,  by  I.  Ott,  M.D.  .  757 
Centres  of  vision.  Cortical  .  .  .651 
Central  nervous  system  of  reptiles,  by 

J.  J.  Mason,  M.D 80,574 

Centum  ovale.  Tumor  of,  by  A.  B.  Ar- 
nold, M.JJ.  305 

Cephalic  souffle  in  the  adult  .        .  674 

Cerebral  cortex.  Functions  of  .  .  818 
Cerebral  hemisphere.  Destructive  lesion 

of  left,  by  H.  D.  Schmidt,  M.D.        .  737 
Cerebral  lesions,   Localized,  by  E.  C. 

Seguin,  M.D. 510 

Cerebral   paralysis    with  trophic    dis- 
orders   383 

Cerebral   or   peripheral  temperatures. 

Blaise.  (Review) 347 

Cerebral  temperature.  Influence  of  the 

bromides  on  188 

Cerebral  thermometry  ....  379 
Cerebro-spinal  and  peripheral  cranial 

ganglia.  Nerve  cells  in  ...  643 

Cervical    ganglion,  first   Influence  of, 

on  the  ins 645 

Cervicale,  ganglion,  supremum;  Phys- 
iological connection  between  it  and 
the  iris  and  arteries  of  the  head  .        .  647 
Chej'ne-Stokes  phenomenon.  The  .  159 

Children,  Occurrence  of  hysteria  in      .  182 
"         Transitory  insanity  from  cold 

in 672 

Chorea,  Acute,  by  F.  P.  Kinnicutt,  M. 

D 506 

Chorea  in  the  aged,  by  W.  Sinkler,  M. 

D 577 

Chronic  alcoholism,  Gait  in,    .        .        .  679 
"         rheumatism.  Nerve  alterations 

in 6C7 

Ciliary  muscular  spasm  of  central  ori- 
gin, by  H.  Gradle,  M.D.      .        .        .464 
Cilio-spinal  centres,  by  I.  Ott,  M.D.,       757 
Civilization,  Influence  of,  in  the  pro- 
duction  of  nervous  and  mental   dis- 
eases, by  J.  S.  Jewell,  M.D.         .      _  .      i 
Coincidence  of  spinal  disease  and  skin 

affections 835 

Cold,  Transitory  insanity  in   children 

from 672 

Color-blindness  in  diseases  of  the  optic 

nerve 384 

Color-blindness,  Some  points  in  regard 

to,  by  H.  M.  Bannister,  M.D.  .  .  49 
Color-blindness,  Some  points  in  regard 

to,  by  B.  J.  Jeffries,  M.D.  .  .  .433 
Commitment  of  lunatics  in  Illinois  .  154 
Compresses  of  hot  water  in  tetanus  .  413 
Conductibility  and  irritability  of  nerve 

fibres 646 

Conium 414 

Connection,  Physiological,  between  the 


INDEX. 


Ill 


PAGE 

ganglion    cervicale    supremum    and 
the  iris  and  arteries  of  the  head        .  647 

Connections,  Reflex,  between  the  lungs, 
heart,  and  blood-vessels      .        .        .  380 

Contraction,  Idio-muscular     .        .        .  161 

Contractions,  spastic,  of  the  nerves  of 
the  extremities,  Nerve-stretching  in, 
by  Drs.  Fenger  and  Lee       .        .        .  208 

Contractions,  X'oluntary,  muscular  Na- 
ture of      .        ,        .        .  .        .  822 

Contributions  to  encephalic  anatomy, 
by  E.G.  Spitzka,  M.D.        .         .        .317 

Contributions  to  the  physiology  of  the 
spinal  cord,  by  G.  B.  W.  Field,  M.D.  211 

Contributions  to  psychiatry,  by  J.  G. 
Kiernan,  M.D.  .        .        .         233,  445 

Cortex,  Cerebral  functions  of         .        .  818 

Cortical  centre,  New  ....  651 
"  centres  of  vision  .  .  .651 
"        malformation  and  insanity        .  371 

Cramp,  Writers' 665 

Cranial  nerves,  Development  of  668,  826 
"  "        Origin  of         ...  824 

"        Peripheral  and    cerebro-spinal 
ganglia.     Nerv^e  cells  in,     .         .        .  643 

Criminal  responsibility  of  the  insane     .  641 

Curare 421 

D 

DaCosta.  Medical  diagnosis.  (Review)  363 
Dangers  and  drawbacks  of  ergotine  .  422 
Death  of  Dr.  Isaac  Ray  .        .        .  373 

Deformity  of  the  hand  as  a  symptom, 
by  R.  W.  Amidon,M.D.      .        .        .  693 

Ddlire  aigu 832 

Delusions,  Insane,  their  mechanism  and 
diagnostic  bearing,  by  E.  C.  Spitzka, 

M.D 25 

Deposits, Calcareou3,in  the  spinal  arach- 
noid          834 

Destructive  lesion  of  the  left  cerebral 

hemisphere,  by  H.  D.  Schmidt,  M.D.  737 
Determmation  of  the  position   of  ob- 
jects in  space 167 

Development  of  the  cranial  nerves  668,  826 
Diabetes,  Symmetrical  neuralgias  of  .  181 
Diagnosis  of  hydrophobia  .  .  .  663 
"  Medical.  DaCosta.  (Review)  363 
Digitaline,  Action  of,  on  the  blood- 
vessels and  heart  .  .  .  .415 
Dilator  nerves  of  the  pupil  .  .  .  644 
Dilators,  Vaso-,  in  the  sympathetic  375,  376 
Diphtheria.  Jacobi.    (Review)        .        .  147 

Diphtheritic  ataxia 634 

Direct  cauterization  of  a  nerve  for  neur- 
algia         190 

Disease,  Graves' 384 

"        of  Isthmus,  Mental  symptoms 

from 840 

Disease,  Spinal  and  skin  affections.  Co- 
incidence of 835 

Diseases,  General  ocular  symptoms  in  .  394 
Diseases,  Nervous   and  mental,  influ- 
ence  of   our  present  civilization    on 
the  production  of,   by  J.   S.  Jewell, 

M.D I 

Diseases  of  the  chest,  throat,  and  nasal 

cavities.   Ingals.    (Review)  .        .        .  810 
Diseases  of  the  nervous  system.  Mitch- 
ell.   (Review) 636 

Diseases  of  the  optic  nerve.  Color- 
blindness in 384 

Diseases  of  the  skin.  Duhring.  (Re- 
view)        363 

Diseases  of  the  skin.  Atlas  of.  Duhring. 

(Review) 147 

Diseases  of  the  throat.  Mackenzie.  (Re- 
view)        364 


PAGE 

Disorders  of  the  brain  in  dyspepsia       .  826 
"             "       male     sexual    organs. 
Gross.  (Review) 810 

Disorders,  trophic,  with  cerebral  paral- 
ysis   383 

Distribution,  Terminal,   of  the  nerves 
in  the  uterine  mucous  membrane        .  166 

Duboisia  in  exophthalmic  goitre    .        .  igo 

Duhring.    Atlas  of  diseases  of  the  skin. 
(Review) 147 

Duhring.      Diseases  of  the  skin.   (Re- 
view.)       363 

Dynamometer,   New  foot,   by   W.   R. 
Birdsall,  M.D.  .        .  .        .  620 

Dyspepsia,  Disorders  of  the  brain  in    .  826 
"  Nervous  phenomena  of       .  400 

E 

Ear  diseases.  Buck.  (Review)  .  .  147 
"  symptoms  in  locomotor-ataxia  .  396 
Early  use  of  strychnia  in  myelitis  .        .  597 

Eclampsia 842 

Editorial  Department  : 

Commitment  of  the  insane  in  Illinois  154 
Cortical  malformation  and  insanity  371 
Criminal   responsibility  of    the   in- 
sane   641 

Death  of  Dr.  Isaac  Ray    .        .        .  373 

Exaugural 813 

Hammond  prize  ....  153 

L'Encephale 371 

Protection  of  the  insane     .        .  151,  369 
Effort,  The  feeling  of.    James.     (Re-      " 

view) 361 

Electricity 427 

"  Beard  and  Rockwell.     CRe- 

view) 364 

Electricity,  Induced  a  new  current  of  .  605 

Static 681 

"            Statical,  Medical  uses  of     .  609 
Electro-muscular    contractility    in    in- 
fantile paralysis 595 

Electro-therapy  of  the  brain   .        .        .  683 
Elongation  of  the  sciatic  nerve  in  loco- 
motor ataxia,  by  W.   A.   Hammond, 

M.D 553 

Encephalic  anatomy.  Contributions  to, 
by  E.  C.  Spitzka,  M.D.         .        .        .317 

Epilepsy 830 

"         Albuminuria  as  a  symptom  of  674 
"         Fatigue  as  a  cause  of       .        .  177 

"         Gastric 832 

"         Nerve-stretching  in,  by  Drs. 

Fenger  and  Lee 281 

Epilepsy,  Real  and  simulated  .        .  843 

Ergotine  :  its  drawbacks  and  dangers  .  422 

Ethyl  bromide 685 

Etiology  of  lepra 829 

Exaugural 813 

Excitability  of  motor  nerves  .  .  .  379 
Excitation,  Mechanical,  of  nerves  .  819 
Exophthalmic  goitre,  Duboisia  in  .  .  190 
Extremities,  Local  asphyxia  of  .  .  831 
"  Local  symmetrical  as- 
phyxia of 392 

Extremities,     Spastic    contractions     of 
nerves  of  Nerve-stretching  in,  by  Drs. 

F^enger  and  Lee 280 

Eye,  Influence  of  section  of  the  trigemi- 
nus upon 648,  825 

F 

Failure,  Mental,  from  strain  .  .  .  385 
Fatigue  as  a  cause  of  epilepsy  .  .  177 
Feeling  of  effort.  James.  (Review)  .  361 
Females,  Insane,  hairy  growths  in  .  676 
Fenger,  Chr.,  M.D.    Nerve-stretching   263 


IV 


INDEX. 


Fever.  Wood.  (Review)  .  ,  .  347 
Fibrine  of  the  blood,  Increase  of,  in 

pericerebritis 298 

Field,  G.  B.  W.,  M.D.,  Contributions 
to  the  physiology  of  the  spinal  cord  .  211 

Folia  ^  deux 399 

Food  for  invalids.     Fothergill.     (Re- 
view)        363 

Fothergill.  Invalid  food.  (Review)  .  363 
Functions  of  the  cerebral  cortex  .  .  818 
Functional  ischsemia  of  the  brain  .        .  175 


Gait  in  chronic  alcoholism 
Galvanization,     Central,    in     paralysis 

agitans,  by  E.  C.  Mann,  M.  D.    . 
Ganglia  of  urinary  passages  of  man  and 

certain  animals       .... 
Ganglia,      Cerebro-spinal      and     peri- 
pheral cranial,  nerve  cells  in 
Ganglion  cerv'icale  supremum  ;  Physio 

logical  connection  between  it  and  the 

iris  and  arteries  of  the  head 
Ganglion,  First  cervical  influence  of,  on 

the  iris 

Gastric  epilepsy        .... 
General  diseases.  Ocular  symptoms  in 
"       and  local  symptoms,  with  in 

juries  of  the  brain 
General      paralysis     of     the     insane 

Mickle.     (Review)         ... 
General      paralysis      of    the     insane 

Tendon  reflex  in     . 
Gheel  and  its  insane,  by  W.  J.  Morton 

M.D 


679 
124 
820 
643 

647 
645 


805 


102 

833 
190 


248 

464 
384 

810 
676 
364 


Glycosuria  from  stretching  the  vagi 
Goitre,  Exophthalmic,  Duboisia  in 
Gradle,  H.,  M.D.,  Optic  nerve 

"  "         Nervous  mechanism 

of  respiration 

Gradle,  H.,  M.D.,  Spasm  of  the  ciliary 

muscles  of  central  origin 
Graves'  disease  .... 

Gross.     Disorders  of   the  male  sexual 

organs.     (Review) 
Growths  of  hair  in  insane  females 
Gynecology.    Mund6.    (Review) 

H 


Hagenbach,  A.  W.,  M.D.,  Surgery 
among  the  insane 91 

Hairy  growths  in  insane  females    .        .  676 

Hallucinations 669 

"  Pathological  anatomy  of  386 

Hammond,  G.  M.,  M.D.,  Hypothetical 
auditory  tract 565 

Hammond  Prize  of  the  American  Neu- 
rological Association     ....  153 

Hammond,  W.  A.,  M.D.  Elongation  of 
the  sciatic  nerve  in  locomotor  ataxia  .  553 

Hammond,  W.  A.,  M.D.  Hypnotism. 
(Review) 356 

Hand,  Deformity  of,  as  a  symptom,  by 
R.  W.  Amidon,  M.D 693 

Head,  Arteries  of,  and  the  iris  ;  Physio- 
logical connection  between  them  and 
the  ganglion  cervicale  supremum        .  647 

Headache  in  school-children  .        .        .  186 

Headaches :  their  nature  and  treatment, 
by  J.  S.  Jewell,  M.D.      .        .        .64,  307 

Heart  and  blood-vessels.  Action  of 
digitaline  on 415 

Heart,  Innervation  of       ...        .  159 
"       lungs,  and  blood-vessels,  Reflex 
connection  between      ....  380 

Heart,  Physiology  of       ...        .  816 

Hemi-ataxia,  Posthemiplegic ,       .       .402 


PAGE 

Hemisphere,  Left  cerebral,  destructive 
lesion  of,  by  H.  D.  Schmidt,  M.D.     .  737 

Historical  case  of  impulsive  monoma- 
nia, by  E.  C.  Spitzka,  M.D.         .        .     87 

Hoang  Nan 845 

Homatropine  hydrobromate,  value  of, 
in  ophthalmic  practice  .        .        .  420 

Hospitals  for  tne  insane.  Kirkbride. 
(Review) 336 

Hot- water  compresses  in  tetanus  .        .  413 

How  to  use  the  bromides,  by  G.  M. 
Beard,  M.  D. 491 

Hydrobromate  of  homatropine,  value 
of,  in  ophthalmic  practice    .        .        .  420 

Hydrophobia 403,  836 

"  and  scepticaemia        .        .  828 

"  "      strychnine  .        .        .  843 

"  Diagnosis  of       .        .        .  663 

Hyoscyamus  in  paralysis  agitans,  by 
E.  C.  Mann.  M.D 124 

Hyperexcitability,  Neuro-muscular,  in 
hysteria 665 

Hypnotism,  by  W.  A.  Hammond, 
M.D.     (Review) 356 

Hypothetical  auditory  tract,  by  G.  M. 
Hammond,  M.D 565 

Hysteria  major          .        •        .        .        .  i8i 
Neuro-muscular,  hyper  excita- 
bility in 665 

Hysteria,  Occurrence  of,  in  children    .  182 

I 

Idio-muscular  contraction       .        .        .  161 

Idiopathic  lateral  sclerosis       .        .        .  403 
neuralgias,    Nerve-stretching 
in,  by  Drs.  Fenger  and  Lee         .        .  276 

Illinois,  Commitment  of  lunatics  in        .  154 

Impulsive  monomania.  Historical  case 
of,  by  E.  C.  Spitzka,  M.D.  ...     87 

Increase  of  fibrine  of  the  blood  in  peri- 
cerebritis         398 

Induced  electricity  ....  605 

Infantile  paralysis.  Electro-muscular 
contractility  in        .        .  .        .  595 

Influence  of  our  present  civilization  on 
the  production  of  nervous  and  men- 
tal diseases,  by  J.  S.  Jewell,  M.D.      .      i 

Influence  of  section  of  the  trigeminus 
upon  the  eye  ....  648,  825 

Influence  of  the  bromides  on  the  cere- 
bral temperature  ....  188 

Influence  of  the  first  cervical  ganglion 
on  the  iris 645 

Initial  symptom  of  tabes         .        .        .  678 

Injuries  of  the  brain,  with  general  and 
local  symptoms 838 

Innervation  of  the  heart         .        .        .  158 
"  "      uterus         .        .        .  161 

Insane,  Association  for  the  protection 
of 151 

Insane,  Criminal  responsibility  of         .  641 
"    delusions,    by    E.    C.   Spitzka, 
M.D 25 

Insane  females.  Hairy  growths  in         .  676 

"    General   paralysis    of,    Mickle. 

(Review) 805 

Insane,  General  paralysis  of,  tendon  re- 
flex in 588 

Insane,  Protection  of       ...        .  369 
Surgerv    among,    by    A.    W. 
Hagenbach,  M.D.  .        .        .        .91 

Insanity,  Alcoholic  cases  of,  in  private 
practice 185 

Insanity  and  cortical  malformation        .  371 

"        National    association  for   the 

prevention  of 151 

Insanity,  Transitory,  from  cold,  in  chil- 
dren         672 


INDEX. 


PAGE 

Intercostal  neuralgia,  Nerve-stretching 
in,  by  Drs.  Fenger  and  Lee        .        .  276 

Iris  and  arteries  of  the  head  ;  Physio- 
logical connection  between  them  and 
the  ganglion  cervicale  supremum       .  647 

Iris,  Influence  of  the  first  cervical 
ganglion  upon 645 

Irritability  and  conductibility  of  nerve 
fibres 646 

Irritant,  The  action  of  an,  by  I.  Ott, 
M.D 581 

Irritation,  Spinal,  by  J.  S.  Jewell,  M.D.  760 

Isthmus  disease.  Mental  symptoms 
from        , 840 

J 

James,  Feeling  of  effort.    (Review)      .  361 

Jeffries,  B.  J.,  Some  points  in  regard  to 
color-blindness 433 

Jewell,  J.  S.,  M.D.,  Influence  of  our 
present  civil'zation  on  the  production 
of  nervous  and  mental  diseases  .        .      i 

Jewell,  J.  S.,  M.D.  Nature  and  treat- 
ment of  headaches  .        .        -  64,  307 

Jewell,  J.  S.,  M.D.,  Spinal  irritation      .  760 

K 

Kieman,  J.  G.,  M.D.,  Contributions  to 
psychiatry 233,  445 

Kiernan,  J.  G.,  M.D.,  Psychoses  before 
traumatism 445 

Kiernan,  J.  G.,  M.D.,  Psychoses  pro- 
duced t)v  heat 243 

Kiernan,  J.  G.,  M.D.,  Psychoses  pro- 
duced by  lead 454 

Kiernan,  J.  G.,  M.D.,  Psychoses  pro- 
duced by  quinine  ....  452 

Kiernan,  J.  G.,  M.D. ,  Psychoses  pro- 
duced by  rheumatism  .        .        .  233 

Kiernan,  J.  G.,  M.D.,  Stealing  as  a  pre- 
monitory symptom  of  progressive 
paresis  461 

Kinnicutt,  F.  P.,  M.D.,  A  case  of  acute 
chorea 506 

Kirkbride,  Insane  hospitals.    (Review)  336 

L 

L'  Encephale 371 

Lateral  sclerosis.  Idiopathic  .        .  403 

Lead,  Psychoses  produced  by        .        .  454 

Lee,  E.  W.,  M.D.,  Nerve-stretching    .  263 

Lepra,  Etiology  of  ....  829 

Leprosy,  Anaesthetic,  Nerve-stretch- 
ing in,  by  Drs.  Fenger  and  Lee  .  300 

Lesions,  Localized  cerebral,  by  E.  C. 
Seguin,  M.D. 510 

Local  and  general  symptoms  with  in- 
juries of  the  brain  ....  838 

Local  asphyxia  of  the  extremities           .  831 
"      symmetrical  asphyxia   of  the  ex- 
tremities   392 

Localized  cerebral  lesions,  by  E.  C. 
Seguin,  M.D. 510 

Locomotor  ataxia.  Elongation  of  the 
sciatic  nerve  in,  by  W.  A.  Hammond, 
M.D 553 

Locomotor  ataxia.  Nerve-stretching 
in,  by  Drs.  Fenger  and  Lee        .        .  292 

Locomotor  ataxy 173 

"  "      Ear  symptoms  in        .  396 

■'  "      Zinc  phosphide  in        .  686 

Lunatics,  Commitment   of,  in  Illinois  154 

"         Occupation  and    reasonable 

liberty  for,  by  W.  J.  Morton,   M.D.  102 

Lungs,  heart,  and  blood-vessels,  Re- 
flex connection  between      .        .        .  380 

Lymphatics,  Vaso-motors  of    .        647,  824 


PAGE 

M 

Mackenzie,  Diseases  of  the  throat. 
(Review) 364 

Magnets,  Therapeutic  use  of  .        .  194 

Malformation,  Cortical,  and  insanity     .  371 

Man,  Brain  weight  of,  Bischoflf.  (Re- 
view)        638 

Mann,  E.  C,  M.D.,  A  case  of  paraly- 
sis agitans 124 

Mason,  J.  J.,  M.D.,  Microscopical  stud- 
ies on  the  central  nervous  system  of 
reptiles  and  batrachians        .        .        .80 

Mason,  J.  J.,  M.D.,  Notes  on  the  cen- 
tral nervous  system  of  reptiles  .  574 

Massage  for  the  relief  of  tabetic  anaes- 
thesia       845 

Mechanical  excitation  of  the  nerves      .  819 

Mechanism  and  diagnostic  bearing  of 
insane  delusions,  by  E.  C.  Spitzka, 
M.D 25 

Medical  Diagnosis,  Da  Costa.  (Review)  363 
"      Uses  of  statical  electricity,  by 
G.  M.  Beard,  M.D 609 

Men,  Autographic 842 

Mental  failure  from  strain        .        .        .  385 
"      symptoms  from  isthmus  disease  840 

Microscopical  studies  on  the  central 
nervous  system  of  reptiles  and  ba- 
trachians, by  J.  J.  Mason,  M.D.  .     80 

Miles,  F.  T.,  M.D.,  >l>'elitis         .        .  621 

Mills,  C.  K.,  M.D.,  Tumor  of  motor 
zone  of  the  brain  ....  630 

Mills,  C.  K.,  M.D.,  Tumor  of  pons  Var- 
olii   470 

Mimic  spasm,  Nerve-stretching  in,  by  . 
Drs.  Fenger  and  Lee     ....  278 

Mind,  The  brain  as  an  organ  of.  Bas- 
tian.     (Review) 145 

Mitchell,  Diseases  of  the  nervous  sys- 
tem.    (Review) 636 

Monomania,  Impulsive,  historical  case 
of,  by  E.  C.  Spitzka,  M.D.  ...     87 

Morton,  W.  J.,  M.D.,  The  town  of 
Gheel  and  its  insane      ....  102 

Motor  brain  centres.  Processes  of  ex- 
citation  and   inhibition    in  (Review)  806 

Motor  and  sensory  nerves.  Action  of 
pressure  upon 162 

Motor  nerves.  Excitability  of         .        .  379 

Mucous  membrane.  Uterine,  terminal 
distribution  of  the  nerves  in,        .        .  166 

Mund6,  P.  F.,  M.D.,  Gynsecolog>-. 
(Review) 364 

Muscles,  Ciliary  spasm  of,  of  central 
origin,  by  H.  Gradle,  M.D.        .        .  464 

Muscular  contractions.  Voluntary  na- 
ture of, 822 

Muscular  wasting  without  disease  of 
the  spinal  cord,  by  j.  J.  Putnam, 
M.D 201 

Myelitis,  Early  use  of  strychnia  in,  by 
J.  S.  Jewell,  M.D 59 

Myelitis,  by  F.  T.  Miles,  M.D.      .        .  62 

I 

N 

National  association  for  the  protection 
of  the  insane 151 

Nature  and  treatment  of  headaches, 
by  J.  S.  Jewell,  M.D.        .        .        64,  307 

Nerve  alterations  in  chronic  rheuma- 
tism          667 

Nerve  cells  in  the  cerebro-spinal  and 
peripheral  cranial  ganglia  .        .  643 

Nerve  fibres,  Irritability  and  conducti- 
bility of 646 

Nerve,  Optic  color-blindness  in  dis- 
eases of 384 


VI 


INDEX. 


PAGE 

Nerve,  Elongation  of  sciatic,  in  loco- 
motor ataxia,  by  W.  A.  Hammond, 
M.D 553 

Nerve-stretching         .        .        411, 671,  687 
"             "          by    Drs.  Chr.  Fenger 
and  E.  W.  Lee 263 

Nerve-stretching  in  ataxia      .        .        .  189 
■'  "  "  locomotor  ataxia    .  615 

"  trunks,  Nerve-stretching  in  neur- 
algias of,  caused  by  surgical  lesions, 
by  Drs.  Fenger  and  Lee      .        .        .  276 

Nerves,  Alterations  of,  in  chronic  rheu- 
matism               667,  829 

Nerves,  Cranial  development  of,  668,  826 
"  Origin  ot  cranial  .  .  .  824 
"  Dilator,  of  the  pupil  .  .  .  644 
"  Mechanical  excitation  of  .  .  819 
"  Motor  and  sensory  action  of 
pressure  on 163 

Nerves,  Excitability  of  motor       .        .  379 
"        Ocular,  paralysis  of  all      .        .  171 

Nerves  of  the  extremities,  Nerve- 
stretching  in  plastic  contractions  of, 
by  Drs.  Fenger  and  Lee       .        .        .  280 

Nerves,  Relations  of,  to  aneurism         .  171 
"      Terminal  distribution  of,  to  the 
uterine  mucous  membrane  .        .  166 

Nerves,  Vaso-dilator       .        .        .        .162 

Nervous  and  mental  diseases,  Influence 
of  our  present  civilization  in  the  pro- 
duction of,  by  J.  S.  Jewell,  M.D.        .      i 

Nervous  mechanism  of  respiration,  by 
H.  Gradle,  M.D.  .        .        .        .248 

Nervous  phenomena  of  dyspepsia         .  400 

"        system  and  brain.  Relations  of 

the  ovaries  to 389 

Nervous  system,  Diseases  of.  Mitchell. 
(Review) 636 

Nervous  system  of  reptiles  and  batrachi- 
ans,  Microscopic  studies  on,  by  J.  J, 
Mason,  M.D. 80 

Nervous  systein.  Central,  of  reptiles, 
notes  on,  by  J.  J.  Mason,  M.D.         .  574 

Neuralgia,  Direct  cauterization  of  a 
nerve  for 190 

Neuralgia,  Nerve-stretching  in  inter- 
costal, by  Drs.  Fenger  and  Lee  .  276 

Neuralgias  caused  by  surgical  lesions 
of  nerve-trunks,  Nerve-stretching  in, 
by  Drs.  Fenger  and  Lee      .        .        .  276 

Neuralgias,  lidiopathic,  nerve-stretch- 
ing in,  by  Drs.  Fenger  and  Lee  .  276 

Neuralgias,  Symmetrical,  of  diabetes    .  181 

Neurasthenia  178 

Nervousness,  American.  Beard.  (Re- 
view)        773 

Neuritis  169 

Neuro-muscular  hyper-excitability  in 
hysteria 665 

Neurological  Association,  American, 
Transactions  of 586 

Nomenclature,  Anatomical,  of  the  brain  652 

Note  on  the  peculiar  action  of  the 
bromides  in  certain  insane  epileptics, 
by  H.  M.  Bannister,  M.D.  .        .  560 

Notes  on  the  central  nervous  system  of 
reptiles,  by  J.  J.  Mason,  M.D.  .  574 

o 

Objects  in  space.  Determination  of  the 
position  of  167 

Occupation  and  reasonable  liberty  for 
lunatics,  by  W.  J.  Morton,  M.D.        .  102 

Occurrence  of  hysteria  in  children        .  182 

Ocular  nerves.  Paralysis  of  all        .        .  171 
"      symptoms  in  general  diseases    .  394 

On  some  points  in  regard  to  color- 
blindness, by  H.  M.  Baumster,  M.D.    49 


On  some  points    in    regard  to  color- 
blindness, by  B.  J.  Jeffries,  M.D.        .  433 

Ophthalmic  practice.  Value  of  homatro- 
pine  hydrobromate  in  ...  420 

Optic  nerve,  by  H.  Gradle,  M.D.           .  128 
''            Color-blindness  in  diseases 
of  384 

Origin  of  the  cranial  nerves  .        .  824 

Ott,  L,  M.D.,  Action  of  an  irritant        .  581 
"  Cilio-spinal  centres  .  757 

Ovaries,  Relation  of,  to  the  brain  and 
nervous  system  ....  389 


Paralysis  agitans,  A  case  of,  by  E.  C. 
Mann,  MJD.  124 

Paralysis,  Cerebral,  with  trophic  dis- 
orders   383 

Paralysis,  General,  of  the  insane. 
Mickle.     (Review)        ....  805 

Paralysis,  Nerve-stretching  in,  by  Drs. 
Fenger  and  Lee  ....  282 

Paralysis  of  all  the  ocular  nerves  .  171 

of  the  bladder  .        .        .  178 

Pathological  anatomy  of  hallucinations  386 

Pathology  of  the  nervous  system  and 
mind,  and  pathological  anatomy, 

169,  383,  663,  826 

Peculiar  effect  of  the  bromides  upon 
certain  insane  epileptics,  by  H.  M. 
Bannister,  M.D.  ....  560 

Pericerebritis,  Increase  of  fibrine  of  the 
blood  in 398 

Peripheral  cranial  and  cerebro-spinal 
ganglia.  Nerve  cells  in         ...  643 

Peripheral  or  cerebral  temperatures. 
Blaise.     (Review)  ....  347 

Phenomena,  Nervous,  of  dyspepsia      .  400 

Phenomenon,  The  Cheyne-Stokes        .  159 

Phosphide  of  zinc  in  locomotor  ataxy    .  686 

Physiological  connection  between  the 
ganglion  cervicale  supremum  and  the 
iris  and  arteries  of  the  head  .        .  647 

Physiology  of  the  heart           .        .        .  816 
"              "      spinal  cord  and  ad- 
jacent parts,  by  G.  B.  W.  Field,  M. 
D 211 

Poliomyelitis  anterior,  Affection  of  the 
abdominal  muscles  in,  by  W.  R. 
Birdsall,  M.D 482 

Pons  Varolii,  Tumor  of,  by  C.  K.  Mills, 
M.D 470 

Posthemiplegic  hemi-ataxia  .        .  402 

Pregnancy,  vomiting  of  ...  681 

Prize,  The  Hammond,  of  the  American 
Neurological  Association  .        .  153 

Processes  of  excitation  and  inhibition 
in  the  motor  brain  centres  .        .  806 

Progressive  paresis.  Stealing  a  premoni- 
tory symptom  of,  by  J.  G.  Kiernan, 
M.D 461 

Prosopalgia,  Nerve-stretching  in,  by 
Drs.  Fenger  and  Lee  .        .        .  274 

Protection  of  the  insane  .        .        .  369 

Psychiatrical  literature  for  1881,  Re- 
view of  ....  .  779 

Psychiatry,  Contributions  to,  by 
Jf.  G.  Kiernan,  M.D.     .        .        .  23^,  445 

Psychoses  from  traumatism,  byJ.G. 
Kiernan,  M.D 445 

Psychoses  produced  by  heat,  by  J.  G. 
Kiernan,  M.D 243 

Psychoses  produced  by  lead,  by  J.  G. 
Kiernan,  M.D 454 

Psychoses  produced  by  quinine,  by 
I.  G.  Kiernan,  M.D 452 

Psychoses  produced  by  rheumatism, 
by  J.  G.  Kiernan,  M.D.       .  .  233 


INDEX. 


Vll 


PAGE 

Pulse,  Semeiologjical  value  of  perma- 
nent retardation  of        ...        .  663 
Pupil,  Dilator  nerves  of  .        .        .        .  644 
Purgatives  in  tetanus        ....  412 
Putnam,  J.  G.,  M.D.    A  case  of  rapid 
and   widespread     muscular  wasting, 
without  disease  of  the  spinal  cord      .  201 

Q 

Quinine,   Psychoses  produced  by,   by 
J.  G.  Kiernan,  M.D 432 

R 

Ray,  Dr.  Isaac,    Death  of       .        .        .  373 
Real  and  simulated  epilepsy      .        .        843 
Reflex  connection  between  the  lungs, 
heart,  and  blood-vessels       .        .        .  380 

Reflex  of  Snellen 377 

Reflexes.  Action  of  anaesthetics  on        .  424 
Relation  of  the  ovaries  to  the  brain  and 

nervous  system 389 

Relief  of  tabetic  anaesthesia.  Massage 

for 845 

Reptiles,  Central   nervous  system  of, 

by  J.  J.  Mason,  M.D 574 

Reptiles,  Microscopic    studies  on    the 
central  nervous  system  of,  by  J.  J. 

Mason,  M.D. 80 

Respiration,    Nervous  mechanism  of, 

by  H.  Gradle,  M.D 248 

Responsibility,  Criminal,  of  the  insane  641 
Retardation,    Permanent,  of  the  pulse, 

semeiological  value  of,  .  .  .  663 
Reviews  and  Notices  :  .  128,  336,636,773 
Albuminuria.  Dickinson  .  .  778 
American  nervousness.  Beard  .  773 
Atlas  of  skin  diseases.  Duhring  .  147 
Brain  as  an  organ  of  mind.  Bastian  145 
Brain  weight  of  man.  Bischoff  .  638 
Catarrh.     Robinson  .        .        .  364 

Cold  pack  and  massage  in  anaemia, 

Jacobi  and  White   .  .        .141 

Cutaneous    and  venereal  memor- 
anda.    Pififard  and  Vox         .        .  148 
Diphtheria.    Jacobi  ....  147 
Diseases  of  the  chest,  throat,  and 

nasal  cavities.    Ingals    .        .        .  810 
Diseases  of  the     nervous  system. 

Mitchell 636 

Diseases  of  the  skin.    Duhring       .  363 
Diseases  of  the  throat.     Mackenzie  364 
Disorders  of  the  male  sexual  or- 
gans.   Gross 810 

Ear  diseases.  Buck  ....  147 
Electricity.  Beard  and  Rockwell  .  364 
Feeling  of  effort.    James  .        .        .  361 

Fever.    Wood 347 

General    paralysis  of   the   insane. 

Mickle 805 

Gynecology.  Mund6  .  .  .  364 
Histolo^.  Satterthwaite  .  .  810 
Hypnotism.  Hammond  .  .  .  356 
Indigestion  and  biliousness.    Foth- 

ergill 810 

Insane  hospitals.  Kirkbride  .  .  336 
Invalid  food.     Fothergill  .        .  363 

Lectures  on  digestion.    Ewald        .  810 
Medical  diagnosis.    Da  Costa         .  363 
Mother's  guide.     Keating        .        .  778 
Ophthalmic  and  otic    memoranda. 
Koosa  and  Ely        ....  148 

Optic  nerve 128 

Peripheral    or    cerebral  tempera- 
ture.   Blaise 347 

Practice  of  medicine.     Bartholow  .  147 
Processes  of  excitation  and  inhibi- 
tion in  the  motor  brain  centres     .  806 


PAGE 

Provinziaten-irren-Anstalten      der 

Rheinprovinz 363 

Psychiatrical  literature,  1881  .  .  779 
Surgical  diagnosis.  Ranney  .  .  147 
Therapeutics.        Trousseau       and 

Pidoux 147 

Visiting  list.  Medical   Record         .  148 
Wilderness  cure.     Cook   .        .        .  778 
Rheumatism,    Chronic,    alterations   of 

the  nerves  in  ...  .  667,  829 
Robinson.  Catarrh  (Review)  .  .  364 
Rockwell.    Electricity  (Review)  .        .  364 

s 

Schmidt.  H.  D..  M.D.  Destructive 
lesion  of  the  left  cerebral  hemisphere  737 

School-children,  Headache  in         .        .  186 

Sciatic  nerve.  Elongation  of,  in  locomo- 
tor ataxia,  lay  W.  A.  Hammond,  M.D.  553 

Sciatica,  Nerve-stretching  in,  by  Drs. 
Fenger  and  Lee 263 

Sclerosis,  Aconitia  in,  by  E.  C.  Se- 
guin,  M.D. 632 

Sclerosis,  Idiopathic  lateral  .        .  403 

Section  of  the  trigeminus,  Influence  of, 
upon  the  eye  ....  648,  825 

Seguin,  E.  C,  M.D.,  Aconitia  in  scle- 
rosis          632 

Seguin,  E.  C,  M.  D.,  Diphtheritic 
ataxia 634 

Seguin,  E.C.,  M.D.,  Localized  cerebral 
lesions 510 

Semeiological  value  of  permanent  re- 
tardation of  the  pulse  .        .        .  663 

Sensory  and  motor  ner\-es.  Action  of 
pressure  upon 162 

Septicaemia  and  hydrophobia  .        .  828 

Simulated  and  real  epilepsy    .        .        .  843 

Sinkler,  W.,  M.D.,  Chorea  in  the  aged.  577 

Skin  affections  and  spinal  disease.  Co- 
incidence of 835 

Skin  diseases,  Atlas  of.  Duhring. 
(Review) 147 

Skin  diseases.    Duhring.    (Review)      .  363 

Snellen,  The  reflex  of       ....  377 

Sodium  bromide  in  paralysis  agitans,  by 
E.  C.  Mann,  M.D 124 

Some  points  in  regard  to  color-blind- 
ness, by  H.  M.  Bannister,  M  D.  .49 

Some  points  in  regard  to  color-blind- 
ness, by  B.  J.  Jeffries,  M.D.        .        .  433 

SoufB6,  Cephalic,  in  the  adult         .        .  674 

Space,  Determination  of  the  position  of 
objects  in 167 

Spasm,  Mimic,  nerve-stretching  in  by 
Drs.  Fenger  and  Lee     ....  278 

Spasm  of  the  ciliary  muscles  of  central 
origin,  by  H.  Gradle,  M.D.  .        .  464 

Spasmodic  torticollis.  Nerve-stretching 
in,  by  Drs.  Fenger  and  Lee         .        .  279 

Spastic  contraction  of  the  nerves  of  the 
extremities,  Nerve-stretching  in,  by 
Drs.  Fenger  and  Lee    ....  280 

Spinal  arachnoid,  Calcareous  deposits 
in 834 

Spinal  cord,  Physiology  of,  by  G.  B. 
W.  Field,  M.D.      .        ...        .        .211 

Spinal  diseases  and  skin  affections.  Co- 
incidence of 835 

Spinal  irritation,  by  J.  S.  Jewell,   M.D.  760 

Spitzka,  E.  C,  M.D.,  A  historical  case 
of  impulsive  monomania      .        .        .87 

Spitzka,  E.  C,  M.D.,  Contributions  to 
encephalic  anatomy       ....  317 

Spitzka,  E.  C,  M.D.,  Insane  delusions  ; 
their  mechanism  and  diagnostic  bear- 

^  '"K  • ,      • . 25 

Static  electricity 681 


VIU 


INDEX. 


Stealing  as  a  premonitory  svBiptom  of 
Drqgressive  paresis,  by  J.  G.  Kiernan, 


VK 


461 

Strain,  Mental  failure  from  .  .  .  385 
Stretching  the  vagi,  Glycosuria  from.  833 
Strychnia,  Early  use  of,  in  myelitis,  by 

J.  S.  Jewell,  M.D 597 

Strychnia  and  hydrophobia  .  .  .  843 
Surgery  among  the  insane,  by  A.  W. 

Hagenbach,  M.D.          .        .        .        .91 
Symmetrical  local  asphyxia  of  the  ex- 
tremities   392 

Sympathetic,  Vaso- dilators  in  the  .  375,  376 
Symptom,  Initial,  of  tabes       .        .        .  678 
Symptom  of  epilepsy.  Albuminuria  as  a  674 
Symptoms,  Ear,  in  locomotor  ataxy      .  396 
"          General  and  local,  with  in- 
juries of  the  brain         ....  838 
Symptoms,  Mental,  from  isthmus  dis- 
ease   840 

Symptoms,  Ocular,  in  general  diseases.  394 
Syphilis,  Tabes  and  ....  668 

System  nervous  and  brain,  Relation  of 

ovaries  to        .        .        .  '      .         .        .  389 
System,  nervous  diseases  of,  Mitchell. 

(Review) 636 

System,  nervous,  of  reptiles,  Notes  on, 

by  J.  J.  Mason,  M.D 574 

System,  nervous,  of  reptiles  and  bat- 
rachians.  Microscopical  studies  on, 
by  J.  J.  Mason.  M.D 80 


Tabes  and  syphilis  ....  668 

"      Initial  symptom  of        .        .         .  678 

Tabetic  anaesthesia.   Massage  for   the 
relief  of  845 

Temperature,    Cerebral,  influence    of 
the  bromides  upon        ....  188 

Tendon  reflex  in  general  paralysis  of 
the  insane 588 

Terminal  distribution  of  the  nerves  to 
the  uterine  mucous  membrane    .        .  166 

Tetanus,  Arsenic  in  .  .        .411 

"         Hot-water  compresses  in        .  413 

"         Purgatives  in     .        .        .        .  412 

"         Traumatic,     nerve-stretching 

in,  by  Drs.  Fenger  and  Lee         .        .  282 

Therapeutic  use  of  magnets  .        .  194 

Therapeutics  of    the  nervous   system 
and  mind  .         .        .  188,  411,  681,  845 

Thermometry,  Cerebral  .        .        .  379 

Throat  diseases.  Mackenzie.  (Review)  364 

Tinnitus  aurium        .....   672 

Torticollis.    Sspasmodic  nerve-stretch- 
ing in,  by  Drs.  Fenger  and  Lee  .  279 

Tract,  Hypothetical    auditory,   by   G. 
M.  Hammond,  M.D 565 

Transactions  of  the  American  Neuro- 
logical Association        .        .        "        .  586 

Transitory  insanity  in  children,  from 
cold  .        ■ 672 

Traumatic    tetanus.    Nerve-stretching 
in,  by  Drs.  Fenger  and  Lee         .        .  282 

Traumatism,    Psychoses  from,    by   J. 
G.  Kiernan,  M.D 445 

Treatment  of  alcoholism         .        .        .  427 
"  asthma       ....  191 

"        of  headaches.  Nature  and, 
by  J.  S.  Jewell,  M.D.    .        .        .     64,307 

Trigeminus,   Influence  of  section    of, 
on  the  eye 648,  825 

Trismus,  Unilateral  ....  678 

Trophic    disorders  with  cerebral  par- 
alysis        383 

Tumor  of  brain,  by  C.  K.  Mills,   M.D.  630 
"           the  centrum  ovale,  by  A.  B. 
Arnold,  M.D 305 


Tumor    of   pons    Varolii,    by    C.    K. 
Mills.  M.D.  470 

u 

Unilateral  trismus 678 

Urechites  subrecta  .        .        .        .191 

Urinary  passages  in  man  and  certain 

animals.  Ganglia  of  ...  .  820 
Use  of  the  cold   pack  and  massage  in 

anaemia.  Jacobi  and  White.  (Review)  141 
Uterine  mucous    membrane.  Terminal 

distribution  of  the  nerves  to  .  .  166 
Uterus,  Innervation  of   .         .        .        .161 

V 

Vagi,  Glycosuria  from  stretching   .       .  833 
Value  of  homatropine  hydrobromate  in 

ophthalmic  practice  ....  420 
Value  of  permanent  retardation  of  the 

pulse  Semeiological      ....  663 
Vaso-dilator  nerves          .        .        .        .162 
"    -dilators  in  the  sympathetic  .        .  375 
"           "      of  the  bucco-labial  region  164 
"      motors  of  the  lymphatics        647,  824 
Vibrations,  .lEsthesiogenic      .        .        .  189 
Vision,  Cortical  centres  of      .        .        .  651 
Voluntary  muscular   contractions,  Na- 
ture of 822 

Vomiting  of  pregnancy  .        .        .  681 


w 

Water  (hot)  compresses  in  tetanus 
Wood.     Fever.     (Review) 
Writers'  cramp         .... 


413 
347 
665 


Zinc  phosphide  in  locomotor  ataxy       .  686 


List  of  Contributors  to  Volume  VIII. 

Amidon,  R.W.,  M.D.,  New  York,  N.  Y.  693 
Arnold,  A.  B.,  M.D.,  Baltimore,  Md.  .  305 
Bannister,    H.    M.    M.D.,    Kankakee, 

111.  49,  560 

Beard,  G.  M.,  M.D.,  New  York,  N.  Y.  491 
Birdsall,  W.R.,M.D.,  New  York,  N.Y.  482 
Fenger,  Chr.,  M.D.,  Chicago,  111.  .  263 

Field,  G.  B.  W.,  M.D.,  Easton,  Pa.  .  211 
Gradle,  H.,  M.D.,  Chicago,  111. 

128,  248,' 464 
Hagenbach,  A.  W.,  M.D.,  Jefferson,  111.  91 
Hammond,  G.  M.    M.D.,  New  York, 

N.  Y 565 

Hammond,  W.  A.,  M.D.,  New  York, 

N.  Y 553 

Jeffries,  B.  J.,  M.D.,  Boston,  Mass.  .  433 
Jewell,  J.  S.,  M.D.,  Chicago,  111. 

I,  64,  307,  760 
Kiernan,  J.  G.,  M.D.,  Chicago,  111. 

233.  445 
Kinnicutt,F.P.,  M.D.,  New  York, N.Y.  506 
Lee.  E.  W.,  M.D.,  Chicago,  111.  .  .  263 
Mann,  E.  C,  M.D.,  New  York,  N.  Y.  124 
Mason,  J.  J.,  M.D.,  Newport,  R.  I..  80,  574 
Mills,  C.  K.,  M.D. ,  Philadelphia,  Pa.  470 
Morton,  W.J. ,  M.D.,New  York^N.Y.  102 
Ott,  I.,  M.D.,  Easton,  Pa.  .        581,  757 

Putnam,  J.  J.,  M.D.,  Boston,  Mass.  .  201 
Schmidt,  H.  D.,  M.D.,  New  Orleans, 

La. 737 

Seguin,  E.C.,  M.D.,  New  York,  N.  Y.  510 
Sinkler,  W.,  M.D.,  Philadelphia,  Pa.  .  577 
Spitzka,  E.  C,  M.D.,  New  York,  N.  Y. 

25.  87,  317 


RC 
321 
J78 
V.8 

Biological 
&  Medical 
&nals 


The  Journal  of  nervous  and 
mental  disease 


PLEASE  DO  NOT  REMOVE 
CARDS  OR  SLIPS  FROM  THIS  POCKET 

UNIVERSITY  OF  TORONTO  LIBRARY